RU2792855C1 - Method of surgical treatment of patients with bilateral hemodynamically significant stenoses of the internal carotid arteries - Google Patents

Abstract

FIELD: medicine; cardiovascular surgery.

SUBSTANCE: at the same time, the isolation of the common carotid artery, external carotid artery, internal carotid artery from both sides is performed by different surgeons. After that, clamping of the common carotid artery, external carotid artery, internal carotid artery on the right and left is performed simultaneously. Then, simultaneously on the right and left sides, a temporary intraluminal shunt is installed, and then endarterectomy, vascular suture, haemostasis, drainage, and wound closure are performed.

EFFECT: method allows performing carotid endarterectomy (CEE) on both sides in patients with bilateral stenoses of the internal carotid artery (ICA) without the risk of distal embolization, ischemic stroke, haemorrhagic stroke and haemorrhagic transformation.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used in the treatment of patients with bilateral hemodynamically significant stenoses of the internal carotid arteries (ICA).

Carotid endarterectomy (CEE) is the most common operation to remove hemodynamically significant stenosis in the ICA ( National guidelines for the management of patients with diseases of the brachiocephalic arteries. Angiology and Vascular Surgery. 2013; 19(2): 4-68., p. 13 ). Hemodynamically significant stenosis is a risk factor for ischemic stroke. The presence of ICA lesions on both sides significantly increases the likelihood of developing acute cerebrovascular accident.

A known method of surgical treatment of patients with stenosis of the ICA on both sides , Bagdavadze G.Sh., Kalinin E.Yu., Zaitseva T.E., Chikin A.E., Linets Y.P. Russian Medical Journal 2020 V. 26 No 3 P. 145-151 ). According to the method, CEE is performed on one side, then a month later, CEE is performed on the other side. However, in the interval between the stages, one lethal outcome was detected due to the development of ischemic stroke on the part of the non-operated ICA and three acute cerebrovascular accidents also on the part of the non-operated ICA. In addition, about a third of patients who are scheduled for a phased CEE on both sides do not attend the second CEE for subjective reasons (forgotten, fear of surgery, did not attach importance, etc.), which can lead to ischemic stroke on the non-operated side .

There is a known method in which CEE is first performed on one side, then after 2–3 months on the other side Baranov A.S., Kalichinin A.E., Lunkov V.G., Terebinov S.V., Falbotsky N.V. Togliatti Medical Council, 2014, No. 3-4, pp. 66-73 ). But this method has an important drawback. In this method, three patients 30, 48 and 50 days after the first CEA developed an ischemic stroke on the side of the non-operated ICA. In addition, given the data presented in the previous method, a number of patients may also not come to the second CEE for subjective reasons, which can lead to ischemic stroke on the non-operated side.

Closest to the claimed method is the method, which consists in the fact that both CEE are performed simultaneously ( SIMULTE OR STAGED CAROTID ENDARTERECTOMY FROM BIO-SIDES. Kazantsev A.N., Chernykh K.P., Zarkua N.E., Leader R.Yu. ., Kubachev K.G., Bagdavadze G.Sh., Kalinin E.Yu., Zaitseva T.E., Chikin A.E., Linets Y.P. Russian Medical Journal, 2020, V. 26, No. 3. pp. 145–151 ). First, the first ICA is operated on. Then a drain is installed and the wound is sutured. Then, within 10 minutes, a neurologist examines the patient, controls the amount of hemorrhagic discharge along the drainage, and performs a color duplex scan of the operated ICA. After that, in the absence of data regarding neurological deficit, hemorrhagic complications and/or thrombosis/restenosis of the ICA, CEA is implemented on the opposite side.

The disadvantages of the method chosen as a prototype are:

When performing the first CEE, blood pressure is increased to 190/100 mm Hg. Art. to compensate for cerebral blood flow due to the lack of blood flow from the clamped ICA. Thus, in the presence of an unstable atherosclerotic plaque, both in the first ICA and in the second ICA, detachment of plaque particles and distal embolization can occur, which will lead to the development of ischemic stroke.

Another disadvantage of the prototype is that the increase in blood pressure can cause hemorrhagic stroke or hemorrhagic transformation in the area of a previously formed ischemic focus in the brain.

Another disadvantage of the prototype is that two operations, following one after another at the same time, lengthen the time of endotracheal anesthesia, which increases the cost of the intervention and increases the risk of side effects from the long-term influence of anesthetic drugs.

The technical problem is to reduce the frequency of complications in the surgical treatment of patients with bilateral ICA stenoses.

The technical result is possibilities performing bilateral CEE in patients with bilateral ICA stenoses without the risk of distal embolization, ischemic stroke, hemorrhagic stroke, and hemorrhagic transformation.

The technical result of the invention is achieved by the fact that the method of surgical treatment of patients with bilateral hemodynamically significant stenoses of the internal carotid arteries, during which the common carotid artery (OCA), external carotid artery (ECA), ICA is simultaneously isolated from both sides by different surgeons. After that, the OCA, NCA, ICA are simultaneously clamped on the right and left. Then, simultaneously on the right and left, a temporary intraluminal shunt is installed, and then endarterectomy, vascular suture, hemostasis, drainage, and wound closure are performed.

The method is carried out as follows:

The patient lies on his back, a roller is placed under the neck so that the head deviates back by 60 °. Endotracheal anesthesia is performed. At the same time, the first and second surgeons make a longitudinal tissue incision along the anterior edge of the sternocleidomastoid muscle and isolate the CCA, ECA, ICA from both sides. At the same time, arteries are clamped with vascular clamps. At the same time, the ICA is cut off from the mouth and the VVSh is installed. After that, using vascular tweezers and vascular scissors, the atherosclerotic plaque is simultaneously removed from the CCA, ECA, ICA from both sides. Then, at the same time, the ICA is implanted in its original place, performing an end-to-side anastomosis, and the ICA is removed. Hemostasis is performed, drainage is established and the wound is sutured. An examination by a neurologist is performed, the amount of hemorrhagic discharge through the drainage is controlled, and a color duplex scan of the operated ICA is performed.

Distinctive essential features and a causal relationship between them and the achieved result:

• All stages of the operation are performed simultaneously from both sides in order to reduce the time of endotracheal anesthesia and operation time, which reduces the risk of side effects of anesthetic drugs and the cost of the operation.

• CEE on the right and left are performed simultaneously, and not in stages, so that the patient does not appear at the second stage of the operation and there is no development of ischemic stroke on the non-operated side.

• There is no increase in blood pressure due to the fact that compensation of cerebral blood flow during clamping of the ICA from both sides is not required due to the functioning of the IAS in the first and second ICA.

Thus, the set of essential distinguishing features is new and ensures the achievement of the technical result and the achievement of the objective of the invention.

The claimed invention is illustrated by examples:

Example 1. Patient A., 64 years old.

The patient was diagnosed with hemodynamically significant stenoses of the ICA on both sides. First, CEE was performed on the first side. The next CEE was scheduled 1 month later. However, after 22 days, the patient developed an ischemic stroke from the non-operated ICA.

Example 2. Patient E., 68 years old.

The patient was diagnosed with hemodynamically significant stenoses of the ICA on both sides. First, CEE was performed on the first side. The next CEE was scheduled 1 month later. However, the patient did not show up for the second operation due to subjective reasons. Two months after the first CEE, the patient developed an ischemic stroke on the part of the non-operated ICA.

Example 3. Patient D., 64 years old.

The patient was diagnosed with hemodynamically significant stenoses of the ICA on both sides. First, CEE was performed on the first side. The next CEA was scheduled in 2 months. However, after 34 days, the patient developed an ischemic stroke from the non-operated ICA.

Example 4. Patient A., 69 years old.

The patient was diagnosed with hemodynamically significant stenoses of the ICA on both sides. First, CEE was performed on the first side. The next CEA was scheduled in 3 months. However, the patient did not show up for the second operation due to subjective reasons. 42 days after the first CEE, the patient developed an ischemic stroke from the non-operated ICA.

Example 5. Patient J., 63 years old.

The patient was diagnosed with hemodynamically significant stenoses of the ICA on both sides. The patient was performed CEA on both sides simultaneously, according to the prototype. After the first CEE, the patient was examined by a neurologist. An ischemic stroke was detected in the non-operated ICA. The cause of the stroke was distal embolization from an atherosclerotic plaque in the unoperated ICA.

Example 6. Patient O., 64 years old.

The patient was diagnosed with hemodynamically significant stenoses of the ICA on both sides. The patient underwent CEE on both sides according to the claimed method. Complications were not identified.

For the period from 2010 to 2022 587 patients with bilateral ICA stenoses were operated on.

The patients were divided into 5 groups:

Group 1 included 112 patients in whom the second CEE was performed 1 month after the first CEE.

Group 2 included 116 patients in whom the second CEE was performed 2 months after the first CEE.

Group 3 included 119 patients in whom the second CEE was performed 3 months after the first CEE.

Group 4 included 123 patients in whom both CEE were performed simultaneously according to the prototype.

Group 5 included 117 patients in whom the claimed method was implemented.

Table 1 shows the results of ongoing studies.

Table 1

Index Group 1 Group 2 Group 3 Group 4 Group 5 n=112 n=116 n=119 n=123 n=117 Development of ischemic stroke in non-operated ICA, n (%) 3 (2.7) 4 (3.4) 4 (3.4) 2 (1.6) 0 Development of hemorrhagic stroke, n (%) 1 (0.9) 2 (1.7) 1 (0.84) 3 (2.4) 0 Development of hemorrhagic transformation, n (%) 0 1 (0.86) 0 1 (0.8) 0 Non-appearance for the second operation due to subjective reasons, n (%) 3 (2.7) 4 (3.4) 6 (5.0) - -

The data in table 1 convincingly demonstrate that in group 5, in which the proposed method was tested, ischemic stroke was not diagnosed and no complications were detected.

Claims (1)

A method of surgical treatment of patients with bilateral hemodynamically significant stenoses of the internal carotid arteries, characterized in that the common carotid artery, external carotid artery, internal carotid artery are simultaneously isolated from both sides by different surgeons, after which the common carotid artery, external carotid artery are simultaneously clamped, of the internal carotid artery on the right and left, then simultaneously on the right and left, a temporary intraluminal shunt is installed, and then endarterectomy, vascular suture, hemostasis, drainage and wound closure are performed.