Immediate and remote results of using carotid endarterectomy and stenting of internal carotid arteries

Dyuzhikov A.A.¹, Khripun A.V.², Malevannyi M.V.², Orlov A.E.¹, Kulikovskikh YA.V.²

1) Centre of Cardiology and Cardiovascular Surgery of the Rostov Regional Clinical Hospital,
2) Regional Vascular Centre of the Rostov Regional Clinical Hospital, Rostov-on-Don, Russia

Objective. The study was aimed at analysing the outcomes of single-centre carefully selected use of the methods of carotid stenting and endarterectomy in patients with atherosclerotic lesions of the cervical segment of the internal carotid artery (ICA) in the immediate and remote postoperative periods.

Patients and methods. We retrospectively analysed the data regarding a total of 340 patients presenting with atherosclerotic lesions of the internal carotid artery over the period from 2007 to 2011. Depending on the method of revascularization, all patients were subdivided into two groups: the group undergoing stenting of the internal carotid artery (a total of 170 patients) and the group of carotid endarterectomy (170 patients). The group of stenting included significantly more patients with a history of myocardial infarction (31.8% versus 5.3% (p<0.001), functional class III-IV chronic cardiac insufficiency (17.6% vs 1.2%, p=0.006), and chronic obstructive pulmonary disease (12.4% vs 3.5%; p=0.004). The first also had more patients with previously endured ischaemic stroke in the basin of the ipsilateral ICA (21.8% vs 12.4%; p=0.03). However, the both groups were comparable by the number of symptomatic (65.3% and 59.4%; p=0.314) and asymptomatic (34.7% and 40.6%; p=0.314) lesions of the ICA. Prior to operative intervention 95.3% of patients were subjected to coronarography and selective angiography of the brachiocephalic arteries (DCA). Stenting of the ICA was carried out under local anaesthesia in 100% of cases. Protection of the brain from embolism was used in all cases of stenting, of theses 103 patients (60.6%) patients received the system of proximal protection MoMa Ultra. Carotid endarterectomy was carried out under general anaesthesia in all patients. A temporary bypass was employed in 36.5% of cases. A patch was sewn into the arteriotomic orifice in 85.9% of cases. The outcomes of carotid revascularization were assessed in both the immediate and remote postoperative periods.

Results. No statistically significant differences by such end points as death, stroke, myocardial infarction, as well as by the composite parameter (death, stroke, infarction) and the number of local complications between the two methods of revascularization in the immediate (up to 30 days) postoperative period were observed. There were two lethal outcomes occurring in the group of carotid endarterectomy due to acute myocardial infarction and major ipsilateral stroke. The groups significantly differed by the frequency of damage to the craniocerebral nerves (0% in the carotid stenting group versus 4.1% in the CEA group; p=0.015). In the remote postoperative period averagely amounting to 16.4±9.5 months, no lethal outcomes in either group were registered, with the groups also not differing by the rate of either strokes, infractions, or restenoses/occlusions of the ICA.

Conclusions. Carefully selected use of CEA and carotid stenting at one medical facility makes it possible to obtain comparably low indices of "death, infarction, stroke" in the immediate postoperative period, which are substantially lower than those reported in large randomized studies [1.2% versus 5.2% (CREST) in stenting, 2.9% vs 4.5% (CREST) in CEA], to considerably decrease the total rate of mortality, stroke, infarction in the immediate postoperative period (2.1% for all patients in the study, and 3.0% for symptomatic patients versus 3.3% for the measure “death, stroke” in the NACET study.), to obtain comparably low rates of death, infarction or stroke in the remote postoperative period, to enlarge the possibilities of carotid revascularization in the presence of limiting factors of each of the techniques.

KEY WORDS: internal carotid artery, stenting, carotid endarterectomy.

P. 102-110

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