GOAL:Presentation of the first Russian computer program (www.carotidscore.ru) for risk stratification of postoperative complications of carotid endarterectomy (CEE).MATERIAL AND METHODS:The present study is based on the analysis of a multicenter Russian database that includes 25,812 patients after CEE operated on from 01/01/2010 to 04/01/2022. The following types of CEE were implemented: 6814 classical CEE with plastic reconstruction of the reconstruction zone with a patch; 18,998 eversion CEE.RESULTS:In the hospital postoperative period, 0.18% developed a lethal outcome, 0.14%-myocardial infarction, 0.35%-stroke. The combined endpoint was 0.68%. For each factor present in patients, a predictive coefficient was calculated. The prognostic coefficient was a numerical indicator reflecting the strength of the influence of each factor on the development of postoperative complications. Based on this formula, predictive coefficients were calculated for each factor present in patients in our study. The total contribution of these factors was reflected in "%" and denoted the risk of postoperative complications with a minimum value of 0% and a maximum of 100%. On the basis of the obtained calculations, a computer program CarotidSCORE was created. Its graphical interface is based on the QT framework (https://www.qt.io), which has established itself as one of the best solutions for desktop applications. It is possible not only to calculate the probability of developing a complication, but also to save all data about the patient in JSON format (for the patient's personal card and his anamnesis). The CarotidSCORE program contains 47 patient parameters, including clinical-demographic, anamnestic and angiographic characteristics. It allows you to choose one of the four types of CEE, which will provide an accurate stratification of the risk of complications for each of them in person.CONCLUSION:CarotidSCORE (www.carotidscore.ru) is able to determine the likelihood of postoperative complications in patients undergoing CEE.

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%.

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.

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.

Objective: to analyze the in-hospital and long-term outcomes of classical carotid endarterectomy (CEE) in extended atherosclerotic lesions in comparison with the outcomes of this operation in local atherosclerotic plaque (AP). Materials and Methods. This study, which lasted from January 2010 to December 2020, included 148 patients with extended AP and hemodynamically significant internal carotid artery (ICA) stenosis. The term “extended” was understood as a hemodynamically significant lesion ≥ 5 cm long. These patients made up Group 1. Group 2 was formed over the same period of time from 632 patients with hemodynamically significant stenosis <5 cm long. In both cohorts, CEE with repair of the reconstruction zone with a diepoxide-treated xenopericardial patch was performed. Long-term follow-up was 71.4 ± 45.6 months. Results. The groups were comparable in terms of frequency of in-hospital complications: death (group 1: 0.67%, n = 1; group 2: 0.5%, n = 3; p = 0.74; OR = 1.42; 95% Cl 0.14-13.6), myocardial infarction (MI) (group 1: 0.67%, n = 1; group 2: 0.5%, n = 3; p = 0.74; OR = 1.42; 95% CI 0.14-13.6), ischemic stroke (group 1: 0%; group 2: 0.5%, n = 3; p = 0.91; OR = 0.6; 95% CI 0.03-11.8), combined endpoint (death + MI + stroke) (group 1: 1.35%, n = 2; group 2: 1.4%, n = 9; p = 0.74; OR = 0.94; 95% CI 0.2-4.43). The groups were also comparable in terms of frequency of long-term complications: death (group 1: 2.0%, n = 3; group 2: 2.05%, n = 13; p = 0.76; OR = 0.98; 95% CI 0.27-3.5), MI (group 1: 2.7%, n = 4; group 2: 2.4%, n = 15; p = 0.95; OR = 1.14; 95% CI 0.37-3.49), ischemic stroke (group 1: 5.4%, n = 8; group 2: 5.2%, n = 33; p = 0.9; OR = 1.03; 95% CI 0.46-2.29), ICA occlusion and restenosis (group 1: 12.8%, n = 19; group 2: 13.3%, n = 84; p = 0.99; OR = 0.96; 95% CI 0.56-1.63), combined endpoint (death + MI + stroke) (group 1: 10.1%, n = 15; group 2: 9.6%, n = 61; p = 0.98; OR = 1.05; 95% CI 0.58-1.91). Analysis of survival graphs revealed no significant intergroup differences for all types of complications (lethal outcome: p = 0.56; MI: p = 0.73; stroke/mini-stroke: p = 0.89; ICA restenosis/occlusion: p = 0.82; combined end point: p = 0.71). Their increase was uniform in both groups. However, more than half of all ICA restenoses and occlusions were visualized in the first 6 months after CEE. Conclusion. Implantation of a long patch (≥ 5 cm) is not characterized by increased incidence of restenosis and all adverse cardiovascular events during in-hospital and long-term follow-up.

В обзоре представлена история развития открытых методов хирургического лечения хронической артериальной недостаточности нижних конечностей. Освещены основные этапы становления реконструктивной хирургии бедренно-подколенного сегмента, сравниваются безопасность и эффективность рассматриваемых методик.

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 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.

Aim. To assess the results of carotid angioplasty with stenting (CAS) performed in the first 3 h after the onset of ischaemic stroke (the most acute period of acute cerebrovascular accident).Methods. This retrospective study included 312 patients from January 2008 to August 2020 with hemodynamically significant stenosis of the internal carotid arteries (ICA) who underwent CAS within 3 h of stroke onset. After a patient was hospitalised in our emergency department, stroke development was assessed by a neurologist. The level of neurological deficit was determined according to the National Institutes of Health Stroke Scale (NIHSS), the modified Rankin scale, the Barthel scale and the Rivermead Mobility Index. Multispiral computed tomography (MSCT) of the brain was then performed. On condition of visualisation of the ischaemic focus, the patient was sent for screening colour duplex scanning of the brachiocephalic arteries (BCA), arteries of the lower extremities, aortic arch and heart. If hemodynamically significant stenosis in the ICA was visualised, the patient underwent MSCT angiography of the BCA. The degree of stenosis was determined using the North American Symptomatic Trial Collaborators (NASCET) classifications. The on-duty ultidisciplinary council determined the tactics of the patient's treatment. Decisions regarding surgical correction and the choice of revascularisation strategy (CAS or carotid endarterectomy) were made based on stratification of the risk of postoperative complications according to the EuroSCORE II scale and the severity of coronary lesions according to the SYNTAX Score (in the presence of a history of coronary angiography). The time between admission to the emergency department and admission to the operating room was 84.5 ± 9.3 minutes. The inclusion criteria were 1. mild neurological disorders from 3 to 8 points on the NIHSS scale, no more than 2 points on the Rankin modification scale and more than 61 points on the Barthel scale; 2. Indication for CAS according to the current national recommendations; 3. Ischaemic focus in the brain no more than 2.5 cm in diameter according to MSCT; 4. Absence of pronounced calcification of the ICA. The exclusion criteria were: 1. Contraindications for CAS; 2. The presence of thrombosis of the ICA requiring the introduction of fibrinolytics (Alteplase), thromboextraction and thromboaspiration.Results. In the hospital postoperative period, 6 (1.92%) patients had lethal outcomes, 5 (1.6%) had myocardial infarctions, 5 (1.6%) had nonfatal stroke, 7 (2.2%) had asymptomatic ‘silent’ stroke, 2 (0.64%) had haemorrhagic transformations and 1 (0.32%) had ICA thrombosis. The combined endpoint (death + stroke + myocardial infarction) was reached in 7.05% of patients (n = 22).Conclusion. CAS is a safe and effective method of brain revascularisation in the first hours after the onset of ischaemic stroke. Interventional correction of hemodynamically significant stenoses of the ICA had permissible levels of ‘stroke + mortality from stroke’ and lethal outcomes, which reached 3.84% and 1.92%, respectively. Urgent implementation of CAS allows a significant regression of neurological deficit which is stable throughout the entire postoperative period.Received 21 September 2020. Revised 1 October 2020. Accepted 10 October 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsConception and design: R.A. Vinogradov, M.A. Chernyavsky, V.A. Porkhanov, E.Yu. Kachesov, G.G. KhubulavaData collection and analysis: V.V. Matusevich, K.P. Chernykh, A.B. Zakeryaev. Drafting the article: A.N. KazantsevStatistical analysis: G.Sh. Bagdavadze, R.Yu. Leader. Critical revision of the article: Final approval of the version to be published: A.N. Kazantsev, R.A. Vinogradov, M.A. Chernyavsky, V.V. Matusevich, K.P. Chernykh, A.B. Zakeryaev, G.Sh. Bagdavadze, R.Yu. Leader, E.Yu. Kachesov, V.A. Porkhanov, G.G. Khubulava

HTML Казанцев А.Н., Виноградов Р.А., Кравчук В.Н., Чернявский М.А., Черных К.П., Матусевич В.В., Лидер Р.Ю., Багдавадзе Г.Ш., Шукуров И.Х., Зайцева Т.Е., Чикин А.Е., Артюхов С.В., Линец Ю.П., Кравчук В.Н. Какая каротидная эндартерэктомия более эффективна в сочетании с коронарным шунтированием? Сердечно-сосудистые заболевания. Бюллетень НЦССХ им. А.Н. Бакулева РАМН. 2020; 21 (6): 649–62. DOI: 10.24022/1810-0694-2020-21- 6-649-662

Цель. Анализ госпитальных результатов каротидной ангиопластики со стентированием, реализованной в первые 3 ч от дебюта острого нарушения мозгового кровообращения, что соответствует острейшему периоду ишемического инсульта. Методы. В данное ретроспективное исследование с января 2008 г. по август 2020 г. вошло 312 пациентов с гемодинамически значимыми стенозами внутренних сонных артерий, которым была реализована каротидная ангиопластика со стентированием в течение 3 ч от дебюта острого нарушения мозгового кровообращения. После экстренной госпитализации в приемное отделение невролог осматривал пациента на предмет развития острого нарушения мозгового кровообращения. Врач определял уровень неврологического дефицита согласно шкале инсульта Национального института здоровья США (англ. National Institutes of Health Stroke Scale, NIHSS), модифицированной шкале Рэнкина, шкале Бартела, индексу мобильности Ривермид. Далее выполнялась мультиспиральная компьютерная томография головного мозга. При условии визуализации ишемического очага больной направлялся на скрининговое цветное дуплексное сканирование брахио­цефальных артерий, артерий нижних конечностей, дуги аорты, сердца. При визуализации гемодинамически значимого стеноза во внутренней сонной артерии пациенту выполнялась мультиспиральная компьютерная томография – ангиография брахиоцефальных артерий. Степень стеноза определялась по классификации Североамериканского исследования симптомной каротидной эндартерэктомии (англ. North American Symptomatic Carotid Endarterectomy Trial, NASCET). Далее дежурный мультидисциплинарный консилиум определял тактику лечения пациента. После принятия решения о хирургической коррекции на основе стратификации риска послеоперационных осложнений по шкале EuroSCORE II, тяжести поражения коронарного русла по шкале SYNTAX Score (при наличии данных коронарографии в анамнезе) выбирали реваскуляризацию между каротидной ангиопластикой со стентированием и каротидной эндартерэктомией. Период между госпитализацией в приемное отделение и поступлением пациента в операционную составлял 84,5 ± 9,3 мин. Критерии включения: 1) неврологические нарушения легкой степени — от 3 до 8 баллов по шкале NIHSS, не более 2 баллов по модифицированной шкале Рэнкина, более 61 балла по шкале Бартела; 2) показания для каротидной ангиопластики со стентированием согласно действующим национальным рекомендациям; 3) ишемический очаг в головном мозге не более 2,5 см в диаметре по данным мультиспиральной компьютерной томографии; 4) отсутствие выраженного кальциноза внутренних сонных артерий. Критерии исключения: 1) противопоказания к каротидной ангиопластике со стентированием; 2) тромбоз внутренних сонных артерий, требующий введения фибринолитиков (алтеплаза), выполнения тромбэкстракции и тромбаспарации. Результаты. В госпитальном послеоперационном периоде выявлено 6 летальных исходов (1,92 %), 5 инфарктов миокарда (1,6 %), 5 нефатальных острых нарушений мозгового кровообращения (1,6 %), 7 бессимптомных «немых» острых нарушений мозгового кровообращения (2,2 %), 2 геморрагические трансформации (0,64 %), 1 тромбоз внутренней сонной артерии (0,32 %). Комбинированная конечная точка (смерть, острое нарушение мозгового кровообращения, инфаркт миокарда) составила 7,05 % (n = 22). Заключение. Каротидная ангиопластика со стентированием — безопасный и эффективный метод реваскуляризации головного мозга в первые часы от дебюта ишемического инсульта. Интервенционная коррекция гемодинамически значимого стеноза внутренних сонных артерий сочетается с допустимыми уровнями инсульта и летальности от инсульта (3,84 %), а также летального исхода (1,92 %). Каротидная ангиопластика со стентированием в ургентном режиме позволяет достичь значимого регресса неврологического дефицита с устойчивым эффектом на протяжении послеоперационного периода. Поступила в редакцию 21 сентября 2020 г. Исправлена 1 октября 2020 г. Принята к печати 10 октября 2020 г. Конфликт интересов Авторы заявляют об отсутствии конфликта интересов. Финансирование Исследование не имело спонсорской поддержки. Вклад авторов Концепция и дизайн: Р.А. Виноградов, М.А. Чернявский, В.А. Порханов, Э.Ю. Качесов, Г.Г. Хубулава Сбор, анализ и интерпретация данных: В.В. Матусевич, К.П. Черных, А.Б. Закеряев Статистический анализ: Г.Ш. Багдавадзе, Р.Ю. Лидер Написание статьи: А.Н. Казанцев Исправление статьи: Р.А. Виноградов, М.А. Чернявский, В.А. Порханов, Г.Г. Хубулава Утверждение окончательной версии статьи: все авторы

In this article a clinical case of surgical treatment for false aneurysm of extracranial department of an internal carotid artery in a 69-year-old patient after numerous surgical treatment for stenosis atherosclerosis of an internal carotid is described. The diagnostic algorithm consisted of triplex scanning of brachiocephalic arteries, a cerebral angiography and a multispiral computer tomography with intravenous contrast enhancement. This patient underwent carotid endarterectomy in combination with reconstruction of an internal carotid and removal of earlier implanted stent and a synthetic patch were performed. The postoperative period was uneventful. Histological assessment proved that extension of an internal carotid was caused by a false aneurysm. Previous surgery and atherosclerosis were the reasons of aneurysm formation.