G.E. Mitroshin, G.I. Antonov, E.R. Miklashevich
Department of Neurovascular Surgery N 3, Vishnevsky Central Military Clinical Hospital, Krasnogorsk, Russia
Carotid endarterectomy (CEE) is the most spread intervention, performed on major arteries of a head. Norman Hertzer noted, "that some operations, such as carotid endarterectomy, are conceptually simple, but they should be performed without the slightest technical error" (cited according to Nicolaides A., 1995). Today technique of surgical correction of the carotid region pathology is developed rather well and, according to our opinion, there will be no new technical methods in the nearest future. The main task is choosing an optimum version of surgical tactics for each specific patient. It depends on experience of a surgical team and technical equipment of a hospital to a great extent.
Beginning with 1996, employees of the Department of Neurovascular Surgery N 3 of the Vishnevsky Central Military Clinical Hospital have performed more than 400 operations on the carotid region; an eversion method was used in 275 of them. The technique of such an operation is rather simple. It is especially typical of patients with an excessive cervical part of ICA. In this case ICA is cut off from the CCA bifurcation in an oblique direction. ICA is everted with simultaneous pulling-up of an atherosclerotic plaque from the vessel with the help of forceps. It is done until the plaque is torn off or comes to naught. It is necessary to stitch intima in the first case in order to prevent its twisting and subsequent thrombosis of the artery. Then the artery is averted once again and washed carefully. When scraps of intima or media are removed, it is sutured into the opening with 6-7/0 microthread. According to our opinion, this technique is preferable due to its simplicity and absence of necessity to widen the opening with the help of patches.
If a plaque does not stretch into ICA very much, but causes considerable stenotic narrowing of CCA, eversion endarterectomy is performed through CCA, which is cut off 1 cm below the bifurcation. The initial stage consists in removal of a plaque from ECA with the purpose of better mobilization of the CCA bifurcation. The second stage is removal of a plaque from ICA. Then a proximal segment of CCA is everted to a length of 1 cm and an atherosclerotic plaque is cut off by scissors. A residual part of a plaque is not stitched in this segment, as it is not in opposition to blood flow and cannot become a source of embolism. It is quite natural, that cases with a disintegrating plaque, demanding standard removal, are excluded.
Comparison of a course of postoperative periods and catamnesis data for 6 years revealed no reliable difference in these periods in groups of patients with standard and eversion endarterectomy. Besides, we did not notice any factors, limiting endarterectomy technique even in case of a long plaque (more than 2.5 cm) in ICA. The maximum length of a plaque was 3 cm, i.e. all manipulations were performed practically in close vicinity to a skull base.
Incompetence of collateral circulation in the Willis circle, watched in some cases, demands use of a temporary intraluminal shunt. It is extremely important to know morphologic properties of an atherosclerotic plaque in such a situation. In case of a heterogeneous plaque, removal of atheromatous masses from ICA is the first step during eversion; then a shunt is inserted. When a plaque surface is smooth, a shut is inserted through it and then removed together with a plaque.
Thus, eversion endarterectomy can be performed in all categories of patients with stenotic lesions of the carotid region. There no limitations, connected with a length of a lesion of major vessels.