Stent Geometry Matters: Impact of Tapered vs. Straight Stents On Persistent Hemodynamic Depression After Carotid Artery Stenting

Introduction: Carotid Artery Stenting (CAS) is an established alternative to carotid endarterectomy, particularly in patients with elevated surgical risk. Hemodynamic Depression (HD) is a common complication that is usually transient; however, persistent HD may compromise cerebral perfusion. The specific impact of stent geometry on persistent HD remains underexplored. Methods: This retrospective study included 109 patients who underwent primary CAS between October 2020 and October 2023. HD was defined as intraoperative hypotension (systolic blood pressure < 90 mmHg) and/or bradycardia (heart rate < 60 bpm), while persistent HD was defined as lasting more than 24 hours despite medical therapy. Patients were evaluated according to stent geometry (straight vs. tapered), carotid bulb involvement, plaque characteristics, and procedural variables. Multivariable logistic regression was performed, adjusting for demographic, clinical, anatomical, and procedural factors. Results: Periprocedural HD occurred in 40.4% of patients, and persistent HD in 25.7%. Persistent HD was significantly more frequent in patients treated with straight stents than in those treated with tapered stents (39.5% vs. 18.6%). Carotid bulb involvement and the use of a straight stent were significantly associated with persistent HD. In multivariable analysis, straight stent use (OR: 1.446; 95% CI: 1.041–2.018) and carotid bulb involvement (OR: 1.490; 95% CI: 1.102–2.015) remained independently associated with persistent HD. Twelve-month clinical outcomes did not differ between stent groups. discussion: Findings support the role of stent geometry and carotid bulb anatomy in the development of persistent HD. Straight stents may exert greater radial force and stimulate baroreceptors, predisposing to prolonged hemodynamic instability. These results align with prior studies suggesting improved tolerance with tapered stents. Limited sample size may explain the lack of observed long-term event differences. Discussion: Persistent hemodynamic depression after carotid artery stenting appears to be influenced not only by patient-related factors but also by procedural characteristics, particularly stent geometry and carotid bulb anatomy. The independent association of straight stent use with prolonged hemodynamic instability underscores the clinical relevance of device selection beyond technical success. Incorporating anatomical conformity into preprocedural planning may reduce prolonged baroreceptor-mediated instability and improve periprocedural safety. Conclusion: Persistent HD is a clinically relevant complication after CAS. Individualized stent selection may help reduce prolonged hemodynamic instability.