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A case of successful emergency carotid endarterectomy (CEE) in the acute period of ischemic stroke (within an hour after the onset of symptoms) in a patient with acute occlusive thrombosis of the internal carotid artery in the course of moderate-severe COVID-19 with a positive result of the polymerase chain reaction of the nasopharyngeal smear for SARS-CoV-2. The diameter of the ischemic focus in the brain according to multispiral computed tomography did not exceed 2.5 cm. The course of ischemic stroke was characterized by mild neurological deficit (score 5 according to National Institute of Health Stroke Scale). It was demonstrated that the severity of the patient’s condition was associated with bilateral, polysegmental, viral penvmonia with 65% damage to the lung tissue, a decrease in SpO2 to 93%. Laboratory noted coagulopathy with an increase in D-dimer (2837.0 ng/ml), prothrombin according to Quick (155.3%), fibrinogen (14.5 g/l) and signs of a “cytokine storm” with leukocytosis (28.4 10E9/l), an increase in C-reactive protein (183.5 mg/l), ferritin (632.8 ng/ml), interleukin-6 (176.9 pg/ml). The patient underwent glomus-sparing eversional CEE. The intervention was performed under local anesthesia due to the high risk of developing pulmonary barotrauma when using mechanical ventilation. To prevent the development of acute hematoma, a double active drainage was used into the paravasal space and subcutaneous fatty tissue (SFT). In case of thrombosis of one of the drainages, the second could serve as a spare. Also, upon receipt of hemorrhagic discharge from the drainage located in the SFT, the patient would not need to be transported to the operating room. Removal of skin sutures with revision and stitching of the bleeding source could be performed under local anesthesia in a dressing room. The postoperative period was uneventful, with complete regression of neurological symptoms. Used anticoagulant (heparin 5 thousand units 4 times a day s/c) and antiplatelet therapy (acetylsalicylic acid 125 mg at lunch). The patient was discharged from the hospital on the 12th day after CEE in satisfactory condition.

Purpose.Analysis of the immediate results of emergency glomus-sparing auto-transplantation of the internal carotid artery (ICA) in the acute period of ischemic stroke, developed on the basis of the City Alexandrovskaya Hospital, St. Petersburg.Material and methods.In this prospective, single-center study from January 2017 to August 2020. 49 patients were included in the acute period of ischemic stroke with hemodynamically significant extended atherosclerotic lesions of the ICA. All patients underwent glomus-sparing ICA autotransplantation, developed on the basis of the City Alexandrovskaya Hospital, St. Petersburg (Kazantsev A. N., Zarkua N. E., Chernykh K. P. et al. Аrteries with extended atherosclerotic lesions of the internal carotid artery. Patent application No. 202.013.4151/14 (062595), filing date 10/16/2020). Glomus-sparing ICA autotransplantation, developed on the basis of the City Alexandrovskaya Hospital, St. Petersburg, was performed as follows. On the inner edge of the external carotid artery (ECA), adjacent to the carotid sinus, 2–3 cm above the orifice, depending on the spread of atherosclerotic plaque (ASB), arteriotomy was performed with the transition to the common carotid artery (CCA) (also 2–3 see below the mouth of the NSA). The ICA was cut off at the site formed by the sections of the wall of the NSA and the CCA. Then the ICA was cut off as distally as possible in front of the hypoglossal nerve, so that the artery was completely resected. In view of the presence of an intact carotid glomus on the resected area of the ICA, which connects it to the wound, endarterectomy from the ICA was performed inside the operating field by its complete eversion. Then, open endarterectomy from ECA and CCA was performed. At the next stage, the ICA was implanted in its previous place with the creation of proximal and distal end-to-end anastomoses, so that the continuing ASB above the endarterectomy zone was fixed with a circular vascular suture.Results.There were no complications in the postoperative period. No cases of restenosis / thrombosis of the reconstruction zone were identified in all the sample according to the color duplex scanning data. On the 7th day after the operation, all patients were diagnosed with regression of neurological symptoms according to the National Institute of Health Stroke Scale: on admission, the mean score was 10.5±3.5; at the moment of the control point — 6.5±1.5; p=0.001. This reflects the effectiveness of the chosen treatment strategy. According to the data on the dynamics of systolic blood pressure, stable systolic parameters were observed in the postoperative period against the background of antihypertensive therapy taken before the operation.Conclusion.Carotid endarterectomy in the acute period of ischemic stroke is safe in the presence of mild neurological deficits (up to 25 points on the National Institute of Health Stroke Scale) and the diameter of the ischemic focus in the brain not exceeding 2.5 cm according to the computer data. tomography. Glomussparing ICA autotransplantation, developed on the basis of the Aleksandrovskaya Hospital, St. Petersburg, does not require the use of a patch and is not characterized by the risk of developing ICA thrombosis as a result of intimal detachment behind the endarterectomy zone. Preservation of the carotid glomus during reconstructive intervention on the ICA prevents the development of labile arterial hypertension and hemorrhagic transformation in the postoperative period.

This literature review is devoted to various carotid endarterectomy (CE) methods that exist today in Russia. The pros and cons of conventional and eversion technique of the operation are given. It is indicated that the former is associated with higher long-term rate of restenosis, aneurysm and patch infection. The second is associated with higher prevalence of intraoperative internal carotid artery (ICA) thrombosis due to intimal detachment distal to endarterectomy area. The following CE methods for patients with prolonged ICA involvement are described: neo bifurcation formation, autoarterial reconstruction, ICA autotransplantation, plastic using an occipital artery flap. The methods of CE with carotid body saving have been demonstrated: 1. Swallow tail type patch repair proposed by R.I. Izhbuldin; 2. S-shaped arteriotomy proposed by K. A. Antsupov; 3. Two types of operations proposed by R. А. Vinogradov; 4. Сutting off the ICA with sections of common and external carotid artery proposed by A. N. Kazantsev; 5. Glomus-saving ICA autotransplantation in patients with prolonged atherosclerotic involvement. The role of ICA transposition over the hypoglossal nerve in eversion CE is presented. The glomus-saving CE with ICA transposition, called Chik-Chirik CE, is described. Conclusions are drawn on the need to demonstrate all CE types in the novel Russian guidelines for the management of patients with of head and neck arterial diseases.

To analyze in-hospital and long-term results of eversion carotid endarterectomy (CEE) with transposition of internal carotid artery (ICA) over hypoglossal nerve.A cohort prospective open-label study included 919 patients with severe ICA stenosis for the period from January 2017 to April 2020. The 1st group (There were no significant between-group differences in cardiovascular morbidity. However, all complications occurred in the 2nd group (traditional eversion CEE). Nevertheless, incidence of adverse events was minimal and combined endpoint did not exceed 0.6% (Eversion CEE with ICA transposition over the hypoglossal nerve ensures optimal conditions for successful redo CEE in case of restenosis. This technique facilitates ICA mobilization without hypoglossal nerve injury. This aspect is valuable for successful postoperative outcome and adequate quality of life. ICA transposition is not difficult and does not require additional experience. Transposition per se is not a risk factor of ICA restenosis. Thus, ICA transposition may be routinely recommended in patients eligible for eversion CEE.Анализ госпитальных и отдаленных результатов эверсионной каротидной эндартерэктомии (КЭЭ) с транспозицией внутренней сонной артерии (ВСА) над подъязычным нервом.В когортное сравнительное проспективное открытое исследование за период с января 2017 г. по апрель 2020 г. вошли 919 пациентов, оперированных по поводу гемодинамически значимого стеноза ВСА. В 1-ю группу (В госпитальном периоде наблюдения значимых межгрупповых различий по частоте кардиоваскулярных осложнений не получено, однако все осложнения произошли во 2-й группе. Тем не менее они находились на минимальном уровне, комбинированная конечная точка не превышала 0,6% (Эверсионная КЭЭ с транспозицией ВСА над подъязычным нервом создает оптимальные условия для успешного исхода повторной КЭЭ при вероятном развитии рестеноза. Подобная методика позволяет выделить ВСА из рубца без травматизации подъязычного нерва и добиться успешного исхода повторной реконструкции с сохранением исходного качества жизни пациента. Техническая часть транспозиции ВСА не требует дополнительных навыков и не характеризуется высокой сложностью реализации. Сам по себе метод не вызывает сужения ВСА и не является прямым предиктором развития рестеноза. Это позволяет рекомендовать применение транспозиции ВСА рутинно во время выполнении эверсионной КЭЭ.