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Yusubbaev A. Z., doctor of vascular separation of the RSCH named after acad. V. Vakhidova Bahriddinov F. Sh., professor, Head of Vascular Surgery of the RSSCH them. Acad. V. Vakhidova Zayniddin Norman Ugli, Ph.D., doctoral student of the RSKH them. V. Vakhidova Rakhmanov A. A., master, TMA. E-mail: Zayniddin_norman@mail.ru Nazirov F.G.,
Director - Academician Republican Specialized Center for Surgery them. Acad. V. Vahidova
SELECTION OF SURGICAL TACTICS IN THE PATHOLOGICAL IZVITOSTI OF CAROTON ARTERIES
Abstract: To study role of color duplex scanning in the diagnosis and choice of surgical technique in pathological tortuosity of the carotid arteries.
Keywords: Carotid artery, tortuosity, color duplex scanning, surgery.
Introduction
The introduction into clinical practice of modern ultrasound methods for diagnosing diseases of the internal carotid arteries (ICA) in many ways positively determine the results of surgical treatment of their pathological tortuosity (PI) [11].
Pathological studies of F. Koskas et. all. [3] found that convoluted carotid arteries are observed in 10-43%, in patients with impaired cerebral circulation. As a cause of impaired cerebral circulation in adults, pathological tortuosity (PI) of the internal carotid arteries (ICA) is second only to atherosclerotic lesions in prevalence.
According to WHO, at least 15 million strokes are recorded every year in the world. Of the 15 million patients who suffer a stroke, 38% die from primary cerebrovascular accident, 28% after a second stroke. The incidence of ischemic stroke recorded in Uzbekistan was 60.000 cases per year for 29 million people.
According to the data of various authors in the USA and Europe, from 62% to 85% of Pokrovsky AV are subjected to surgical treatment [2]. However, unlike atherosclerotic lesions, which have been the subject of extensive multicenter studies, and as a result of which clear generally accepted conclusions and recommendations were obtained, no such studies have been conducted on the problem of PI branches of the aortic arch, and the indications for surgical treatment largely continue to depend on the personal opinion of the surgeon and neuropathologist on this issue Bockeria L. A. et al., [1].
The most difficult for this category of patients is the determination of indications for surgical treatment, the hemodynamic significance of the PI of the carotid arteries, which ensures the effectiveness of the performed operation [4-10].
Material and methods
For the period from 2006 to 2014 in the Department of Vascular Surgery RSCH them. Acad. V. Vakhidov examined 223 patients with PI CA, of whom 115 according to duplex scanning revealed hemodynamically insignificant pathological deformations of the ICA, and the remaining 108 patients underwent 138 surgical interventions. The patients' age ranged from 29 to 74 years. There were 56 women (51.8%) men - 52(48.1%). In 112(81.1%) cases, bilateral ICA deformity was detected, in 26(18.8%) cases on the one hand. In 1 case, the PI BCA was accompanied by an aneurysmal expansion at the site of bending (Figure 1). In (2%) patients, the pathological deformation of the ICA was combined with the pathological tortuosity of the common carotid artery (OCA), in 34(31.4%) cases, the PI ICA and the vertebral arteries were diagnosed. In 62 cases, PI was combined with ICA stenosis in various percentages, of which 33(30.5%) patients had hemodynamically significant stenosis: (more than 70%). In the overwhelming number of cases of the disease, arterial hypertension was accompanied in 124 patients.
Table 1.
Crimp Distribution
The form Number of cases Percent
S- and C-shaped (tortuosity) 52 37.6%
Kinks 59 42.7%
Double kinks 23 16.6%
Looping (coiling) 4 2.1%
Total 138 100%
Figure 1. Aneurysm of the ICA at the site of bending. MDCT angiography and intraoperative imaging
In determining the stage of cerebrovascular insufficiency, we were guided by the classification of A. V. Pok-rovsky (1979).
I st. HNMK (Asymptomatic Current) - 14 (12.9%);
II st. HNMK (Transient ischemic attacks) - 79 (54.6%);
III Art. HNMK (Dyscirculatory encephalopathy) - 41 (28.7%);
IV art. HNMK (Stroke) - 4 (3.8%).
Asymptomatic PI was observed in 14(12.9%) patients, and 124 (89.8%) had symptoms of cerebral circulation of various degrees: transient ischemic attacks (TIA) occurred in 79(57.2%) patients, dyscirculatory encephalopathy (DE) -in 41(29.7%), ischemic stroke (IS) history was observed in 4(2.8%) patients. It is necessary to emphasize that diseases with C- (8 patients) and S-shaped (4 patients) tortuosities, 2 patients with kinks of the ICA, asymptomatically proceeded.
Table 1. - Clinical manifestations of cerebral ischemia
Clinical manifestations of the media S-shaped crimp Coiling Atherosclerosis Kink
1 2 3 4
Asymptomatic 12 0 2
Tia 24 2 53
Dyscirculatory encephalopathy 14 2 25
1 2 3 4
Ischemic stroke in history 2 0 2
Total 52 4 82
As already noted, out of 52(37.6%) cases with C and S-shaped tortuosity, neurological deficit was observed in 40(76.9%) patients: TIA - in 24, DE - in 14. In 2 cases, the clinical picture of SMN accompanied It was produced by the spiral-shaped tortuosity of the ICA in combination with the atherosclerotic lesion of the OSA bifurcation, in these
patients there was an AI in history.
Of 82(59.4%) cases of excesses, 23 were observed to have double, 80(97.2%) had the following events: TIA - in 51, DE- in 27.
The leading role in the study ofblood flow in case of pathological tortuosity is assigned to color duplex scanning, the information content of which exceeds 90% (Zanneti P.P. et al., 1997; Del Corso L. et.all. 1998; Kazanchyan P. O., 2001; Valikov Ye. A. ., 2003; Pokrovsky A. B., 2010. etc.).
*
Figure 2. S-shaped crimp. C-shaped crimp The picture of color duplex mapping (kink) is shown in pathology of the intracranial segments of the brachiocephalic
(Figure 2).
All patients underwent color duplex scanning (Logic PQ-6, USA) and transcranial Doppler sonography (Angiodin-PC) using standard techniques. In case of insufficient infor-mativeness of U3I - methods, if there is a suspicion on the
arteries, we perform multislice computer tomography with contrast (GE, OPTIMA 660 USA).
A picture of multislice computed tomography with contrast (kink) is presented in (Figure 3).
Figure 3.
We used the classification of J. Weibel and W. Fields (1965). Under tortuosity (tortuosity) should be presented Sor C-shaped deformation of the ICA without acute angles and visible blood flow disorders. This type of deformity is hemo-
dynamically controversial. Looping (coiling) is characterized by circular deformation with the formation of a loop. Under the bending (kinking) refers to hemodynamically significant angulation of the ICA with stenosis of its lumen.
S-or C-shaped deformation of the ICA without acute angles and visible impairment of blood flow was detected in 115(51.5%) patients. These patients received conservative treatment and are under observation.
These patients received conservative treatment and are under observation. The tortuosity of the ICA with an acute angle and hemodynamic blood flow disorders was detected in 52(37.6%) patients. Looping (coiling) was detected in 4(3.2%) patients. Kinking - in 59(42.7%) patients and double kinking in 23(16.6%) patients.
Evaluation of hemodynamic changes in blood flow in the ICA due to pathological deformity was carried out according to the duplex scanning standard and the significance of the deformities:
Table 2.- Linear rotary
- change in the form of blood flow proximal to the deformity with elevated indices of peripheral resistance - turbulence;
- an increase in the linear blood flow velocity (BFV) in the deformation zone by more than 2 times the initial one;
- reduction recorded by the VSA LSK after deformation, compared LSK before bending.
Changes in the blood flow parameters in the region of the deformity of the carotid arteries and segments distal to the deformity of the artery are presented in (table 2).
Results
The need for surgery in patients with pathological deformity requires clear indications for surgical treatment, primarily based on the determination of the hemodynamic significance of tortuosity.
eed on duplex scaning
Crimpiness LSK to the zone of deformation m/s LSK deformation zone m/s LSK after deformation zone m/s Number of patients
S-shaped tortuosity (tortuosity) 0.60-0.70 0.9-1.0 0.30-0.40 52(37.6%)
Kink (kink) 0.55-0.70 0.8-1.0 0.25-0.30 82(59.4%)
Looping (coiling) 0.40-0.60 0.7-1.0 0.30-0.50 4(2.8%)
Norm: 0.40-0.50 from 40years and up
Regarding the pathological tortuosity of the carotid arteries, 138 operations were performed in 108 patients. The nature of the operations performed is presented in (Table 3).
Table 3.
Operation name Number of patients
Resection of the ICA with redressing and reimplantation into the old mouth 101(70.7%)
Resection of the ICA and redressing with reimplantation into the old mouth after eversion carotid endarterectomy 31(24.3%)
Resection of the ICA with anastomosis (end-end) 4(3.3%)
Prosthetics of the ICA (with a modified wall) 2(1.7%)
Total: 138(100%)
We have experience in surgical correction of 138 crimps in 108 patients. In case of correction of PI VSA, we prefer the operation of resection of an abnormal artery segment with redressing and implanting it into the old mouth. This operation was performed in 101 cases, and in 31 cases it was combined with eversion carotid endarterectomy. In the case of a small length of the process, with fibrous transformation and aneurism outside the tortuosity zone, a resection with anastomosis from end to end (6 C and S figurative tortuosity and coiling operations) was carried out when the ICA was bent.
Discussion
The observations show high sensitivity and informative duplex scanning and spiral computed tomography in determining the type of PI, identifying the combined atherosclerotic lesions of the carotid arteries, including the study of the morphological
characteristics of plaque and its surface structure. Intraoperative data on the character of PI coincided with the information obtained during the examination in 80% of cases.
The method of CDS allows to characterize in detail the form of tortuosity, its localization and to reveal the nature of the blood flow. The criteria for local hemodynamic significance of PI VSA are:
1. gradient peak systolic blood flow velocity between the proximal and distal parts of the vessel in relation to the place of tortuosity with a decrease in speed in the distal direction by 20% or more:
2. the increase in peak velocity at the site of angulation compared to the proximal site of the ICA by 30% or more: disorganization of blood flow in the tortuosity zone, manifested by an increase in spectral expansion and violation of the blood
flow pattern in the color mapping mode: compared with the same area unchanged contralateral ICA.
Thus, it has been established that one of the links in the pathogenesis of cerebral circulatory disorders in PI ICA is a local hemodynamic disorder in the tortuous zone with a decrease in blood flow in the distal direction.
The use of duplex scanning as a non-invasive method for studying the vessels of the brain, combining the advantages of visualization and quantitative assessment of blood flow, has expanded the understanding of this pathology. In adults, changes in the length and shape of the carotid arteries are most often seen in the sixth decade of life. The ratio of men and women at the same time is 4: 1, respectively.
Currently, the PI VSA may be the cause of transient and persistent violation of cerebral circulation. In the presence of modern ultrasound equipment, the CDS diagnostics of the PI VSA does not represent technical complexity.
When deciding on the treatment tactics, it is necessary to proceed from the hemodynamic significance of the lesion. In the case of concomitant atherosclerotic stenosis of the carotid arteries, the morphology of the plaque is important. The indication for surgery is the presence of a hemodynamically significant lesion of the vessel with a change in blood flow velocity at the site of stenosis, that is, an increase in the linear blood flow rate by 2 times.
In case of correction of PI ICA, we prefer the operation of resection of an excess artery segment with redressing and implanting it into the old mouth. This operation performed in 101 cases, and in 31 cases combined with eversion carotid endarterectomy.
Analysis of the clinical results of operations showed a positive dynamics of neurological status. Repeated TIA and AI in the pool of the operated SA was not observed. The symptoms of DE were completely eliminated in 23 of 41 patients, 15 patients showed partial regression of neurological symptoms, in 3 patients the neurological status remained unchanged, due to a lesion in the contralateral carotid artery. In 4 patients with a
history of AI who underwent repeat stroke was not observed. Long-term results of the operation (at follow-up periods of up to 3 years) were followed up in 58 patients.
The absence of neurological symptoms, TIA, ONMK during the observation period. The surgical effect of the performed reconstructions was evaluated using ultrasound diagnostics, the state of the anastomosis, the straightness of the vessel stroke, and hemodynamic disorders were studied. Good and satisfactory results were obtained in 92.3% of cases.
Findings:
1. Ultrasound duplex scanning is a highly informative method for the diagnosis of pathological tortuosity of the ICA. The method makes it possible in 90.2% to diagnose not only the anatomical structure of the pathological tortuosity of the carotid arteries, but also to determine the hemodynamic significance of the lesion, which is important in determining the indications for surgical intervention.
2. Hemodynamically significant pathological tortuosity of the carotid arteries is an indication for the surgical treatment of this disease, pathology as prevention of acute cerebrovas-cular accident.
3. When determining the indications for reconstructive surgeries at the SAI, it is necessary to clearly assess the clinical manifestations of the disease, thoroughly study the anatomical structure, that is, determine the place and degree of artery bend, determine the hemodynamic significance of vessel damage blood flow and resistance index of the affected artery, the type of tortuosity and the presence of concomitant stenotic lesions.
4. Surgical intervention in pathological tortuosity is shown when the linear flow velocity in the deformation zone is accelerated by 2 times. Characteristic for the inflection of the internal carotid artery should be considered the asymmetry of the reaction with an increase in BFV.
5. Surgical correction of the pathological tortuosity of blood vessels is a more effective method of treating and preventing the progression of chronic cerebrovascular insufficiency in the carotid pool compared with conservative therapy.
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