CC BY
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I. ДИАГНОСТИКА И ЛЕЧЕНИЕ
YflK 616.132.
THE RESULTS OF CAROTID ENDARTERECTOMY IN PATIENTS WITH MULTIFOCAL ATHEROSCLEROSIS
ABOUT THE AUTHORS
Demeuov Talgat Nurmuhanovich, director of vascular surgery department, doctor of higher category. E.mail: talgadem@mail.ru
Tergeussizov Ablay Sovetzhanovich, vascular surgeon. E.mail: tima9_9@mail.ru. Mob.: 8-701-970-32-29.
Keywords:
multifocal atherosclerosis, carotid endarterectomy, ischemic stroke, carotids artery.
АВТОРЛАР ТУРАЛЫ
Демеуов Талраг Н±рмахаи±лы, ангиохирургия бол'шшеоШ'щ мецгерушм, А.Н.Сыжанов ашндаш YfXO, M.f.K., жорары санагыныц дэргерi, E.mail: taigadem@maii.ru
Тергеуйзов Абылай Совегжан±лы, ангиохирург-дэр1гер E.mail: tima9_9@maii.ru. гел: 8-701-970-32-29.
Туйш сездер
мультифокалды атеросклероз, каротидт эндартерэктомия, инсульт ишемиясы, ±йкы артериялары
Demeuov T.N., Akanov E.K., Matkerimov A.Zh., Tergeussizov A.S.
National scientific center of surgery named after A.N. Syzganov
Summary
The results of 118 of operations in 106 patients (84 multivascular patients) had been analyzed. Postoperative ischemic stroke rate after operations in multivascular patients did not exceed European indicators. From 106 patients 12 carried carotid endarterectomy on either side stage-by-stage, beginning the most heavily staggered side. An interval between operations made from a 8 twenty-four hours to 7 months. This research shows that frequency of ischemic stroke after carotid endarterectomy in the group of multifocal atherosclerosis does not exceed the indexes of complications of operative treatment at the isolated defeat carotid pool.
Мультифокалды атеросклероз барысындагы каротидт эндартерэктомияньщ нэтижелер1
Демеуов Т.Н., Аканов Е.К., Маткер1мов А.Ж., Тергеусизов A.C.
А.Н. Cbi3f3H0B атындаш Улттык, шлыми хирургия оталыш
Ацдатпа
Каротидт эндартерэктомия жасаткан 106 пациенту 118 нэтижеа зерделендi. Мультифокальды атеросклероз то-бында операциядан кешнп ишемиялык инсульттыу жилю еуропалык керсетюштен аспайды. Каротидтi эндартерэктомия жасаткан пациенттердщ шнен, ауыр закымданеан жаеынан бастап, ею жактан каротидтi эндартерэктомияны жасаткан 12 ауру кезец-кезецмен кешт.i. Операциялар арасындаеы узшю 8 тэул!ктен бастап 7 ай^а дешн барады.
Мультифокальды атеросклероз тобында операциядан кешнп ишемиялык инсульттьщ жилю каротидтi бассешннщ ощауламан закымдаман кезнде жедел емдеу аскынуларыныц керсетюштернен аспайды.
ОБ АВТОРАХ
Демеуов Талгат Нурмаханович, заведующий отделением ангиохирургии, ННЦХим. А.Н. Сызганова, к.м.н., врач высшей категории. E.mail: taigadem@maii.ru
Тергеусизов Аблай Советжанович, врач ангиохирург. E.mail: tima9_9@mail.ru. Тел: 8-701-970-32-29.
Ключевые слова:
мультифокальный атеросклероз, каротидная эндартерэк-томия, ишемический инсульт, сонные артерии
Результаты каротидной эндартерэктомии при мультифокальном атеросклерозе
Демеуов Т.Н., Аканов Е.К., Маткеримов А.Ж., Тергеусизов А.С.
Национальный научный центр хирургии имени А.Н. Сызганова
Аннотация
Изучены результаты 118 каротидной эндартерэктомии у 106 пациентов. Частота послеоперационного ише-мического инсульта в группе мультифокального атеросклероза не превышает европейский показатель. Из 106 пациентов 12 перенесли каротидную эндартерэктомию с обеих сторон поэтапно, начиная наиболее тяжело пораженной стороны. Интервал между операциями составил от 8 суток до 7 месяцев. Данное исследование показывает, что частота ишемического инсульта после каротидной эндартерэктомии в группе мультифокального атеросклероза не превышает показателей осложнений оперативного лечения при изолированном поражении каротидного бассейна.
Carotid endarterectomy (CE) - one of the most frequently performed vascular operations worldwide. In the US, according to the Dartmouth Institute performed FE 2.5 per 1,000 population over 65 years, in absolute numbers it is 100 thousand. Operations per year (1).
European Society of Vascular Surgeons (ESV) analyzed data 48025 interventions on the carotid arteries performed in 383 clinics in 10 countries for the period from 2012 to 2015. The following results: mortality after CE was 0.45%, with no kind of technique (classical with / without the use of a patch, eversion) of any type of anesthesia (general / local) did not affect the frequency of deaths. The frequency of postoperative stroke was 1.3% (2).
Under the conditions of our country atherosclerotic lesions of the carotid arteries is accompanied by involvement of other vascular beds, which affects the general condition of the patient.
The purpose of research - to study the results of CE in patients with multifocal atherosclerosis (MA). (1)
Subjects and methods.
118 studied FE results in 106 patients who were hospitalized in the department of vascular surgery NNTSH them. A.N. Syzganova for the period from 2012 to 2015. Age ranged from 47 to 81, with the prevalence in patients aged 50 to 70 years (Table 1).
All patients had stenosis of the internal carotid artery (ICA), more than 60% (by ECST-method). In 56 (52.8%) patients had a history of ischemic
stroke or transient ischemic attack (TIA) in the last 6 months, 50 patients (47.2%) of the carotid artery lesion was of asymptomatic character. 28 patients (26.4%) had previously transferred reconstructive surgery on the arteries during the period from 4 months to 8 years. However, in all patients TBE performed first.
In 84 (79.2%) patients (group 1) took place the MA that is revealed hemodynamically significant lesion 2 or more vascular beds. In group 2 included patients with isolated aortic atherosclerotic lesions arc basin (Table 2). In 59.5% of patients of group 1 were «symptomatic,» that is transferred to an isch-emic stroke or TIA (6 months). In the second group the percentage of these patients was 2-fold less -27.3%. (2)
Almost half of the cases of multifocal atherosclerosis observed defeated two pools - 49.1%. This stenosis of the brachiocephalic arteries in 24 (48.0%) patients with combined coronary disease, and 26 (52.0%) - with the defeat of the basin of the lower extremities (Table 3).
In the majority of patients (22 of 26) with three-vessel disease was observed following the combination of the defeat: brachiocephalic artery + + artery coronary arteries of the lower extremities (Table 4).
Achieved 118 CE. Of the 106 patients 12 suffered carotid endarterectomy on both sides in phases, beginning the most heavily affected side. The interval between operations was 8 days to 7 months. (3)
In 14 cases out of 118 applied eversion EC, in other cases, the operation is performed in the
Age 40-49 years 50-59 years 60-69 years 70-79 years Over 80 years All
M. 4 28 44 18 2 96
W. 0 2 4 4 0 10
All 4 30 48 22 2 106
Table 1.
Distribution of patients by age and sex.
1 pool 2 pool 3 pool 4 pool All
M. 16 48 26 6 96
W. 6 4 0 0 10
All 22 52 26 6 106
(20,8%) (49,1%) (24,5%) (5,7%)
TIA / stroke 6 34 12 4 56
(27,3%) (65,4%) (46,2%) (66,7%) (52,8%)
Table 2.
Distribution of patients on the prevalence of atherosclerotic lesions and neurological characteristics.
Table 3.
Distribution of patients with vessel disease by a combination of pools
(BCA - brachiocephalic bed, CA - coronary artery, ALL - the arteries of the lower limbs, VA - visceral branches of the abdominal aorta (renal arteries)).
BCA + CA BCA + ALL BCA + VA All
M. 23 24 0 47
W. 2 2 0 4
All 25 26 0 51
BULLETIN OF SURGERY IN KAZAKHSTAN № 1-2017
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Table 4.
Distribution of patients with three-vessel disease by a combination of pools.
BCA + CA +ALL BCA + CA + VA BCA + VA + ALL All
M. 22 2 2 26
W. 0 0 0 0
All 22 2 2 26
Stroke Bleeding Damaging cranial nerves Total
1 group (n - 94) 1 (1,1%) 3 (3,2%) 4 (4,3%) 8 (8,5%)
2 group (n - 24) 1 (4,2%) 0 0 1 (4,2%)
Total (n - 118) 2 (1,7%) 3 (2,5%) 4 (3,4%) 9 (7,6%)
«classical» style, with / without patch. In 4 cases, the EC combined with a carotid-subclavian bypass. In one case, made simultaneous operations FE + aorto-femoral alloshuntirovanie. (4)
All operations were performed under general anesthesia. Control of the cerebral circulation was carried out on the basis of cerebral oximetry and indicators retrograde pressure in the BCA.
Results
In the immediate postoperative deaths was not observed (Table 5).
In both groups, 1 case of ischemic stroke was observed in the ipsilateral side of the hemisphere without lethal outcome, which was 1.1% for the group of multifocal atherosclerosis and 4.2% for the group of isolated lesions of the BCA. Unfortunately, the study included an inadequate number of patients with isolated lesions of the BCA, which prevented comparison of the groups.
In the analysis of cases of postoperative stroke development, it was found that both patients had bilateral critical stenosis of the internal carotid artery diagnosed. A patient from group 1 had a history of 2 ischemic stroke. In the same patient, due to the pronounced syndrome of subclavian steal-
References
ing, one-stage intervention was performed - CE + sleep-subclavian alloscience. Patient from group 2 had a history of TIA.
Presumably, the outcome of the operation was heavily influenced by factors such as the state of the contralateral ICA, the prevalence of the atherosclerotic process within the brachiocephalic bed, and the neurological history. These aspects are the subject of further research.
Studying other complications, it was found out that in all 3 cases of postoperative bleeding, which required a second operation, the cause of bleeding was insufficiently thorough hemostasis. In 4 cases, signs of damage to the cranial nerves appeared in the postoperative period, in all cases, appropriate treatment was performed with a positive effect in 3 patients. In 1 patient after 6 months there were residual phenomena in the form of hoarseness.
Conclusion
Thus, the incidence of ischemic stroke after carotid endarterectomy in the group of multifocal atherosclerosis does not exceed the rates of complications of surgical treatment with isolated carotid involvement.
1. Trends and regional variation in carotid revascularization // The Dartmouth Institute for Health Policy and Clinical Practice, 2010.
2. VASCUNET (on behalf of the ESVS). Second Vascular Surgery Database Report, 2008
3. Vascular Surgery. Edited by Dai Yamanouchi, ISBN 978-953-51-0328-8, 272 pages, Publisher: InTech, Chapters published.
4. Vascular and Endovascular Surgery Jonathan D. Beard.
