Экстренное стентирование тандемных стенозов внутренней сонной артерии с применением проксимальной защиты от дистальной эмболии «MoMa»

Man, 61 years old. Admitted with complaints of severe weakness in the right limbs, which developed about 4 hours ago. Multispiral computed tomography with cerebral angiography: signs of ischemic stroke in the basin of the left middle cerebral artery. Angiography of the brachiocephalic arteries (BCA) was performed: angiographic signs of damage to the BCA: the left internal carotid artery (ICA) of the C2–C3 segments up to subocclusion, up to 75% in the mouth and right third. The circle of Willis is closed.A multidisciplinary council made a decision on emergency stenting of tandem ICA stenoses using proximal protection against distal embolism “MoMa”. The course of the operation: after angiography, the sheath introducer was replaced by a guidewire sheath with a 9F introducer. A proximal protection system “MoMa” was installed along the diagnostic conductor 260 cm at the mouth of the left external carotid artery (ECA) and the middle third of the left common carotid artery (OCA). Baloons in the ECA and OCA were inflated. The Promus element 4.0x12 mm (DES) ICA was brought into the affected area of C2–C3 segments, positioned and opened at a pressure of up to 14 atm. The balloon catheter has been removed. Aspiration from the ICA. On check angiography, residual stenosis of the ICA stenting zone was 0%. On the test angiography intracranial arteries without signs of embolism. A Protege (7x10x40) mm stent was placed, positioned and deployed in the affected area of the orifice and the right third of the ICA. The delivery system has been removed. Aspiration from the ICA. On the test angiography, the residual stenosis of the ICA stenting zone was up to 0%. The distal embolism protection system has been removed. On the control angiography intracranial arteries without signs of embolism.The postoperative period was uneventful. On the 10th day after stenting, the neurological deficit regressed completely, the patient was discharged for outpatient observation in a satisfactory condition.CONCLUSIONS When performing brain revascularization in the most acute period of ischemic stroke, it is necessary to take into account the recommendations of multicenter studies that report such conditions for a successful outcome of the operation as: the diameter of the ischemic focus in the brain, not exceeding 2.5 cm and the absence of severe neurological deficit (more than the Rankin scale score 2). Within the framework of this clinical example, these recommendations were taken into account, which, among other things, contributed to the optimal outcome of urgent revascularization. Emergency stenting of tandem stenosis of the internal carotid artery using the device for proximal protection “MoMa” is effective in the presence of a closed structure of the circle of Willis. The technical complexity of the operation is associated with the installation of a catheter guide and its diameter of 9 Fr (catheters up to 7 Fr are usually used), which requires additional manual skills.Мужчина, 61 год. Поступил с жалобами на выраженную слабость в правых конечностях, развившуюся около 4 часов назад. Мультиспиральная компьютерная томография с ангиографией головного мозга: признаки ишемического инсульта в бассейне левой средней мозговой артерии. Выполнена ангиография брахиоцефальных артерий (БЦА): ангиографические признаки поражения БЦА: левой внутренней сонной артерии (ВСА) сегментов С2–С3 до субокклюзии, в устье и правой трети до 75%. Виллизиев круг замкнут.Мультидисциплинарным консилиумом принято решение об экстренном стентировании тандемных стенозов ВСА с применением проксимальной защиты от дистальной эмболии «МоМа». Ход операции: после ангиографии интродьюсер по проводнику заменен на интродьюсер 9F. По диагностическому проводнику 260 см в устье левой наружной сонной артерии (НСА) и средней трети левой общей сонной артерии (ОСА) установлена система проксимальной защиты «MoMa». Баллоны в НСА и ОСА раздуты. В зону поражения сегментов С2–С3 ВСА заведен, позиционирован и раскрыт на давлении до 14 атм стент Promus Element 4,0×12 мм (DES). Баллонный катетер удален. Аспирация из ВСА. На контрольной ангиографии остаточный стеноз зоны стентирования ВСА 0%. На контрольной ангиографии интракраниальные артерии без признаков эмболии. В зону поражения устья и правой трети ВСА заведен, позиционирован и раскрыт стент Protege — 7×10×40 мм. Система доставки удалена. Аспирация из ВСА. На контрольной ангиографии остаточный стеноз зоны стентирования ВСА до 0%. Система защиты от дистальной эмболии удалена. На контрольной ангиографии интракраниальные артерии без признаков эмболии.Послеоперационный период протекал без особенностей. На 10-е сутки после стентирования неврологический дефицит регрессировал полностью, пациент выписан на амбулаторное наблюдение в удовлетворительном состоянии.ЗАКЛЮЧЕНИЕ Выполняя реваскуляризацию головного мозга в острейшем периоде ишемического инсульта, необходимо учитывать рекомендации многоцентровых исследований, которые сообщают о таких условиях для успешного исхода операции, как: диаметр ишемического очага в головном мозге, не превышающий 2,5 см и отсутствие тяжелого неврологического дефицита (более 2 баллов по шкале Рэнкин). В рамках настоящего клинического примера были учтены данные рекомендации, что в том числе способствовало оптимальному исходу реваскуляризации в ургентном режиме. Экстренное стентирование тандемного стеноза внутренней сонной артерии с применением устройства для проксимальной защиты «МоМа» эффективно при обязательном наличии замкнутого строения Виллизиева круга. Техническая сложность операции связана с установкой гайд катетера и его диаметр в 9Fr (обычно используются катетеры до 7Fr), что требует дополнительных мануальных навыков

Ten-year long-term outcomes of conventional and eversion carotid endarterectomy. Multicenter study

Aim. To analyze the immediate and long-term outcomes of eversion and conventional carotid endarterectomy (CE) with patch angioplasty.Material and methods. For the period from February 1, 2006 to September 1, 2021, the present retrospective multicenter open comparative study included 25106 patients who underwent CE. Depending on the technique of operation, the following groups were formed: group 1 (n=18362) — eversion CE; group 2 (n=6744) — conventional CE with patch angioplasty. The long-term follow-up period was 124,7±53,8 months.Results. In the hospital postoperative period, the groups were comparable in incidence of all complications: lethal outcome (group 1: 0,19%, n=36; group 2: 0,17%, n=12; p=0,89; odds ratio (OR) =1,1; 95% confidence interval (CI) =0,57- 2,11); myocardial infarction (MI) (group 1: 0,15%, n=28; group 2: 0,13%, n=9; p=0,87; OR=1,14; 95% CI=0,53-2,42); stroke (group 1: 0,33%, n=62; group 2: 0,4%, n=27; p=0,53; OR=0,84; 95% CI=0,53-1,32); bleeding with hematoma formation (group 1: 0,39%, n=73; group 2: 0,41%, n=28; p=0,93; OR=0,95; 95% CI=0,61-1,48); internal carotid artery (ICA) thrombosis (group 1: 0,05%, n=11; group 2: 0,07%, n=5, p=0,9; OR=0,8; 95% CI=0,28-2,32). In the long-term follow-up, the groups were comparable only in MI incidence: group 1: 0,56%, n=103; group 2: 0,66%, n=45; p=0,37; OR=0,84; 95% CI=0,59-1,19. All other complications were more frequent after conventional CE with patch angioplasty: all-cause death (group 1: 2,7%, n=492; group 2: 9,1%, n=616; p<0,0001; OR=0,27; 95% CI=0,24-0,3); lethal ischemic stroke (group 1: 1,0%, n=180; group 2: 5,5%, n=371; p<0,0001; OR=0,17; 95% CI=0,14-0,21); non-lethal ischemic stroke (group 1: 0,62%, n=114; group 2: 7,0%, n=472; p<0,0001; OR=0,08; 95% CI=0,06-0,1); ICA restenosis >60%, requiring re-revascularization (group 1: 1,6%, n=296; group 2: 12,6%, n=851; p<0,0001; OR=0,11; 95% CI=0,09-0,12). Thus, the composite endpoint (lethal ischemic stroke + non-lethal ischemic stroke + MI) after conventional CE with patch angioplasty was more than 6 times higher than this parameter of eversion CE: group 1: 2,2%, n=397; group 2: 13,2%, n=888; p<0,0001; OR=0,14; 95% CI=0,12-1,16.Conclusion. Conventional CE with patch angioplasty is not prefer for cerebral revascularization in the presence of hemodynamically significant ICA stenosis due to the high prevalence of deaths, stroke, and ICA restenosis in the long-term follow-up

ENDOSCOPIC AND ROENTGENOVASCULAR INTERVENTIONS IN TREATMENT OF PATIENTS WITH BLEEDING FROM A GASTRODUODENAL ULCER

The authors analyzed the results of treatment of 965 patients with bleeding from gastroduodenal ulcers. The endoscopic hemostasis was carried out in 20,2% patients, however a recurrence of bleeding was noted in 12,8% cases. The combined endoscopic hemostasis was performed in 76,9% patients, though the relapse of bleeding had only 4,2% and 49 patients were safe. A surgery was required for 3,2% patients

Transcatheter arterial embolization in the treatment of gastrointestinal ulcer bleeding

The objective was to study the efficacy of transcatheter arterial embolization of gastric and duodenal vessels and to determine the indications for its use in gastroduodenal ulcer bleeding.Material and methods. The study was based on the results of arterial embolization in 61 patients with gastroduodenal ulcer bleeding.Results. Transcatheter arterial embolization of the left gastric artery, its branches and the gastroduodenal artery with an adhesive glue composite based on N-butyl-2-cyanoacrylate is highly effective in arresting bleeding permanently and preventing its relapse.Conclusion. Transcatheter arterial embolization is an alternative to the surgical treatment in patients with gastrointestinal bleeding