ЦЕЛЬ ИССЛЕДОВАНИЯ Анализ непосредственных результатов каротидной эндартерэктомии (КЭЭ) с селективным применением временного шунта (ВШ) и отказом от него. МАТЕРИАЛ И МЕТОДЫ В данное многоцентровое ретроспективное исследование за период с января 2005 г. по октябрь 2020 г. вошли 4967 пациентов с гемодинамически значимыми стенозами внутренней сонной артерии (ВСА), которым выполнена классическая КЭЭ с пластикой зоны реконструкции заплатой. В зависимости от применения ВШ все пациенты были распределены на три группы: 1-я (n=1328, 26,7%) — ВШ был установлен ввиду низкого ретроградного давления в ВСА (<60% от системного); 2-я (n=1853, 37,3%) — ВШ не был установлен ввиду удовлетворительного ретроградного давления (≥60% от системного); 3-я (n=1786, 35,9%) — ВШ не был установлен умышленно (ретроградное давление в ВСА не измеряли). Среднее время установки шунта в 1-й группе составило 46,2±17,6 с. В работе описана подробная инструкция по установке ВШ с наглядными иллюстрациями, указаны основные нюансы процедуры. Предложенные этапы установки ВШ могут лечь в основу обучения ординаторов и молодых сосудистых хирургов, а также должны быть внесены в новую версию национальных рекомендаций. РЕЗУЛЬТАТЫ В госпитальном периоде группы были сопоставимы по частоте летальных исходов (p=0,62), фатальных (p=0,96) и нефатальных инфарктов миокарда (ИМ) (p=0,73), фатальных острых нарушений мозгового кровообращения (ОНМК) (p=0,54) и нефатальных ОНМК/транзиторных ишемических атак (ТИА) (p=0,12). Однако наибольшее количество «немых» ОНМК было зафиксировано в группе больных, в которой ВШ был установлен (1-я группа: 2,56%, n=34; 2-я группа: 0,5%, n=9; 3-я группа: 0,55%, n=10; p<0,0001). Это состояние повлияло на максимальные значения комбинированной конечной точки (с учетом «немых» ОНМК), которую чаще определяли в 1-й группе (1-я группа: 3,3%, n=44; 2-я группа: 1,02%, n=19; 3-я группа: 1,56%, n=28; p<0,0001). Наибольшее количество фатальных ишемических ОНМК зафиксировано при стенозе ВСА 60—80% в 1-й группе (p=0,02; селективная установка ВШ), 91—99% во 2-й группе (p=0,003; отказ от ВШ ввиду удовлетворительного ретроградного давления) и 3-й группе (p<0,0001; умышленный отказ от ВШ). Подавляющее количество нефатальных ОНМК (1,8%; n=5) выявлено в группе 3 (умышленный отказ от ВШ) при выраженности контралатерального стеноза ВСА 91—99% (p=0,0008). Наибольшее количество «немых» ОНМК (4,4%; n=11) было зафиксировано в 1-й группе (селективная установка ВШ) при выраженности контралатерального стеноза ВСА 91—99% (p=0,02). Таким образом, комбинированная конечная точка показала, что ОНМК чаще развивается при выраженности контралатерального стеноза ВСА 91—99% (1-я группа: 0,4%, n=6; 2-я группа: 0,2%, n=6; 3-я группа: 1,85%, n=15; p<0,0001). ВЫВОД В госпитальном послеоперационном периоде при применении ВШ было выявлено наибольшее количество «немых» ОНМК, в результате чего комбинированная конечная точка в данной группе имела наибольшие показатели. По частоте нефатальных/фатальных ОНМК, ТИА, ИМ, летальных исходов значимых различий не выявлено. Измерение ретроградного давления не всегда соответствовало действительным компенсаторным возможностям коллатерального кровообращения. В результате при нормальных показателях (≥60% от системного) было выявлено значимое возрастание частоты ОНМК в условиях контралатерального стеноза ВСА 60—80%. При умышленном отказе от установки ВШ установлена значимая динамика в увеличении количества случаев фатальных и нефатальных ОНМК в условиях контралатерального стеноза ВСА 91—99%.

Analysis of the results of emergency carotid endarterectomy (CEE) against the background of internal carotid artery (ICA) thrombosis in the acute period of acute cerebrovascular accident (ACVA) in patients with COVID-19. During the COVID-19 pandemic (April 1, 2020-May 1, 2021), 43 patients with ICA thrombosis and a positive polymerase chain reaction (PCR) result for SARS-CoV-2 were included in this prospective study. In all cases, CEE was performed in the acutest period of ACVA. These patients were included in group 1. The comparison group was represented by 89 patients who underwent CEE in the acute period of stroke, in the period before the COVID-19 pandemic (April 1, 2019-March 1, 2020). According to laboratory parameters, patients with COVID-19 had severe coagulopathy (with an increase in D-dimer: 3832 ± 627.2 ng/mL, fibrinogen: 12.6 ± 3.1 g/L, prothrombin: 155.7 ± 10, 2%), inflammatory syndrome (increased ferritin: 646.2 ± 56.1 ng/mL, C-reactive protein: 161.3 ± 17.2 mg/L, interleukin-6: 183.3 ± 51.7 pg/mL, leukocytosis: 27.3 ± 1.7 10E9/L). In the hospital postoperative period, the groups were comparable in terms of the incidence of deaths (group 1: 2.3%, n = 1; group 2: 1.1%, n = 1; P= 0.81; OR=2.09; 95 % CI = 0.12-34.3) myocardial infarction (group 1: 2.3%, n = 1; group 2: 0%; P= 0.7; OR = 6.3; 95% CI = 0.25-158.5), CVA (group 1: 2.3%, n = 1; group 2: 2.2%, n = 2; P= 0.55; OR = 1.03; 95% CI = 0,.09-11.7). ICA thrombosis and hemorrhagic transformations were not recorded. However, due to severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 more often developed bleeding in the operation area (group 1: 11.6%, n = 5; group 2: 1.1%, n = 1; P= 0.02; OR = 11.5; 95% CI = 1.3-102.5). In all cases, the flow of hemorrhagic discharge came from the drainage localized in the subcutaneous fat. This made it possible to remove skin sutures in a dressing room, suturing the source of bleeding and applying secondary sutures under local anesthesia. Emergency CEE in the acute period of stroke is an effective and safe method of cerebral revascularization in case of ICA thrombosis in conditions of COVID-19.

OBJECTIVE:To analyze in-hospital and long-term results of eversion carotid endarterectomy (CEE), carotid endarterectomy with patch repair and carotid artery stenting (CAS) in patients with high bifurcation of common carotid artery.MATERIAL AND METHODS:A retrospective multiple-center open study included 1983 patients who underwent internal carotid artery (ICA) repair for severe stenosis between 2010 and 2021. Three groups of patients were distinguished depending on revascularization option: group 1 (n=638) - eversion CEE; group 2 (n=351) - CEE with patch repair; group 3 (n=994) - CAS.RESULTS:In-hospital postoperative mortality and incidence of stroke and myocardial infarction were similar. All bleedings (n=39) occurred after CEE. ICA thrombosis was diagnosed in groups 1 and 2 due to intimal detachment after insertion of temporary bypass tube. Incidence of laryngeal paresis, neuropathy of hypoglossal and glossopharyngeal nerves, Horner syndrome, damage to salivary glands was comparable in groups 1 and 2. Long-term mortality was the highest (n=10; 2.8%) after CEE with patch repair due to fatal stroke. In turn, the highest incidence of ICA restenosis and restenosis-induced ischemic stroke was observed after CEE with patch repair and CAS.CONCLUSION:1. Classical and eversion CEE in patients with high CCA bifurcation is followed by high in-hospital incidence of damage to cranial nerves and salivary glands, laryngeal paresis, Horner syndrome, bleeding and risk of ICA thrombosis. 2. In patients with high CCA bifurcation, CAS and CEE with patch repair are accompanied by high incidence of ICA restenosis, restenosis-induced stroke and mortality in long-term postoperative period. 3. Eversion CEE demonstrates the lowest rates of all adverse cardiovascular events in long-term follow-up period.

Aim. To demonstrate the first Russian computer program (carotidscore.ru) for risk stratification of postoperative complications of carotid endarterectomy (CE).Material and methods. The present study is based on the analysis of a multicenter Russian database including 25812 patients after CE operated on from January 1, 2010 to April 1, 2022. The following types of CE were implemented: conventional CE with patch angioplasty — 6814 patients; eversion CE — 18998 patients. Following postoperative complications were assessed during the study: death, stroke, myocardial infarction (MI), composite endpoint (death + stroke + MI).Results. During inhospital postoperative period, 0,18% of participants died, while 0,14% had MI, 0,35% — stroke. The composite endpoint was recorded in 0,68%. For each factor present in patients, a predictive coefficient was estimated. The predictive coefficient was considered as a numerical parameter reflecting the strength of the effect of each factor on the development of postoperative complications. Based on this equation, predictive coefficients were calculated for each factor present in patients in our study. The total contribution of these factors was reflected as a percentage and denoted the risk of postoperative complications with a minimum of 0% and a maximum of 100%. On the basis of obtained calculations, a CarotidSCORE program was created. Its graphical interface is based on the QT framework. It is possible not only to estimate the risk of a complication, but also to save all data about a patient in JSON format. The CarotidSCORE program contains 47 patient parameters, including clinical, demographic, anamnestic and angiographic characteristics. It makes it possible to choose one of the four CE types, which will provide an accurate stratification of the complication risk for each of them.Conclusion. CarotidSCORE (carotidscore.ru) may determine the probability of postoperative complications in patients undergoing CE.

At present, there are no studies on the analysis of the incidence of complications in patients with concomitant lesions of the coronary and internal carotid arteries (ICA) after combined operation of carotid endarterectomy (CE) and coronary artery bypass grafting (CABG) against the background of type 2 diabetes (T2D). However, there is no doubt that this condition can be a predictor of cardiovascular and wound complications during in-hospital and long-term postoperative periods.Aim. To study in-hospital and long-term outcomes of combined CABG+CE in patients with and without type 2 diabetes.Material and methods. This multicenter retrospective study for the period from January 2015 to December 2019 included 653 patients with concomitant atherosclerotic lesions of ICA and coronary arteries, who underwent combined CE+CABG. Depending on presence of type 2 diabetes, 2 groups were formed: group 1 (n=183) — patients with type 2 diabetes; group 2 (n=471) — patients without type 2 diabetes. The duration of postoperative follow-up was 37,8±14,9 months.Results. During hospitalization, significant differences in the incidence of death (group 1 =1,1%; group 2 =1,0%; p=0,97), myocardial infarction (MI) (group 1 =1,1%; group 2 =0,8%; p=0,76), bleeding events (group 1 =1,1%; group 2 =0,8%; p=0,76) were not detected. However, stroke (group 1 =3,8%; group 2 =0,4%; p=0,0008), sternal wound infection and mediastinitis (group 1 =3,3%; group 2 =0,2%; p=0,0006) were significantly more often developed in patients with type 2 diabetes.In the long-term follow-up period, death (group 1 =6,6%; group 2 =1,1%; p<0,0001), MI (group 1 =4,9%; group 2 =0,8%; p=0,0008), stroke (group 1 =7,7%; group 2 =1,5%; p<0,0001), ICA restenosis (group 1 =8,8%; group 2 =1,6%; p<0,0001), repeated emergency myocardial revascularization (group 1 =7,2%; group 2 =1,5%; p=0,0002), repeated emergency cerebral revascularization (group 1 =8,8%; group 2 =1,6%; p<0,0001) were significantly more often recorded in patients with type 2 diabetes.Kaplan-Meier curve analysis and its comparison using the log rank test revealed that the death, MI, and stroke were also significantly more often observed in patients with type 2 diabetes (p=0,0007, p=0,003, p<0,0001, respectively).Conclusion. Patients with type 2 diabetes who are referred for combined CE+CABG are at an increased risk of stroke, sternal wound infection and mediastinitis in the in-hospital postoperative period, as well as all adverse cardiovascular events in the long-term follow-up period.

Aim of study. Analysis of the dynamics of resistant arterial hypertension (RAH) and the spectrum of adverse cardiovascular events in patients after classical carotid endarterectomy (CEE) with preservation of carotid body (CB) and eversion CEE with CB transection. Material and methods. This cohort, comparative, retrospective, open-label study from January 2014 to December 2020 included 761 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA) and RH lasting more than 3 years. Depending on the implemented revascularization strategy, 2 groups were formed: Group 1: 38.0% (n=289) — classical CEE with plasty of the reconstruction zone with a patch (made of diepoxy-treated xenopericardium or synthetic); Group 2: 62% (n=472) — eversion CEE with CB transection. To study the dynamics of systolic blood pressure (SBP) in the preoperative period for 4 days, and in the postoperative period, blood pressure was measured for 10 days (during the period when the patient was in intensive care - according to daily monitoring of blood pressure; in the department - 10 times per day, daily). The average SBP figures for all patients were taken into account when constructing a graph of BP fluctuations. Results. In the postoperative period, the groups were comparable in the frequency of the following events: death (group 1: 0.34% (n=1), group 2: 0.63% (n=3); p=0.98; OR 0.54; 95% CI 0.05–5.21), myocardial infarction (group 1: 0.34% (n=1), group 2: 0.84% (n=4); p=0.71; OR 0, 40; 95% CI 0.04–3.65), ischemic stroke (group 1: 0.34% (n=1), group 2: 1.27% (n=6); p=0.36; OR 0.26; 95% CI 0.03–2.25), hemorrhagic transformation (group 1: 0%, group 2: 0.84% (n=4); p=0.29; OR 0.17; 95% CI 0.009–3.35). However, in terms of the number of all complications (death + myocardial infarction + ischemic stroke + hemorrhagic transformation) presented as a combined endpoint, patients after eversion CEE with CB transection were three times superior to classical surgery (group 1: 1.03% (n=3 ), group 2: 3.60% (n=17); p=0.05; OR 0.28; 95% CI 0.08–0.9). Conclusion. The choice of a revascularization strategy in patients with hemodynamically significant ICA stenosis should be personalized and based on the conclusion of a multidisciplinary consultation, and not only on the preferences of the operating surgeon. In patients with RH, it is more expedient to use classical CEE with plasty of the reconstruction zone with a patch in view of the preservation of the CB during this operation. The intersection of the latter with eversion CEE provokes labile hypertension, progression of RAH and a statistically significant increase in the number of all unfavorable cardiovascular events. Thus, the use of carotid body preserving CEE in patients with RAH confirms the therapeutic mechanism of this manipulation in achieving the target SBP level.

This review of the literature discusses the solution of unresolved issues related to carotid endarterectomy in Russia: (1) A program has been created for choosing the tactics of revascularization of patients with simultaneous atherosclerotic lesions of the coronary and carotid arteries; (2) Using the methods of computer modeling, studying the genetics and morphology of restenosis, it was found that the classic carotid endarterectomy with plasty of the reconstruction zone with a patch is an unsafe type of revascularization; (3) An eversion carotid endarterectomy with transposition of the internal carotid artery over the hypoglossal nerve has been developed, which makes it possible to prevent damage to the latter during repeated carotid endarterectomy for restenosis; (4) It has been established that carotid endarterectomy is associated with a high risk of complications in patients over 75 years of age; (5) It has been proven that emergency carotid endarterectomy in the first hours after the development of a stroke is not safe because. combined with the maximum number of all non-favorable cardiovascular events; (6) 3 new types of carotid endarterectomy with carotid glomus preservation have been developed.

Aim. To analyze the immediate and long-term outcomes of eversion and conventional carotid endarterectomy (CE) with patch angioplasty.Material and methods. For the period from February 1, 2006 to September 1, 2021, the present retrospective multicenter open comparative study included 25106 patients who underwent CE. Depending on the technique of operation, the following groups were formed: group 1 (n=18362) — eversion CE; group 2 (n=6744) — conventional CE with patch angioplasty. The long-term follow-up period was 124,7±53,8 months.Results. In the hospital postoperative period, the groups were comparable in incidence of all complications: lethal outcome (group 1: 0,19%, n=36; group 2: 0,17%, n=12; p=0,89; odds ratio (OR) =1,1; 95% confidence interval (CI) =0,57- 2,11); myocardial infarction (MI) (group 1: 0,15%, n=28; group 2: 0,13%, n=9; p=0,87; OR=1,14; 95% CI=0,53-2,42); stroke (group 1: 0,33%, n=62; group 2: 0,4%, n=27; p=0,53; OR=0,84; 95% CI=0,53-1,32); bleeding with hematoma formation (group 1: 0,39%, n=73; group 2: 0,41%, n=28; p=0,93; OR=0,95; 95% CI=0,61-1,48); internal carotid artery (ICA) thrombosis (group 1: 0,05%, n=11; group 2: 0,07%, n=5, p=0,9; OR=0,8; 95% CI=0,28-2,32). In the long-term follow-up, the groups were comparable only in MI incidence: group 1: 0,56%, n=103; group 2: 0,66%, n=45; p=0,37; OR=0,84; 95% CI=0,59-1,19. All other complications were more frequent after conventional CE with patch angioplasty: all-cause death (group 1: 2,7%, n=492; group 2: 9,1%, n=616; p<0,0001; OR=0,27; 95% CI=0,24-0,3); lethal ischemic stroke (group 1: 1,0%, n=180; group 2: 5,5%, n=371; p<0,0001; OR=0,17; 95% CI=0,14-0,21); non-lethal ischemic stroke (group 1: 0,62%, n=114; group 2: 7,0%, n=472; p<0,0001; OR=0,08; 95% CI=0,06-0,1); ICA restenosis >60%, requiring re-revascularization (group 1: 1,6%, n=296; group 2: 12,6%, n=851; p<0,0001; OR=0,11; 95% CI=0,09-0,12). Thus, the composite endpoint (lethal ischemic stroke + non-lethal ischemic stroke + MI) after conventional CE with patch angioplasty was more than 6 times higher than this parameter of eversion CE: group 1: 2,2%, n=397; group 2: 13,2%, n=888; p<0,0001; OR=0,14; 95% CI=0,12-1,16.Conclusion. Conventional CE with patch angioplasty is not prefer for cerebral revascularization in the presence of hemodynamically significant ICA stenosis due to the high prevalence of deaths, stroke, and ICA restenosis in the long-term follow-up.

AIM OF STUDY Study of hospital results of emergency carotid endarterectomy (CEE) and carotid angioplasty with stenting (CAS) in the acute period of acute cerebrovascular accident (ACVA).MATERIAL AND METHODS From January 2008 to August 2020, the study included 615 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), operated on in the acute period of ischemic stroke (within 3 days from the onset of stroke). Depending on the type of revascularization implemented, all patients were divided into 2 groups: group 1 — CAS (n=312); 2nd group — CEE (n=357). Inclusion criteria were as follows: 1. Mild neurological disorders: NIHSS score 3–8; Modified Rankin Scale score 2 of less; Barthel Scale > 61; 2. Indications for CEE / CAS according to the current national recommendations; 3. Ischemic focus in the brain not more than 2.5 cm in diameter. Exclusion criteria: 1. Presence of con-traindications to CEE / CAS. Carotid angioplasty with stenting was performed according to the standard technique; in all cases, distal embolism protection systems were used. Carot-id endarterectomy was performed according to the classical and eversion techniques. When the retrograde pressure in the ICA was less than 60% of the systemic pressure, a temporary shunt (TS) was installed. In the postoperative period, all patients underwent multispiral computed tomography (MSCT) of the brain. In the absence of negative dynam-ics in the neurological status, MSCT was performed on the 7th day after the operation, if available, it was performed urgently. The checkpoints were the development of such unfa-vorable cardiovascular events as death, myocardial infarction (MI), stroke / transient is-chemic attack (TIA), “mute” stroke, “mute” hemorrhagic transformations, combinedend-point (death + all strokes / TIA + MI). Strokes were mute if diagnosed according to MSCT, without symptoms.RESULTS In 69% of diabetic patients with anterior myocardial infarction and in 63% of patients with posterolateral MI 12 months after PCI, signs of LV inferiority were revealed in the form of an increase in the indices of end-diastolic and systolic volumes of the LV and low ejection fraction (≤45%). In patients without diabetes, these figures were 18% and 31%, respectively. High concentrations of NT-proBNP on the first day of myocardial infarction after PCI were of the greatest value in the diagnosis and prognosis of LV UR after 12 months.RESULTS When analyzing hospital complications, significant differences in the frequency of lethal outcome were not obtained (group 1: n=6 (1.92%); group 2: n=8 (2.24%); p=0.98; OR=0.85; 95% CI 0.29–2.49); MI (group 1: n=5 (1.6%); group 2: n=5 (1.4%); p=0.91; OR=1.14; 95% CI 0.32–3.99 ); ACVA (ischemic type) / TIA (group 1: n=5 (1.6%); group 2: n=6 (1.7%); p=0.82; OR=0.95; 95% CI 0.28–3.15), as well as “mute” ACVA (group 1: n=7 (2.2%); group 2: n=15 (4.2%); p=0.23; OR=0.52; 95% CI 0.21–1.3). However, the vast majority of hemorrhagic transformations (group 1: n=2 (0.64%); group 2: n=13 (3.6%); p=0.018; OR=0.17; 95% CI 0.03–0.76) and all “mute” hemorrhagic transformations (group 1: n=0; group 2: n=26 (7.3%); p=0.001; OR=0.02; 95% CI 0.001–0.33) were observed only in the CEE group, which was reflected in the maximum values of the combined end point: group 1: n=22 (7.05%); group 2: n=73 (20.4%); p<0.0001; OR=0.29; 95% CI 0.17–0.48). Thus, in the CEE group, every 5th patient had a complication.CONCLUSION Carotid angioplasty with stenting is the safest method of revascularization for patients in the acute period of ACVA. This is largely due to the reduction in the risk of reperfusion syndrome and the prevention of embolism due to the use of modern protection systems. Carotid endarterectomy can be performed with comparable efficiency only when a tempo-rary shunt is placed in the internal carotid arteries in the absence of unstable atheroscle-rotic plaque.

BACKGROUND: The circle of Willis (CW) is an important network of collaterals that provide compensatory redistribution of hemodynamic load. Several studies showed that the CW is open in approximately 50%90% of cases, and the number of missing segments correlates with low brain tolerance to ischemia in internal carotid artery (ICA) compression. Currently, studies dedicated to the relationship of different configurations of CW with the risk of ischemic brain damage. AIM: The analyze the immediate results of eversion carotid endarterectomy (CEA) in patients with different configurations of the structure of the CW. MATERIALS AND METHODS: We included 641 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA) in a study period from 2010 to 2020. All patients underwent multispiral computed tomography with angiography of the extracranial and CW arteries. Based on the structural variants of the CW, six groups of patients were studied: group 1 (64.9%, n = 416) closed posterior part (CPP) with the existence of posterior communicative artery (PCA) and P1 segment of the posterior cerebral artery (PCerA); group 2 (27%, n = 173) an intermediate structure of the posterior part (IPP) with hypoplasia of the PCA or PCerA; group 3 (8.1%, n = 52) open posterior part (OPP) with the absence of PCA or PCerA; group 4 (85.95%, n = 551) closed anterior part (CAP) with the presence of the anterior communicating artery (ACA) and A1 segment of the anterior cerebral artery (ACerA); group 5 (7.95%, n = 51) an intermediate structure of the anterior part (IAP) with hypoplasia of ACA or ACerA; group 6 (6.1%, n = 39) open anterior part (OAP) with the absence of ACA or ACerA. To assess the compensatory potentials of the brain, all patients underwent measurement of the retrograde pressure in the ICA and intraoperative cerebral oximetry. RESULTS: In the postoperative period, 1 death was recorded in group 4 (CAP) due to a hemorrhagic transformation in the zone of ischemic stroke, on the background development of hyperperfusion syndrome. The largest number of ischemic strokes of the cardioembolic subtype was diagnosed in the ACerA territory in the presence of an unstable atherosclerotic plaque: group 1 (CPP) 0%; group 2 (IPP) 0%; group 3 (OPP) 0.24%, n = 1; group 4 (CAP) 0.18%, n = 1; group 5 (IAP) 1.96%, n = 1; group 6 (OAP) 5.1%, n = 2; p 0.9999. The probable cause was embolization against the background increase in the arterial pressure before ICA clamping. In turn, the majority of ischemic strokes of the hemodynamic subtype developed in the territory of PCerA: group 1 (CPP) 0%; group 2 (IPP) 1.73%, n = 3; group 3 (OPP) 3.8%, n = 2; group 4 (CAP) 0.18%, n = 1; group 5 (IAP) 0%; group 6 (OAP) 2.56%, n = 1; p 0.9999. This pattern coincided with the largest number of patients with CW of the IPP and OPP types among all open variants of the structure. CONCLUSION: Parameters of retrograde pressure in the ICA and intraoperative cerebral oximetry do not always demonstrate the need for a temporary shunt (TS). Due to the opened structure of CW, the redistribution of blood flow occurs with the formation of zones of hypo- and hyperperfusion, causing ischemic alterations in the brain matter. Thus, in order to maintain adequate cerebral hemodynamics, to mitigate the effect of hypo- and hyperperfusion, and reduce the risk of ischemic stroke, the open variant of the CW structure should be considered as an indication for a TS.

Aim. To analyze the results of multicenter study on dynamics of resistant hypertension (RH) in patients after various types of carotid endarterectomy (CE) with and without carotid body savingMaterial and methods. During the period from January 2010 to December 2020, 1827 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RH were operated on. Depending on CE type, the two groups were selected. Group 1 (n=1135; 62,2%) consisted of patients received glomus-saving surgery: 19,2% (n=351) -conventional CE with a patch repair of reconstitution point; 13,6% (n=248) — glomus-saving CE sensu R. A. Vinogradov; 7,3% (n=133) — glomus-saving CE sensu K. A. Antsupov; 11,7% (n=214) — glomus-saving CE sensu A. N. Kazantsev; 4,6% (n=84) — Chick-Chirik CE; 5,7% (n=105) — swallow tail type patch repair sensu R. I. Izhbuldin. Group 2 (n=692; 37,8%) consisted of patients received CE without glomus saving: 18,6% (n=341) — eversion CE with carotid body cutoff; 6,3% (n=115) — CE with new bifurcation plasty; 5,85% (n=107) — autoarterial reconstruction; 7,1% (n=129) ICA autotransplantation sensu E. V. Rosseikin.Results. The mortality rate, as well as the prevalence of myocardial infarction (MI) and ischemic strokes were comparable in groups. The incidence of hemorrhagic transformation (group 1: 0%; group 2: 0,6%; p=0,04; OR=0,06; 95% CI, 0,003-1,25) and composite endpoint (death+MI+ischemic stroke+hemorrhagic transformation) (group 1: 1,06%; group 2: 3,0%; p=0,004; odds ratio (OR)=0,34; 95% CI, 0,16-0,69) significantly differs between groups. After glomus-saving CE, the number of patients with the target blood pressure (BP) level reached 51,1% (p <0,0001; OR=0,0009; 95% CI, 6,05-15,9). The number of patients with grade II (31,1%; p<0,0001; OR=12,7; 95% CI, 10,4-15,52) and III (3,6%; p<0,0001; OR=10,26; 95% CI, 6,71-15,67) hypertension significantly decreased. In the group 2, the prevalence grade III hypertension increased (48,0%; p<0,0001; OR=0,23; 95% CI, 0,18-0,3), while the number of patients with grade I (0%; p<0,0001; OR=77,0; 95% CI, 4,71-12,58) and II (52%; p<0,0001; OR=3,06; 95% CI, 2,43-3,86) hypertension decreased.Conclusion. Glomus-saving CE contributes to achieving target BP in patients with RH. Its removal increases the risks of labile hypertension, postoperative hypertensive crisis, hyperperfusion syndrome and hemorrhagic transformation.

Aim . To analyze inhospital outcomes of carotid endarterectomy (CE) in the acute period (within 3 days from the onset) of ischemic stroke. Material and methods . This retrospective multicenter study for the period from January 2008 to August 2020 included 357 patients who underwent CE in the acute period of stroke. An interdisciplinary commission defined the revascularization timing. There were following inclusion criteria: 1. Mild neurological disorders: NIHSS stroke of 3-8; modified Rankin Scale score 61; 2. Indications for CE according to the current national guidelines; 3. Brain ischemic focus 3b bleeding, internal carotid artery thrombosis, composite endpoint (death + all strokes/TIA + MI). Silent strokes were those strokes, established according to control multi-slice computed tomography angiography, without symptoms. Results . During the in-hospital follow-up period, 8 deaths (2,24%), 5 MIs (1,4%), 6 strokes/TIAs (1,7%), 15 silent ischemic strokes (4,2%), 13 hemorrhagic transformations (3,6%), 26 silent hemorrhagic transformations (7,3%), and 6 BARC type >3b bleeding (1,7%) were recorded. Thus, the combined endpoint was 20,4% (n=73). Conclusion . Due to the high incidence of cardiovascular events, CE is not a safe operation for patients in the acute period of ischemic stroke. The stroke + mortality rate exceeding 3% demonstrates the ineffectiveness of this method of treatment.

Aim. To cоmpare the results оf infra-spinal reconstructions of the lower extremities with the formatiоn of a distal anastomоsis below the knee joint fissure with the use of a bioprosthesis and autovein in critical limb ischemia (CLI).Methods. The hospital results of revascularization were retrospectively analyzed in 53 patients with CLI who underwent primary prosthetics of the femoral-popliteal segment with the fоrmation of a distal anastomоsis belоw the knee joint gap. All patients, depending on the prоsthetic material used, were divided into two groups: 1) autovein was used as a prosthesis (39.6%, n = 21)) and 2) a bioprosthesis was used (“KemAngioprosthesis” closed joint-stock company “NeoCor” Kemerovo, Russia) (60.4%, n = 32).Results. In the early postoperative period, thrombosis developed in group 1 in 7 cases (33.3%): in 5 patients – on the first day after the surgery; 2 out of 5 patients were with chronic arterial insufficiency (CAI) of the fourth degree, 1 was with acute arterial insufficiency of the first degree, and 2 patients with the third degree of CAI. In group 2, there were 6 prosthetic thrombosis (18.7%), 4 cases of which developed thrombosis on the first day, 3 patients with CAI of the fourth degree and 1 case with acute arterial insufficiency of the second degree.Conclusion. The application of infra-lingual reconstructions using bioprostheses is quite effective and safe in patients with CLI, in particular with purulent-necrotic trophic processes when a suitable autovein to be used as a prosthetic material is absent.

Aim. To analyze inhospital outcomes of carotid endarterectomy (CE) in the acute period (within 3 days from the onset) of ischemic stroke.Material and methods. This retrospective multicenter study for the period from January 2008 to August 2020 included 357 patients who underwent CE in the acute period of stroke. An interdisciplinary commission defined the revascularization timing. There were following inclusion criteria: 1. Mild neurological disorders: NIHSS stroke of 3-8; modified Rankin Scale score <2; Bartel index >61; 2. Indications for CE according to the current national guidelines; 3. Brain ischemic focus <2,5 cm in diameter. There were following exclusion criteria: 1. Presence of contraindications to CE. The endpoints were such unfavorable cardiovascular events as death, myocardial infarction (MI), stroke/transient ischemic attack (TIA), silent stroke, silent hemorrhagic transformations, Bleeding Academic Research Consortium (BARC) type >3b bleeding, internal carotid artery thrombosis, composite endpoint (death + all strokes/TIA + MI). Silent strokes were those strokes, established according to control multi-slice computed tomography angiography, without symptoms.Results. During the in-hospital follow-up period, 8 deaths (2,24%), 5 MIs (1,4%), 6 strokes/TIAs (1,7%), 15 silent ischemic strokes (4,2%), 13 hemorrhagic transformations (3,6%), 26 silent hemorrhagic transformations (7,3%), and 6 BARC type >3b bleeding (1,7%) were recorded. Thus, the combined endpoint was 20,4% (n=73).Conclusion. Due to the high incidence of cardiovascular events, CE is not a safe operation for patients in the acute period of ischemic stroke. The stroke + mortality rate exceeding 3% demonstrates the ineffectiveness of this method of treatment.

OBJECTIVE:To analyze the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (CEE) in patients with resistant arterial hypertension (RAH).MATERIALS AND METHODS:The study included 1577 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RAH for more than 3 years. Patients were enrolled from January 2014 to December 2020. Depending on the implemented revascularization strategy, 5 groups were formed: group 1 (n=289 (18.3%)) with classical CEE with plasty of the reconstruction zone with a patch, group 2 (n=472 (29.9%)) with eversional CEE with cut-off of carotid glomus (CG); group 3 (n=109 (6.9%)) with the formation of a new bifurcation; group 4: (n=117 (7.4%)) with autoarterial reconstruction; group 5: (n=590 (37.4%)) with glomus-saving CEE.RESULTS:In the postoperative period, no significant differences were obtained in the frequency of deaths (0.34% for group 1; 0.63% for group 2; 0% for groups 3, 4 and 5), myocardial infarction (0.34%, 0.84%, 1.83, 0.85%, 0.33%, respectively); ischemic stroke (0.34%, 1.27%, 0.91%, 0.85%, 0.17%, respectively), hemorrhagic transformation (0%, 0.84%, 0.91%, 0.85%, 0%, respectively). However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (1.03%, 3.6%, 3.67%, 2.56%, 0.5%, respectively). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG.CONCLUSION:Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE.

Цель. Анализ частоты повторных тромбозов после тромбэктомии из артерий нижних конечностей при назначении различных схем антикоагулянтной и дезагрегантной терапии у пациентов с COVID-19.

OBJECTIVE To compare long-term outcomes in patients after carotid endarterectomy and those who refused surgical correction and received only conservative treatment. MATERIAL AND METHODS There were 1035 carotid endarterectomies performed at the Kemerovo Regional Clinical Hospital and Kemerovo Regional Clinical Cardiology Dispensary for the period 2014-2017. Surgery was refused by 136 patients for the same time. Thus, two groups of patients were formed: 1 - carotid endarterectomy group; 2 - conservative treatment group. INCLUSION CRITERIA significant carotid stenosis, absence of severe neurological deficit (over 25 scores by the National Institutes of Health Stroke Scale), absence of concomitant diseases limiting long-term follow-up. RESULTS Lethal outcome (p=0.0038) and fatal acute cerebrovascular accident (p=0.0005) were significantly more common in the 2nd group in long-term follow-up period. Thus, combined endpoint took the greatest values in patients who refused surgery compared with patients who received surgical treatment (p=0.0001). It should be noted that ischemic stroke de novo occurred in 9 (6.6%) patients of the 2nd group after 10.8 ± 2.5 months. This complication required subsequent hospitalization for carotid endarterectomy. CONCLUSION Preventive role of carotid endarterectomy was convincingly proved in comparison with drug therapy regarding mortality and fatal ischemic stroke in patients with significant carotid stenoses within 2.5 years of follow-up period.

The increase of the number of patients with atherosclerosis of the aorta leads to steady growth of the number of operations on aorta-femoral segment. In this regard, Federal programs of Federal funding are created for treatment of this disease. However, a high rate of mortality in cases of standard operations causes surgeons to minimize the volume of surgical treatment. The method of operation of the aorta from short-scar incision is studied quite enough; however, there are some problems, such as incision conversion and intraoperative complications. The aim of this study is to improve the results of operations on the aorta from the short-scar incision by access modeling. We analyzed the results of treatment of 88 patients operated from short-scar incision to the aorta in the Kemerovo Regional Clinical Hospital. Patients were divided into two groups - 55 patients operated without access modeling and 33 patients operated with preoperative access modeling. In the result in the second group there was reduction of incision conversions frequency to 3,03%, also there was reduction of the operation time in comparison with the first group without access modeling, with comparable characteristics of the groups and of the same frequency and nature of complications.