Classical Carotid Endarterectomy Research Articles

The comparison of the postoperative complications, mortality, and morbidity of the eversion technique and the classical technique in carotid endarterectomy

In the present study, the purpose was to compare the postoperative early and mid-term results of Eversion Carotid Endarterectomy (ECEA) and Classical Carotid Endarterectomy (CCEA) techniques used in the surgical treatment of carotid artery disease. A total of 269 patients who underwent carotid endarterectomy (105 ECEA and 164 CCEA) were included in the study. The 1st, 6th, and 12th-month follow-ups of 266 patients were performed because three patients died in the early postoperative period. All patients were started on acetylsalicylic acid, clopidogrel, and statin treatment in the postoperative period. When the postoperative results were evaluated, it was found that the cross-clamp and operation times of the surgeries performed with the ECEA technique were shorter than the CCEAat statistically significant levels (p=0.0002). Although there statistically significant differences were detected in terms of bleeding/drainage, need for reoperation because of bleeding, and restenosis, ECEA had more positive results than CCEA, and there were no statistically and proportionally significant differences between the two methods in terms of postoperative stroke and mortality. Considering the experience of the surgical team, the use of the ECEA technique has more positive results in terms of operation time and cross-clamp time compared to CCEA. We think that extending the follow-up periods of patients in the postoperative period and conducting multicenter studies with more patients would be more accurate in comparing these two methods.

Effects of different types of carotid endarterectomy on the course of resistant arterial hypertension.

Analysis of the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (СЕЕ) (classical with plasty of the reconstruction zone with a patch, eversion, formation of a new bifurcation, autoarterial reconstruction, glomus-saving techniques) in patients with resistant arterial hypertension (RAH). The actual cohort, comparative, retrospective, open research for the period from January 2013 to December 2021 includes 1577 patients with significant hemodynamic stenosis of the internal carotid artery Depending on revascularization strategy five groups were formed: Group 1: 18.3% (n = 289) - classical Carotid endarterectomy with plasty of the reconstruction zone with a patch (from diepoxy-treated xenopericardium or synthetic); Group 2: 29.9% (n = 472) - eversional CEE with cut-off of carotid gloomus (CG); Group 3: 6.9% (n = 109) - the formation of a new bifurcation; Group 4: 7.4% (n = 117) - autoarterial reconstruction; Group 5: 37.4% (n = 590) - glomus-saving CEE (1 technique - according to A.N. Kazantsev; two technicians - according to R.A. Vinogradov; three technicians - according to K.A.Antsupov). According to the 24-h blood pressure monitor in the preoperative period, the following degrees of AH were identified: 1° - 5.7% (n = 89); 2° - 64.2% (n = 1013); and 3° - 30.1% (n = 475). In the postoperative period, no significant differences were obtained in the frequency of deaths, myocardial infarction, stroke, hemorrhagic transformation. However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (group 1: 1.03% (n = 3); group 2: 3.6% (n = 17); group 3: 3.67% (n = 4); group 4: 2.56% (n = 3); group 5: 0.5% (n = 3); p = 0.10). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG. Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE, accompanied by the lowest incidence of adverse cardiovascular events caused by postoperative hypertensive crisis and hyperperfusion syndrome.

Comparative Assessment of the Results of Different Techniques of Carotid Bifurcation Reconstruction

INTRODUCTION: Nowadays, to restore the patency of the carotid artery bifurcation in atherosclerotic stenoses, three main methods of reconstruction are used, namely, classic carotid endarterectomy (cCEAE), prosthetic repair of the internal carotid artery, and eversion carotid endarterectomy (eCEAE). The study conducted a comparative analysis of the immediate and long-term results of using these methods in the case of stenosis of the carotid artery bifurcation. CONCLUSION: As regards the immediate results, the analysis of literature does not permit allow making an unambiguous conclusion about the evident advantages of a particular method of intervention. Thus, several authors obtained better results with the use of eCEAE, whereas others did not find any significant differences between eCEAE and cCEAE, if it was not a question about using a straight seam, and this can be referred to both meta-analyses and original studies. Regarding the long-term results, practically all literary sources indicate more optimal results with the use of the eversion technique. The results of the analysis imply the preference for eCEAE if the character of the lesion of the carotid bifurcation and anatomical interrelations in the surgical wound allow it.

The predictive value of internal carotid artery wall thickness in computed tomography angiography to avoid complications of plaque removal failure in modified eversion carotid endarterectomy.

The benefits of computed tomography carotid angiography (CTA) in terms of evaluating the anatomical structure of the carotid arteries, surgical planning, and evaluating possible risks were reported in previous studies. This study aimed to calculate the predictive value of internal carotid wall thickness in CTA that can predict whether a modified carotid eversion endarterectomy (MCEE) will result in a successful or not. This study was designed in a retrospective cross-sectional format. Consecutive 83 symptomatic carotid surgery patients who were operated in our hospital and had CTA were included in this study. The wall thickness of the internal carotid artery (ICA) 20mm distal from the carotid bifurcation was calculated in axial sections using a three-dimensional imaging technique. In addition, all patients' characteristics and laboratory findings were recorded. Patients who failed MCEE and required classical carotid endarterectomy were compared with patients who had successful MCEE. MCEE technique was applied to 62 patients. In 21 patients, the MCEE technique failed and the classical endarterectomy technique was required. Preoperative clinical and laboratory characteristics were similar in both groups. The mean ICA wall thickness was 0.65mm 20mm distal to from the carotid bifurcation and it was lower in the group with successful MCEE (1.03 ± 0.21mm vs. 0.56 ± 0.08mm) (p < 0.001). The critical ICA wall thickness was calculated as 0.76mm in the group that MCEE failed and classical carotid endarterectomy was required. Cut-off analysis of ICA wall thickness was calculated as 0.755mm in ROC analysis (p < 0.001), (95% confidence interval, curve area; 0.985). Successful carotid endarterectomy with the MCEE method is associated with distal ICA wall thickness and distal extension of the atheroma plate. The use of ICA wall thickness 20mm distal to from the bifurcation as a predictive value for the success of the MCEE technique is beneficial to avoid serious complications.

Multicenter Study of Resistant Arterial Hypertension Course After Classic and Eversion Carotid Endarterectomy

Aim of study. Analysis of the dynamics of resistant arterial hypertension (RAH) and the spectrum of adverse cardiovascular events in patients after classical carotid endarterectomy (CEE) with preservation of carotid body (CB) and eversion CEE with CB transection.Material and methods. This cohort, comparative, retrospective, open-label study from January 2014 to December 2020 included 761 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA) and RH lasting more than 3 years. Depending on the implemented revascularization strategy, 2 groups were formed: Group 1: 38.0% (n=289) — classical CEE with plasty of the reconstruction zone with a patch (made of diepoxy-treated xenopericardium or synthetic); Group 2: 62% (n=472) — eversion CEE with CB transection. To study the dynamics of systolic blood pressure (SBP) in the preoperative period for 4 days, and in the postoperative period, blood pressure was measured for 10 days (during the period when the patient was in intensive care - according to daily monitoring of blood pressure; in the department - 10 times per day, daily). The average SBP figures for all patients were taken into account when constructing a graph of BP fluctuations.Results. In the postoperative period, the groups were comparable in the frequency of the following events: death (group 1: 0.34% (n=1), group 2: 0.63% (n=3); p=0.98; OR 0.54; 95% CI 0.05–5.21), myocardial infarction (group 1: 0.34% (n=1), group 2: 0.84% (n=4); p=0.71; OR 0, 40; 95% CI 0.04–3.65), ischemic stroke (group 1: 0.34% (n=1), group 2: 1.27% (n=6); p=0.36; OR 0.26; 95% CI 0.03–2.25), hemorrhagic transformation (group 1: 0%, group 2: 0.84% (n=4); p=0.29; OR 0.17; 95% CI 0.009–3.35). However, in terms of the number of all complications (death + myocardial infarction + ischemic stroke + hemorrhagic transformation) presented as a combined endpoint, patients after eversion CEE with CB transection were three times superior to classical surgery (group 1: 1.03% (n=3 ), group 2: 3.60% (n=17); p=0.05; OR 0.28; 95% CI 0.08–0.9).Conclusion. The choice of a revascularization strategy in patients with hemodynamically significant ICA stenosis should be personalized and based on the conclusion of a multidisciplinary consultation, and not only on the preferences of the operating surgeon. In patients with RH, it is more expedient to use classical CEE with plasty of the reconstruction zone with a patch in view of the preservation of the CB during this operation. The intersection of the latter with eversion CEE provokes labile hypertension, progression of RAH and a statistically significant increase in the number of all unfavorable cardiovascular events. Thus, the use of carotid body preserving CEE in patients with RAH confirms the therapeutic mechanism of this manipulation in achieving the target SBP level.

Results of different kinds of carotid endarterectomy in patients with and without type 2 diabetes mellitus

BACKGROUND: Type 2 diabetes mellitus (DM) is one of the important markers for the development of adverse cardiovascular events after carotid endarterectomy (CEE). However, studies on this issue are based on small sample of patients and do not take into account the type of surgery as an additional factor of potentially negative impact on the course of the postoperative period.AIM: Analysis of hospital and long-term results of eversion and classical CEE with plastic surgery of the reconstruction zone with a biological patch in patients with type 2 diabetes and without it.MATERIALS AND METHODS: In this multicenter retrospective study from January 2010 to December 2020. included 5731 patients. Depending on the presence / absence of type 2 diabetes and the type of implemented CEE, 4 groups were formed: group 1 — 12.2% (n = 702) — patients with type 2 diabetes and eversion CEE; Group 2 — 55.0% (n = 3153) patients without type 2 diabetes and eversion CEE; Group 3 — 8.5% (n = 484) patients with type 2 diabetes and classical CEE; Group 4 — 24.3% (n = 1392) patients without type 2 diabetes and classical CEE. The duration of postoperative follow-up was 78.6 ± 39.2 months.RESULTS: At the long-term follow-up stage, patients with type 2 diabetes after the classical surgical technique demonstrated the highest rates of all types of complications: death (p &lt;0.0001), MI (p = 0.011), ischemic stroke (p &lt;0.0001), restenosis / occlusion of the ICA (p &lt;0.0001), combined end point (p &lt;0.0001). At the same time, the group of eversion CEE with impaired carbohydrate metabolism took the second position in terms of the prevalence of adverse events. These circumstances demonstrate that patch implantation is accompanied by an increased risk of developing not only myocardial infarction, but also restenosis of the reconstruction zone, as well as the associated ischemic stroke, which was demonstrated by our results.CONCLUSION: Patients with type 2 diabetes and a history of CEE are at increased risk of ischemic stroke at the hospital stage of observation and all unfavorable cardiovascular conditions (death, myocardial infarction, ischemic stroke, restenosis or ICA occlusion in the reconstruction zone) in the long-term postoperative period.

Hybrid revascularization of the heart and brain: which carotid endarterectomy is preferable?

The aim of this study was to analyse the inpatient and long-term results of hybrid surgery, incorporating percutaneous coronary intervention (PCI) and different types of carotid endarterectomy (CEA).&#x0D; Materials and methods. A prospective, open-label cohort comparison study was conducted in 20182020 and included 363 patients with atherosclerosis of both the internal carotid artery (ICA) and coronary artery, who underwent hybrid revascularization of the brain and myocardium. All patients were divided into four groups based on the revascularization strategy: group 1 (n = 107; 29.5%) PCI + eversion CEA; group 2 (n = 98; 27%) PCI + classic CEA with patch angioplasty; group 3 (n = 72; 19.8%) PCI + glomus-sparing CEA according to R.A. Vinogradov; and group 4 (n = 86; 23.7%) PCI + glomus-sparing CEA according to A.N. Kazantsev. The follow-up period was 20.8 8.0 months.&#x0D; The patient received a loading dose of clopidogrel (300 mg) before the PCI, and the procedure was then performed in an endovascular operating room. A radial artery catheter was inserted, and the patient received 10,000 IU of intravenous heparin before the procedure. After the PCI, the patient was taken to the vascular operating room, where they underwent the CEA. The patient received 5,000 IU of intravenous heparin before artery clamping. Glomus-sparing CEA according to A.N. Kazantsev was performed as follows: an arteriotomy was conducted along the internal edge of the external carotid artery (ECA), adjacent to the carotid sinus and 23 cm above the ostium, and extending to the common carotid artery (CCA) (also 23 cm below the ECA ostium), depending on the size of the atherosclerotic plaque. The ICA was transected in the area bound by the ECA and CCA walls. Eversion CEA of the ICA was performed, followed by open CEA of the ECA and CCA. The ICA was implanted in its previous position in the preserved area.&#x0D; Results. No mortality was recorded during the inpatient follow-up period. All cases of myocardial infarction occurred after eversion and classic CEA: 3 in group 1 (2.8%) and 1 in group 2 (1.02%); р = 0.2. No ischaemic stroke was recorded only in patients who underwent CAE according to A.N. Kazantsev (р = 0.66); however, ischaemic stroke occurred in two patients in group 1 (1.8%), in two patients in group 2 (2.04%) and in one patient in group 3 (1.38%). The highest number of cardiovascular events occurred in group 1, due to carotid glomus injury, which led to poorly controlled hypertension during the inpatient stay. This tendency influenced the composite endpoints (death + myocardial infarction + ischaemic stroke), which were highest in group 1 (5 or 4.6%) compared to 3 (3.06%), 1 (1.38%) and 0 in groups 24, respectively (р = 0.18). The groups were comparable in the frequency of long-term complications. However, the incidence of ICA restenosis was lowest and no ECA thrombosis/occlusion was observed after glomus-sparing CEA according to R.A. Vinogradov and A.N. Kazantsev.&#x0D; Conclusion. A hybrid PCI + CEA for brain revascularization should be glomus-sparing. CEA according to A.N. Kazantsev was characterized by lack of procedural arteriotomy complications. This procedure enables blood pressure monitoring in the postoperative period, thus minimizing the risk of cardiovascular complications.

Computer modeling of different shaped patches in classical carotid endarterectomy

Objective: to construct geometric models of carotid bifurcation and build a computer modeling for carotid endarterectomy (CEA) operations with patches of various configurations.Materials and methods. The method uses reconstructed models of a healthy blood vessel obtained from a preoperative computed tomography (CT) study of the affected blood vessel of a particular patient. Flow in the vessel is simulated by computational fluid dynamics using data from the patient's ultrasonic Doppler velocimetry and CT angiography. Risk factors are assessed by hemodynamic indices at the vessel wall associated with Wall Shear Stress (WSS).Results. We used the proposed method to study the hemodynamic results of 10 virtual CEA operations with patches of various shapes on a reconstructed healthy artery of a particular patient. The reason for patch implantation was to ensure that the vessel lumen is not narrowed as a result of the surgery, since closing the incision without a patch can reduce the vessel lumen circumference by 4–5 mm, which adversely affects blood flow. On the other hand, too wide a patch creates aneurysmorphic deformation of the internal carotid artery (ICA) mouth, which is not optimal due to formation of a large recirculation zone. In this case, it was found that the implanted patch width of about 3 mm provides an optimal hemodynamic outcome. Deviations from this median value, both upward and downward, impair hemodynamics. The absence of a patch gives the worst of the results considered.Conclusion: The proposed computer modeling technique is able to provide a personalized patch selection for classical CEA with low risk of restenosis in the long-term follow-up.

Eversion carotid endarterectomy with nerve-sparing component in a case of high location of common carotid artery bifurcation

We performed carotid endarterectomy on a patient with 75% stenosis of the left internal carotid artery (ICA), 70% stenosis of the left common carotid artery (CCA), 60% stenosis of the right ICA and 55% stenosis of the right CCA after a transient ischaemic attack on the premises of the surgical unit of Russian Railways Hospital–Medicine (Samara), which is the clinical site for the care of surgical diseases at Samara State Medical University. During the preoperative evaluation and physical examination, we determined that the chance of high CCA bifurcation was high because the patient had a brachymorphic physique and his neck was short and broad. In fact, during the surgical exploration of the carotid triangle area, the CCA bifurcation was identified 7 ± 0.5 cm higher than the shield-like cartilage rim; thus the CCA bifurcation area crossed the stems of the glossopharyngeal (IX), vagus (X) and hypoglossal (XII) nerves, which precluded classic carotid endarterectomy. We then decided to perform carotid endarterectomy, using the eversion method and transposing the ICA above the rami of the cranial nerves. Through this method, we minimised traction and nerve stem trauma during the process of reconstructing brachiocephalic trunk arteries, prevented morbidities involving the cranial nerves during postsurgical period, accelerated the patient’s recovery and improved the patient’s quality of life. With further patient monitoring during the early and late postoperative periods, no abnormalities of peripheral innervation occurred.Received 26 March 2021. Revised 6 May 2021. Accepted 11 May 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authors: The authors contributed equally to this article.

Implantation of a long biological patch in classical carotid endarterectomy for extended atherosclerotic lesions. Long-term outcomes

Objective: to analyze the in-hospital and long-term outcomes of classical carotid endarterectomy (CEE) in extended atherosclerotic lesions in comparison with the outcomes of this operation in local atherosclerotic plaque (AP).Materials and Methods. This study, which lasted from January 2010 to December 2020, included 148 patients with extended AP and hemodynamically significant internal carotid artery (ICA) stenosis. The term “extended” was understood as a hemodynamically significant lesion ≥ 5 cm long. These patients made up Group 1. Group 2 was formed over the same period of time from 632 patients with hemodynamically significant stenosis &lt;5 cm long. In both cohorts, CEE with repair of the reconstruction zone with a diepoxide-treated xenopericardial patch was performed. Long-term follow-up was 71.4 ± 45.6 months.Results. The groups were comparable in terms of frequency of in-hospital complications: death (group 1: 0.67%, n = 1; group 2: 0.5%, n = 3; p = 0.74; OR = 1.42; 95% Cl 0.14-13.6), myocardial infarction (MI) (group 1: 0.67%, n = 1; group 2: 0.5%, n = 3; p = 0.74; OR = 1.42; 95% CI 0.14-13.6), ischemic stroke (group 1: 0%; group 2: 0.5%, n = 3; p = 0.91; OR = 0.6; 95% CI 0.03-11.8), combined endpoint (death + MI + stroke) (group 1: 1.35%, n = 2; group 2: 1.4%, n = 9; p = 0.74; OR = 0.94; 95% CI 0.2-4.43). The groups were also comparable in terms of frequency of long-term complications: death (group 1: 2.0%, n = 3; group 2: 2.05%, n = 13; p = 0.76; OR = 0.98; 95% CI 0.27-3.5), MI (group 1: 2.7%, n = 4; group 2: 2.4%, n = 15; p = 0.95; OR = 1.14; 95% CI 0.37-3.49), ischemic stroke (group 1: 5.4%, n = 8; group 2: 5.2%, n = 33; p = 0.9; OR = 1.03; 95% CI 0.46-2.29), ICA occlusion and restenosis (group 1: 12.8%, n = 19; group 2: 13.3%, n = 84; p = 0.99; OR = 0.96; 95% CI 0.56-1.63), combined endpoint (death + MI + stroke) (group 1: 10.1%, n = 15; group 2: 9.6%, n = 61; p = 0.98; OR = 1.05; 95% CI 0.58-1.91). Analysis of survival graphs revealed no significant intergroup differences for all types of complications (lethal outcome: p = 0.56; MI: p = 0.73; stroke/mini-stroke: p = 0.89; ICA restenosis/occlusion: p = 0.82; combined end point: p = 0.71). Their increase was uniform in both groups. However, more than half of all ICA restenoses and occlusions were visualized in the first 6 months after CEE.Conclusion. Implantation of a long patch (≥ 5 cm) is not characterized by increased incidence of restenosis and all adverse cardiovascular events during in-hospital and long-term follow-up.

The Carotid Endarterectomy Cadaveric Investigation for Cranial Nerve Injuries: Anatomical Study.

Cerebral stroke continues to be one of the leading causes of mortality and long-term morbidity; therefore, carotid endarterectomy (CEA) remains to be a popular treatment for both symptomatic and asymptomatic patients with carotid stenosis. Cranial nerve injuries remain one of the major contributor to the postoperative morbidities. Anatomical dissections were carried out on 44 sides of 22 cadaveric heads following the classical CEA procedure to investigate the variations of the local anatomy as a contributing factor to cranial nerve injuries. Concurrence of two variations was found to be important in hypoglossal nerve injury: the presence of a direct smaller vein in proximity of the carotid bifurcation, and the intersection of the hypoglossal nerve (HN) with this vein. Based on the sample investigated, this variation was observed significantly higher on the right side. Awareness of possible anatomical variations and early ligation of any small veins can significantly decrease iatrogenic injury risk.

Emergency Glomus-Sparing Carotid Endarterectomy According to A.N. Kazantsev

Aim of study.Analysis of the results of a new method of emergency glomus-sparing carotid endarterectomy (CEE) according to A.N. Kazantsev in the acute period of ischemic stroke.Material and methods.This cohort comparative prospective open-label study from January 2017 to April 2020 included 517 patients operated on for occlusive stenotic lesions of the internal carotid arteries (ICA) in the acute period of ischemic stroke (within 24 hours after the development of ischemic stroke). Depending on the implemented revascularization strategy, all patients were divided into three groups: group 1 — 214 patients (41.4%) — glomus-sparing CEE according to A.N. Kazantsev; 2nd group — 145 (28%) — classical CEE with plasty of the reconstruction zone with a patch; 3rd group — 158 (30.6%) — eversion CEE. The observation period was 35.2±9.6 months. Glomus-saving СE according to A.N. Kazantsev was carried out as follows. Arteriotomy with transition to the common carotid artery (CCA) was performed along the inner edge of the external carotid artery (ECA) adjacent to the carotid sinus, 2–3 cm above the ostium, depending on the spread of atherosclerotic plaque, the ICA was cut off at the site formed by the sections of the wall of the ECA and CCA. Then endarterectomy from the ICA was performed using the eversion technique. The next step was open endarterectomy from ECA and CCA. Then the ICA was implanted in the same position on the saved site.Results.In the hospital follow-up period, there were no significant intergroup differences in the number of complications. However, it should be noted that in the CEE group according to A.N. Kazantsev had no adverse cardiovascular events. In the long-term follow-up period, the smallest number of cardiovascular accidents was detected after CEE according to A.N. Kazantsev. However, intergroup differences were found only in the combined endpoint and the incidence of thrombosis, which were the highest in the 2nd and 3rd groups (p = 0.01). When analyzing the survival curves, it was revealed that the greatest number of cardiovascular accidents in the group of classical and eversion CEE occurred either during the hospital observation period or during the first months after surgery, and after CEE according to A.N. Kazantsev - in a year or more. When analyzing the graph of the dynamics of systolic blood pressure (BP), it was revealed that after glomus-sparing CEE according to A.N. Kazantsev, stable numbers are maintained while receiving preoperative antihypertensive therapy and do not rise above 140 mm Hg. In turn, after classical and eversion CEE, critical hypertension persists in the first three days, which is difficult to treat. In the future, blood pressure figures are unstable and fluctuate in the range from 140 to 160 mm Hg. All cases of myocardial infarction and ischemic stroke were recorded against the background of critical numbers of systolic blood pressure, reaching 180-200 mm Hg.Conclusion.The presented glomus-sparing carotid endarterectomy according to A.N. Kazantsev meets the modern standards of carotid surgery, combined with the minimum permissible risks of developing adverse cardiovascular events, both in hospital and in the long-term follow-up. The confident effect of the developed revascularization is based on the precise removal of plaque from the common, external and internal carotid arteries, as well as maintaining the stability of hemodynamic parameters.

A multicenter study on the influence of different kinds of carotidal endarterectomy on the course of resistant arterial hypertension

To analyze the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (CEE) in patients with resistant arterial hypertension (RAH). The study included 1577 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RAH for more than 3 years. Patients were enrolled from January 2014 to December 2020. Depending on the implemented revascularization strategy, 5 groups were formed: group 1 (n=289 (18.3%)) with classical CEE with plasty of the reconstruction zone with a patch, group 2 (n=472 (29.9%)) with eversional CEE with cut-off of carotid glomus (CG); group 3 (n=109 (6.9%)) with the formation of a new bifurcation; group 4: (n=117 (7.4%)) with autoarterial reconstruction; group 5: (n=590 (37.4%)) with glomus-saving CEE. In the postoperative period, no significant differences were obtained in the frequency of deaths (0.34% for group 1; 0.63% for group 2; 0% for groups 3, 4 and 5), myocardial infarction (0.34%, 0.84%, 1.83, 0.85%, 0.33%, respectively); ischemic stroke (0.34%, 1.27%, 0.91%, 0.85%, 0.17%, respectively), hemorrhagic transformation (0%, 0.84%, 0.91%, 0.85%, 0%, respectively). However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (1.03%, 3.6%, 3.67%, 2.56%, 0.5%, respectively). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG. Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE.

Evolution of carotid endarterectomy: A literature review

This review investigates the various methods used for carotid endarterectomy (CEE). These methods are presented, and allow us to analyse effective revascularisation with extended damage to the internal carotid artery. The data of studies comparing the results of eversion and classical carotid endarterectomy with plasty of the reconstruction zone with a patch made of diepoxy-treated pericardium are presented. Special attention is paid to emergency carotid endarterectomy and carotid endarterectomy in the acute period of ischemic stroke. The important and main aspects of the glomus-saving species of CEE are also demonstrated. The main complications behind operations, and causes of restenosis in long-term follow-up periods are also duly noted. Similarly, suggestions to eliminate these issues are also proposed. This review comprehensively covers the state of the art of carotid endarterectomy and dissects current techniques and methods in the area.Received 16 July 2020. Revised 24 August 2020. Accepted 25 August 2020.Conflict of interest: Authors declare no conflicts of interest.Funding: The study did not have sponsorship.Author contributionsConception and study design: G.G. KhubulavaDrafting the article: A.N. KazantsevCritical revision of the article: A.A. Erofeev, V.N. Kravchuk, K.P. ChernykhFinal approval of the version to be published: G.G. Khubulava, A.N. Kazantsev, A.A. Erofeev, V.N. Kravchuk, K.P. Chernykh

Emergency Extra-Intracranial Microanastomosis After Carotid Endarterectomy Complicated With Thrombosis of the Internal Carotid Artery

We report a case of emergency extra- intracranial microanastomosis in a patient with acute thrombosis of the internal carotid artery, formed on the first day after classical carotid endarterectomy using a temporary by-pass under conditions of contralateral occlusion. The causes of the complication are analyzed. A set of instrumental examinations was demonstrated, including multispiral computed tomography with angiography of the brain and extracranial arteries, as well as multispiral computed tomography with the study of parameters of cerebral perfusion after acetazolamide. The main stages of surgical correction, the dynamics of clinical indicators are presented. The conclusion was made about the effectiveness and safety of the chosen revascularization strategy.

Autoarterial remodeling of the common carotid artery bifurcation in treatment of stenotic lesions

Carotid endarterectomy is the main operation carried out for prevention of ischaemic stroke in haemodynamically significant stenoses of the bifurcation of the common carotid artery. Despite the literature data demonstrating some advantages of eversion carotid endarterectomy over the classical technique there arises a series of complicated, as yet unsolved problems. This concerns the control of the distal portion of an atherosclerotic plaque in prolonged lesions of the internal carotid artery, the absence of a temporary bypass graft, necessity of prosthetic repair of the internal carotid artery in detachment of the distal border of the plaque. We suggested a new technique of carotid endarterectomy making it possible to widen visual removal of atheromatous masses from the internal carotid artery, to improve the control of the distal portion of the plaque in a prolonged lesion of the internal carotid artery. We carried out a comparative assessment of efficacy and safety of the new method of carotid endarterectomy versus the classical variant in a randomized study. The proposed technique of carotid endarterectomy turned out to be compatible by safety and demonstrated similar results with the classical carotid endarterectomy by the number of ischaemic strokes, transitory ischaemic attacks, and myocardial infarctions in the early and remote postoperative periods. When comparing the groups by efficiency, the primary efficacy endpoint, including cases of restenosis >50% according to the findings of ultrasonographic examination of the brachiocephalic arteries, all cases of ischaemic events (acute impairments of cerebral circulation, transitory ischaemic attacks), as well as the presence of the clinical picture of cranial nerve paresis demonstrated a significant advantage of the new technique versus the comparison group at the expense of a lower incidence of restenoses in the area of the operation during the whole period of follow up. In the group of autoarterial remodelling, the composite endpoint of outcomes occurred in 6 patients (6.1%) and in the group with the classic carotid endarterectomy - in 19 (19.6%) patients, p=0.005.

COMPARATIVE CHARACTERISTIC OF ANESTHESIOLOGICAL SUPPORT AND TYPES OF SURGICAL INTERVENTION IN PATIENTS WITH ATHEROSCLEROTIC LESIONS OF BRAHIOCEPHAL ARTERIES

Introduction. Atherosclerotic lesions of the branches of the aortic arch in 60% of cases is the cause of the development of ischemic stroke. As a radical means of preventing neurological disorders, carotid endarterectomy is used, since there is currently no effective drug treatment.Material and methods. This article presents a comparative characteristic of anesthesiological support and types of surgical intervention in 710 patients with atherosclerotic lesions of brachiocephalic arteries in the period from January 2010 to December 2017 in Department of Vascular Surgery at the Clinic of the Bashkir State Medical University. To perform this comparative characteristic, the patients were divided into 2 groups, depending on the time interval. Group 1 — patients operated from 2010 to 2013 (291 patients). Group 2 — patients operated from 2014 to 2017 (491 patients). In Group 1, operations were predominantly performed under regional anesthesia and classical carotid endarterectomy predominated over an eversion. In Group 2, operations were performed under general anesthesia, and here the overthe-top carotid endarterectomy predominated over the classical one. Patients were comparable in age, sex and risk of anesthesia and surgical intervention according to the ASA classification. The overall incidence of ischemic postoperative complications was 4.22%.Results. According to our data, the application of the eversion method of carotid endarterectomy under general anesthesia reduces the relative risk of neurological complications by 1.648 times (as in the 2nd group the technique of eversion carotid endarterectomy under general anesthesia was used). The use of general anesthesia with carotid endarterectomy allows to provide adequate gas exchange, manageability by hemodynamic parameters, absence of emotional reactions from the patient.Conclusion. Thus, at the present moment, our experience in treating patients with atherosclerotic lesions of the brachiocephalic arteries is approaching the optimal one, allowing us to achieve good results of carotid endarterectomy.

COMPARATIVE CHARACTERISTICS OF CLASSICAL AND EVERSION ENDARTERECTOMY OF THE CAROTID ARTERIES

Purpose. The effectiveness of classical and eversion carotid endarterectomy (CE) in patients with cerebral ischemia in atherosclerotic stenosing carotid artery disease (ICA) was compared in the article.Material and methods. The examination and analysis of data of 122 patients with more than 60% ICA stenosis was held: men — n = 92 (60.1%), women n = 61 (39.9%). The average age was 52.3 years (ranged from 34 to 74 years). All the patients were symptomatic. 92 patients underwent an eversion endarterectomy (CE), 30 patients underwent classical CE.The effectiveness of surgical treatment was assessed by the dynamics of the neurological status, the change in the parameters of duplex and transcranial studies before the operation, on day 10, at 1, 3, 6, 9 months, 1, 1.5, 2, 3 years.Results. In patients who underwent eversion CE, in the early postoperative period, a significant decrease in the asymmetry coefficient was revealed in the study of background LSC valuesdue to an increase in the blood flow velocity in the ipsilateral middle cerebral artery (MCA) and a decrease in the linear velocity of the blood flow (LVBF) in the posterior cerebral artery (PCA) on the side of the initially stenotic ICA on the background of improvement of hemodynamic conditions in all cases (p &lt; 0.05). In patients, a significant increase in the reactivity factor for the hypercapnic load from the initial value was noted against the background of approaching the normative indices of the pulsation index. The latent period of vascular reactivity was shortened to 24.3 ± 3.7 seconds. In patients who underwent classical CEAE n = 30, in early terms of up to 1 month, a decrease in the coefficient of asymmetry of LVBF was noted due to the normalization of the velocity characteristics of cerebral blood flow in all the main cerebral vessels of the carotid and vertebrobasilar basins. Comparative analysis of the spectral expansion (SE) values obtained initially and recorded in groups with different types of surgical intervention revealed a significant difference in the resulting data (p &lt; 0.05). Restoration of SE parameters to normative ones was registered in the group of classical CEA in 26.7% (n = 8) and 79.3% (n = 73) with an eversion EAE for 1 month. The maximum rate of positive dynamics was traced during the first month after cerebral revascularization, complete recovery was recorded at the end of the 18th month in the group of eversion CE and 24 months in the group of classical CE. There were no significant differences in the resultant indices of regression of neurological disorders in the postoperative period of an eversion EAE and classical EAE (p &gt; 0.05).With the eversion CE, the total number of complications was n = 9 (9.8%), and 1 (1.1%) case — restenosis in the reconstruction zone. In the case of classical CE, the total number of complications was n = 10 (33.3%), of which n = 1 (3.3%) cases of hyperperfusion syndrome were observed; in n = 2 (6.6%) patients, development of a stroke, 1 (3.3%) developed myocardial infarction. Restenosis in the reconstruction zone was formed in n = 2 (6.6%) patients, peripheral nerve damage was in n = 4 (13.3%) patients.Conclusions. Classic and eversion CE are both effective. Short- and long-term clinical and hemodynamic results of surgical treatment by the method of eversion of the CE are somewhat better than the results of classical one.Classical CE is indicated in cases of extended plaque, eversion of the CE is indicated in the cases of short local plaques.

EFFICACY OF CLASSICAL CAROTID ENDARTERECTOMY USING TEMPORARY SHUNT

The study generalized the 15-year experience of classical carotid endarterectomy performance with application of a temporary carotid shunt and an autovenous path in 325 patients. There were analyzed the more frequent complications in standard groups. Advantages of given method were determined and it was specified the ways, which facilitated to reduction of intraoperative risks and increase of technical quality realization of different stages of surgery.

Immediate and long-term outcomes of carotid bifurcation remodeling

Immediate and long-term outcomes of carotid endarterectomy (CEA) performed in 363 patients at 6 months to 4 years are presented. It was found out that when using a xenopericardial patch, the occurrence of carotid artery restenosis is significantly lower if compared with the application of a PTFE patch. In comparison with classical CEA (carotid plasty with a xenopericardial patch and PTFE), eversion CEA and CEA with autoarterial bifurcation remodeling have a significantly lower frequency of restenosis (p&lt;0,01) during long-term follow-up.