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

Abstract

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.

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

“…Of additional interest may be the method of draining the wound. In elective “non-covid” surgery, we repeatedly used two drains for patients with severe hypoaggregation and hypocoagulation [27] . Patients with COVID-19, despite the current coagulopathy, are under the influence of heparin and antiplatelet therapy, according to the Interim Guidelines for the Prevention, Diagnosis and Treatment of Novel Coronavirus Infection (COVID-19) of the Ministry of Health of the Russian Federation.…”

“…Patients with COVID-19, despite the current coagulopathy, are under the influence of heparin and antiplatelet therapy, according to the Interim Guidelines for the Prevention, Diagnosis and Treatment of Novel Coronavirus Infection (COVID-19) of the Ministry of Health of the Russian Federation. Thus, this cohort of patients is at risk of developing acute hematoma in the intervention area after carotid endarterectomy, which is often accompanied by tracheal displacement and respiratory failure [27] . For patients with initial respiratory failure on the background of viral pneumonia, this development of events can be fatal.…”

"<i>Festina lente</i>" — a multicenter study on the outcomes of carotid endarterectomy, depending on vessel suturing speed

“…[24]. При этом последующий перифокальный отек подобных образований все-таки может индуцировать легкую неврологическую симптоматику, которая в ряде случаев остается не замеченной [24][25][26]. Поэтому установка временного шунта является небезопасной манипуляцией и должна реализовываться только сугубо селективно, при наличии сниженных показателей компенсаторных возможностей коллатерального кровообращения головного мозга [20][21][22][23][24]26].…”

Vertebral triangle of doctor A.N. Kazantsev - double vertebral artery in V3 segment

“…In the presence of hemodynamically significant stenosis of the internal carotid artery (ICA), some studies come to conclusions about the safety and efficacy of both carotid endarterectomy and carotid angioplasty with stenting in the acute period (days 1-3) stroke [6] , [7] , [8] , [9] , [10] . Other authors, referring to the high risk of developing hemorrhagic transformation, in some cases call for postponing emergency brain revascularization until the acute (days 4-28) or early recovery (days 29-6 months) stroke periods [11] , [12] , [13] , [14] , [15] .…”