Hybrid revascularization of the heart and brain: which carotid endarterectomy is preferable?

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Abstract

The aim of this study was to analyse the inpatient and long-term results of hybrid surgery, incorporating percutaneous coronary intervention (PCI) and different types of carotid endarterectomy (CEA).

Materials and methods. A prospective, open-label cohort comparison study was conducted in 2018–2020 and included 363 patients with atherosclerosis of both the internal carotid artery (ICA) and coronary artery, who underwent hybrid revascularization of the brain and myocardium. All patients were divided into four groups based on the revascularization strategy: group 1 (n = 107; 29.5%) — PCI + eversion CEA; group 2 (n = 98; 27%) — PCI + classic CEA with patch angioplasty; group 3 (n = 72; 19.8%) — PCI + glomus-sparing CEA according to R.A. Vinogradov; and group 4 (n = 86; 23.7%) — PCI + glomus-sparing CEA according to A.N. Kazantsev. The follow-up period was 20.8 ± 8.0 months.

The patient received a loading dose of clopidogrel (300 mg) before the PCI, and the procedure was then performed in an endovascular operating room. A radial artery catheter was inserted, and the patient received 10,000 IU of intravenous heparin before the procedure. After the PCI, the patient was taken to the vascular operating room, where they underwent the CEA. The patient received 5,000 IU of intravenous heparin before artery clamping. Glomus-sparing CEA according to A.N. Kazantsev was performed as follows: an arteriotomy was conducted along the internal edge of the external carotid artery (ECA), adjacent to the carotid sinus and 2–3 cm above the ostium, and extending to the common carotid artery (CCA) (also 2–3 cm below the ECA ostium), depending on the size of the atherosclerotic plaque. The ICA was transected in the area bound by the ECA and CCA walls. Eversion CEA of the ICA was performed, followed by open CEA of the ECA and CCA. The ICA was implanted in its previous position in the preserved area.

Results. No mortality was recorded during the inpatient follow-up period. All cases of myocardial infarction occurred after eversion and classic CEA: 3 in group 1 (2.8%) and 1 in group 2 (1.02%); р = 0.2. No ischaemic stroke was recorded only in patients who underwent CAE according to A.N. Kazantsev (р = 0.66); however, ischaemic stroke occurred in two patients in group 1 (1.8%), in two patients in group 2 (2.04%) and in one patient in group 3 (1.38%). The highest number of cardiovascular events occurred in group 1, due to carotid glomus injury, which led to poorly controlled hypertension during the inpatient stay. This tendency influenced the composite endpoints (death + myocardial infarction + ischaemic stroke), which were highest in group 1 (5 or 4.6%) compared to 3 (3.06%), 1 (1.38%) and 0 in groups 2–4, respectively (р = 0.18). The groups were comparable in the frequency of long-term complications. However, the incidence of ICA restenosis was lowest and no ECA thrombosis/occlusion was observed after glomus-sparing CEA according to R.A. Vinogradov and A.N. Kazantsev.

Conclusion. A hybrid PCI + CEA for brain revascularization should be glomus-sparing. CEA according to A.N. Kazantsev was characterized by lack of procedural arteriotomy complications. This procedure enables blood pressure monitoring in the postoperative period, thus minimizing the risk of cardiovascular complications.

About the authors

Anton N. Kazantsev

Alexander City Hospital

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

cardiovascular surgeon, Surgery department No. 3

Russian Federation, Saint Petersburg

Roman A. Vinogradov

Research Institute Regional Clinical Hospital No. 1 named after prof. S.V. Ochapovsky; Kuban State Medical University

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0001-9421-586X

D. Sci. (Med.), Associate Professor, Head, Department of Vascular Surgery, Chief vascular surgeon of the Krasnodar Territory, cardiovascular surgeon, Department of Surgery No. 1, FPK and PPS

Russian Federation, Krasnodar; Krasnodar

Sergey V. Artyukhov

Alexander City Hospital; I.I. Mechnikov North-Western State Medical University

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0001-8249-3790

Cand. Sci. (Med.), Deputy chief physician

Russian Federation, Saint Petersburg; Saint Petersburg

Lyudmila V. Roshkovskaya

Alexander City Hospital

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0002-6735-5020

Cand. Sci. (Med.), Deputy chief physician for neurology

Russian Federation, Saint Petersburg

Vyacheslav V. Matusevich

Research Institute Regional Clinical Hospital No. 1 named after prof. S.V. Ochapovsky

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0001-9461-2726

cardiovascular surgeon

Russian Federation, Krasnodar

Goderzi Sh. Bagdavadze

I.I. Mechnikov North-Western State Medical University

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0001-5970-6209

ordinator

Russian Federation, Saint Petersburg

Roman Yu. Lider

Kemerovo State Medical University

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0002-3844-2715

student

Russian Federation, Kemerovo

Merab O. Janelidze

Western Regional Center of Modern Medical Technologies

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0002-5135-0479

Cand. Sci. (Med.), leading surgeon

Georgia, Kutaisi

Aleksandr E. Chikin

Alexander City Hospital

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0001-6539-0386

Cand. Sci. (Med.), Deputy сhief doctor for surgical care

Russian Federation, Saint Petersburg

Tatyana E. Zaitseva

Alexander City Hospital

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0001-8971-7558

Cand. Sci. (Med.), Deputy chief physician for medical work

Russian Federation, Saint Petersburg

Yuriy P. Linets

Alexander City Hospital

Email: dr.antonio.kazantsev@mail.ru
ORCID iD: 0000-0002-2279-3887

D. Sci. (Med.), Professor, chief physician

Russian Federation, Saint Petersburg

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2. Fig. 1 Different CEA techniques. A — CEA according to R.A. Vinogradov; B — CEA according to K.A. Antsupov; C — CEA according to A.N. Kazantsev; D — CEA according to E.V. Rosseykin. 1 — external carotid artery; 2 — internal carotid artery; 3 — arteriotomy line; 4 — common carotid artery.

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3. Fig. 2. Systolic blood pressure changes in the inpatient postoperative period.

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4. Fig. 3. Survival rate (%), non-fatal. Logrank test, р = 0,73

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5. Fig. 4. Survival rate (%), no myocardial infarction. Logrank test, р = 0,22.

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6. Fig. 5. Survival rate (%), no cerebrovascular accident/transient ischemic attack. Logrank test, р = 0,09.

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7. Fig. 6. Survival (%), no haemodynamically significant ICA restenosis. Logrank test, p = 0.2.

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8. Fig. 7. Survival rate (%), no composite endpoint. Logrank test, р = 0,07.

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9. Fig.8. Interactive programme for selecting the simultaneous or staged revascularization approach in patients with combined coronary and internal carotid artery disease.

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Copyright (c) 2021 Kazantsev A.N., Vinogradov R.A., Artyukhov S.V., Roshkovskaya L.V., Matusevich V.V., Bagdavadze G.S., Lider R.Y., Janelidze M.O., Chikin A.E., Zaitseva T.E., Linets Y.P.

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