Kopolovets, Berek, Sihotsky, Kubikova , Torma, Stefanic, and Frankovicova: Differentiated approach to surgical treatment of atherosclerotic lesions of supra-aortic arteries



Problem statement and analysis of the recent research

Nowadays supra-aortic artery disease is considered as a risk factor for developing acute cerebrovascular disease [3, 8]. Atherosclerotic lesions of the extracranial arteries are the leading cause of cerebral ischemia accounting for about 75% of all cases [6]. Atherosclerotic lesions are mainly localized in the carotid artery bifurcations and proximal portion of the internal carotid artery (ICA) and almost 80% of patients develop atherosclerotic lesions of two and more vascular territories of the brain [4]. In addition, almost 60% of patients suffer from atherosclerotic lesions of other vascular territories (IHD, lower extremity peripheral arterial disease, peripheral arterial disease in the abdominal part of the aorta) [1]. Another potential problem in patients with atherosclerotic lesions is their polymorbidity as there is a high probability of developing arterial hypertension, diabetes mellitus, and metabolic syndrome [2, 8].

Therefore, considering the polymorbidity in patient with atherosclerotic lesions affecting the aortic arch branches, the selection of surgical tactics when treating this group of patients remains disputable and requires further study.

The objective of the research was to systematize the principles of surgical treatment of patients with atherosclerotic lesions of the supra-aortic arteries taking into consideration their polymorbidity and the multicentricity of atherosclerosis.

Materials and methods

In the period 2011-2015, 468 patients underwent surgery on the supra-aortic arteries in Clinic of Vascular Surgery of East Slovak Institute of Cardiovascular Diseases. The average age of patients was 64.5±7.2 years. Types of surgery are presented in Table 1.

Table 1.

Surgery on the supra-aortic arteries (2011-2015)

Arterial reconstruction Number of patients (n=468) %
Carotid endarterectomy 379 81.0
CEA+correction of pathological deformation of the ICA 21 5.4
Resection of pathological deformation of the ICA 9 1.9
Concurrent surgery (CEA+ coronary artery bypass graft surgery) 38 8.1
Resection of an aneurysm of the extracranial portion of the ICA 2 0.4
Transposition of the SCA to the CCA 6 1.3
Carotid-subclavian arterial bypass 4 0.9
Carotid-carotid bypass 3 0.6
Endarterectomy of the common carotid artery 2 0.4
Removal of the aortic body tumor 4 0.9

Notes:

CEA - carotid endarterectomy;

ICA – internal carotid artery;

SCA – subclavian artery;

CCA – common carotid artery;

All the patients were divided into two groups. Group I included 276 (59%) patients with previous surgical or endovascular intervention on any vascular territory for treatment of atherosclerotic lesions being admitted to the hospital for elective surgery on the extracranial arteries (Table 2).

Group II included 192 (41%) patients without previous surgical and invasive treatments of arterial pathology being hospitalized for surgery on the supra-aortic arteries. Between both groups there were no differences in age and sex.

Examination protocol included preoperative general examination considering somatic and neurological risk factors. Ultrasound (US) imaging of the carotid arteries, CT angiography and angiography were the main screening methods for the detection of atherosclerotic lesions of the extracranial arteries. Echocardiography and diagnostic coronary angiography if necessary were performed in patients with ischemic heart disease (IHD).

Table 2.

Methods of treatment of arterial pathology in the anamnesis of patients of Group I

Method of treatment Number of patients (n=276) %
Coronary stenting 84 30.4
Coronary artery bypass graft surgery 32 11.6
CEA on the contralateral side 21 7.6
CEA on the ipsilateral side (restenosis) 2 0.7
CA stenting on the contralateral side 12 4.3
Vertebral artery stenting 8 2.9
Subclavian artery stenting 5 1.8
Resection of abdominal aortic aneurysm 2 0.7
Stenting of abdominal aortic aneurysm 4 1.4
Aortobifemoral bypass surgery 3 1.1
Endovascular interventions on the iliac arteries and lower extremity vessels 76 27.5
Direct surgery on the iliac arteries and lower extremity vessels 48 17.4

Notes:

CA – carotid arteries;

CEA – carotid endarterectomy.

Clinical characteristics of patients is presented in Table 3.

Table 3.

Characteristics of clinical material

Parameters Groups
Group I (n=276) Group II (n=192)
Past infarction 42.1% 3.6%
Past stroke 52.5% 46.3%
IHD 78.4% 53.2%
EF (%) 57.3±6.2% 62.5±7.4%
Hypertensive disease 72.4 58.6%
COPD 3.2 1.4%
Obliterating atherosclerosis of the aorta and vessels of the lower extremities 24.5 15.5%
Diabetes mellitus 37.2% 26.5%
Obesity 29.5% 18.7%

Notes:

CA – carotid arteries;

CEA – carotid endarterectomy.

All the patients were operated on under general anaesthesia. The intraoperative monitoring of cerebral blood flow was performed by means of the INVOS 5100 device (Somanetics, USA).

Eversion CEA was performed in 72% of cases. The intraoperative shunt was used in 12.5% of cases.

Statistical processing was performed using the statistical program “Microsoft Excel 2013”. All results are presented in tables in the form of quantitative characteristics and percentage ratio. Statistical significance of the results in groups was assessed using Mann-Whitney U test (SPSS 22.0.)

Results

When analyzing the obtaining results in Group I it was revealed that according to the objective and clinical methods of examination, the patients’ condition in this group was more critical (Table 3).In addition, as we have already mentioned, each patient of Group I underwent surgical or endovascular repair of the arterial system previously (Table 2).

In Group I (276 patients) during the early postoperative period 11 (3.9%) patients developed severe complications (ACD and myocardial infarction); 4 (1.4%) patients died. In Group II (192 patients) during the early postoperative period 5 (2.6%) patients developed severe complications (ACD and myocardial infarction); 1 (0.5%) patient died. When comparing the results of postoperative complications between both groups there was no statistically significant difference (p<0.05). The overall rate for serious complications (ACD and myocardial infarction) in both groups was 3.4%; the mortality rate was 1.1%.

Discussion

The problem of atherosclerosis is its multicentricity and polymorbidity of patients [6].According to literature data, almost 70% of patients with pathological changes in the extracranial arteries develop atherosclerotic lesions of other vascular territories, coronary arteries of the abdominal aorta and vessels of the lower extremities in particular [1, 3].Therefore, the approach to treatment of the pathology of aortic arch branches should be comprehensive taking into consideration somatic and neurological risk factors.

Nowadays the main indications for performing carotid endarterectomy include the degree of stenosis and its symptomatic character [7].

In symptomatic patients stenosis of 50% or more is the indication for carotid endarterectomy [5]. When selecting the optimal time interval between a stroke and carotid endarterectomy we recommend performing the latter within the first 14 days after stroke onset in the presence of intracranial ischemic focus not more than 2x3 cm in size and minimal neurologic symptoms. If the size of ischemic focus is more than 2x3 cm or there are several ischemic foci carotid endarterectomy is recommended to be performed 5-6 weeks after the onset of ACD. The more the size of ischemic focus is, the greater risk of developing hemorrhage into the ischemic area on the background of heparinization during surgery [9].

The time interval between a stroke and performing carotid endarterectomy differs due to the fact that in patients with symptomatic ICA stenosis the average annual risk of recurrent ACD is 2 times higher than within the first 14 days after the onset of cerebrovascular accident [7]. It should also be noted that the average annual risk of developing ACD in patients with symptomatic ICA stenosis is almost 10 times higher than in patients with asymptomatic ICA stenosis [6].

Urgent carotid endarterectomy (within 3 days) is indicated in patients with recurrent transient ischemic attacks during the day in the presence of unstable atherosclerotic plaque with a high embolic potential and critical ICA stenosis (85-95%) [8]. Urgent CEA was performed in 7 (2.9%) patients.

In asymptomatic patients carotid endarterectomy is indicated in severe stenosis (70% and more) [5]. In case of significant (>70%) bilateral stenosis surgery is performed on one side only (the side with more pronounced stenosis, and/or atherosclerotic plaque with high risk of embolization) [6]. Carotid endarterectomy may be performed under both general and regional anaesthesia [8]. Each method has its advantages and disadvantages, and the advantage of one of them has not been proven yet [9]. However, in general anaesthesia intraoperative monitoring of cerebral blood flow is mandatory [10]. We give priority to general anaesthesia and an intraoperative monitoring of cerebral blood flow by means of the INVOS 5100 device (Somanetics, USA). When transcranial oxygen saturation decreases by more than 25-30% we use an intraoperative shunt.

In patients with pathological deformation of the ICA the indications for surgery include manifestations of ACD and in patients with chronic cerebrovascular insufficiency – ineffective conservative treatment during 6 months [3].

In combined atherosclerotic lesions of the coronary and carotid arteries concurrent surgery (carotid endarterectomy and coronary artery bypass graft surgery) is performed only in patients with unstable angina and co-existent symptomatic ICA stenosis > 60% and in patients with asymptomatic critical ICA stenosis.

In subclavian-vertebral steal syndrome endovascular interventions are used [1]. If recanalization of atherosclerotic occlusion of the subclavian artery or brachiocephalic trunk is not possible by minimally invasive methods it is advisable to perform stenting first followed by open extranatomic reconstructions [2].

We prefer the transposition of the subclavian artery to the CCA. Carotid-carotid bypass was performed in patients with chronic dissection of the aortic arch prior to scheduled stent-graft implantation. The performance of carotid-carotid bypass was caused by the need of performing revascularization of the left CCA since when placing a stent-graft the ostium of the left CCA was covered.

Thus, considering the multicentricity of atherosclerosis and prevalence of atherosclerotic lesions of the extracranial arteries one of the most important stages is an effective comprehensive diagnosis together with careful selection of patients for surgical treatment.

Conclusions

  • Approximately 87% of surgical reconstructions of the aortic arch branches are aimed at the prevention of acute cerebrovascular disease.

  • Surgical treatment of atherosclerotic lesions of the supra-aortic arteries allows us to achieve good postoperative results.

References

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Copyright (c) 2017 I. Kopolovets, P. Berek, V. Sihotsky, M. Kubikova, N. Torma, P. Stefanic, M. Frankovicova

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