Abstract:

In recent years, with the growth of number of patients with multifocal atherosclerosis, revascularization of the brain and myocardium through hybrid intervention is gaining popularity. Although, in the world literature there are practically no results of significant randomized researches concerning percutaneous coronary intervention and carotid endarterectomy in hybrid mode, this technique is becoming more and more preferable and promising in comparison with other methods of treatment.

Aim: was to demonstrate results of revascularization of the brain and myocardium with staged and hybrid strategies, on the base of evaluation of advantages and disadvantages of these strategies on the example of case reports.

Materialsand methods: article presents two case reports, demonstrating different approaches to surgical treatment in patients with combined lesions of arteries of the brain and myocardium. Both patients were over 65 years age, at the time of treatment, had a history of acute cerebral circulation disorders, coronary heart disease and arterial hypertension. At the outpatient stage, they received antiplatelet, hypotensive, and hypolipidemic therapy. During further examination, both patients were found to have unilateral hemodynamically significant stenoses of internal carotid arteries and isolated stenoses of coronary arteries. In first case, patient was selected for hybrid surgical tactics in the volume of carotid endarterectomy and stenting of coronary artery, which was performed with a further favorable prognosis. In the second case, tactics was determined in favor of a staged procedure: first performing carotid endarterectomy, then stenting the affected coronary artery. However, taking into account subjective and objective factors, none of planned interventions were performed.

Results: hybrid revascularization allows to perform correction in two arterial of different regions in a short period of time using surgical and endovascular techniques. An important advantage of this method is the one-time performance, that means correction of MFA manifestations for one hospitalization, or even one anesthesia, with increasing in the availability of revascularization. In the first case report, the successful implementation of a hybrid approach in the treatment of combined vascular pathology in an elderly patient with a burdened anamnesis and significant comorbidities was demonstrated. Within one day, we managed to complete the planned volume of myocardial and brain revascularization and avoid the development of adverse events both in the early postoperative and long-term follow-up periods. The second clinical example clearly shows disadvantages of staged strategy, when the patient is at risk of developing adverse cardiovascular events while waiting for staged interventions, or for subjective reasons may refuse to be hospitalized in a clinic for performimg a particular operation, that as a result, led to negative dynamics and fatal outcome due to acute stroke.

Conclusions: thus, demonstrated case reports show significant potential and effectiveness of hybrid myocardial and brain revascularization using percutaneous coronary intervention and carotid endarteectomy in treatment of patients with combined lesions of two vascular regions. This method of treatment is especially promising in patients with burdened anamnesis and additional risk factors. It not only prevents adverse cardiovascular events in brain and myocardium, but also has greatest availability and implementation of the planned volume of treatment, completely excluding the influence of subjective factors (change of tactics, failure of patient to attend the next stage of treatment, etc.).

References

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Abstract:

Aim: was to develop a compleх ultrasound assessment of atherosclerotic plaque instability in correlation with morphological evaluation.

Material and methods: research included 121 patients with stenosis of left/right internal carotic artery (ICA) of 50% and more (due to NASCET scale): 80 men and 41 women, mean age 56,0 years. All patients underwent standart and contrast-enhanced ultrasonic scanning (CEUS), bilateral duplex monitoring of cerebral blood flow with registration of microembolic signals (MES). All patients in period up to 3 days after hospitalization - underwent carotid endarterectomy with histological examination of atheroscleroitc plaque.

Results: analysis of relationship between ultrasound and histological characteristics showed a moderate association between the intensity of contrast agent accumulation and the degree of plaque vascularization (Cramer's V 0,529; p<<0,000;) number of lipofages (Cramer's V 0,569; p<<0,001). There were no significant differences between the degree of plaque vascularization and the degree of plaque stenosis (p<0,05). We revealed significant differences between the number of MES and the intensity of atherosclerotic plaque blood supply (<<0,001).

Discussions: intensive accumulation of contrast agent in a plaque is associated with the process of angiogenesis and inflammation, and contrast-enhanced ultrasound examination of the plaque is promising for assessing its instability and the possible risk of developing cerebral vascular complications. Neovascularization intensity detected by contrast-enhanced ultrasound is associated with the number of detected microparticles in the cerebral blood flow, and does not depend on the degree of stenosis.

Conclusions: method of comprehensive assessment using CEUS and Doppler detection of microembolic particles can be effective in stratifying the risk of possible ischemic stroke in asymptomatic patients, for optimizing indications for surgical treatment of atherosclerotic plaque, and evaluating the effectiveness of lipid-lowering and statin therapy.

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Abstract:

Aim: was to identify risk factors of early adverse cerebral events after carotid artery stenting anc endarterectomy

Materials and methods: 908 patients who underwent isolated carotid stenting (N = 522) and carotid endarterectomy (N = 386) were included in this retrospective analysis. Patients with simultaneous cardiac surgery and patients with symptomic stenosis of CA were excluded from research. The primary end point was ipsilateral perioperative ischemic stroke, proved by neurologist and CT/MRI data. To identify predictors, multivariate regression was used, with factors that could influence endovascular and surgical methods of treatment.

Results: patients from two groups were similar in main clinical and demographic characteristics. There were no deaths and cerebral hemorrhagic complications. The stroke rate in the endovascular and surgical groups was 1.7% and 1.04% respectively (p = 0.5). The total rate of strokes and transitory ischemic attack (TIA) using two methods was 1.4%. The TIA rate was higher in the endovascular group without statistically difference (1.3% vs. 0.3%, p = 0.1). The regression analysis showed that predictor of the adverse cerebral events was the degree of carotid artery stenosis in endovascular group (OR 1.318, 95% CI: 1.131-1.535, p <0.001). There were no any predictive factors of TIA or stroke in the surgical group.

Conclusions: the independent predictor of early TIA and stroke in endovascular group, unlike endarterectomy, was the degree of carotid stenosis.

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Abstract:

Aim: was to analyze long-term results of carotid endarterectomy (CEA) in patients with unilateral lesion of the internal carotid artery (ICA), the lack of/or insignificant lesion on the contralateral side on statin therapy.

Materials and methods: for the period January 2009-December 2010, 262 CEA performed in 262 patients. Evaluated results of survival rate, stroke and myocardial infarction, condition of carotid arteries, effect of various factors on features of atherosclerotic lesions and effect of statin therapy on these processes.

Results: in late follow-up period - 245(93,5%) survivors. Patients were divided into groups: simvastatin - 60(24,5%) patients, atorvastatin - 134(54,7%) observations, rosuvastatin - 51(20,8%) cases. 14 patients died, data were obtained on the 13, average loss of 6.06%. The frequency of cardiovascular events leading to death is seven cases. Non-fatal stroke of any location - 5(1,9%) observations. The influence of hypertension (p=0,019), smoking (p=0,004), type 2 diabetes (p=0,03), dyslipidemia: hypercholesterolemia (p=0,05), hypertriglyceridemia (p=0,02), low-density lipoprotein (LDL) level is higher than normal (p=0,015), high-density lipoprotein (HDL) is below normal (p = 0,03) and other factors. Lowering cholesterol by 5,9% is marked in the atorvastatin group, maintaining at recommended values throughout the period from the initial selection in the rosuvastatin group (p = 0,0001). LDL cholesterol decreased by 19,1% in the mean value in the atorvastatin group (p = 0,0001), the increase of HDL level of 3,4% in the rosuvastatin group (p=0,02). Achievement of recommended levels of cholesterol was more often observed in the rosuvastatin group at 64,7% compared with simvastatin (p = 0,03). Risk factors influenced the incidence of restenosis ipsilateral side in 3 patients (1,2%). The greatest influence of risk factors was determined in the atorvastatin group (4,1%, p=0,001). Atorvastatin therapy stabilized the wall of the ICA 17,6% more often (p=0,05) and contralateral common carotid artery, leaving it intact at 84,6% (p=0,002) compared with other groups of statins.

Conclusion: the purpose of statin therapy depends on the severity of the atherosclerotic process the characteristics of the lipid profile and the need correction of risk factors. The most effect is provided by the group of synthetic statin above semisynthetic. Atorvastatin therapy is effective with moderate hypercholesterolemia; rosuvastatin prescribed with severe dyslipidemia.

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Abstract:

Acute cerebrovascular accident (CVA) is one of leading causes of death and disability in the population, both in Russia and around the world.

Aim: was to improve the effectiveness of the prevention of ischemic stroke (IS) in patients with asymptomatic stenosis of internal carotid arteries (ICA).

Materials and methods: this article is an analysis of the world literature on the subject of stroke in patients without focal or ocular symptoms (asymptomatic stenosis), medical and surgical (carotid stenting / carotid endarterectomy) correction of such stenotic lesions, postoperative complications, and the risk of stroke in the immediate and late postoperative period. We presented data on development of stroke, depending on the type of plaques, brain CT data, comorbidities in these patients, the method of surgical correction of stenosis. On the basis of international multicenter studies and experience of individual domestic and foreign clinics we performed evaluation of IS conservative anc surgical prophylaxis in this group of patients.

Results: performed analysis allowed to formulate recommendations on the tactics of treatment and examination of patients with asymptomatic internal carotid artery stenosis.

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Abstract:

Revascularization strategy definition in acute coronary syndrome in patients with multivessel coronary artery disease is a significant problem of modern interventional cardiology.

Aim: was to evaluate effectiveness of special PC programs «Sapphire 2015 - Right dominance» and «Sapphire 2015 - Left dominance» designed to the revascularization strategy definition ir acute coronary syndrome patients.

Materials and methods: revascularization strategy of 50 acute coronary syndrome patients was analyzed. In all cases the revascularization strategy was defined by the group of intervention cardiologists with the help of independent experts and special PC programs «Sapphire 2015 - Right dominance» and «Sapphire 2015 - Left dominance». Experts-, physicians-, and soft- based revascularization strategies were compared among themselves

Results: complete coincidence between expert-based and soft-based revascularization strategies was registered in 66% patients and the incomplete coincidence - in 32% patients. Complete mismatch between expert-based and soft-based revascularization strategies was registered in 2% patients. The complete coincidence between physicians-based and soft-based revascularization strategies was registered in 42% patients and the incomplete coincidence - ir 52% patients. Complete mismatch between physicians-based and soft-based revascularization strategies was registered in 6% patients.

Conclusion: as well as experts, special PC programs «Sapphire 2015 - Right dominance» and «Sapphire 2015 - Left dominance» provide success in the revascularization strategy definition 1г acute coronary syndrome patients with multivessel coronary artery disease.

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Abstract:

Aim: was to estimate efficacy and safety of carotid stenting and carotid endarterectomy Г patients, admitted to center of cardiovascular surgery.

Material and methods: we investigated possibilities of treatment with randomization one-by-one, according to admittance to hospital and use of carotid endarterectomy or stenting. Final decision in each case was made by consilium. For the period 2011-2013, 269 patients were treated including 132 patients who underwent carotid endarterectomy and 137 patients who underwent carotid stenting. The majority of patients had an anamnesis of coronary heart disease or needed coronary revascularization. Symptomatic stenosis was an indication for 19,0 % revascularization in both groups (p = 0.994).

Results: there were no in-hospital deaths registered. Incidence of stroke after carotid endarterectomy was 6(4,5%) and 2(1,5%) after stenting. Transient ischemic attack occurred in 3(2,2 %) patients in the stenting and 1 patient (0,76 %) in endarterectomy groups. Major bleeding was observed in both groups with equal frequency (p = 0,584). Defeat of cranial nerves (7,6 %; p = 0,001) was only observed in the endarterectomy group. Finally both methods of carotid revascularization showed the same level of complications (p = 0,569) besides cranial nerve defeat.

Conclusion: carotid stenting and endarterectomy show similar results in the treatment of patients with atherosclerotic lesions of carotid arteries. Both methods can equally be used in clinics with adequate experience in surgical interventions on the heart and peripheral vessels. The complex assessment of the patient and the lesion by the vascular team is necessary.

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