Intravenous Clevidipine for Inducing Hypotensive Challenge During Carotid Balloon Test Occlusion

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To JNA Readers:
Balloon test occlusions (BTOs) are used in endovascular neurointerventional surgery to predict which patients may tolerate permanent occlusion of the internal carotid artery (ICA) for treatment of fusiform aneurysms or for tumors of the head and neck that envelope or are adherent to the ICA. The patient’s blood pressure must be reduced during occlusion of the internal carotid with the balloon to verify the patient’s ability to tolerate carotid sacrifice at a wide range of blood pressures. However, rapid reduction of the blood pressure during BTO can be difficult.1 We describe the use of the dihydropyridine calcium channel blocker, clevidipine for inducing hypotension during BTO.
A 66-year-old man presented to our hospital for BTO to determine the feasibility of therapeutic occlusion of the ICA during excision of a squamous cell carcinoma of the neck that enveloped the ICA’s origin. The procedure was performed while the patient was awake and anticoagulated. A 6 mm×9 mm Ascent balloon was inflated in the distal cervical ICA below the skull base until the balloon’s edges were observed to be in contact with the walls of the ICA. A contrast injection in the guide catheter proximal to the inflated balloon confirmed occlusion of the ICA. There were no changes in neurological examination at a blood pressure of 172/82 mm Hg. A continuous intravenous infusion of clevidipine was started at 5 mg per hour. A maximum dose of 20 mg/h of clevidipine was used to reduce the blood pressure to as low as 117/62 mm Hg. The above change in blood pressure was achieved in a precise manner in approximately 15 minutes. The patient experienced no changes in neurological examination at the above 2 widely different blood pressures while the internal carotid was occluded (Fig. 1).
Intravenous clevidipine has been used to control postoperative hypertension in patients undergoing cardiac surgery. Clevidipine has been shown to reduce blood pressure more rapidly during treatment of the acute hypertensive response in stroke patients compared with other agents such as labetalol and nicardipine.2 The infusion has been used to rapidly reduce blood pressure in 5 minutes in patients with intracerebral hemorrhage.3
To our knowledge, the use of clevidipine to reduce systemic blood pressure during BTO has not been previously described. The advantages of clevidipine are its rapid onset of action and short duration of action compared with other agents.
Clevidipine begins to have an effect on blood pressure within 2 to 4 minutes of administration and the duration of the effect is 5 to 15 minutes (compared with a duration of effect of nicardipine which can be up to 4 to 6 h).

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