A RETROSPECTIVE REVIEW OF THE TREATMENT PERFORMED FOR STENOSING LESIONS OF THE INTERNAL CAROTID ARTERIES, OVER 5 YEARS IN THE CONDITIONS OF JSC NSCS Текст научной статьи по специальности «Клиническая медицина»

I. SURGERY

МРНТИ 76.29.39

Baubekov A.A.

orcid.org/0000-0001-7197-4871

Mierbekov E.M.

orcid.org/0000-0002-7609-0300 Egemberdiev T.Zh.

orcid.org/0000-0001-6518-5825

Israilova V.K.

orcid.org/0000-0001-7778-9618 Matkerimov M.Zh.

orcid.org/0000-0001-8492-2958

Tergeusizov A.S.

orcid.org/0000-0002-5069-4034 Zhakubaev M.A.

orcid.org/0000-0002-0376-3172

Tadjibaev T.K.

orcid.org/0000-0002-9007-063X Shamshiev A.S.

orcid.org/0000-0001-5868-057X

Makkamov R.O.

orcid.org/0000-0002-7222-1713 Saduakas A.E.

orcid.org/0000-0001-9213-2630

Erkinbayev N.N.

orcid.org/0000-0003-1409-6624 Khanchi M.

orcid.org/0000-0002-9372-4707

Corresponding author: Baubekov A.A. - vascular surgeon, «A.N. Syzganov National scientific center for surgery»JSC. E-mail: baubekov81@mail.ru Conflict of interest The authors declare that they have no conflicts of interest

Keywords

atherosclerosis, carotid endarter-ectomy, carotid artery stenting, ischemic stroke

Корреспонденция уш'ш автор: Баубеков А.А. - кан тамырлары хирургi, «А.Н. Сызранов атындары Улттык хирургия орталыгы» АК. E-mail: baubekov81@mail.ru

Мудделер кактыгысы

Авторлар мудделер кактыгысынын, жоктырын мeлiмдейдi

Туйш сездер

атеросклероз, каротидтк энтертерэктомия, уйкы артериясын стенттеу, ишемиялык инсульт

A RETROSPECTIVE REVIEW OF THE TREATMENT PERFORMED FOR STENOSING LESIONS OF THE INTERNAL CAROTID ARTERIES, OVER 5 YEARS IN THE CONDITIONS OF JSC NSCS

Baubekov A.A., Mierbekov E.M., Egemberdiev T.Zh., Israilova V.K., Matkerimov A.Zh., Tergeusizov A.S., Zhakubaev M.A., Tadjibaev T.K., Shamshiev A.S., Makkamov R.O., Saduakas A.E., Erkinbayev N.N., Khanchi M.

«A.N. Syzganov National Scientific Center for Surgery» JSC, Almaty, Kazakhstan

Abstract

Prevention and treatment of acute disorders of cerebral circulation is the most important medical and social problem, is of great socio-economic importance. For the prevention of ischemic stroke, carotid endarterectomy has been used since 1954 (Eastcott H.H., 1954; DeBakey M.E., 1975), and carotid angioplasty and stenting since the mid-80s. (Kerber R., 1980). Despite a significant number of randomized multicenter comparative studies of the results of carotid endarterectomy and carotid stenting SAPPHIRE, CREST, CARESS, EVA-3S, SPACE, the issue of choosing the optimal method of surgical treatment of patients with carotid artery stenosis is currently not completely resolved. The work is based on the analysis of the results of surgical treatment of 113 patients with stenosis of the carotid arteries who were treated at the A.N. Syzganov from 2015 to June 2020. The patients were divided into two main groups according to the method of treatment. In the group of carotid endarterectomy, operations were performed in 58 patients, in the group of carotid stenting - 55 operations of stenting of the internal carotid artery with cerebral protection in patients. Thus, the statistical analysis included the results of 113 cases of primary surgery. In the conclusion of the work carried out, recommendations were developed for the introduction and selection of tactics for the introduction of patients with cerebrovascular atherosclerosis.

«А.Н. Сызганов атындагы ¥fXO» АК шю уйкы артерияларыньщ стенозды закымдануы кезшде журпзшген емге 5-жылдык ретроспектива шолу

Баубеков А.А., Миербеков Е.М., Егембердиев Т.Ж., Исраилова В.К., Маткеримов А.Ж., Тергеусизов А.С., Жакубаев М.А., Таджибаев Т.К., Шамшиев А.С., Маккамов Р.О., Садуакас А.Е., Еркшбаев Н.Н., Ханчи М.

«А.Н. Сыз?анов атында?ы Улттык, ?ылыми хирургия орталь™» АК,, Алматы к,., Казахстан

Ацдатпа

Ми кан айналымынын жедел бузылуларынын алдын алу жэне емдеу манызды элеумет^к-экономикалык манызы бар медициналык-элеумет^к проблема болып табылады. Ишемиялык инсультн алдын алу Yшiн 1954 жылдан бастап каротидтк эндартерэктомия (Eastcott H.H., 1954; DeBakey M.E., 1975), ал 80-шi жылдардыц ортасынан бастап каротидт ангиопластика жэне стенттеу колданылады. (Кербер Р., 1980). SATPHIRE, CREST, CARESS, EVA-3S, SPACE каротидт эндартерэктомия жэне каротидт стенттеу нэтижелерiн рандомизирленген мультиорталыкты салыстырмалы зерттеулер^н манызды санына кдрамастан, казiргi уакытта каротид артериясынын стенозы бар наукастарды онтайлы хирургиялык емдеу эдiсiн тандау мэселеа толыЕымен шешiлмегенi шешШщ. Жумыс тэжiрбиесi 2015 жылдан 2020 жылдын маусымына дейiн А.Н.СызЕанов атындаЕы Улттык Еылыми хирургия орталыЕында емделген каротид артерияларынын стенозы бар 113 наукастын хирургиялык емдеу нэтижелерiн талдауЕа непзделген. Наукастар емдеу эдiсi бойынша ею Yлкен топка бвлiндi. Каротидлк эндартерэктомия то-бында 58 наукаска операциялар, каротидт стенттеу тобында - наукастарЕа мидын корЕанысымен iшкi уйкы артериясын 55 рет стентациялау операциялары жасалды. Осылайша, статистикалык талдауЕа алЕашкы хирургиялык араласудын 113 жаЕдайынын нэтижелерi енгiзiлдi. ЖYргiзiлген жумыс корытындысында цереброваскулярлык ате-росклерозбен ауыратын наукастарды енпзу тактикасын енпзу жэне тандау бойынша усыныстар эзiрлендi.

Ретроспективный обзор проведенного лечения при стенозирующих поражениях внутренних сонных артерий, за 5 лет в условиях АО ННЦХ

Баубеков А.А., Миербеков Е.М., Егембердиев Т.Ж., Исраилова В.К., Маткеримов А.Ж., Тергеусизов А.С., Жакубаев М.А., Таджибаев Т.К., Шамшиев А.С., Маккамов Р.О., Садуакас А.Е., Еркинбаев Н.Н., Ханчи М.

АО «Национальный научный центр хирургии им. А.Н. Сызганова», г. Алматы, Казахстан

Аннотация

Профилактика и лечение острых нарушений мозгового кровообращения является важнейшей медико-социальной проблемой, имеет большое социально экономическое значение. Для профилактики ишемического инсульта каротидная эндартерэктомия применяется с 1954 года (Eastcott H.H., 1954;DeBakey M.E., 1975), а каротидная ангиопластика и стентирование с середины 80-х гг. (Kerber R., 1980). Несмотря на значительное количество проведенных рандомизированных многоцентровых сравнительных исследований результатов каротидной эндартерэктомии и каротидного стентирования SAPPHIRE, CREST, CARESS, EVA-3S, SPACE - вопрос выбора оптимального метода хирургического лечения больных со стенозами сонных артерий в настоящее время окончательно не решен. В основу работы положен анализ результатов хирургического лечения 113 пациентов со стенозами сонных артерий, проходивших лечение в ННЦХ им. А.Н.Сызганова с 2015 по июнь 2020 года. Пациенты были разделены на две основные группы по методу лечения. В группе каротидной эндартерэктомии выполнено операций у 58 больных, в группе ка-ротидного стентирования - 55 операции стентирования внутренней сонной артерии с церебральной протекцией у больных. Таким образом, в статистический анализ вошли результаты 113 случаев первичных операций. В заключении проведенной работы, были выработаны рекомендации по введению и выборе тактики введения пациентов, с цере-броваскулярным атеросклерозом.

Автор для корреспонденции: Баубеков А.А. - сосудистый хирург, АО «Национальный научный центр хирургии им. А.Н. Сызганова». E-mail: baubekov81@mail.ru

Конфликт интересов

Авторы заявляют об отсутствии конфликта интересов

Ключевые слова

атеросклероз, каротидная эндартерэктомия, стентирование сонной артерии, ишемический инсульт

Topicality

Prevention and treatment of acute cerebral circulatory disorders is the most important medical and social problem and is of great social and economic importance. Carotid endarterectomy has been used for the prevention of ischemic stroke since 1954 (Eastcott H.H., 1954; DeBakey M.E., 1975), and carotid angioplasty and stenting since the mid-80s (Kerber R., 1980). (Kerber R., 1980) Prospective randomized multicenter NASCET, ECST and ACAS studies demonstrated the long-term effectiveness of carotid endarterectomy (CEE) in symptomatic and asymptomatic patients with severe carotid artery stenosis compared with conservative therapy. Due to these results, CEE has become the operation of choice subject to the standards developed by Stroke Council and American Heart Association in 1989 (Beebe H.G., 1989). These standards define the results, in which surgical treatment for clinically significant atherosclerotic stenoses of the internal carotid artery is in any case preferable for patients than conservative therapy.

Further, in the comparative studies of carotid angioplasty and stenting (CAS) and CEE, the first endovascular interventions on the carotid arteries using stents and protection systems were performed in patients with high risk of surgical treatment, where they proved the advantage over open surgery (Yadav J.S. et al., 2004). However, in the treatment of symptomatic patients, the best treatment results show carotid endarterectomy (Mas al., 2004). And a number of J.L. et researchers found

that there are also risk factors for carotid stenting (Biasi G.M. et al., 2004).

Thus, in spite of a significant number of randomized multicenter comparative studies of the results of carotid endarterectomy and carotid stenting SAPPHIRE, CREST, CARESS, EVA-3S, SPACE, the issue of optimal surgical treatment of patients with carotid artery stenosis has not been finally resolved. Stenting is an alternative to endarterec-tomy for the treatment of carotid stenosis, but its long-term efficacy has not been determined. We present data comparing these treatments: 113 patients with symptomatic carotid stenosis from 2015 to 2020.

Materials and methods

The paper is based on the analysis of the results of surgical treatment of 113 patients with carotid artery stenoses treated at the A.N. Syzganov NSCS. A.N. Syzganov from 2015 to June 2020. The patients were divided into two main groups according to the method of treatment. In the carotid endarterectomy group 58 patients underwent operations, in the carotid stenting group - 55 operations of internal carotid artery stenting with cerebral protection in patients. Thus, the statistical analysis included the results of 113 cases of primary operations.

We applied the following criteria for inclusion of patients in the study.

Presence of carotid artery stenosis over 60% in combination with: previously suffered transient ischemic attacks or amaurosis fugas

Table 1

The ratio of patients in the CEE and CAS group by age, sex, number of main operations

Characteristic CEE group CAS group Р

Number of patients 58 55 -

Number of operations, n 58 (100%) 55 (100%) -

Operations performed in men (%) 51 (87.9%) 50 (90.9%)

Operations performed on women (%) 7 (12.0%) 5 (9.0%)

Age, years - - -

Middle " + M 64,69±6,89 65,20±9,24 0,68

Range, years 49-78 39-82 -

Age up to 75 years 78 (90,7%) 73 (87,9%) 0.62

Age 75 and older (%) 8 (9,3%) 10 (12,1%) 0.62

m - standard deviation

dyscirculatory encephalopathy; previous ischemic stroke; presence of embolism-associated ASD; presence of carotid artery stenosis over 70% in the absence of clinical manifestations of chronic cerebrovascular insufficiency and stable ASD.

Patients with: restenosis after previous carotid endarterectomy or carotid stenting, post-radiation carotid artery stenosis were excluded from the study;

predominant lesions of the vertebro-basilar basin (lesions of the vertebral and subclavian arteries);

previously performed extra-intracranial micro-anastomosis on the side of the occlusion;

severe heart rhythm disorders (atrial fibrillation, atrial fibrillation and ventricular flutter); Severe respiratory insufficiency; heart failure III-IV functional class. Patients with contraindications to one of the treatment methods (acute coronary syndrome, he-modynamically significant tortuosity or kinking of the target carotid artery, pronounced atherosclerotic plaque calcification) were also excluded from the study.

To test the null hypothesis regarding patient homogeneity, we investigated differences in the compared groups by sex, age (Table 1), and concomitant pathology (Table 2) by t-criterion and Chi-square test (х2).

All patients were examined before surgery by neurologist and cardiologist, and if necessary

by endocrinologist. The neurological status, the degree of chronic cerebrovascular insufficiency according to the classification of A.V. Pokrovsky (1979), and the severity of concomitant cardiovascular pathology (Table 2).

The Canadian Heart Association classification was used to assess the functional class of angina, the New York Heart Association classification was used for heart failure class, the Fontaine-Pokrovsky classification was used to assess the severity of chronic ischemia of the lower extremities.

Conclusions

1. The incidence and nature of cerebrovascular complications (stroke, transient ischemic attack) and cardiovascular complications (acute coronary syndrome, myocardial infarction) during carotid endarterectomy and carotid stenting in the immediate and long-term postoperative period did not significantly differ (p0,05).

2. For carotid endarterectomy, risk factors for cerebrovascular complications were contralateral occlusion in patients who had had a stroke less than 6 months earlier (p0.05) and age over 75 years in patients who needed a temporary intraluminal shunt (p0.05).

For carotid stenting, risk factors for cerebrovascular complications were hypoechogenic heterogeneous type of atherosclerotic plaque (p0.05) and atherosclerotic plaque surface ulceration (p0.05).

Table 2

Frequency of comor-bidities in patients in the CEE and CAS groups

Associated disease CEE group CAS group Р

Ischemic heart disease (%) 51 (59,3%) 52 (62,6%) 0,94

FC angina pectoris 1 or 2 (%) 51 (59,3% 52 (62,6% 0,94

FC angina above 3 (%) 15 (17,4%) 21 (25,3%) 0,26

History of myocardial infarction (%) 12 (13,9%) 15 (18,1%) 0,53

Arterial hypertension (%) 58 (100%) 55 (100%) 0.99

Arrhythmias (%) 11 (12,7%) 15 (18,1%) j 0,39

Chronic ischemia of the lower extremities (%) 31 (36,1%) 34 (40,9%) 0,87

Type II diabetes mellitus (%) 12 (13,9%) 10 (12,0%) 0,82

3. A risk factor for the development of cardiovascular complications for carotid endarterectomy is the presence of initial functional class III angina (p0,05). No cardiovascular risk factors were found for carotid stenting.

4. Carotid endarterectomy and carotid stenting are effective methods for prevention and treatment of cerebral circulatory disorders in patients with carotid artery stenosis, and treatment results over 36 months do not differ significantly (p0,05).

5. Optimal conditions for carotid endarterec-

References

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6. Optimal conditions for carotid stenting are an isoechogenic, homogeneous or heterogeneous hyperechogenic atherosclerotic plaque without surface ulceration.

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