The Three Most Discussed Questions in Carotid Artery Surgery. Review of Russian and Foreign Studies in the Last Five Years

This literature review analyzes Russian and foreign publications over the past five years on the three most discussed issues related to carotid artery surgery: l.Which is more effective: eversion carotid endarterectomy or conventional carotid endarterectomy with patch closure? 2. Which is better: carotid endarterectomy (CEE) or carotid angioplasty and stenting (CAS)? 3. How soon after the development of ischemic stroke should cerebral revascularization be performed? The authors of the article came to the following conclusions: 1. According to the majority of large studies and meta-analyses, conventional CEE with patch closure is associated with a higher risk of internal carotid artery restenosis compared to eversion carotid endarterectomy. Single-center trials with small samples of patients do not find statistical differences between the outcomes of applying both surgical techniques. 2. Large multicenter randomized trials are required to address the effectiveness of CEA and CAS in symptomatic and asymptomatic patients. To date, there has been no consensus on this matter. 3. CEE and CAS can be equally effective and safe in the most acute and acute periods of ischemic stroke when performed in the presence of a mild neurological deficit and the ischemic brain lesion not exceeding 2.5 cm in diameter. Nevertheless, the choice of treatment strategy should be made strictly personalized by a multidisciplinary council based on the experience of the institution and current recommendations. © 2023 Sklifosovsky Research Institute for Emergency Medicine. All rights reserved.

Endovascular Stent Thrombectomy in Patients With Acute Lower Limb Arterial Thrombosis on the Background of COVID-19

AIM Analysis of the outcomes of endovascular stent thrombectomy in patients with acute arterial thrombosis of the lower extremities on the background of COVID-19. MATERIAL AND METHODS This retrospective study for the period from January 1, 2020 to March 1, 2022 included 34 patients with acute lower limb ischemia who were diagnosed with the novel coronavirus infection SARS-COV-2. Endovascular stent thrombectomy was performed according to the standard technique using a Destination 8F guiding sheath (Terumo), an Advantage 0.014" guidewire fTerumo), and a Casper stent (Microvention, Terumo) as a stent retriever. In case of fragmentation of thrombotic masses in the guide sheath, manual aspiration of thrombi was performed using a standard 50, 0 ml syringe. Self-expanding nitinol stents were implanted in 11 clinical cases. RESULTS Intraoperative bleeding from the puncture site of the artery developed in 14.7% of cases, which required additional manipulation to achieve hemostasis. Every tenth (11.8%) patient developed myocardial infarction, in 2.9% of cases - ischemic stroke. In the hospital postoperative period during the first hours after surgery, 26.5% of patients developed rethrombosis which required re-intervention. In 8.8% of cases, retrombectomy was unsuccessful, and limb amputation was performed. A fatal outcome occurred in 67.6% of cases, which was due to an increase in multiple organ failure and the development of sepsis. CONCLUSION Endovascular stent thrombectomy is characterized by a low risk of rethrombosis and amputation in the context of COVID-19. © 2023 Sklifosovsky Research Institute for Emergency Medicine. All rights reserved.

Results of thrombectomy in lower-extremity ischemia in patients with COVID-19 and respiratory failure of different severity

Aim. To analyze the results of thrombectomy in lower-extremity ischemia in patients with coronavirus disease 2019 (COVID-19) and respiratory failure of different severity. Material and methods. This retrospective, cohort, comparative study for the period from May 1, 2020 to March 1, 2022 included 305 patients with acute lower-extremity ischemia and COVID-19. Depending on the type of oxygen support, three groups of patients were formed: group 1 (n=168) - nasal oxygen insufflation;group 2 (n=92) - non-invasive ventilation (NIV);group 3 (n=45) - artificial ventilation (AV). Thrombectomy was carried out according to the standard technique using Fogarty catheters (3F-6F - depending on the vessel size). After the diagnosis was established before and after the start of surgical treatment, all patients received the following therapy: Unfractionated IV heparin infusion at an initial rate of 1000 U/r, adjusted to maintain the activated partial thromboplastin time at 2-3 times the normal value;2. Oral acetylsalicylic acid 125 mg;3. Analgesics. Results. Myocardial infarction and ischemic stroke were not detected in the total sample. The highest number of deaths (group 1: 5,3%, n=9;group 2: 72,8%, n=67;group 3: 100%, n=45;p<0,0001), retrombosis (group 1: 18,4%, n=31;group 2: 69,5%, n=64;group 3: 91,1%, n=41;p<0,0001) and limb amputations (group 1: 9,5%, n=16;group 2: 56,5%, n=52;group 3: 91,1%, n=41;p<0,0001) was recorded in group 3 patients. Conclusion. In patients receiving mechanical ventilation, COVID-19 have more aggressive course, which is expressed in an increase in laboratory para-meters (C-reactive protein, ferritin, interleukin-6, D-dimer), the severity of pneumonia and location of thrombosis in the tibial arteries. Among patients with COVID-19 receiving mechanical ventilation, the greatest number of re-thromboses (91,1%), limb amputations (91,1%), and deaths (100%) are noted, which suggests the expediency of abandoning open thrombectomy in favor of anticoagulant/antiplatelet therapy in this cohort of patients. The development of arterial thrombosis in patients with COVID-19 receiving mechanical ventilation is an indicator of a high risk of death. Open thrombectomy in combination with anticoagulant/antiplatelet therapy is most effective in patients on nasal oxygen insufflation or NIV. Copyright © 2022, Silicea-Poligraf. All rights reserved.

ARTERIAL THROMBOSES: CHANGE OF PARADIGM IN THE ERA OF COVID-19 (review of literature)

This literature review focuses on the problem of peripheral arterial thrombosis in patients with COVID-19. Russian and international recommendations for the treatment of this cohort of patients were created in the period before the pandemic and do not take into account the new genesis of the development of the disease. In turn, this leads to the ineffectiveness of the existing methods of reperfusion, aimed primarily at removing the thrombus and administering anticoagulants/antiplatelet agents. The elimination of endotheliitis, as one of the key factors of arterial thrombosis, is not always possible, which is accompanied by the development of repeated thrombosis with further unfavorable events. The lack of prospective randomized trials, as well as information in the Interim Guidelines for the Prevention, Diagnosis and Treatment of New Coronavirus Infection (COVID-19) of the Ministry of Health of the Russian Federation, where infectious coronavirus hospitals operate, creates uncertainty in the choice of methods for treating arterial thrombosis when infected with SARS-CoV-2. This trend is associated with a high rate of amputations and deaths in patients with COVID-19. To date, there is no method of revascularization in the presence of arterial thrombosis that demonstrates optimal results for patients with new coronavirus infection. © 2022 Research Results in Biomedicine. All rights reserved.

Thrombosis in unvaccinated and Gam-COVID-Vac-vaccinated patients with COVID-19

Aim. To analyze the incidence of thrombotic events in unvaccinated and Gam-COVID-Vac-vaccinated patients with coronavirus disease 2019 (COVID-19). Material and methods. This prospective study included 316 patients (group 1) vaccinated with two doses of Sputnik V (Gam-COVID-Vac) hospitalized between November 20, 2020 and June 1, 2021 for COVID-19. Group 2 included 754 unvaccinated patients with a positive polymerase chain reaction test for SARS-CoV-2. Results. During inhospital period, deaths were recorded only in unvaccinated patients (group 1 — 0%;group 2 — 10,7% (n=87);p<0,0001). Among unvac-cinated patients, the following thrombotic events were more common: upper-extremity deep vein thrombosis (group 1 — 0,63% (n=2);group 2 — 5,4% (n=41);p=0,0003), lower-extremity deep vein thrombosis (group 1 — 2,21% (n=7);group 2 — 11,4% (n=86);p<0,0001), pulmonary embolism (PE) (group 1 — 0%;group 2 — 3,4% (n=26);p=0,0008), lower limb arterial thrombosis followed by thrombectomy (group 1 — 0,31% (n=1);group 2 — 12% (n=91);p <0,0001), lower limb arterial retrombosis after retrombectomy (group 1 — 0,31% (n=1);group 2 — 8,7% (n=66);p<0,0001), lower limb amputation (group 1 — 0%;group 2 — 8,7% (n=66);p<0,0001), composite endpoint (group 1 — 3,8% (n=12);group 2 — 55,2% (n=416);p<0,0001). In the long-term follow-up period (125,5±26,5 days), recurrent COVID-19 developed significantly more often in unvaccinated patients (group 1 — 0,63% (n=2);group 2 — 3,6% (n=24);p=0,007). All arterial and venous thromboses, limb amputations were diagnosed only among unvaccinated patients. Conclusion. Vaccination with Sputnik V (Gam-COVID-Vak) prevents the severe COVID-19 with the development of deaths, pulmonary embolism, venous and arterial thrombosis.

Carotid Enadrterectomy for Thrombosis of the Internal Carotid Artery in Patients With COVID-19.

Analysis of the results of emergency carotid endarterectomy (CEE) against the background of internal carotid artery (ICA) thrombosis in the acute period of acute cerebrovascular accident (ACVA) in patients with COVID-19. During the COVID-19 pandemic (April 1, 2020-May 1, 2021), 43 patients with ICA thrombosis and a positive polymerase chain reaction (PCR) result for SARS-CoV-2 were included in this prospective study. In all cases, CEE was performed in the acutest period of ACVA. These patients were included in group 1. The comparison group was represented by 89 patients who underwent CEE in the acute period of stroke, in the period before the COVID-19 pandemic (April 1, 2019-March 1, 2020). According to laboratory parameters, patients with COVID-19 had severe coagulopathy (with an increase in D-dimer: 3832 ± 627.2 ng/mL, fibrinogen: 12.6 ± 3.1 g/L, prothrombin: 155.7 ± 10, 2%), inflammatory syndrome (increased ferritin: 646.2 ± 56.1 ng/mL, C-reactive protein: 161.3 ± 17.2 mg/L, interleukin-6: 183.3 ± 51.7 pg/mL, leukocytosis: 27.3 ± 1.7 10E9/L). In the hospital postoperative period, the groups were comparable in terms of the incidence of deaths (group 1: 2.3%, n = 1; group 2: 1.1%, n = 1; P= 0.81; OR=2.09; 95 % CI = 0.12-34.3) myocardial infarction (group 1: 2.3%, n = 1; group 2: 0%; P= 0.7; OR = 6.3; 95% CI = 0.25-158.5), CVA (group 1: 2.3%, n = 1; group 2: 2.2%, n = 2; P= 0.55; OR = 1.03; 95% CI = 0,.09-11.7). ICA thrombosis and hemorrhagic transformations were not recorded. However, due to severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 more often developed bleeding in the operation area (group 1: 11.6%, n = 5; group 2: 1.1%, n = 1; P= 0.02; OR = 11.5; 95% CI = 1.3-102.5). In all cases, the flow of hemorrhagic discharge came from the drainage localized in the subcutaneous fat. This made it possible to remove skin sutures in a dressing room, suturing the source of bleeding and applying secondary sutures under local anesthesia. Emergency CEE in the acute period of stroke is an effective and safe method of cerebral revascularization in case of ICA thrombosis in conditions of COVID-19.

[Hybrid revascularization in a patient with Covid-19 and chronic limb ischemia stage IV]. / Gibridnaya revaskulyarizatsiya u patsienta s COVID-19, khronicheskoi ishemiei nizhnei konechnosti IV stepeni.

The authors report hybrid treatment of a patient with angina pectoris class II, multiple previous reconstructive interventions on the aortofemoral segment and chronic ischemia of the left lower limb stage IV and concomitant COVID-19. Coronary angiography was performed after regression of infectious disease under antiviral therapy. Occlusion of the left anterior descending artery was observed that required LAD stenting. On the next day, hybrid revascularization of the lower extremities was implemented: thrombectomy and endarterectomy from the branch of the aorto-femoral bypass graft and deep femoral artery at the first stage, stenting of the orifice of proximal branch of aorto-femoral bypass graft at the second stage, endarterectomy from superficial femoral artery, recanalization and stenting of superficial femoral artery and popliteal artery at the third stage and prosthetic- femoral bypass with autologous vein at the fourth stage. Postoperative angiography revealed patent stents and no residual stenoses. The choice in favor of these procedures and step-by-step approach has been substantiated. The authors emphasized effectiveness and safety of this treatment strategy.

COVID-19 Course in Vaccinated Patients

AIM OF STUDY To conduct a retrospective analysis of treatment outcomes for COVID-19 in unvaccinated and vaccinated patients. MATERIAL AND METHODS The present retrospective single-center study included 209 patients who were vaccinated in history and hospitalized at the City Aleksandrovskaya Hospital for infection with COVID-19 in the period from April 5, 2020 to July 9, 2021. The average period between vaccine administration and hospitalization was 18.0 ± 11.0 days. In all cases, a positive result of the polymerase chain reaction (PCR) for the presence of SARS-CoV-2 was obtained. These patients were included in Group 1. The comparison group included 475 unvaccinated patients with comparable lung tissue damage according to multispiral computed tomography of the chest (MSCT) and a positive PCR result for the presence of SARS-CoV-2, selected randomly over the same observation period. RESULTS The lesions of the lung tissue according to the results of chest MSCT upon admission of the group were comparable (p=0.55). All deaths were observed in the group of unvaccinated patients (n=46;9.7%;p<0.0001). In all cases, the cause was an increase in multiple organ failure. In the same cohort of patients, there was a statistically significantly greater number of deep vein thrombosis of the upper and lower extremities (p=0.02). In the group of vaccinated patients (1st), arterial thrombosis of various location was not diagnosed, while in the 2nd group (comparison), this pathology was detected in every 10th patient. At the same time, thrombosis of the arteries of the lower extremities developed statistically more often (n=52;10.9%;p<0.0001). This condition was accompanied by an increase in laboratory parameters of the inflammatory reaction and coagulopathy with the progression of lung tissue damage to the 3-4th degree according to the results of MSCT. However, in 37 (7.8%) cases, open thrombectomy was not possible, and on the first day after the operation, repeated thrombosis developed, followed by amputation of the limb. In 23 (4.8%) cases, a fatal outcome was observed. CONCLUSION Vaccination prevents the severe course of covid-19: the progression of pneumonia, coagulopathy, and inflammatory syndrome. In vaccinated patients, no deaths, pulmonary embolism were observed, which demonstrates the absence of a severe course of the disease. All arterial thrombosis associated with covid-19 develops in unvaccinated patients and is accompanied by a high incidence of repeated thrombosis, requiring subsequent amputation of the limb. The widespread introduction of vaccination will help reduce the severity of the course and prevent complications of the new coronavirus infection. © 2021 Sklifosovsky Research Institute for Emergency Medicine. All rights reserved.

Emergency carotid endarterectomy for internal carotid artery thrombosis in the course of COVID-19

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. © 2021 Sklifosovsky Research Institute for Emergency Medicine. All rights reserved.

[Carotid endarterectomy in patients with internal carotid artery thrombosis in the acutest period of ischemic stroke with COVID-19]. / Karotidnaya endarterektomiya u patsientov s trombozom vnutrennei sonnoi arterii v ostreishem periode ishemicheskogo insul'ta na fone COVID-19.

OBJECTIVE: Analysis of the results of emergency carotid endarterectomy (CEE) in internal carotid artery (ICA) thrombosis in the acute period of acute cerebrovascular accident (ACVI) in patients with COVID-19. MATERIAL AND METHODS: During the COVID-19 pandemic (April 1, 2020 - May 1, 2021), 43 patients with ICA thrombosis and a positive polymerase chain reaction (PCR) result for SARS-CoV-2 were included in this prospective study. In all cases, CEE was performed in the acutest period of ACVA. These patients were included in group 1. The comparison group was represented by 89 patients who underwent CEE in the acute period of stroke, in the period before the COVID-19 pandemic (April 1, 2019 - March 1.2020). RESULTS: In the hospital postoperative period, the groups were comparable in terms of the incidence of deaths (group 1: 2.3%, n=1; group 2: 1.1%, n=1; p=0.81; OR=2.09; 95% CI=0.12-34.3) myocardial infarction (group 1: 2.3%, n=1; group 2: 0%; p=0.7; OR=6.3; 95% CI=0.25-158.5), CVA (group 1: 2.3%, n=1; group 2: 2.2%, n=2; p=0.55; OR=1.03; 95% CI=0.09-11.,7). ICA thrombosis and hemorrhagic transformations were not recorded. However, in view of severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 more often developed bleeding in the operation area (group 1: 11.6%, n=5; group 2: 1.1%, n=1; p=0.02; OR=11.5; 95% CI=1.3-102.5). CONCLUSION: Emergency CEE in the acute period of stroke is an effective and safe method of cerebral revascularization in case of ICA thrombosis in conditions of COVID-19.

Rapid popliteal artery release sensu A. N. Kazantsev in acute thrombosis in patients with COVID-19

Aim. To analyze the outcomes of popliteal thrombectomy using the standard release technique with vascular instruments and rapid release sensu A. N. Kazantsev in patients with acute popliteal artery thrombosis (PAT) and coronavirus disease 2019 (COVID-19). Material and methods. The present prospective single-center study for the period from April 1, 2020 to March 17, 2021 included 157 patients with acute PAT and COVID-19 at the Alexandrovskaya City Hospital. All patients were divided into 2 groups depending on the popliteal artery access: group 1 (n=88;56%) — rapid release sensu A. N. Kazantsev;group 2 (n=69;44%) — standard popliteal artery release using vascular instruments (vascular forceps and scissors) and tourniquets. Rapid popliteal artery release was distinguished by the fact that fasciotomy and hemostasis, the fatty tissue behind it and up to the artery was torn with two index fingers. First, the fingers were joined together at the lateral edges and inserted into the wound middle. Then the wound together with tissues was stretched with fingers to proximal and distal edges until the popliteal artery was visualized. Further, a Beckmann retractor was used to fix the torn fiber to the upper and lower wound walls. The tourniquets were not used. Results. Surgical access duration (group 1, 4,5±1,3 minutes;group 2, 11,41±0,9 minutes;p=0,005), as well as the total procedure duration (group 1, 47,5±2,8 minutes;group 2, 62,15±4,5 min;p=0,001) had the lowest values in the group of rapid popliteal artery release. Moreover, all intraoperative bleedings (n=11;15,9%) was recorded in group 2 as a result of popliteal vein injuries and/or bleeding from popliteal artery. The retrombosis rate in the rapid release group was lower (group 1, 40,9%;group 2, 55,1%;p=0,03). On the first day after surgery, 18% of thrombosis developed in group 1, and 39% in group 2. The mortality rate was highest in the standard artery release group (group 1, 55,7%;group 2, 86,9%;p<0,0001;OR, 0,18;95% CI, 0,08-0,42). In all cases, the cause of death was systemic multiple organ failure due to severe pneumonia, pulmonary edema, and cytokine storm. Conclusion. The use of rapid popliteal artery release sensu A. N. Kazantsev significantly reduces the thrombectomy duration in the context of COVID-19. This effect is achieved due to a decrease in the incidence of intraoperative bleeding, no need to use tourniquets and vascular instruments. A decrease in the ischemia duration using novel release technique reduces the retrombosis rate, as well as deaths caused by systemic multiple organ failure against the background of hyperperfusion and compartment syndrome. Reducing the operation duration with the use of rapid popliteal artery release sensu A. N. Kazantsev reduces the time of intraoperative mechanical ventilation, which in COVID-19 patients reduces the risks of pneumothorax, pneumomediastinum, emphysema, and pulmonary embolism. Thus, the rapid popliteal artery release sensu A. N. Kazantsev can be recommended for popliteal thrombectomy in patients with COVID-19.