Оперативное лечение дистальных аневризм экстракраниального отдела внутренней сонной артерии, сочетающихся с ее патологической извитостью К.м.н. в.Э. ГУжиН, а.в. ДУБовой, а.в. череПаНов ФГБУ «Федеральный центр нейрохирургии» минздрава россии, Новосибирск, россия аневризмы экстракраниального отдела внутренней сонной артерии (вса), расположенные у входа в череп, являются редкой патологией. При данной патологии показано проведение хирургического вмешательства из-за опасности артерио-артериальной эмболии с развитием нарушения мозгового кровообращения. в отечественной и зарубежной литературе представлены единичные случаи или небольшие по числу наблюдений группы успешного хирургического лечения пациен-тов с дистально расположенными аневризмами внутренней сонной артерии в сочетании с ее патологической извитостью. открытое оперативное вмешательство при этой локализации аневризмы является сложным из-за травматичности доступа. Проведение эндоваскулярных вмешательств не всегда возможно из-за наличия дегенеративных изменений сосудистой стенки и патологической извитости артерии. Предложен вариант хирургического вмешательства по созданию экстраана-томического высокопотокового шунта между наружной сонной артерией и м2 сегментом среднемозговой артерии. Пред-ставлены результаты успешного применения данной методики у 3 пациентов с дистально расположенными аневризмами экстракраниального отдела внутренней сонной артерии в сочетании с ее патологической извитостью.
Ключевые слова: патологическая извитость артерий, аневризма, внутренняя сонная артерия, высокопотоковый шунт.
Surgical treatment of distal extracranial internal carotid artery aneurysms associated with pathological artery kinkingv.E. Guzhin, a.v. DuBovoY, a.v. chErEPanov Federal center of neurosurgery, novosibirsk, russia Extracranial internal carotid artery (ica) aneurysms located at the entrance of the skull are a rare pathology. Surgical treatment is indicated for this pathology because of the risk of arterio-arterial embolism and the development of cerebrovascular disease. the domestic and international literature reports single cases or small group cases of successful surgical treatment of patients with distal internal carotid artery aneurysms associated with pathological kinking of the artery. open surgery for aneurysms of this localization is complicated because of a high injury risk associated with the approach. Endovascular interventions are not always possible due to the presence of degenerative changes in the vascular wall and pathological artery kinking. We propose a surgical option for creating a high-flow ec-ic bypass between the external carotid artery and the m2 segment of the middle cerebral artery. the article describes the results of successful application of this technique in three patients with distal extracranial internal carotid artery aneurysms associated with pathological kinking of the artery.
Implementation of a large number of surgeries enabled improvement of the technique and clarification of the prerequisites for preoperative examination, intraoperative control, and postoperative management of patients. A low mortalits rate suggests this technique for use in clinical practice. The surgery is indicated for the treatment of giant aneurysms of the petrous, cavernous, and clinoid segments of the ICA. In the case of giant supraclinoid aneurysms, the surgery may be combined with removal of thrombotic masses from the aneurysm sac for rapid decompression of the cranial nerves. Application of this surgery for treatment of giant aneurysms of the trunk and bifurcation of the basilar artery is promising but requires further investigation. The surgery is also recommended for improving cerebral perfusion in the setting of complex stenotic occlusive lesions of the BCA: prolonged BCA stenoses, tandem ICA stenoses located in both the extracranial and intracranial segments, nonspecific vasculitis and arteriitis, subcranial aneurysms, kinking etc.
The most careful attitude to caudal group of cranial nerves adjacent or involved into neoplasm allows to minimize postoperative neurological complications.
Combination treatment, including microsurgical intervention after endovascular embolization, is an effective treatment for AVMs, in particular for high grade (S&M grade III-V) AVMs. Teamwork and coordination among the surgeon, endovascular surgeon, and radiologist in treatment of AVMs is a prerequisite for a good outcome.
Generalization of the results indicates that one-stage surgery is more preferable in the treatment of mirror cerebral aneurysms. However, the two-stage approach remains important and, in the case of certain anatomical peculiarities, is the only possible treatment. A combination of microsurgical and endovascular techniques improves clinical outcomes in treatment of mirror aneurysms of the anterior part of the cerebral arterial circle.
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