Distal radial artery access in noncoronary procedures

Effects of different types of carotid endarterectomy on the course of resistant arterial hypertension

OBJECTIVE

Analysis of the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (СЕЕ) (classical with plasty of the reconstruction zone with a patch, eversion, formation of a new bifurcation, autoarterial reconstruction, glomus-saving techniques) in patients with resistant arterial hypertension (RAH).

MATERIALS AND METHODS

The actual cohort, comparative, retrospective, open research for the period from January 2013 to December 2021 includes 1577 patients with significant hemodynamic stenosis of the internal carotid artery Depending on revascularization strategy five groups were formed: Group 1: 18.3% (n = 289) - classical Carotid endarterectomy with plasty of the reconstruction zone with a patch (from diepoxy-treated xenopericardium or synthetic); Group 2: 29.9% (n = 472) - eversional CEE with cut-off of carotid gloomus (CG); Group 3: 6.9% (n = 109) - the formation of a new bifurcation; Group 4: 7.4% (n = 117) - autoarterial reconstruction; Group 5: 37.4% (n = 590) - glomus-saving CEE (1 technique - according to A.N. Kazantsev; two technicians - according to R.A. Vinogradov; three technicians - according to K.A.Antsupov). According to the 24-h blood pressure monitor in the preoperative period, the following degrees of AH were identified: 1° - 5.7% (n = 89); 2° - 64.2% (n = 1013); and 3° - 30.1% (n = 475).

RESULTS

In the postoperative period, no significant differences were obtained in the frequency of deaths, myocardial infarction, stroke, hemorrhagic transformation. However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (group 1: 1.03% (n = 3); group 2: 3.6% (n = 17); group 3: 3.67% (n = 4); group 4: 2.56% (n = 3); group 5: 0.5% (n = 3); p = 0.10). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG.

CONCLUSION

Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE, accompanied by the lowest incidence of adverse cardiovascular events caused by postoperative hypertensive crisis and hyperperfusion syndrome.

Vertebral triangle of doctor A.N. Kazantsev - double vertebral artery in V3 segment

We have described a variant of the structure of the vertebral artery. In the V3 segment, the vertebral artery bifurcated and then joined again. This building looks like a triangle. Such anatomy has not been previously described in the world literature. By the right of the first description, this anatomical formation was called the «vertebral triangle of Dr A.N. Kazantsev». This discovery was made during stenting of the V4 segment of the left vertebral artery in the most acute period of stroke.

Distal Radiation Access as an Alternative to Conventional Radial Access for Coronary Angiography and Percutaneous Coronary Interventions (According to TENDERA Trial)

The aim of this study was to assess the immediate and medium-term (3 months) results of the safety and efficacy of distal radial access (DRA) in coronary interventions compared with conventional transradial radial access (TRA). TRA is the recommended access for coronary procedures because of increased safety: fewer local complications, large and small bleeding. Recently, DRA has emerged as a promising alternative access to minimize radial artery occlusion (RAO) risk, as well as other complications. A large-scale, international, randomized trial comparing medium-term results with TRA and DRA is lacking. An analysis of 776 patients of the prospective randomized TENDERA trial was carried out: the distal artery access group (DRA) - 391, the transradial access group (TRA) - 385. Statistically more often the crossover access was in the DRA group (5.1% and 0.8%, P < 0.001). The primary endpoint was early or late thrombosis/occlusion of the radial artery (RA). Secondary endpoints: (1) composite complications from access vessels; (2) access parameters. Statistically significant differences were obtained for the primary endpoint: DRA 2.7% (n = 10), TRA 6.8% (n = 26), P = 0.008. Occlusion of the distal radial artery (DRAt), with patent RA: DRA 1.3% (n = 5), TRA 0 (0), P = 0.023. At the secondary composite endpoint, statistically significant differences were obtained for the following groups of complications: BARC type I bleeding (DRA: 3.8% (n = 14), TRA: 21.7% (n = 83), P < 0.001); hematoma larger than 5 cm on day 1 (DRA: 10% [n = 37], TRA: 25.9% [n = 98], P < 0.001); hematoma larger than 5 cm on day 7 (DRA: 12.4% [n = 45], TRA: 34.6% [n = 132], P < 0.001). Of the access parameters, the following statistically significantly differed: puncture time DRA 19.0 (8.0; 50), TRA 13.5 (5.0; 29), P < 0.001; insertion of introducer DRA 42.0 (26.0; 84.0), TRA 35.0 (23.0; 55.0), P < 0.001, access artery hemostasis duration (min.) DRA 180.0 (120.0; 480.0), TRA 155.0 (115.0; 195.0), P < 0.001. The duration of the procedure and fluoroscopy, radiation dose, RA spasm in both groups had no statistically significant differences. In the TENDERA trail, DRA demonstrated efficacy and safety in interventional coronary interventions compared with TRA in the medium-term follow-up period: a statistically significant lower incidence of RA occlusion and local complications.

Update in Carotid Disease

This review of the literature analyzes publications over the past five years on various problems associated with carotid endarterectomy: 1. Is the eversion or classical technique of surgery with plastic repair of the reconstruction area with a patch more effective? 2. Carotid endarterectomy or carotid angioplasty with stenting is more optimal? 3. When should brain revascularization be performed after the development of ischemic stroke? 4. Should a temporary shunt be used to protect the brain during carotid endarterectomy? 5. How to prevent and treat different types of intraoperative ischemic strokes? 6. What tactics of treatment of patients with combined lesions of the carotid and coronary arteries is more effective? 7. What are the causes and methods of elimination of restenosis of the internal carotid artery known? 8. Is carotid endarterectomy safe in old age?

An alternative anatomical classification for carotid bifurcation and impact on outcome of carotid endarterectomy: a multicenter study

Background

The present multicenter retrospective study included 7148 patients who underwent carotid endarterectomy (CEA) between 2010 and 2021. Based on the results of angiography (AG)/multislice computed tomography (MSCT) angiography, 3 types of carotid bifurcation were identified depending on the projection of the carotid sinus to the cervical vertebrae: type I (high)—from the upper edge of the body of the II cervical vertebra to the lower edge of intervertebral disc located between III and IV cervical vertebrae; type II (medium)—from the upper edge of the body of the IV cervical vertebra to the lower edge of the body of the V cervical vertebra; and type III (low)—from the upper edge of the intervertebral disc located between the V and VI cervical vertebrae to the lower edge of the body of the VII cervical vertebra.

Purpose of the study

To develop a new classification of the types (high, medium, low) of carotid bifurcations (based on the level of cervical vertebrae) with analysis of the results of CEA depending on the type.

Results

The largest number of ischemic strokes (n = 15; 1.1%; p = 0.0001) was found in type I (high) bifurcation of the carotid artery. The majority of bleedings of type 3b and higher according to the BARC scale with the formation of acute hematomas in the intervention area (n = 14; 1.2%; p = 0.0029) were recorded in type III carotid bifurcation (low).

Conclusions

Type II (medium) carotid bifurcation may be the most preferred for CEA.

Computer Modeling of Carotid Endarterectomy With the Different Shape Patches and Prediction of the Atherosclerotic Plaque Formation Zones

The article describes a method for constructing geometric models of the carotid bifurcation and computer simulation of endarterectomy surgery with the patches of various configurations. The purpose of this work is to identify the areas of the greatest risk of restenosis in the constructed models and to conduct a comparative analysis of risk factors when using the patches of different widths and shapes. The method is demonstrated on a reconstructed model of a healthy vessel. Its building is based on a preoperative computed tomography study of a particular patient's affected vessel. The flow in the vessel is simulated by computational fluid dynamics using data from the patient's ultrasound Doppler velocimetry. Risk factors are assessed through the hemodynamic indices on the vessel wall associated with Wall Shear Stress. The distribution of risk zones in the healthy vessel, presumably leading to its observed lesion (plaque), is analyzed. Comparative evaluation of 10 various patches implantation results is carried out and the optimal variant is determined. The proposed method can be used to predict the hemodynamic results of surgery using patches of various sizes and shapes.