Extended lesion of the internal carotid artery: carotid autotransplantation, creation of a neobifurcation or prosthetic repair?

Abstract

The aim of our investigation was to analyse the results of autotransplantation, creation of a neobifurcation or prosthetic repair of the internal carotid artery during the in-hospital and long-term follow-up periods. The study included a total of 241 patients presenting with and treated for extended atherosclerotic lesions of the internal carotid artery from 2016 to 2019. The patients were divided into three groups depending on the surgical modality employed: group 1 - autotransplantation of the internal carotid artery (27.8%, n=67), group 2 - creation of a neobifurcation (55.2%, n=133), and group 3 - prosthetic repair of the internal carotid artery (17.0%, n=41). The duration of the postoperative follow-up period amounted to 24.8±11.9 months. The outcome measures selected were as follows: all-cause mortality, myocardial infarction, ischaemic stroke, haemodynamically significant restenosis, and a composite endpoint (death + myocardial infarction + ischaemic stroke + haemodynamically significant restenosis). During the in-hospital postoperative period we registered 1 (2.4%) ischaemic stroke in the group of prosthetic repair, with no significant inter-group difference revealed (p=0.08). In the remote period of follow-up, no statistical differences were revealed for the following outcome measures: all-cause mortality (group 1: 7.5%, n=5; group 2: 10.5%, n=14; group 3: 14.6%, n=6; p=0.49); cardiovascular-related death (group 1: 4.5%, n=3; group 2: 6.7%, n=9; group 3: 12.2%, n=5; p=0.31); myocardial infarction (group 1: 1.5%, n=1; group 2: 3%, n=4; group 3: 4.9%, n=2; p=0.59). However, the patients in the group of prosthetic repair of the internal carotid artery were found to have the highest incidence rates of ischaemic stroke (group 1: 3%, n=2; group 2: 3%, n=4; group 3: 14.6%, n=6; p1-2=0.1; p1-3=0.02; p2-3=0.008), haemodynamically significant restenosis (group 1: 0%, n=0; group 2: 0%, n=0; group 3: 14.6 %, n=6; p1-2>0.99; p1-3=0.000; p2-3=0.000), and higher values of the composite endpoint (group 1: 12 %, n=8; group 2: 16.5%, n=22, group 3: 48.8%, n=20; p1-2>0.99; p1-3=0.000; p2-3=0.000). Prosthetic repair of the internal carotid artery for an extended atherosclerotic lesion is a less preferable method compared with autotransplantation and creation of a neobifurcation, as evidenced by the highest incidence rates of ischaemic stroke, haemodynamically significant restenosis, and higher values of the composite endpoint in the remote period of follow up.