The carotid sinus syndrome: long term results of carotid denervation

Carotid sinus syndrome (CSS) is a relatively unknown cause of syncope in the
elderly leading to high comorbidity. An abnormal carotid baroreflex can lead to
asystole (cardioinhibition) or extreme hypotension (vasodepression) leading to
syncope, dizziness and unaccidental falls. Symptoms are reproducible by carotid
sinus massage. Last decades pacemaker implantation is considered to be
treatment of choice in CSS. However pacemaker implantation is not effective in
all types of CSS. Surgical carotid denervation seems to be an effective
treatment option in all types of CSS on the short term.
In our hospital 27 patients suffering from CSS underwent a surgical carotid
denervation in the period 1980-2007.

Evaluation of the long term results of surgical carotid denervation in patients
suffering from CSS.

Primary question:
Is surgical denervation an effective treatment option for symptoms caused by
CSS, eg dizziness and syncope, on the long term.

Secundary question:
-Does surgical denervation lead to chronic hypertension, dysrythms or
baroreflexfailure on the long term ?
-Occurence of postoperative complications: cranial nerve injury (nervus
hypoglossus, nervus facialis) en sensibility loss of the skin
-Dilatation/ aneurysm of the internal carotid artery after peri-adventitial
stripping?

Patient selection:
Patients with CSS who underwent a surgical carotid denervation in our institute

Inclusioncriteria:
Patients who underwent a surgicalcarotid denervation

Exclusioncriteria:
Exclusion from carotid sinus massage if:
-carotid stenosis on duplex
myocardial infarction<3 months
-TIA or CVA<3 months

A carotid duplex is performed to:
1. exclude carotid stenosis
2. measure the diameter of the internal carotid artery. Dilatation?


History taking is performed by drs. M. van der Leest
Clnical examination isperformed by R.J. Toorop.

Cardiac care unit:
An intra-arterial line is placed by R.J. Toorop. A Finapres blood pressure
device is placed around a finger.
Carotid sinus massage is performed during 10 s on theleft and right side in
lying position. If there is no response, the test is repeated in 60 degrees
tilt. If a cardioinhibitory reponse is observed the test is repeated after IV
injection of 1 mg atropine to unmask a vasodepressor reponse.Then a table
tilttest is perfrmed by dr. Huige, cardiologist.

Risks
-intra-arterial catheter:
The incidence of complications is low. The small catheter (22 gauche), is
immediately removed carotid sinus massage, so there is a very low risk of
thrombosis. No Seldinger technique is performed, so there is little chance of
dissection of the radial artery. There is always a chance of a small hematoma.
-Carotid sinus massage:
The incidence of neurological complications is low, eg 0.4%.