rpmjResearch'n Practical Medicine JournalResearch and Practical Medicine Journal2410-1893"QUASAR", LLC10.17709/2409-2231-2020-7-4-6rpmj-633Research ArticleОригинальные статьи. ХирургияOriginal Articles. SurgeryОптимальная техника реконструкции сонной артерии при ее атеросклеротическом пораженииOptimum technique of carotid artery reconstruction in her atherosclerotic lesionhttps://orcid.org/0000-0001-7625-9156АхметовВ. В.AkhmetovV. V.

Ахметов Владимир Вениаминович – к.м.н., докторант кафедры общей и факультетской хирургии, врач отделения сосудистой хирургии

185910, г. Петрозаводск, пр. Ленина, д. 33

SPIN: 7141-1401

AuthorID: 940347

Vladimir V. Akhmetov – Cand. Sci. (Med.), doctoral student of the department of general and faculty surgery, doctor of the department of vascular surgery

33 Lenin ave., Petrozavodsk, 185910

SPIN: 7141-1401

AuthorID: 940347

avv60@mail.ruhttps://orcid.org/0000-0002-9388-9931ДунаеваВ. И.DunaevaV. I.

Дунаева Виктория Игоревна – аспирант кафедры общей и факультетской хирургии

185910, г. Петрозаводск, пр. Ленина, д. 33

Viktoriya I. Dunaeva – fellow student of the Department of General and faculty surgery

33 Lenin ave., Petrozavodsk, 185910

https://orcid.org/0000-0002-0268-8561ВрыгановФ. А.VryganovF. A.

Врыганов Федор Александрович – аспирант кафедры общей и факультетской хирургии

185910, г. Петрозаводск, пр. Ленина, д. 33

Fedor A. Vryganov – fellow student of the Department of General and faculty surgery

33 Lenin ave., Petrozavodsk, 185910

https://orcid.org/0000-0002-9348-618XОрдынецС. В.OrdynetsS. V.

Ордынец Станислав Витальевич – к.м.н., докторант кафедры общей и факультетской хирургии, врач отделения сосудистой хирургии

185910, г. Петрозаводск, пр. Ленина, д. 33

191014, г. Санкт-Петербург, Литейный пр., д. 56

Stanislav V. Ordynets – Cand. Sci. (Med.), doctoral student at the Department of General and faculty surgery, doctor of vascular surgery Department City Mariinsky hospital

33 Lenin ave., Petrozavodsk, 185910

56 Liteyny ave., Saint Petersburg, 191014

https://orcid.org/0000-0002-0629-6581ДудановИ. П.DudanoI. P.

Дуданов Иван Петрович – д.м.н., профессор, чл.-корр. РАН, заведующий кафедрой общей и факультетской хирургии, руководитель Регионального сосудистого центра

185910, г. Петрозаводск, пр. Ленина, д. 33

191014, г. Санкт-Петербург, Литейный пр., д. 56

SPIN: 7617-9535

AuthorID: 107304

Ivan P. Dudanov – Dr. Sci. (Med.), professor, corresponding member of the Russian Academy of Sciences, head of the Department of General and faculty surgery, head of the Regional vascular center City Mariinsky hospital

33 Lenin ave., Petrozavodsk, 185910

56 Liteyny ave., Saint Petersburg, 191014

SPIN: 7617-9535

AuthorID: 107304

ФГБОУ ВО «Петрозаводский государственный университет»РоссияPetrozavodsk state UniversityRussian FederationФГБОУ ВО «Петрозаводский государственный университет»; СПб ГБУЗ «Городская Мариинская больница»РоссияPetrozavodsk state University; City Mariinsky hospitalRussian Federation202021122020746278Copyright © Ахметов В.В., Дунаева В.И., Врыганов Ф.А., Ордынец С.В., Дуданов И.П., 20202020Ахметов В.В., Дунаева В.И., Врыганов Ф.А., Ордынец С.В., Дуданов И.П.Akhmetov V.V., Dunaeva V.I., Vryganov F.A., Ordynets S.V., Dudano I.P.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.rpmj.ru/rpmj/article/view/633Цель исследования

Цель исследования. Сравнить результаты различных методик выполнения классической КЭAЭ у больных с ишемическим инсультом.

Материалы и методы

Материалы и методы. В ретроспективном исследовании мы собрали данные по 1242 паци-ентам, которым была выполнена КЭАЭ в период с января 2011 г. по декабрь 2019 г.. КЭАЭ с использованием заплаты для закрытия артериотомического отверстия выполнена в 239 случаях. В 1003 — закрытие артериотомического отверстия осуществлялось первичным швом. Использовали 3 методики закрытия артериотомии с применением заплаты и три методики обвивного шва. Мужчин было 848, женщин 394. Средний возраст составил 63,16 года. Все больные были симптомными. У 49,2% пациентов было преходящее нарушение мозгового кровообращения (ТИА), ишемический инсульт перенесли 50,8% больных. У всех пациентов имелся стеноз сонной артерии. После операции у 5 (0,4%) пациентов развился ишемический инсульт, у 1 (0,08%) — повреждение n.hypoglossus, у 3 (0,24%) — послеопера ционная гематома. При выполнении КЭАЭ использование внутрипросветного шунта не потребовалось. Всем больным после операции выполнялось дуплексное исследование через 1, 3, 6, 12 ме-сяцев. Далее — каждый год. Пристально оценивалась область реконструкции: состояние геометрии артерии в дистальной и проксимальных частях артериотомии, особенности кровотока по артерии, наличие и степень нарастания неонтимы. Развитие рестеноза сравнивались между группами в течение 36 месяцев наблюдения.

Результаты

Результаты. При оценке геометрических изменений в группе с наложением заплаты отмечено, что наихудшие результаты получены при использовании методики с П-образным фиксирующим швом на дистальную часть заплаты и применением широкой заплаты. При применении узкой заплаты геометрические изменения по ширине наименьшие. Основной причиной частых геометрических изменений в дистальной части заплаты явилось подворачивание заплаты внутрь артерии с образованием дубликатуры. Применение модифицированной методики закрытия артериотомии заплатой позволило сократить количество искажений в зоне операции, избежать образования стенозов артерии в месте наложения заплаты, предотвратить изменения геометрии бифуркации внутренней сонной артерии. Наилучшие резуль-таты при наложении первичного краевого шва получены при методике закрытия артериотомии встречным краевым швом с прецизионным контролем наложения. Применение П-образного шва по краям артериотомии позволило избежать деформаций в этом месте. Контроль вкола иглы за счет расправления и подъема края стенки обеспечило отсутствие деформаций шва.

Purpose of the study

Purpose of the study. Was to compare the early and long-term results of different variants of the classical KEAE.

Materials and methods

Materials and methods. In a retrospective study, we collected data on 1.242 patients who trans- ferred KEA from January 2011 to December 2019, using a patch was performed in 239 cases in 1003 — primary suture closure. We used 3 methods of arteriotomy closure with the use of a patch. There were 848 men and 394 women, the average age was 63.16 years, all of them were sympto- matic. Most patients had a transient disorder (49.2%) or ischemic stroke (50.8%). All patients had significant (moderate to severe) carotid stenosis. After the operation 5 (0.4%) patients had ischemic stroke, 1 (0.08%) had n. hypo-glossus damage, 3 (0.24%) had postoperative hematoma. The usual endarterectomy was performed without a shunt in all cases. All arteriotomies were mostly open. Early and late results of this procedure with a period of observation of at least 36 months were ana-lyzed: technical aspects of arteriotomy, features of restoration of the integrity of the vessel, changes in the "geometry" of the vessel, the use of zaplat. We studied the state of hemodynamics and complications in the early (30 days) and late postoperative period, the development of restenosis was compared between groups during the 36 months of observation. 

Results

Results. When assessing the geometrical changes in the group with the patching, it was noted that the worst results were obtained using the technique with a U-shaped fixation suture on the distal part of the patch and the use of a wide patch. When using a narrow patch geometric changes in the width of the patch are the smallest. The main reason of the frequent geometrical changes in the dis-tal part of the patch was the patch wrapping inside the artery with the formation of a duplicate. The application of the modified technique of patch closure allowed to reduce the number of distortions in the operation area, to avoid the formation of artery stenoses in the place of patch imposition, to prevent changes in the bifurcation geometry of the internal carotid artery. The best results in the application of the primary edge suture were obtained by the method of closing the arteriotomy with the counter edge suture with the precision control of the application. The application of the U-shaped suture along the edges of the arteriotomy allowed avoiding deformations in this place. Con-trol of needle injection by means of straightening and lifting of the wall edge ensured absence of deformations in the suture.

Conclusions

Conclusions. The post-CEAE closure technique affects the hemodynamic profile. Sewing patch-ing does not seem to create favorable flow dynamics. Consideration should be given to the elective use of the patch to improve disturbed flows. However, the linear precision suture remains the method of choice for suturing the arteriotomy.

хирургическая техникасонные артериистеноз сонной артериицереброваскулярное кровообращениетехника эндартерэктомииобвивной шовendarterectomy techniquecarotid arteriescerebrovascular blood circulationcause of stenosis re-currenceReferencesAhmed SB, Daniel G, Benezit M, Ribal J-P, Rosset E. Eversion carotid endarterectomy without shunt: concerning 1385 consecutive cases. J Cardiovasc Surg (Torino). 2017 Aug;58(4):543–550. https://doi.org/10.23736/S0021-9509.16.08495-0Ahmed SB, Daniel G, Benezit M, Ribal J-P, Rosset E. Eversion carotid endarterectomy without shunt: concerning 1385 consecutive cases. J Cardiovasc Surg (Torino). 2017 Aug;58(4):543–550. https://doi.org/10.23736/S0021-9509.16.08495-0Skelly CL, Meyerson SL, Curi MA, Desai TR, Bassiouny HS, McKinsey JF, et al. Routine early postoperative duplex scanning is unnecessary following uncomplicated carotid endarterectomy. Vasc Endovascular Surg. 2002 Apr;36(2):115–122. https://doi.org/10.1177/153857440203600206Skelly CL, Meyerson SL, Curi MA, Desai TR, Bassiouny HS, McKinsey JF, et al. Routine early postoperative duplex scanning is unnecessary following uncomplicated carotid endarterectomy. Vasc Endovascular Surg. 2002 Apr;36(2):115–122. https://doi.org/10.1177/153857440203600206Chen GZ, Wu YZ, Diao PY, Ma L, Yan S, Chen XY, et al. Comparison of Eversion Carotid Endarterectomy and Patch Carotid Endarterectomy: A Retrospective Study of 6 Years of Experience. Med Sci Monit. 2018 Aug 21;24:5820–5825. https://doi.org/10.12659/MSM.907762Chen GZ, Wu YZ, Diao PY, Ma L, Yan S, Chen XY, et al. Comparison of Eversion Carotid Endarterectomy and Patch Carotid Endarterectomy: A Retrospective Study of 6 Years of Experience. Med Sci Monit. 2018 Aug 21;24:5820–5825. https://doi.org/10.12659/MSM.907762McBride R, Porter J, Al-Khaffaf H. The modified operative technique of partial eversion carotid endarterectomy. J Vasc Surg. 2017 Jan;65(1):263–266. https://doi.org/10.1016/j.jvs.2016.10.057McBride R, Porter J, Al-Khaffaf H. The modified operative technique of partial eversion carotid endarterectomy. J Vasc Surg. 2017 Jan;65(1):263–266. https://doi.org/10.1016/j.jvs.2016.10.057Tsantilas P, Kühnl A, Kallmayer M, Pelisek J, Poppert H, Schmid S, et al. A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery. J Vasc Surg. 2017 Jan;65(1):12-20.e1. https://doi.org/10.1016/j.jvs.2016.07.116Tsantilas P, Kühnl A, Kallmayer M, Pelisek J, Poppert H, Schmid S, et al. A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery. J Vasc Surg. 2017 Jan;65(1):12-20.e1. https://doi.org/10.1016/j.jvs.2016.07.116Howell SJ. Carotid endarterectomy. Br J Anaesth. 2007 Jul;99(1):119–131. https://doi.org/10.1093/bja/aem137Howell SJ. Carotid endarterectomy. Br J Anaesth. 2007 Jul;99(1):119–131. https://doi.org/10.1093/bja/aem137Baram A, Majeed G, Subhi Abdel-Majeed A. Carotid endarterectomy: neither shunting nor patching technique. Asian Cardiovasc Thorac Ann. 2018 Jul;26(6):446–450. https://doi.org/10.1177/0218492318788777Baram A, Majeed G, Subhi Abdel-Majeed A. Carotid endarterectomy: neither shunting nor patching technique. Asian Cardiovasc Thorac Ann. 2018 Jul;26(6):446–450. https://doi.org/10.1177/0218492318788777Zarins CK. Carotid endarterectomy: the gold standard. J Endovasc Surg. 1996 Feb;3(1):10–15. https://doi.org/10.1583/1074-6 218(1996)003<0010:CETGS>2.0.CO;2Zarins CK. Carotid endarterectomy: the gold standard. J Endovasc Surg. 1996 Feb;3(1):10–15. https://doi.org/10.1583/1074-6 218(1996)003<0010:CETGS>2.0.CO;2Avrahami I, Raz D, Bash O. Biomechanical Aspects of Closing Approaches in Postcarotid Endarterectomy. Comput Math Methods Med. 2018;2018:4517652. https://doi.org/10.1155/2018/4517652Avrahami I, Raz D, Bash O. Biomechanical Aspects of Closing Approaches in Postcarotid Endarterectomy. Comput Math Methods Med. 2018;2018:4517652. https://doi.org/10.1155/2018/4517652Mannheim D, Weller B, Vahadim E, Karmeli R. Carotid endarterectomy with a polyurethane patch versus primary closure: a prospective randomized study. J Vasc Surg. 2005 Mar;41(3):403– 407; discussion 407–408. https://doi.org/10.1016/j.jvs.2004.11.036Mannheim D, Weller B, Vahadim E, Karmeli R. Carotid endarterectomy with a polyurethane patch versus primary closure: a prospective randomized study. J Vasc Surg. 2005 Mar;41(3):403– 407; discussion 407–408. https://doi.org/10.1016/j.jvs.2004.11.036Al-Rawi PG, Turner CL, Waran V, Ng I, Kirkpatrick PJ. A randomized trial of synthetic patch versus direct primary closure in carotid endarterectomy. Neurosurgery. 2006 Oct;59(4):822– 828; discussion 828–829. https://doi.org/10.1227/01.neu.0000232640.11438Al-Rawi PG, Turner CL, Waran V, Ng I, Kirkpatrick PJ. A randomized trial of synthetic patch versus direct primary closure in carotid endarterectomy. Neurosurgery. 2006 Oct;59(4):822– 828; discussion 828–829. https://doi.org/10.1227/01.neu.0000232640.11438Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD000160. https://doi.org/10.1002/14651858.CD000160.pub3Rerkasem K, Rothwell PM. Patch angioplasty versus primary closure for carotid endarterectomy. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD000160. https://doi.org/10.1002/14651858.CD000160.pub3MaertensV, Maertens H, Kint M, Coucke C, Blomme Y. Complication Rate after Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure. Ann Vasc Surg. 2016 Jan;30:248–252. https://doi.org/10.1016/j.avsg.2015.07.045MaertensV, Maertens H, Kint M, Coucke C, Blomme Y. Complication Rate after Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure. Ann Vasc Surg. 2016 Jan;30:248–252. https://doi.org/10.1016/j.avsg.2015.07.045Bond R, Rerkasem K, Naylor AR, Aburahma AF, Rothwell PM. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. J Vasc Surg. 2004 Dec;40(6):1126–1135. https://doi.org/10.1016/j.jvs.2004.08.048Bond R, Rerkasem K, Naylor AR, Aburahma AF, Rothwell PM. Systematic review of randomized controlled trials of patch angioplasty versus primary closure and different types of patch materials during carotid endarterectomy. J Vasc Surg. 2004 Dec;40(6):1126–1135. https://doi.org/10.1016/j.jvs.2004.08.048Ho KJ, Nguyen LL, Menard MT. Intermediate-term outcome of carotid endarterectomy with bovine pericardial patch closure compared with Dacron patch and primary closure. J Vasc Surg. 2012 Mar;55(3):708–714. https://doi.org/10.1016/j.jvs.2011.10.007Ho KJ, Nguyen LL, Menard MT. Intermediate-term outcome of carotid endarterectomy with bovine pericardial patch closure compared with Dacron patch and primary closure. J Vasc Surg. 2012 Mar;55(3):708–714. https://doi.org/10.1016/j.jvs.2011.10.007Domanin M, Buora A, Scardulla F, Guerciotti B, Forzenigo L, Biondetti P, et al. Computational Fluid-Dynamic Analysis after Carotid Endarterectomy: Patch Graft versus Direct Suture Closure. Ann Vasc Surg. 2017 Oct;44:325–335. https://doi.org/10.1016/j.avsg.2017.04.016Domanin M, Buora A, Scardulla F, Guerciotti B, Forzenigo L, Biondetti P, et al. Computational Fluid-Dynamic Analysis after Carotid Endarterectomy: Patch Graft versus Direct Suture Closure. Ann Vasc Surg. 2017 Oct;44:325–335. https://doi.org/10.1016/j.avsg.2017.04.016

The authors declare that there are no conflicts of interest present.