Effects of different types of carotid endarterectomy on the course of resistant arterial hypertension

Abstract

Objective Analysis of the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (СЕЕ) (classical with plasty of the reconstruction zone with a patch, eversion, formation of a new bifurcation, autoarterial reconstruction, glomus-saving techniques) in patients with resistant arterial hypertension (RAH). Materials and methods The actual cohort, comparative, retrospective, open research for the period from January 2013 to December 2021 includes 1577 patients with significant hemodynamic stenosis of the internal carotid artery Depending on revascularization strategy five groups were formed: Group 1: 18.3% ( n = 289) – classical Carotid endarterectomy with plasty of the reconstruction zone with a patch (from diepoxy-treated xenopericardium or synthetic); Group 2: 29.9% ( n = 472) – eversional CEE with cut-off of carotid gloomus (CG); Group 3: 6.9% ( n = 109) – the formation of a new bifurcation; Group 4: 7.4% ( n = 117) - autoarterial reconstruction; Group 5: 37.4% ( n = 590) – glomus-saving CEE (1 technique – according to A. N. Kazantsev; two technicians – according to R.A. Vinogradov; three technicians – according to K.A.Antsupov). According to the 24-h blood pressure monitor in the preoperative period, the following degrees of AH were identified: 1° – 5.7% ( n = 89); 2° – 64.2% ( n = 1013); and 3° – 30.1% ( n = 475). Results In the postoperative period, no significant differences were obtained in the frequency of deaths, myocardial infarction, stroke, hemorrhagic transformation. 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 (group 1: 1.03% ( n = 3); group 2: 3.6% ( n = 17); group 3: 3.67% ( n = 4); group 4: 2.56% ( n = 3); group 5: 0.5% ( n = 3); p = 0.10). 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, accompanied by the lowest incidence of adverse cardiovascular events caused by postoperative hypertensive crisis and hyperperfusion syndrome.

Vertebral triangle of doctor A.N. Kazantsev - double vertebral artery in V3 segment

“…In the case of the development of hemodynamically significant stenosis of the internal carotid artery and with complete patency of the vertebral artery, the formation of vertebrobasilar insufficiency due to a deficiency of hemocirculation is possible [13] . In such a situation, the effect of carotid endarterectomy leads to regression of vertebrobasilar insufficiency [ [16] , [17] , [18] , [19] , [20] ]. In our clinical case, stenting of the left vertebral artery had a protective effect in order to eliminate circulatory insufficiency in the basin of the left middle cerebral artery.…”

Carotid endarterectomy in Russia. What if current guidelines do not answer difficult questions?

“…Отдельный интерес может вызывать вариантное строение Виллизиева круга. В ситуации, когда последний представлен в разомкнутой конфигурации, коллатеральный кровоток вероятнее всего будет недостаточным [32,33]. По мнению ряда авторов, эта особенность может быть рассмотрена как показание к установке ВШ без предварительного измерения ретроградного давления и церебральной оксиметрии [32,33].…”

“…Другая проблема данной когорты пациентов связана с отсутствием регламентирующих документов, позволяющих определить оптимальный временной отрезок между ипси-и контралатеральной КЭЭ [1]. В такой ситуации, основываясь на своем локальном опыте, каждое учреждение устанавливает разные сроки для второй госпитализации [31][32][33]. Появляются сообщения о том, что пациент не поступает в назначенную дату, зачастую по субъективным причинам ("уборка урожая", "забыл" и т.д.).…”

“…Исследования, изучающие сравнительные результаты обоих способов реваскуляризации, показали, что КАС сочетается с низким риском развития геморрагической трансформации ввиду отсутствия такого этапа, характерного только для КЭЭ, как пережатие ВСА [46]. Дело в том, что пуск кровотока после удаления сосудистых зажимов сопровождается гемодинамическим ударом в зону ишемии и последующим гиперперфузионным синдромом [45,48]. При КАС, в свою очередь, сохраняется постоянство ипсилатеральной гемоциркуляции [46].…”