Eversion carotid endarterectomy with transposition of the internal carotid artery according to A.N. Kazantsev. Hospital and long-term results

Aim. This study provides an analysis of the results of eversion carotid endarterectomy (CEE) with transposition of the internal carotid artery (ICA) over the hypoglossal nerve, according to A.N. Kazantsev. Materials and Methods. The given prospective open study covering the period from January 2017 to May 2020 involved 311 patients who underwent eversion CEE with transposition of ICA over the hypoglossal nerve, according to A.N. Kazantsev. Transposition was performed in the following way: after standard isolation of the carotid arteries, their compression, arteriosection, and removal of atherosclerotic plaque, ICA was extracted in the area above the hypoglossal nerve and was implanted to the same position. The condition of the patient was controlled on repeated visits to the clinic every six months. Hemodynamics in the reconstruction zone were studied using multispiral computed tomography with angiography of carotid bifurcation with 0.6 mm steps and processing the obtained results in Sim Vascular and Open Foam programs in DICON format. The follow-up period was 18.3±7.1 months. In case of development of restenosis, reCEE was performed with patch plasty of the reconstruction zone. For histologic examination, the restenosis area was stained by the van Gieson method. Results. In the hospital follow-up period, one case of myocardial infarction was noted that developed due to the stent's thrombosis in the anterior descending artery deployed two years before. When studying the hemodynamic properties of carotid bifurcation in the postoperative period using computer modeling, in all cases, no changes or obstacles to blood flow were formed in the ICA in the area above the hypoglossal nerve. In the long-term follow-up period, two cases of lethal outcome were recorded connected with the onset of an oncological disease. In one case, due to recurrence of the pulmonary artery thromboembolism. In two cases, the cause of myocardial infarction was thrombosis/occlusion of venous anastomoses (in one patient to the circumflex artery, in the other – to the right coronary artery). In four cases, repeated acute cerebrovascular accidents developed due to restenosis after CEE. In cases of significant restenosis (n=8), reCEE was performed with plasty of the reconstruction zone with a patch. The average restenosis period was 8.2±3.6 months. No cardiovascular complications and cases of hypoglossal nerve traumatization were identified. Intraoperatively, it was confirmed that restenosis was formed in the bifurcation zone, in front of the perimeter of the primary arteriosection. According to the results of histological examination, the main cause of all restenoses was hyperplasia of the neointima. Conclusion. The eversion CEE with the transposition of the ICA, according to A.N. Kazantsev, creates conditions for additional maneuvers in case of restenosis and implementation of reCEE. The ICA's placement over the hypoglossal nerve during primary CEE allows more confident isolation of carotid artery bifurcation from scar tissues with a zero risk of damage to the hypoglossal nerve. Such a course of the operation makes it possible to apply a clamp on the ICA and perform arteriotomy in any location without the threat of injury to the nerve structures.