Eversion carotid endarterectomy with transposition of the internal carotid artery according to A.N. Kazantsev. Hospital and long-term results.

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Abstract

Aim. This study provides an analysis of the results of eversion carotid endarterectomy (CEE) with transposition of the internal carotid artery (ICA) over the hypoglossal nerve, according to A.N. Kazantsev.

Materials and Methods. The given prospective open study covering the period from
January 2017 to May 2020 involved 311 patients who underwent eversion CEE with transposition of ICA over the hypoglossal nerve, according to A.N. Kazantsev. Transposition was performed in the following way: after standard isolation of the carotid arteries, their compression, arteriosection, and removal of atherosclerotic plaque, ICA was extracted in the area above the hypoglossal nerve and was implanted to the same position. The condition of the patient was controlled on repeated visits to the clinic every six months. Hemodynamics in the reconstruction zone were studied using multispiral computed tomography with angiography of carotid bifurcation with 0.6 mm steps and processing the obtained results in Sim Vascular and Open Foam programs in DICON format. The follow-up period was 18.3±7.1 months. In case of development of restenosis, reCEE was performed with patch plasty of the reconstruction zone. For histologic examination, the restenosis area was stained by the van Gieson method.

Results. In the hospital follow-up period, one case of myocardial infarction was noted
that developed due to the stent’s thrombosis in the anterior descending artery deployed two years before. When studying the hemodynamic properties of carotid bifurcation in the postoperative period using computer modeling, in all cases, no changes or obstacles to blood flow were formed in the ICA in the area above the hypoglossal nerve. In the long-term follow-up period, two cases of lethal outcome were recorded connected with the onset of an oncological disease. In one case, due to recurrence of the pulmonary artery thromboembolism. In two cases, the cause of myocardial infarction was thrombosis/occlusion of venous anastomoses (in one patient to the circumflex
artery, in the other – to the right coronary artery). In four cases, repeated acute cerebrovascular accidents developed due to restenosis after CEE. In cases of significant restenosis (n=8), reCEE was performed with plasty of the reconstruction zone with a patch. The average restenosis period was 8.2±3.6 months. No cardiovascular complications and cases of hypoglossal nerve traumatization were identified. Intraoperatively, it was confirmed that restenosis was formed in the bifurcation zone, in front of the perimeter of the primary arteriosection. According to the results of histological examination, the main cause of all restenoses was hyperplasia of the neointima.

Conclusion. The eversion CEE with the transposition of the ICA, according to A.N. Kazantsev, creates conditions for additional maneuvers in case of restenosis and implementation of reCEE. The ICA’s placement over the hypoglossal nerve during primary CEE allows more confident isolation of carotid artery bifurcation from scar tissues with a zero risk of damage to the hypoglossal nerve. Such a course of the operation makes it possible to apply a clamp on the ICA and perform arteriotomy in any location without the threat of injury to the nerve structures.

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About the authors

Anton N. Kazantsev

Alexander Hospital

Author for correspondence.
Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0002-1115-609X
SPIN-code: 8396-1845

Cardiovascular Surgeon

Russian Federation, Saint-Petersburg, Russia

Konstantin P. Chernykh

Alexander Hospital

Email: info@eco-vector.com
ORCID iD: 0000-0002-5089-5549
SPIN-code: 3968-2649

Cardiovascular Surgeon

Russian Federation, Saint-Petersburg, Russia

Nona E. Zarkua

Mechnikov North-West State Medical University

Email: info@eco-vector.com
ORCID iD: 0000-0002-7457-3149
SPIN-code: 4568-4125

MD, PhD, Surgeon

Russian Federation, Saint-Petersburg, Russia

Artem D. Abdullaev

Pskov Regional Infection Hospital

Email: info@eco-vector.com
ORCID iD: 0000-0003-1594-7611
SPIN-code: 1265-3122

Head of the Admission Department

Russian Federation, Pskov, Russia

Anastasiya V. Povtoreiko

Pskov Regional Infection Hospital

Email: info@eco-vector.com
ORCID iD: 0000-0001-9017-0190

Chief Physician

Russian Federation, Pskov, Russia

Goderzi Sh. Bagdavadze

Alexander Hospital

Email: info@eco-vector.com
ORCID iD: 0000-0001-5970-6209

Cardiovascular Surgeon of the Surgery

Russian Federation, Saint-Petersburg, Russia

Еvgeniy Yu. Kalinin

Mechnikov North-West State Medical University

Email: info@eco-vector.com
ORCID iD: 0000-0003-3258-4365
SPIN-code: 9120-1351

MD, PhD, Head of the Surgery Department №3

Russian Federation, Saint-Petersburg, Russia

Tatyana E. Zaitseva

Alexander Hospital

Email: info@eco-vector.com
ORCID iD: 0000-0001-8971-7558
SPIN-code: 5323-1513

MD, PhD, Deputy Chief Physician for Medical Work

Russian Federation, Saint-Petersburg, Russia

Aleksandr E. Chikin

Alexander Hospital

Email: info@eco-vector.com
ORCID iD: 0000-0001-6539-0386
SPIN-code: 3461-6134

к.м.н., зам. главного врача по хирургической помощи, СПб ГБУЗ Городская Александровская больница

Russian Federation, Saint-Petersburg, Russia

Yuriy P. Linets

Alexander Hospital

Email: info@eco-vector.com
ORCID iD: 0000-0002-2279-3887
SPIN-code: 4522-6791

MD, PhD, Professor, Chief Physician

Russian Federation, Saint-Petersburg, Russia

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Supplementary files

Supplementary Files
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1. Fig. 1. Scheme of hypoglossal nerve transposition, according to A.N. Kazantsev: A – Natural location of the hypoglossal nerve over the internal carotid artery; B – Location of the hypoglossal nerve under the internal carotid artery after transposition, according to A.N. Kazantsev; 1A – hypoglossal nerve; 2A – internal carotid artery; 2A – internal carotid artery; 2B – hypoglossal nerve

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2. Fig. 2. The result of eversion CEE with transposition of the internal carotid artery, according to A.N. Kazantsev:A – intraoperative photo: 1 – common carotid artery; 2 – area of arteriosection with primary suture; 3 – the place of implantation of the internal carotid artery to the same position; 4 – internal carotid artery; 5 – a part of the internal carotid artery above the hypoglossal nerve; B – multislice computed tomography with angiography after 12 months after eversion CEE with transposition of the internal carotid artery, according to A.N. Kazantsev: 1 – a part of the internal carotid artery above the hypoglossal nerve; 2 – the place of implantation of the internal carotid artery to the same position; 3 – area of arteriosection with primary suture; 4 – common carotid artery

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3. Fig. 3. Computer modeling of carotid bifurcation in the postoperative period: 1 – common carotid artery; 2 – projection of arteriosection; 3 – external carotid artery; 4 – internal carotid artery; 5 – the area of the internal carotid artery above the hypoglossal nerve

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4. Fig. 4. Death-free survival (noncardiovascular causes)

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5. Fig. 5. Myocardial infarction-free survival

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6. Fig. 6. Stroke-free survival

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7. Fig. 7. Combined endpoint-free survival

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8. Fig. 8. ICA restenosis-free survival

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Copyright (c) 2021 Kazantsev A.



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