UA66117A - Method for reconstructing carotid arteries - Google Patents

Abstract

The method for reconstructing the carotid arteries provides for the access to the arteries and the mobilization of the internal carotid artery at a distance of 4-5 cm from bifurcation. Then heparin is injected at a dose of 5000 U and the fragment of the large saphenous vein of the lower limb is separated. The vein is reversed, inflated, and checked for its leak-tightness. Then two clips are applied onto the common carotid artery downstream the atherosclerotic plaque. The common carotid artery is incised between two clips. The edges of the incision are rounded with the aid of perforator. The central "end-to-side" anastomosis is applied between the autovenous insert and the common carotid artery using the polypropylene thread N 6.0 and the leak-tightness of the anastomosis is checked up. Then the clip is applied onto the distal part of the internal carotid artery upstream the atherosclerotic plaque. The sewed autovenous by-pass is clampednear anastomosis and the proximal clip is removed from the common carotid artery. The clip is applied onto the base of the internal carotid artery being dissected and the distal "end-to-end" anastomosis is applied between the autovenous insert and the distal part of the internal carotid artery using the polypropylene thread N 6.0. Upon generation of the distal anastomosis, the distal clip is removed from the internal carotid artery. The common carotid artery is temporarily clamped proximal to the central anastomosis, while the external carotid artery is clamped at the site of the origin of the upper thyroid artery. Then the proximal clamp is removed from the by-pass and the blood is allowed to outflow in a retrograde way via the cut stump of the internal carotid artery. Finally, the blood flow through the internal carotid artery is restored by displacing the clip to the common carotid artery upstream the anastomosis. The endarterectomy is performed from the former bifurcation of the carotid arteries and the external carotid artery.

Description

The invention relates to medicine, in particular vascular surgery and neurosurgery, and can be used to prevent ischemic stroke.

There is a known method of carotid artery reconstruction (traditional carotid endarterectomy) (1), which includes the use of longitudinal endarterectomy, removal of atherosclerotic plaque, and closure of the arteriotomy with or without a patch. The use of patches reduces the risk of restenosis, but the use of a patch from a large saphenous vein causes a serious threat of aneurysm development, and can also lead to stenosis of the internal carotid artery with sutures in its distal segment. The use of alolatka contains all the disadvantages associated with the implantation of a foreign body and somewhat increases the bleeding of the IZ,4,5|. Before opening the artery, the question of the need to use a temporary intra-arterial shunt is decided. If the operation is performed under general anesthesia, then either intra-arterial shunting is used (because they consider the existing methods of assessing the state of the brain to be uninformative), or all patients are operated on without shunts (because they believe that the risk of using a shunt is practically equal to the risk of developing ischemic brain complications during clamping of the carotid arteries) , and in most cases intra-arterial shunting is used selectively. In the latter case, the need for shunting is most often based on indicators of retrograde pressure in the internal carotid artery. In some cases, the following non-invasive studies are used to assess the state of the brain, intracranial blood flow and decide whether an intra-arterial shunt is necessary: transcranial dopplerography, continuous electroencephalogram recording, induced work potential. When performing carotid endarterectomy under local or general anesthesia, direct contact with the patient and determination of the strength of the arm opposite to the side of the intervention are crucial for deciding the need to use an intra-arterial shunt. The appearance of signs of brain ischemia is accompanied by weakness in the opposite limb. In such cases, an intra-arterial shunt is used. The described methods of carotid artery reconstruction have the following disadvantages:

To perform a traditional endarterectomy, it is necessary to compress the common, external and internal carotid arteries at the same time. This, in turn, can lead to ischemia of the brain in the case of an anomaly of the circle of Willis.

The most effective method of eliminating the latter is the establishment of an intra-arterial shunt, however, to solve the issue of the presence of brain ischemia and the establishment of a shunt, it is necessary to use invasive or expensive diagnostic methods. In addition, the use of a temporary intra-arterial shunt can injure the intima of the artery, complicate the endarterectomy, increase the duration of the operation, cause more blood loss, and in some cases its use may be ineffective (extension of the distal part of the internal carotid artery).

When performing an endarterectomy, the intima can peel off in the distal direction, which in turn can lead to arterial thrombosis. To prevent this complication, there is a need to apply additional stitches on the back wall in order to fix the plaque. Attempts to perform endarterectomy from the external carotid artery cause an increase in the duration of brain ischemia. Closing the longitudinal arteriotomy incision with a continuous suture can cause stenosis of the artery. When using a patch for the prevention of internal carotid artery stenoses, the duration of the operation increases, closing the arteriotomy incision with a Dacron, polytetrafluoroethylene, or other synthetic material flap causes a risk of patch infection, and when using an autovein there is a risk of developing an aneurysm.

The closest to the proposed method of carotid artery reconstruction is eversion carotid endarterectomy (5).

Access and mobilization of the carotid arteries is performed as in traditional endarterectomy. The internal carotid artery is mobilized at a distance of 4-5 cm from the bifurcation. After clamping the external, internal and common carotid arteries, the internal carotid artery is cut with a scalpel near the mouth. The transected internal carotid artery is recorded. The intima with the media from the adventitia of the artery is circularly peeled off with a thin spatula. After that, the assistant twists the adventitia in the distal direction with two thin tweezers. The twisting of the artery continues until the plaque is gone.

After removing the plaque, the internal lumen of the distal part of the internal carotid artery is examined.

The presence of detached intima and its flotation is checked with a strong stream of physiological solution from a syringe.

The surgeon must make sure of the tight fixation of the remaining intima and the absence of its fragments in the lumen of the distal part of the internal carotid artery. If the intima is tightly fixed, then after monitoring the state of the lumen of the distal part of the internal carotid artery, the wall of the artery is smoothly moved in the proximal direction. The next step is an open endarterectomy from the common carotid artery. As a rule, the lateral, side wall of the common carotid artery is additionally dissected down in the caudal direction.

An endarterectomy is performed from the common carotid artery, and its plaque is cut circularly in the proximal corner of the wound. Then an endarterectomy is performed from the external carotid artery. When performing the anastomosis of the internal carotid artery with the common carotid artery, the inner side wall of the internal carotid artery is additionally dissected beforehand. The anastomosis is applied with a 6.0 polypropylene thread. The wound is drained and sutured in layers.

With this method, as with traditional endarterectomy, all carotid arteries (common, external, and internal) must be compressed at the same time, which can cause brain ischemia, and removing a plaque from the external carotid artery increases the duration of ischemia. There is often a need to place a shunt with corresponding complications, and this procedure in this operation is very difficult. In addition, in this method of operation, the intima can peel off in the distal direction.

The invention is based on the task of providing during the operation the possibility of constant collateral blood flow to the brain, getting rid of brain ischemia, which, in turn, will reduce the number of intra- and postoperative complications.

The task is achieved by the fact that in the method of carotid artery reconstruction, which consists in carrying out access and mobilization of the carotid arteries, mobilizing the internal carotid artery at a distance of 4-5 cm from the bifurcation, injecting 5000 units of heparin and, according to the invention, taking a fragment of the large of the subcutaneous vein of the thigh, the vein is reversed, inflated, the tightness is checked and two clamps are placed on the common carotid artery below the atherosclerotic plaque, a small dissection of the common carotid artery is performed with a scalpel between the clamps, and the edges of the dissection are rounded with the help of a perforator, after which a central anastomosis is placed between the carotid vein and the common end-to-side carotid artery with a monolithic thread made of polypropylene 6.0, the tightness of the anastomosis is checked, then a clamp is applied to the distal part of the internal carotid artery above the atherosclerotic plaque, the sewn autovenous shunt is clamped near the anastomosis and the proximal clamp is removed from the general carotid artery, then a clamp is placed on the base of the internal carotid artery which is crossed, the distal anastomosis is placed with a 6.0 propylene thread "end to end" between the autovenous and distal parts of the internal carotid artery, after the completion of the distal anastomosis, the clamp is removed from the distal part of the internal carotid artery, temporarily the common carotid artery is clamped proximal to the central anastomosis and the external carotid artery at the exit of the superior thyroid artery, then the proximal clamp is removed from the shunt and blood is retrogradely released through the severed stump of the internal carotid artery, after that blood flow is restored through the internal carotid artery by moving the vascular clamp to the common carotid artery above the anastomosis and perform endarterectomy from the old bifurcation of the carotid arteries and the external carotid artery.

With this method of performing the operation, the common, external and internal carotid arteries are never clamped at the same time, which allows the collateral blood circulation to function continuously, and this prevents ischemia of the brain and rejects the need for the use of a temporary intra-arterial shunt, as well as possible injury to the intima of the artery, making it difficult to perform endarterectomy , increasing the duration of the operation and blood loss. Permanent functioning of the collateral circulation does not require the use of invasive or expensive diagnostic methods. In addition, when performing the proposed reconstruction of the carotid arteries, there is no danger of peeling of the intima in the distal direction, since the distal anastomosis is applied along the entire circumference of the artery, constantly fixing the distal part of the intima. Plaque is almost always removed from the external carotid artery without increasing the term of brain ischemia, as at this point brain revascularization has already been restored.

The proposed method can be used in patients with diabetes and in patients with a long atherosclerotic plaque. This is achieved due to an autovenous shunt, which can be used in different lengths.

Figure 1 shows a selected bifurcation of the carotid arteries; in Fig. 2 - taking a large saphenous vein from the thigh; in Fig. 2-3 - arteriotomy in the common carotid artery; in Fig. 4 - superimposition of the central anastomosis; in Fig. 5 - checking the tightness of the central anastomosis; in fig. b - restoration of blood flow through the common and external carotid arteries; in Fig. 7 - preparation for imposing a distal anastomosis; in Fig. 8 - checking the patency and tightness of the distal anastomosis; in Fig. 9 - endarterectomy from the old bifurcation of the carotid arteries and the external carotid artery; Fig. 10 is the final view of the reconstruction.

The method is carried out as follows.

Position of the patient on his back. The operation, as a rule, is performed under a combination of local and general anesthesia (although, if desired, it can also be performed under general anesthesia). The incision is made along the front edge of the sternocleidomastoid muscle. After selection of the internal jugular vein, it is bypassed along the back wall and shifted medially. After that, conductive anesthesia of the cervical plexus is performed and the carotid arteries are isolated. To control the vessels and establish a clamp around the common, internal, external carotid and upper thyroid arteries, holders made of thin, soft rubber tubes are passed (Fig. 1). After assessing the extent of the atherosclerotic plaque, the necessary fragment of the large saphenous vein is taken under local anesthesia in the upper third of the thigh (Fig. 2). The vein is reversed, inflated, checked for tightness and, if available, the valves are destroyed with a catheter. After that, 5000 units are administered to the patient. heparin and 3 minutes after its introduction, two clamps are applied only to the common carotid artery below the atherosclerotic plaque. With such clamping, the collateral blood flow from the external to the internal carotid artery is preserved, which prevents brain ischemia.

A small dissection is performed with a sharp end scalpel on the external-lateral surface of the common carotid artery between the clamps. The edges of the dissection are rounded with a perforator (Fig. 3). After that, they proceed to impose a central anastomosis between the prepared autovein and the common carotid artery in an end-to-side manner." To expand the anastomosis, the autovein is preliminarily dissected obliquely. The anastomosis is applied with a monolithic thread made of polypropylene 6.0 (Fig. 4). After the anastomosis is completed, its tightness is checked by removing of the distal clamp from the common carotid artery (Fig. 5). This maneuver also prevents possible embolization from the atherosclerotic plaque. The next step is to apply the clamp to the distal part of the internal carotid artery above the atherosclerotic plaque (Embolization prevention). Then the sewn autovenous shunt is clamped immediately near anastomosis and the proximal clamp is removed from the common carotid artery. At this moment, blood from the common carotid artery enters the external carotid artery and through its terminal branches retrograde along the ophthalmic artery provides blood supply to the brain. (fig.b). Then a clamp is placed on the base of the internal carotid artery th artery and the latter are crossed above the atherosclerotic plaque. To prevent stenosis of the distal anastomosis, the free end of the autovein and the distal end of the artery are obliquely dissected (Fig. 7). The distal anastomosis is placed with a 6.0 propylene thread in an end-to-end fashion. Seams are placed in such a way that the distal part of the intima is constantly stitched from the middle to the outside. After the completion of the distal anastomosis, the clamp is first removed from the distal part of the internal carotid artery in order to check the patency and tightness of the distal anastomosis (Fig. 8). Then, the common carotid artery proximal to the central anastomosis and the external carotid artery at the exit of the superior thyroid artery are temporarily clamped. The proximal clamp is removed from the shunt and blood is retrogradely released through the severed stump of the internal carotid artery in order to prevent microembolization into the system of the internal carotid artery. After that, the blood flow through the internal carotid artery is restored by moving the vascular clamp to the common carotid artery above the anastomosis, and endarterectomy is calmly performed from the old bifurcation of the carotid arteries and the external carotid artery (Fig. 9). After the endarterectomy is completed, the arteriotomy is closed by dilating the external carotid artery with the remains of the internal carotid artery with continuous polypropylene suture with a 6.0 thread. (fig. 10). To prevent a hematoma on the neck when suturing the wound, careful hemostasis should be performed. The wound is drained. If heparinization was used, protamine sulfate may be used to reduce bleeding. The wound is sutured in layers.

Example 1. Patient Ch., 4 years old, was admitted to the Department of Vascular Surgery on October 7, 2002. with a clinic of repeated acute disruption of cerebral blood circulation in the basin of the right middle cerebral artery. It is known from the anamnesis that the first transient ischemic attacks occurred in December 2001. In May 2001 the first acute violation of cerebral circulation occurred, which partially regressed within 2 weeks. 09/27/2002 there was a repeated acute violation of cerebral blood circulation in the basin of the right middle cerebral artery, which was clinically manifested by a speech disorder and left-sided hemiparesis. The effect of conservative treatment for 10 days was not observed. A duplex examination on October 1, 2002 revealed pronounced atherosclerotic changes in the bifurcation of the right carotid artery with critical stenosis of the right internal carotid artery about 9095 in length to the entrance to the skull. At the bifurcation of the left carotid artery - pronounced atherosclerotic changes due to a mixed, heterogeneous plaque with a height of 3.5 mm.

Computed tomography from 02.10.2002.

Conclusions: cystic-atrophic changes of the brain as a result of an acute violation of cerebral blood circulation in the basin of the middle cerebral artery.

Consultation of a neuropathologist from October 8, 2000.

Conclusions: Repeated acute cerebral circulation disorder of the ischemic type in the middle cerebral artery basin with left-sided hemiparesis and motor dysarthria.

Clinical diagnosis: Atherosclerosis. Stenosis of both internal carotid arteries. Critical stenosis of the right internal carotid artery with acute disruption of cerebral circulation with left-sided hemiparesis.

Taking into account the high risk of thrombosis of the critically stenosed right internal carotid artery, repeated acute cerebral circulation disorder of the ischemic type in the basin of the middle cerebral artery, the lack of effect of conservative treatment with the preservation of a significant neurological deficit, surgical treatment is recommended for a patient with a high risk based on vital signs.

The operation under a combination of local and general anesthesia with retrojugular access was performed on October 8, 2002. in the proposed way and lasted 2 hours.

The postoperative period was uneventful. The surgical wound healed with primary tension.

Neurological symptoms regressed. The patient was discharged for outpatient treatment on the sixth day after the operation.

Example 2. Patient B., 2 years old, was admitted to the Department of Vascular Surgery on 12/25/2002. with a clinic of transient ischemic attacks in the form of impaired speech, coordination, dizziness, blood pressure drops.

It is known from the anamnesis that the first transient ischemic attacks occurred more than 3 years ago. He was repeatedly treated in the neurological department. The effect of conservative treatment was not observed. The frequency and duration of transient ischemic attacks has recently increased. A duplex examination dated November 15, 2002 revealed a critical stenosis of the left internal carotid artery greater than 9095 (ZOmm).

Computed tomography from 14.12.2002.

Conclusions: Zones of pathological density and volumetric formations were not detected.

Clinical diagnosis: Atherosclerosis. Critical stenosis of the left internal carotid artery with clinical manifestation in the form of increasing transient ischemic attacks.

Taking into account the high risk of thrombosis of the critically stenosed left internal carotid artery, the clinic of increasing transient ischemic attacks and the lack of effect from conservative treatment, the patient is recommended surgical treatment.

Operation under a combination of local and general anesthesia with retrojugular access on the left 12/27/02. performed as described above, lasted 1 hour 50 minutes.

The postoperative period was uneventful. The wound healed with primary tension. Transient ischemic attacks stopped. The patient was discharged for outpatient treatment on the third day after the operation.

Sources of information: 1. Pokrovsky A.V. Classical carotid artery zndarterzectomy // Angiology and vascular surgery, - 2001.-Me1, vol.7.-p.101-104. 2. Agopivye OR. Rgemepiip oi eapu Ievtepoviz apa (pgotroziv-ossiysiop apyeg sagoiiy epdapegesiotu Bu zarpepoiv5 meip raisp apdioriaviu. 5igoKe 1986; 17:901-905 3. Znap OM, Oapipd AS I, Spapud VV, Kgeieyepregu RV, Raiu ROK, Sagoii rupetu! Adm Zygu 1999;33:459-475 4. Vaiotsa E, Sa Siats S, Zaiadipi M, Arbgy272eze E, Nepop GI, Totayu A. Sagoia epdapegesiotu mn raisn siozyge meggivs sagoyy emegsiop epdapegesiotu apa ge-imitriapiayresopii: a tiorghey. Vschau, Zigdegu, 1999

Mag. 125(3):271-9. 5. Esopotorotsioz KU, Sepitsshe AT, Veptap 55. Sotraigizopoi sagoy epadapegesiotu tsvypd rigitagu siozyge, raisp siozyge, apa emegviop (esppidnev5. At U Byga. 1999Oes; 178(6):505-10. 6. Pokrovsky A.V. Zversionnaya carotid sndarterzectomy // Angiology and vascular surgery.- 2001.-

Me2, vol.7.-6p.105-106.

V nn VH LE xx OVU

In s o. o. VAV. In the western VOK

By OK, you are B; M KN Z UNO OVO VH

KN ZE V and V

In NC KK

HOW about VK

PO V MO oo V i

CONDITIONS Vo

UMO V and VC

M. OM and V I OD

We. MMOK OKH OO about Kn M

ZV OM v

Ki W W KU Ya

Co. VV Vr OO V V a

KK and V o

Penn KN V V I I it

КОVO В о в

III KO

WEB HC in VHF

MIV: oh EE KU eYA

MOM IOV V

KK V x sosny sha Y M V Y KT EYAYA sa

MEM OO MK ih BOKY

WE "TV OO ok din popa; u

PHOEBE

SANY - p

Short circuit in Z I I

ZMEN, h

OKO Sa Han: KE sk PAK U yi ;

BO OB kon Y CHE show EM ke y o, g. U S s « ok, vina Z. Me u pol se che KE B " in o Z hE

What are you talking about? AND

I am the same heh - still ach I KZ

KO OM she Z g KU

In what - in. xx

EM ZO KK in I TO no dz

CHEEKS HO OO po, she and ov V eh Seya still

HU She o V i WE VN

EK yaki V oo an B - pu KIM eh A Ka Kn «derty nyn ee ZE 7 y y Chi kkd them

There is SKK, dl shk Neo NYA Ok » oh kre

Ko and in OM ON

WHAT'S IN THE EYE

She has Х КК and ЭХ С 5 ОХ. p Pl z a sl, ZU MK U she ZK o i o OO M TOK nn . sh

I OK U ,- OO KO y o pi m, 5

ET vymy I nya this and PEK V kit AFC OBOV Skh IOM

MK schi BUH and V MV

Y s V MO o dn o VO U ZO U

MAO o o its OBO PURPOSE UZ KOKO y SOMY KK PI UKH UKA KKU

PO o A V OO

OM vn o o dy M y sokhia Fashions: vya OO You I KOH - he Y M MM

SHO Zh "i OK V NNYA SV

MOM EM in ME ME what MOM NE Bi me. ha PO their OO. SE

OM I HUMN х х-

ВХ сх ВА КО Зк, : seMmUm. V SK M M, I "KOZH ze UVA Po te --yu o, Vse eh -ya PM Khan WOVK V kh vu

Fa silo loyu yut jere

Residential and commercial buildings

ZM o KM o m M -- TOWER

OO KT no: y y

KK ooo o NN i ke chi o i V V o ONY

MK V PoKKKYA OK SUYA OA TEO

OO МХТКК Ва Ки НН шчи НА

OM about ZNy ION write ZH

ZY yus and Leh

Vol one ee He ia kan o NM OO PO py sha ia

Ж КК Yes Ж MEN КК К К и OK В о SA

UZH He OO VA V eh xx KK 5 OKOM IC Mt y sho U tu OM OH sih

MES V M and VK

OK and

University of Vy

DY I PO vat y she o y and SEQ vy i Z

VC OVK mon M KE in ozh

MO OH M Ush

KON and OK V V

ОН m in НО

COM M M I o To ee

MOM juice CENTURY with Ya

MO ke Ha U p A Ok o KK KO

RBC I and NNYA

TU OO en M KU Oh Kedy, Yaz

OKU OO eye I SI KO pEMOMYA I VM NN s xx s 5 i i i t

Unit

My so DO oo and what MO: oh ev

Zoo o KV : ОХ КН s s s s s Х ХВ -

From the OWL pk. pi is the UN INN Fr. ABOUT. tu Ushyu s UKH ih KOKO Ka Va OKH s lay s i SH Khh

MO 0 and UC Uzh Zoya. ENN Ko z I XX hHOVay p. ZO ZASVNYSHY an Y y m» o 5 MOJ KVK U koh: s Z i s Uh 6. okon KK i hu Ta Sa 5. MUK B p I s she Jh shi i

In the cocoon of PC VU In Ohm With OKKO VU

VS poh selmzhye ZO o OA UKH

ВХ У ОО OK ОО УХ

YOU I SSS: With ee her NN. Me

She OH ko Yakykh, book V children t

RE gold

OKO Moi: Xia,

ОО ОО . : ssh oso ovo o OK yaki LO : : in MK EK KO I Kolo a y U

OK OH but HVAC

Yes s sho x s y I Koshchev s OK p e s that sha a v. o ( (. i KU X zOSVO ny nn. 000 Cl DA KE her" Z p KK o OK ХХ ХК her КХ s py ХХ s her U KE o: z o Lesson KK s a zh. OO. Z s ih shk KOH ZOV shin iv KK KOJZ My uncle U i B 0 3 VO t. OK Bak; OO kah p -N p a SOKY AK HO yu i KKU, ХК и v. ЗИ o У вх сш и что де ча За Х m ОО Usoi enya ke DK do KV M UMH Szhnya x KV OA: MOH ZO skdknkkh. OK PKEE MOU OKH HE pnya revn. x NNYA LIYA On Ko MOH

Yanv So Shi In pAANNYH and More under che. DE t ovoveis i Shawn Nya lizh KE cha el i "I B OKU and soso KV a OH MK p he what

I A KE va OS

MO dey Ya o p KK

KO KY their Kk NI UVK PE VrK So hya

Ak ky B: 1. ee i

TO O VK U m o Se i i

OO 0. OO ZE Von kV : o. Oeya V SYA KU

PVC e О ВХ in TE OO gives in. Uh AH KUM KO, o ko invb neo VN LEO di; VMO Secondary School

MV Z NAH SON: KOKO OK S MI KOMU

OKH ON M s OO, and nya S

S i OH KK o VO SVO

M OH Oh. In about KO about.

MU DAK KK V "EX sh V KO

NO ey ZO ЗХ u KO KY X Kr UK zh ko KO I: Oh a AH shi 6 i o. ree M OV vh ak M: pila she s 5 y y Kz PO o o o: 555 shi. s she o. V. " : in: U OH KU KVU ovrm

REIT, dor pava ee u: soskou OT OppdoyuH: p MK OV

COCO OKO Zh po u v : : p a tA. I oh u same sia OKO : s 2 s Os : OV AV Z s Z to M I By ZU s: eV - ee OM I g V de 6. o OO y I s

Women's PE: o sh 2-0. i am 3

MM Z ne Z EH : OB n Oh vve. with o

MO ze ovii shi M KK 5 ЭХ 5

KK pis OK KK ih ZE ke s Seenn V. . at.

MEM and EM MUK KM SCHE I efdimlAAn KU z o ВХ ОХ Pon kon VU o i Ou oz shi o z 5 s. 7 Y ZHUK OO B MK: KK oh shi KE ek U

Produces juice of KKU PODYH IC ke beer M oon Okh o intes Z UNO M. y pi ik a

Fe. 8 not pi

Kk, M r VH m Z

M - what. ; Pe EK shchi Z

OO. VEK v. Kha s even KK SO rya VU o B. pek ozh her s s

VU their p. in s hu Mak Sak what KO p. about

VOK x, EK in b also p. . o u 5 By Ka ov : 3

OH M. ke U: r OO o KK eV KO M x KA VK

With xx ke o X OKO i U i o 0-5 V: 5 U KI

VO oh I Z zh Ku Ko i shcha POKK that i vu s o o. In 5 ka Yak zhu Esse, СХ СХ o - p. t o

OH KK ih i. hu s: . o I code t o oh h her . with

TV and o. 5 / s : n U o se U x: . s p. oi su M o eo nn. with the west of it. with Zo Ya

LLC in at. with . not p in and g; what t - he be Z, oh oh her DF. wow

VO and SE with nn. r SOS u o Z o o OK A HK U s MO more

ВХ шх и пык 3 in Z Z s dEeKKE va A -. Ah

ZK s Sa o z "noVVk, zh KK i s ka ve" Meven M S Z , Ge o: o zhk shcha

TOZ x kK. that she is from p

KK OK in the Zoo, S OO o. with.

KOH ZO i U KKU OH OO o; M her OO OK p.

C XX p s ah OO c. o and 0 o.

K Te U OKU M OO KO o 5 . at

CO OO ZOV oz U ZO Z o

KO sh Oh KOS UOKya OO OH 0 more

But also with ze OH sn i

VO Fr. KSO OO U Okh p. sh OO SO mok VN s o 5 OO s SOU x p g p. s 0» o. ME n. 5 1 - n MOH -

From 0 o. In o. OO KK U

E 15 - about 5 km E village. oh p o i Ky o p H ka kn - . o: Oh ok

KK x ZON in Zx ZKU and: . with Same KE p. With IC I - ; x her xx

SU KOKKOV A re

Claims (1)

The method of carotid artery reconstruction, which consists in carrying out access and mobilization of the carotid arteries, mobilizing the internal carotid artery at a distance of 4-5 cm from the bifurcation, injecting 5000 units of heparin, which is distinguished by the fact that a fragment of the great saphenous vein of the thigh, vein they reverse, inflate, check for tightness and apply two clamps to the common carotid artery below the atherosclerotic plaque, a small dissection of the common carotid artery is performed with a scalpel between the clamps, and the edges of the dissection are rounded with the help of a perforator, after which a central anastomosis between the autovenous and common carotid arteries is applied according to the type end to side" with a monolithic thread made of polypropylene 6.0, the tightness of the anastomosis is checked, then a clamp is applied to the distal part of the internal carotid artery above the atherosclerotic plaque, a sewn autovenous shunt is clamped near the anastomosis and the proximal clamp is removed from the common carotid artery, then applied a clamp on the base of the internal carotid artery, which is crossed, the distal anastomosis is placed with a 6.0 propylene thread "end to end" between the autovenous and distal parts of the internal carotid artery, after the completion of the distal anastomosis, the clamp is removed from the distal part of the internal carotid artery, temporarily clamped the common carotid artery proximal to the central anastomosis and the external carotid artery at the departure point of the superior thyroid artery, then the proximal clamp is removed from the shunt and blood is retrogradely released through the severed stump of the internal carotid artery, after that blood flow is restored through the internal carotid artery, moving the vascular clamp to the common carotid artery above the anastomosis and perform endarterectomy from the old bifurcation of the carotid arteries and the external carotid artery.