OBJECTIVE
To study the immediate and long-term results of different types of reconstruction for extended atherosclerotic lesion of internal carotid artery (ICA).
MATERIAL AND METHODS
There were 1012 patients with severe extended atherosclerotic lesions of ICA for the period from January 2017 to August 2020. An extended lesion was determined as an atherosclerotic plaque extending from the ICA orifice in distal direction for ≥3 cm. Depending on reconstruction, all patients were divided into 6 groups: group 1 — ICA replacement (n=76); group 2 — carotid endarterectomy (CEE) with patch repair (n=341); group 3 — carotid artery bifurcation de novo (n=238); group 4 — autologous arterial reconstruction of carotid artery bifurcation (n=177); group 5 — ICA autotransplantation (n=94); group 6 — glomus-sparing ICA autotransplantation (n=86). Long-term follow-up period was 28.1±5.9 months.
RESULTS
We found significant differences in the incidence of external carotid artery (ECA) occlusion (group 1 — 12 (15.8%); group 2 — 35 (10.3%); group 3 — 0; group 4 — 0; group 5 — 6 (6.4%); group 6 — 0; p<0.0001). At the same time, no complications were obtained in group 6. Combined endpoint (death + stroke + myocardial infarction) occurred in the following cases: group 1 — 1 (1.3%); group 2 — 2 (0.6%); group 3 — 2 (0.84%); group 4 — 3 (1.7%); group 5 — 1 (1.1%); group 6 — 0; p=0.75). ICA thrombosis was not detected. Blood pressure (BP) was measured within 7 days after surgery. Unstable hemodynamics with a tendency to hypertension following injury of carotid glomus was recorded in all groups except for groups 2 and 6. In long-term follow-up period, significant differences were obtained in the incidence of ischemic stroke (group 1 — 8 (10.5%); group 2 — 14 (4.1%); group 3 — 2 (0.8%); group 4 — 3 (1.7%); group 5 — 1 (1.1%); group 6 — 0; p<0.0001), ICA restenosis >60% (group 1 — 10 (13.2%); group 2 — 29 (8.5%); group 3 — 5 (2.1%); group 4 — 9 (5.1%); group 5 — 1 (1.1%); group 6 — 0; p<0.0001), ECA occlusion (group 1 — 26 (34.2%); group 2 — 37 (10.8%); group 3 — 8 (3.4%); group 4 — 6 (3.4%); group 5 — 7 (7.4%); group 6 — 0; p<0.0001) and combined endpoint (group 1 — 9 (11.8%); group 2 — 17 (5.0%); group 3 — 3 (1.3%); group 4 — 4 (2.3%); group 5 — 1 (1.1%); group 6 — 1 (1.2%); p<0.0001).
CONCLUSION
Glomus-sparing ICA autotransplantation is the most promising method for extended atherosclerotic lesion. This conclusion is due to exclusion of such shortcomings of other techniques as trauma of carotid glomus followed by unstable blood pressure, ICA restenosis and ECA occlusion. If glomus-sparing ICA autotransplantation is not possible, alternative methods can be carotid artery bifurcation de novo, autoarterial reconstruction of carotid artery bifurcation, ICA autotransplantation. However, these procedures require careful postoperative monitoring of blood pressure due to the risk of hypertensive crisis and subsequent hyperperfusion syndrome. Conventional CEE with patch repair and ICA replacement should be excluded for extended ICA lesion due to high risk of symptomatic restenosis in mid- and long-term follow-up period.
