Determination of indications and contraindications for reconstructive operations in atherosclerotic lesions of arteries of the carotid system

Vereshchagin N.V., Dobzhansky N.V., Dzhibladze D.N., Nikitin Yu.M., Ladoga O.V., Kugoev A.I., Chechyotkin A.O., Barkhatov D.Yu., Sharypova T.N., Pukanov V.S.

(Research Institute of Neurology of the Russian Academy of Medical Science)

The analysis of surgical treatment of 205 patients aged 38-76 (182 males, 23 females) was carried out. The patients had multiple (associated) atherosclerotic occluding lesions of arteries of the carotid system and underwent 329 different reconstructive operations. They were as follows: 250 extra-intracranial microarterial anastomoses (EICMA), 52 endarterectomies of internal carotid arteries, 18 endarterectomies of external carotid arteries, 9 endarterectomies of subclavian or vertebral arteries. All operations were performed in 1980-2000. One or several episodes of ischemic disorders in one or both hemispheres were watched in 85% of patients; 76% of cases had locomotive deficiency, marked to this or that extent; aphasic disorders took place in 30% of patients.

The best clinical results were obtained in transitory ischemic attacks (95%) and progressive stroke (80%), which were not accompanied by extensive ischemic changes in the brain. Patients with completed ischemic stroke were characterized by insignificant improvement or its absence. It was irrespective of a degree of neurologic deficit.

Endarterectomy in tandem stenosis of ICA (more than 50%) resulted in arterial occlusion with development of neurologic deficit in 3 out of 8 patients; successful operation did not lead to clinical improvement in the rest 5 cases.

Results of a follow-up (138 patients), ranging from 1 up to 20 years (8.5 years on the average), were as follows: working ability was preserved in 42 cases; 52 patients could do some work about the house; 8 cases need assistance. There were 36 fatal outcomes, which were conditioned by myocardial infarction (18), repeated stroke (8, including 2 cases, who died from hemorrhagic stroke), other causes (6).

Thus, carotid endarterectomy, EICMA or bilateral EICMA are effective methods of treatment and prevention of ischemic disorders of cerebral circulation in patients with multiple (associated) lesions of cerebral arteries. In case of tandem stenosis of ICA endarterectomy of its opening does not achieve its goal rather often and can cause development of neurologic complications. It is necessary to carry out individual complex estimation of a patient's state for determination of indications and a type of reconstructive operations.