Comparative Results of Emergency Carotid Endarterectomy and Emergency Carotid Angioplasty With Stenting in the Acute Period of Ischemic Stroke. Multicenter Study Results

 AIM OF STUDY Study of hospital results of emergency carotid endarterectomy (CEE) and carotid angioplasty with stenting (CAS) in the acute period of acute cerebrovascular accident (ACVA).

MATERIAL AND METHODS From January 2008 to August 2020, the study included 615 patients with hemodynamically significant stenosis of the internal carotid arteries (ICA), operated on in the acute period of ischemic stroke (within 3 days from the onset of stroke). Depending on the type of revascularization implemented, all patients were divided into 2 groups: group 1 — CAS (n=312); 2nd group — CEE (n=357). Inclusion criteria were as follows: 1. Mild neurological disorders: NIHSS score 3–8; Modified Rankin Scale score 2 of less; Barthel Scale > 61; 2. Indications for CEE / CAS  according to the current national recommendations; 3. Ischemic focus in the brain not more than 2.5 cm in diameter. Exclusion criteria: 1. Presence of  con-traindications to CEE / CAS. Carotid angioplasty with stenting was performed according to the standard technique; in all cases, distal embolism  protection systems were used. Carot-id endarterectomy was performed  according to the classical and eversion techniques. When the retrograde pressure in the ICA was less than 60% of the systemic pressure, a temporary shunt (TS) was installed. In the postoperative period, all patients underwent multispiral computed tomography (MSCT) of the brain. In the absence of negative dynam-ics in the neurological status, MSCT was performed on the 7th day after the operation, if available, it was performed urgently. The checkpoints were the development of such unfa-vorable cardiovascular events as death, myocardial infarction (MI), stroke / transient is-chemic attack (TIA), “mute” stroke, “mute” hemorrhagic transformations, combined
end-point (death + all strokes / TIA + MI). Strokes were mute if diagnosed according to MSCT, without symptoms.RESULTS In 69% of diabetic patients with anterior myocardial infarction and in 63% of patients with posterolateral MI 12 months after PCI, signs of LV inferiority were revealed in the form of an increase in the indices of end-diastolic and systolic volumes of the LV and low ejection fraction (≤45%). In patients without diabetes, these figures were 18% and 31%, respectively. High concentrations of NT-proBNP on the first day of myocardial infarction after PCI were of the greatest value in the  diagnosis and prognosis of LV UR after 12 months.

RESULTS When analyzing hospital complications, significant differences in the frequency of lethal outcome were not obtained (group 1: n=6 (1.92%); group 2: n=8 (2.24%); p=0.98; OR=0.85; 95% CI 0.29–2.49); MI (group 1: n=5 (1.6%); group 2: n=5 (1.4%); p=0.91; OR=1.14; 95% CI 0.32–3.99 ); ACVA (ischemic type) / TIA (group 1: n=5 (1.6%); group 2: n=6 (1.7%); p=0.82; OR=0.95; 95% CI 0.28–3.15), as well as “mute” ACVA (group 1: n=7 (2.2%);  group 2: n=15 (4.2%); p=0.23; OR=0.52; 95% CI 0.21–1.3). However, the vast majority of hemorrhagic transformations (group 1: n=2 (0.64%); group 2:  n=13 (3.6%); p=0.018; OR=0.17; 95% CI 0.03–0.76) and all “mute” hemorrhagic transformations (group 1: n=0; group 2: n=26 (7.3%); p=0.001;  OR=0.02; 95% CI 0.001–0.33) were observed only in the CEE group, which was reflected in the maximum values of the combined end point: group 1: n=22 (7.05%); group 2: n=73 (20.4%); p<0.0001; OR=0.29; 95% CI 0.17–0.48). Thus, in the CEE group, every 5th patient had a complication.

CONCLUSION Carotid angioplasty with stenting is the safest method of revascularization for patients in the acute period of ACVA. This is largely due to the reduction in the risk of reperfusion syndrome and the prevention of embolism due to the use of modern protection systems. Carotid  endarterectomy can be performed with comparable efficiency only when a tempo-rary shunt is placed in the internal carotid arteries in the absence of unstable atheroscle-rotic plaque. 

1. Natsional’nye rekomendatsii po vedeniyu patsientov s zabolevaniyami brakhiotsefal’nykh arteriy. Mosсow, 2013. (in Russ.) Available at: http://www.angiolsurgery.org/recommendations/2013/recommendations_brachiocephalic.pdf [Accessed 16 Feb, 2021]

2. Kazantsev AN, Burkov NN, Anufriev AI, Mironov AV, Lider RYu, Guselnikova YuI, et al. Mid-term results of carotid endarterectomy in patients with contralateral carotid lesion. Russian Journal of Cardiology and Cardiovascular Surgery. 2020;13(2):95–103. https://doi.org/10.17116/kardio20201302195

3. Dakour Aridi H, Locham S, Nejim B, Malas MB. Comparison of 30-day readmission rates and risk factors between carotid artery stenting and endarterectomy. J Vasc Surg. 2017;66(5):1432–1444.e7. https://doi.org/10.1016/j.jvs.2017.05.097

4. Vinogradov RA, Pykhteev VS, Lashevich KA. Remote Results of Open Surgical and Endovascular Treatment of Internal Carotid Artery Stenoses. Angiology and Vascular Surgery. 2017;23(4):164–170. (In Russ.)

5. Kazantsev AN, Burkov NN, Bayandin MS, Guselnikova YuI, Lider RYu, Yakhnis YeYa, et al. In-hospital outcomes of carotid artery stenting in patients with multifocal atherosclerosis. Russian Journal of Cardiology and Cardiovascular Surgery. 2020;13(3):224–229. (In Russ.) https://doi.org/10.17116/kardio202013031224

6. Chen L, Jiang CY. Outcome differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in postoperative ventricular arrhythmia, neurological complications, and in-hospital mortality. Postgrad Med. 2020;1–8. https://doi.org/10.1080/00325481.2020.1768765

7. Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis. J Vasc Surg. 2017;66(2):607–617. https://doi.org/10.1016/j.jvs.2017.04.053

8. Timaran CH, Mantese VA, Malas M. Differential outcomes of carotid stenting and endarterectomy performed exclusively by vascular surgeons in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). J Vasc Surg. 2013;57(2):303–308.

9. Pfaff JAR, Maurer C, Broussalis E. Acute thromboses and occlusions of dual layer carotid stents in endovascular treatment of tandem occlusions. J Neurointerv Surg. 2020;12(1):33–37. doi:10.1136/neurintsurg-2019-015032

10. Toljan K, Jovanović I, Starčević K, et al. Acute Carotid Stent Thrombosis in an Ultrarapid Clopidogrel Metabolizer: Case Report and Literature Review. Vasc Endovascular Surg. 2019;53(7):602–605. https://doi.org/10.1177/1538574419857965

11. Kazantsev AN, Burkov NN, Shabayev AR, Volkov AN, Ruban EV, Lider RYu, et al. Surgical treatment of a patient with stent restenosis in the mouth of the general carotid artery and the proximal department of the internal carotid artery. Circulation Pathology and Cardiac Surgery. 2019;23(3):104–110. (In Russ.). http://dx.doi.org/10.21688/1681-3472-2019-3-104-110

12. Alekyan BG, Petrosyan KV, Makhaldiani BZ. Surgical and Endovascular Treatment Atherosclerotic Lesions of Internal Carotid Artery. Russian Journal of Thoracic and Cardiovascular Surgery. 2017;59(3):171–180. https://doi.org/10.24022/0236-2791-2017-59-3-171-180

13. Kazantsev AN, Chernykh KP, Zarkua NE, et al. Immediate and long-term results of carotid endarterectomy in different periods of ischemic stroke. I.P. Pavlov Russian Medical Biological Herald. 2020;28(3):312–322. (in Russ.) https://doi.org/10.23888/PAVLOVJ2020283312-322

14. Pokrovskiy AV, Golovyuk AL. Sostoyanie sosudistoy khirurgii v Rossiyskoy Federatsii v 2018 godu. Angiology and Vascular Surgery. 2019;25(2):1–48. (In Russ.)

15. Darvish NA, Abdulgasanov RA, Shogenov MA, Abdulgasanova MR. Carotid endarterectomy and carotid artery stenting in the prevention of ischemic stroke. Annals of Surgery. 2019;24(4):245–252. (in Russ.) https://doi.org/10.24022/1560-9502-2019-24-4-245-252

16. Khripun AI, Pryamikov AD, Mironkov AB, Tyurin IN, Asratyan SA, Suryakhin VS., et al. Outcomes of Open Endovascular Operations on the Internal Carotid Artery in Acute Stage of Ischaemic Stroke. Angiology and Vascular Surgery. 2017; 23(3):112–120. (in Russ.)

17. Altman DA, Fokin AA, Vladimirskiy VV, Baryshnikov AA, Ignatov VA, Chernousov VV, et al. The Experience of Reconstructive Interventions on Carotid Arteries in Patients With Acute Phase Of Ischemic Stroke. Vestnik Chelyabinskoy Oblastnoy Klinicheskoy Bol’’nitsy. 2018; 40 (2): 4–44. (In Russ.)

18. Zozulya AI, Zozulya ІS. Surgical Approach to Acute Ischemic Stroke Treatment. Khirurgiya Ukrainy. 2014;51(3):17–22. (in Russ.)

19. Fokin AA, Vardugin PV. Identification of indications for urgent surgery on carotid arteries in acute ischemic disorders of cerebral circulation. Regional Blood Circulation and Microcirculation. 2002;1(1):27–31. (in Russ.)

20. Cukurova LA, Timchenko LV, Golovko EN, Usachev AA, Fedorchenko AP, Porkhanov VA. The successful urgent operations on brachiocephalic arteries at two patients in acute period of ischemic stroke. Russian Journal of Neurosurgery. 2013;(4):70–72. (in Russ.)

21. Kazantsev AN, Burkov NN, Tarasov RS, Anufriev AI, Shabaev AR, Ruban EV., et al. Carotid endarterectomy in acute ischemic stroke. Carotid endarterectomy in acute ischemic stroke. Circulation Pathology and Cardiac Surgery. 2018;22(1):66–72. (in Russ.). http://dx.doi.org/10.21688/1681-3472-2018-1-66-72

22. Jankowitz BT, Tonetti DA, Kenmuir C, Rao R., Ares WJ, Zussman B., et al. Urgent Treatment for Symptomatic Carotid Stenosis: The Pittsburgh Revascularization and Treatment Emergently After Stroke (PIRATES) Protocol. Neurosurgery. 2020;87(4):811–815. PMID: 32294211 https://doi.org/10.1093/neuros/nyaa096

23. De Rango P, Brown MM, Chaturvedi S, Howard VJ, Jovin T, Mazya MV., et al. Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks. Stroke. 2015;46(12):3423–3436. PMID: 26470773 https://doi.org/10.1161/STROKEAHA.115.010764

24. Roussopoulou A, Tsivgoulis G, Krogias C, Lazaris A, Moulakakis K, Georgiadis GS, et al. Safety of urgent endarterectomy in acute non-disabling stroke patients with symptomatic carotid artery stenosis: an international multicenter study. Eur J Neurol. 2019;26(4):673–679. PMID: 30472766 https://doi.org/10.1111/ene.13876

25. Vinogradov RA, Kosenkov AN, Vinokurov IA, Zyablova EI, Sidorenko V. Silent Brain Ischemic Lesion After Revascularization of Brachiocephalic Arteries. Bulletin of Pirogov National Medical & Surgical Center. 2017;12(2):52–54. (in Russ.)

26. Schnaudigel S., Gröschel K., Pilgram S.M., Kastrup A. New foci of ischemic injury after carotid artery stenting and carotid endarterectomy. Systematic review. Journal of the National Stroke Association / Stroke / Russian edition. 2008;4:74–83.

27. Merkulov D.V., Savello V.E., Voznyuk I.A., Dudanov I.P. The value of multislice computed tomography in determining treatment tactics and predicting results in the acute phase of ischemic stroke. Radiation diagnostics and therapy. 2017;3(8):112–113.

28. Perini P, Bonifati DM, Tasselli S, Sogaro F. Routine Shunting During Carotid Endarterectomy in Patients with Acute Watershed Stroke. Vasc Endovascular Surg. 2017;51(5):288–294. PMID: 28504077 https://doi.org/10.1177/1538574417708130

29. Vasilchenko N.O., Rubleva O.V., Verbitsky O.P., Ordynets S.V., Shabonov A.A., Dudanov I.P. Cerebral hyperperfusion syndrome after carotid endarterectomy in the acute period of ischemic stroke. Medical academic journal. 2017;17(4):17–21.

30. Dudanov I.P., Belinskaya V.G., Laptev K.V., Vasilchenko N.O., Koblov E.S., Sterlin O.V. Reconstructive surgery on the carotid arteries in the complex treatment of acute ischemic stroke. Medical academic journal. 2011;11(2):109–116.