Carotid Enadrterectomy for Thrombosis of the Internal Carotid Artery in Patients With COVID-19.

Analysis of the results of emergency carotid endarterectomy (CEE) against the background of internal carotid artery (ICA) thrombosis in the acute period of acute cerebrovascular accident (ACVA) in patients with COVID-19. During the COVID-19 pandemic (April 1, 2020-May 1, 2021), 43 patients with ICA thrombosis and a positive polymerase chain reaction (PCR) result for SARS-CoV-2 were included in this prospective study. In all cases, CEE was performed in the acutest period of ACVA. These patients were included in group 1. The comparison group was represented by 89 patients who underwent CEE in the acute period of stroke, in the period before the COVID-19 pandemic (April 1, 2019-March 1, 2020). According to laboratory parameters, patients with COVID-19 had severe coagulopathy (with an increase in D-dimer: 3832 ± 627.2 ng/mL, fibrinogen: 12.6 ± 3.1 g/L, prothrombin: 155.7 ± 10, 2%), inflammatory syndrome (increased ferritin: 646.2 ± 56.1 ng/mL, C-reactive protein: 161.3 ± 17.2 mg/L, interleukin-6: 183.3 ± 51.7 pg/mL, leukocytosis: 27.3 ± 1.7 10E9/L). In the hospital postoperative period, the groups were comparable in terms of the incidence of deaths (group 1: 2.3%, n = 1; group 2: 1.1%, n = 1; P= 0.81; OR=2.09; 95 % CI = 0.12-34.3) myocardial infarction (group 1: 2.3%, n = 1; group 2: 0%; P= 0.7; OR = 6.3; 95% CI = 0.25-158.5), CVA (group 1: 2.3%, n = 1; group 2: 2.2%, n = 2; P= 0.55; OR = 1.03; 95% CI = 0,.09-11.7). ICA thrombosis and hemorrhagic transformations were not recorded. However, due to severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 more often developed bleeding in the operation area (group 1: 11.6%, n = 5; group 2: 1.1%, n = 1; P= 0.02; OR = 11.5; 95% CI = 1.3-102.5). In all cases, the flow of hemorrhagic discharge came from the drainage localized in the subcutaneous fat. This made it possible to remove skin sutures in a dressing room, suturing the source of bleeding and applying secondary sutures under local anesthesia. Emergency CEE in the acute period of stroke is an effective and safe method of cerebral revascularization in case of ICA thrombosis in conditions of COVID-19.

[Subclavian-carotid transposition and subclavian artery stenting for steal-syndrome]. / Podklyuchichno-sonnaya transpozitsiya i stentirovanie podklyuchichnoi arterii v lechenii stil-sindroma.

OBJECTIVE: To analyze in-hospital results of subclavian-carotid transposition and subclavian artery stenting in patients with steal-syndrome. MATERIAL AND METHODS: A retrospective open study included 137 patients with occlusion or severe stenosis of the first segment of subclavian artery and steal-syndrome. The 1st group included 50 patients who underwent stenting or recanalization with stenting of the first segment of subclavian artery between January 2010 and March 2020. The 2nd group included 87 patients who underwent subclavian-carotid transposition between January 2010 and March 2020. RESULTS: There were no in-hospital mortality, myocardial infarction, ischemic stroke or bleeding. In the second group, damage to recurrent laryngeal nerve with irreversible laryngeal paresis occurred in 6.9% of patients, and one patient had brachial plexus neuropathy. One patient developed lymphorrhea with chylothorax accompanied by shortness of breath on exertion. Conservative management with repeated pleural punctures was not accompanied by clinical compensation. The patient was discharged for outpatient treatment. Thromboembolism of the left branch of the aorto-femoral prosthesis and deep femoral artery on the left was diagnosed in the endovascular correction group after implantation of Protege GPS stent (10´60 mm) and post-dilation with a PowerFlex PRO balloon catheter (9´4 mm). Acute ischemia of the left lower limb required thrombectomy with patch repair of deep femoral artery. The patient was discharged after 5 days. In another case, vertebral artery dissection occurred after implantation of Protege GPS stent (10×40 mm) and post-dilatation with a PowerFlex PRO balloon catheter (8´20 mm). In this regard, the patient underwent stenting of the fourth segment of vertebral artery (Endeavor Resolute 4.0´24 mm stent) with post-dilation (Boston Scientific Samurai balloon catheter 0.014´190 cm). The patient was discharged after 3 days. CONCLUSION: Subclavian-carotid transposition and subclavian artery stenting are safe methods of revascularization that are not accompanied by myocardial infarction, ischemic stroke or mortality. However, subclavian-carotid transposition is characterized by higher risk of neurological disorders (laryngeal paresis, phrenic nerve paresis, brachial plexus neuropathy) and wound complications (lymphorrhea, chylothorax). In turn, subclavian artery stenting is associated with the risk of dissection and embolism. Therefore, the choice of treatment strategy in patients with occlusive-stenotic lesions of the first segment of subclavian artery should be personalized and carried out by a multidisciplinary team.

[Long-term results of carotid endarterectomy and carotid artery stenting in patients with high bifurcation of common carotid artery: a multiple-center study]. / Otdalennye rezul'taty karotidnoi endarterektomii i karotidnoi angioplastiki so stentirovaniem u patsientov s vysokim raspolozheniem bifurkatsii obshchei sonnoi arterii. Rezul'taty mnogotsentrovogo issledovaniya.

OBJECTIVE: To analyze in-hospital and long-term results of eversion carotid endarterectomy (CEE), carotid endarterectomy with patch repair and carotid artery stenting (CAS) in patients with high bifurcation of common carotid artery. MATERIAL AND METHODS: A retrospective multiple-center open study included 1983 patients who underwent internal carotid artery (ICA) repair for severe stenosis between 2010 and 2021. Three groups of patients were distinguished depending on revascularization option: group 1 (n=638) - eversion CEE; group 2 (n=351) - CEE with patch repair; group 3 (n=994) - CAS. RESULTS: In-hospital postoperative mortality and incidence of stroke and myocardial infarction were similar. All bleedings (n=39) occurred after CEE. ICA thrombosis was diagnosed in groups 1 and 2 due to intimal detachment after insertion of temporary bypass tube. Incidence of laryngeal paresis, neuropathy of hypoglossal and glossopharyngeal nerves, Horner syndrome, damage to salivary glands was comparable in groups 1 and 2. Long-term mortality was the highest (n=10; 2.8%) after CEE with patch repair due to fatal stroke. In turn, the highest incidence of ICA restenosis and restenosis-induced ischemic stroke was observed after CEE with patch repair and CAS. CONCLUSION: 1. Classical and eversion CEE in patients with high CCA bifurcation is followed by high in-hospital incidence of damage to cranial nerves and salivary glands, laryngeal paresis, Horner syndrome, bleeding and risk of ICA thrombosis. 2. In patients with high CCA bifurcation, CAS and CEE with patch repair are accompanied by high incidence of ICA restenosis, restenosis-induced stroke and mortality in long-term postoperative period. 3. Eversion CEE demonstrates the lowest rates of all adverse cardiovascular events in long-term follow-up period.

[Carotid endarterectomy in patients with internal carotid artery thrombosis in the acutest period of ischemic stroke with COVID-19]. / Karotidnaya endarterektomiya u patsientov s trombozom vnutrennei sonnoi arterii v ostreishem periode ishemicheskogo insul'ta na fone COVID-19.

OBJECTIVE: Analysis of the results of emergency carotid endarterectomy (CEE) in internal carotid artery (ICA) thrombosis in the acute period of acute cerebrovascular accident (ACVI) in patients with COVID-19. MATERIAL AND METHODS: During the COVID-19 pandemic (April 1, 2020 - May 1, 2021), 43 patients with ICA thrombosis and a positive polymerase chain reaction (PCR) result for SARS-CoV-2 were included in this prospective study. In all cases, CEE was performed in the acutest period of ACVA. These patients were included in group 1. The comparison group was represented by 89 patients who underwent CEE in the acute period of stroke, in the period before the COVID-19 pandemic (April 1, 2019 - March 1.2020). RESULTS: In the hospital postoperative period, the groups were comparable in terms of the incidence of deaths (group 1: 2.3%, n=1; group 2: 1.1%, n=1; p=0.81; OR=2.09; 95% CI=0.12-34.3) myocardial infarction (group 1: 2.3%, n=1; group 2: 0%; p=0.7; OR=6.3; 95% CI=0.25-158.5), CVA (group 1: 2.3%, n=1; group 2: 2.2%, n=2; p=0.55; OR=1.03; 95% CI=0.09-11.,7). ICA thrombosis and hemorrhagic transformations were not recorded. However, in view of severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 more often developed bleeding in the operation area (group 1: 11.6%, n=5; group 2: 1.1%, n=1; p=0.02; OR=11.5; 95% CI=1.3-102.5). CONCLUSION: Emergency CEE in the acute period of stroke is an effective and safe method of cerebral revascularization in case of ICA thrombosis in conditions of COVID-19.

[A multicenter study on the influence of different kinds of carotidal endarterectomy on the course of resistant arterial hypertension]. / Mnogotsentrovoe issledovanie vliyaniya razlichnykh vidov karotidnoi endarterektomii na techenie rezistentnoi arterial'noi gipertenzii.

OBJECTIVE: 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). MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSION: 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.

[Transposition of internal carotid artery over hypoglossal nerve in eversion carotid endarterectomy]. / Eversionnaya karotidnaya endarterektomiya: transpozitsiya vnutrennei sonnoi arterii nad pod"yazychnym nervom.

OBJECTIVE: To analyze in-hospital and long-term results of eversion carotid endarterectomy (CEE) with transposition of internal carotid artery (ICA) over hypoglossal nerve. MATERIAL AND METHODS: A cohort prospective open-label study included 919 patients with severe ICA stenosis for the period from January 2017 to April 2020. The 1st group (n=172) included patients who underwent eversion CEE with ICA transposition over hypoglossal nerve; the 2nd group (n=747) - who underwent conventional eversion CEE. ICA transposition technique included standard mobilization of the carotid arteries, cross-clamping, arterial wall incision, removal of atherosclerotic plaque and ICA translocation above the hypoglossal nerve for subsequent anastomosis. All patients were examined every 6 months. Mean follow-up period was 17.5±6.9 months. RESULTS: There were no significant between-group differences in cardiovascular morbidity. However, all complications occurred in the 2nd group (traditional eversion CEE). Nevertheless, incidence of adverse events was minimal and combined endpoint did not exceed 0.6% (n=5). Both groups were also comparable by overall incidence of cardiovascular events in long-term period. All ICA restenoses (over 70%) were symptomatic with similar incidence (4 (2.3%) vs. 18 (2.4%), respectively, p=0.83; OR 0.96; 95% CI 0.32-2.88). Mean restenosis-free period was 7.2±2.6 months. In case of significant restenosis, redo CEE with patch repair was performed. There were no cardiovascular complications. All cases of hypoglossal nerve injury occurred in the 2nd group (0 vs. 18 (100%), respectively; p=0.0001; OR 0.003; 95% CI=5.21-0.17) without ICA transposition over the hypoglossal nerve. CONCLUSION: Eversion CEE with ICA transposition over the hypoglossal nerve ensures optimal conditions for successful redo CEE in case of restenosis. This technique facilitates ICA mobilization without hypoglossal nerve injury. This aspect is valuable for successful postoperative outcome and adequate quality of life. ICA transposition is not difficult and does not require additional experience. Transposition per se is not a risk factor of ICA restenosis. Thus, ICA transposition may be routinely recommended in patients eligible for eversion CEE.

[Progression of precerebral atherosclerosis and predictors of ischemic complications in cardiac patients]. / Progressirovanie pretserebral'nogo ateroskleroza i prediktory ishemicheskikh oslozhnenii u patsientov kardiokhirurgicheskogo profilya.

OBJECTIVE: To identify predictors of progression of precerebral atherosclerosis in long-term period after coronary artery bypass surgery. MATERIAL AND METHODS: There were 97 procedures of carotid endarterectomy in patients after previous coronary artery bypass grafting for the period from 2006 to 2017. Inclusion criteria were previous CABG, no significant (over 60%) stenosis of internal carotid arteries at discharge after CABG. The control group included 447 patients without progression of precerebral atherosclerosis in long-term period after CABG. RESULTS: Careful monitoring of progression of precerebral atherosclerosis and therapeutic prevention of ischemic stroke are required in patients with mild-to-moderate ICA stenosis after CABG. The most significant predictors of progression of precerebral atherosclerosis after CABG were AF (OR=1.97, 95% CI 1.04-3.73), previous occlusion of stent (OR=7.89, 95% CI=2.3-27.0), chronic brain ischemia grade II or III (OR=22.45, 95% CI=11.9-42.3), chronic kidney disease (OR=15.8, 95% CI=5.04-49.5). CONCLUSION: It was revealed that the majority of predictors of adverse ischemic cerebral and myocardial events are indirectly associated with atrial fibrillation.

[Personalized brain revascularization: computer modeling of the reconstruction zone for carotid endarterectomy]. / Personifitsirovannaya revaskulyarizatsiya golovnogo mozga: metod komp'yuternogo modelirovaniya zony rekonstruktsii dlya provedeniya karotidnoi endarterektomii.

OBJECTIVE: To develop a technique of computer modeling of hemodynamics before conventional CEE. MATERIAL AND METHODS: Classical CEE is performed according to conventional patch technique. Duplex parameters of stenosis and blood flow velocity in the carotid arteries were analyzed by using of a linear transducer 7-7.5 MG (Acuson 128XP scanner, Acuson, USA). Multispiral computed tomography with angiography and subsequent processing of data using the Clear canvas software were performed to visualize the main geometric characteristics of the carotid arteries and features of atherosclerotic plaque. RESULTS: Blood flow hemodynamics is essential in the occurrence of postoperative restenosis. Therefore, computer simulation of blood flow using CFD (Computational Fluid Dynamics) methods based on particular patient's data makes it possible to assess localization of zones with high risk of restenosis. CFD approach implies construction of blood flow parameters at absolutely every point of the vessel considering geometric shape of the vessel and flow characteristics at the entrance and exit from the vessel. Pressure curves at the inlet and outlet are constructed using blood flow velocity curves. Pressure curves are subsequently used in the CFD model. The result of blood flow CFD modeling is non-stationary three-dimensional fields of pressure and velocity in the investigated area. Visual analysis of blood flow dynamics in these fields makes it possible to judge possible problem areas along the blood flow and on the inner wall of the vessel. DISCUSSION: Patch technique of classical CEE is characterized by great risk of parietal thrombosis and hyperproliferation of neointima that explains more frequent development of restenosis. Computer modeling is valuable to consider some important technical aspects in implementation of various surgical techniques for carotid artery reconstruction. CONCLUSION: This result demonstrates an importance of achieving the optimal ratio of the diameter of common, internal and external carotid arteries. Modification of patch based on computer simulation is required for these purposes.

[Bentall-DeBono procedure with xenopericardial valved conduit: a 24-year follow-up data]. / Operatsiya Bentalla­De Bono s primeneniem ksenoperikardial'nogo konduita: rezul'taty 24-letnego nablyudeniya.

Long-term outcome of surgical treatment of a patient with severe aortic insufficiency and ascending aortic aneurysm is reported. The patient underwent Bentall-DeBono procedure with xenopericardial valved conduit. This technique is associated with no complications specific for Dacron conduits and ensures clinical compensation of heart failure, improves prognosis and quality of life.

[In-hospital results of renal artery stenting in patients with multifocal atherosclerosis]. / Gospital'nye rezul'taty stentirovaniia pochechnykh arterii u patsientov s mul'tifokal'nym aterosklerozom.

OBJECTIVE: A retrospective analysis of in-hospital results of renal artery stenting in patients with multifocal atherosclerosis. MATERIAL AND METHODS: The study included 19 patients who underwent stenting for renal artery stenosis for the period 2011-2015 in the Kemerovo Cardiology Dispensary. Renal function was assessed considering glomerular filtration rate (GFR). Blood pressure and GFR were evaluated before the stenting procedure and at discharge. RESULTS: Stenting resulted optimal outcomes in all 19 patients. Severity of residual stenosis was 11±3%. In-hospital mortality was absent. Blood pressure in early postoperative period was similar to baseline values. One patient had a normalization of blood pressure up to 115-140/85-90 mm Hg without administration of antihypertensive drugs. Decrease of systolic blood pressure up to 155.3±32.6 mm Hg was noted in other patients at discharge. Blood creatinine levels decreased up to 0.167±0.56 mmol/L. In addition, mean GFR increased from 34.17 ml/min/1.69 m2 up to 37.16 ml/min/1.69 m2. CONCLUSION: Endovascular treatment of renal artery stenosis and secondary hypertension is effective and relatively safe approach.

[Long-term results of surgical and conservative treatment of patients with occlusive-stenotic lesions of carotid arteries]. / Otdalennye rezul'taty khirurgicheskogo i konservativnogo lecheniia patsientov s okkliuzionno-stenoticheskimi porazheniiami sonnykh arterii.

OBJECTIVE: To compare long-term outcomes in patients after carotid endarterectomy and those who refused surgical correction and received only conservative treatment. MATERIAL AND METHODS: There were 1035 carotid endarterectomies performed at the Kemerovo Regional Clinical Hospital and Kemerovo Regional Clinical Cardiology Dispensary for the period 2014-2017. Surgery was refused by 136 patients for the same time. Thus, two groups of patients were formed: 1 - carotid endarterectomy group; 2 - conservative treatment group. INCLUSION CRITERIA: significant carotid stenosis, absence of severe neurological deficit (over 25 scores by the National Institutes of Health Stroke Scale), absence of concomitant diseases limiting long-term follow-up. RESULTS: Lethal outcome (p=0.0038) and fatal acute cerebrovascular accident (p=0.0005) were significantly more common in the 2nd group in long-term follow-up period. Thus, combined endpoint took the greatest values in patients who refused surgery compared with patients who received surgical treatment (p=0.0001). It should be noted that ischemic stroke de novo occurred in 9 (6.6%) patients of the 2nd group after 10.8 ± 2.5 months. This complication required subsequent hospitalization for carotid endarterectomy. CONCLUSION: Preventive role of carotid endarterectomy was convincingly proved in comparison with drug therapy regarding mortality and fatal ischemic stroke in patients with significant carotid stenoses within 2.5 years of follow-up period.

[Long-term outcomes of coronary artery bypass surgery in young patients]. / Otdalennye iskhody koronarnogo shuntirovaniia u patsientov molodogo vozrasta.

OBJECTIVE: To analyze long-term outcomes of CABG in young patients, incidence and structure of adverse cardiovascular events depending on patients' age. MATERIAL AND METHODS: There were 175 young patients (up to 44 years old in accordance with WHO classification) who underwent CABG for the period from 2006 to 2016. The control group included 175 patients aged 45 years and older who were randomly selected among patients operated in the same period. Overall long-term follow-up period was 81.9±15.75 months (≈ 6.8 years). Data on long-term survival and adverse cardiovascular events were available in 86.3% of patients in general sample and 72.6% of young patients. RESULTS: Young patients undergoing CABG were usually characterized by the absence of severe concomitant diseases, moderate coronary atherosclerosis by SYNTAX Score scale, high percentage of left ventricular aneurysm and previous PCI. Incidence and structure of in-hospital and long-term adverse cardiovascular events in young and older patients confirmed satisfactory results of CABG regardless age.

[Computer-assisted simulation of haemodynamic parameters of carotid artery bifurcation after carotid endarterectomy]. / Komp'iuternoe modelirovanie gemodinamicheskikh pokazatelei v bifurkatsii sonnykh arterii posle karotidnoi éndarteréktomii.

Computer-aided simulation appropriately using the method of computational fluid dynamics (CFD) makes it possible to determine the elevated-risk zones of most probable formation of restenosis. The main idea of the method described in our article consists in a possibility of creating by the model of the geometrical shape of the vessel and characteristics of the flow at inlets and outlets the parameters of flow in each point of a vessel. The curves of velocity are used to create the curves of pressure at inlets and outlets, which are used in a CFD model. The resulting from CFD simulation of blood flow are nonstationary three-dimensional fields of pressure and velocity in the area under study. Visual examination of the dynamics of these fields makes it possible to judge about possible problem zones inside the area of flow and on the internal wall of the vessel. This article also presents a clinical case report illustrating the use of this technique.

[Surgical repair of common carotid artery aneurysm insix years after carotid endarterectomy]. / Rezektsiya anevrizmy obshchei sonnoi arterii u patsienta spustya shest' let posle karotidnoi endarterektomii.

Surgical repair of common carotid artery aneurysm as an extremely rare complication of carotid endarterectomy in long-term period is described. Aneurysmectomywasfollowed by patch repair of the artery. It was concluded that this intervention is effective approach for this complication. The main causes of this adverse event are identified.

[Predictors of long-term complications after carotid endarterectomy]. / Prediktory oslozhnenii v otdalennom periode posle karotidnoi éndarteréktomii.

AIM: To analyze the predictors of complications within 3 years after carotid endarterectomy (CEE). MATERIAL AND METHODS: The study included 1035 patients after CEE for the period 2011-2016. Long-term follow-up period was 42.4±18.6 months (≈ 3.5 years). The endpoints were such unfavorable cardiovascular events as death, myocardial infarction, stroke/transient ischemic attack, redo revascularization. Statistical analysis was carried out by using of Statistica for Windows 8.0 software package (StatSoft Inc., USA). Stepwise logistic regression was applied to identify risk factors of adverse outcomes and death in long-term postoperative period. RESULTS: Comprehensive analysis of numerous factors (anamnestic, instrumental-diagnostic, surgical) allowed us to identify predictors of long-term unfavorable outcomes in patients with occlusive-stenotic lesions of carotid arteries. Risk factors of long-term complications were SYNTAX score ≥33 (high risk), unstable plaque in the contralateral ICA, occlusion of contralateral ICA, LVEF <39%, ICA cross-clamping >40 min, previous CABG. CONCLUSION: These data are extremely important and can be used to create prognostic models. The last ones are necessary to determine optimal treatment strategy in patients with occlusive-stenotic lesions of supra-aortic vessels.