Kazantsev A N, Vinogradov R A, Chernykh K P, Chernyavsky M A, Kravchuk V N, Shmatov D V, Erofeev A A, Lutsenko V A, Sultanov R V, Shabaev A R, Radjabov I M, Bagdavadze G Sh, Zarkua N E, Matusevich V V, Vaiman E F, Solobuev A I, Lider R Yu, Abdullaev A D, Porkhanov V A, Khubulava G G
City Alexandrovskaya Hospital, St. Petersburg, Russia.
Ochapovsky Research Institute Regional Clinical Hospital No.1, Krasnodar, Russia.
Zh Nevrol Psikhiatr Im S S Korsakova. 2021;121(9):19-30. doi: 10.17116/jnevro202112109119.
To analyze the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (CEE) in patients with resistant arterial hypertension (RAH).
The study included 1577 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RAH for more than 3 years. Patients were enrolled from January 2014 to December 2020. Depending on the implemented revascularization strategy, 5 groups were formed: group 1 (=289 (18.3%)) with classical CEE with plasty of the reconstruction zone with a patch, group 2 (=472 (29.9%)) with eversional CEE with cut-off of carotid glomus (CG); group 3 (=109 (6.9%)) with the formation of a new bifurcation; group 4: (=117 (7.4%)) with autoarterial reconstruction; group 5: (=590 (37.4%)) with glomus-saving CEE.
In the postoperative period, no significant differences were obtained in the frequency of deaths (0.34% for group 1; 0.63% for group 2; 0% for groups 3, 4 and 5), myocardial infarction (0.34%, 0.84%, 1.83, 0.85%, 0.33%, respectively); ischemic stroke (0.34%, 1.27%, 0.91%, 0.85%, 0.17%, respectively), hemorrhagic transformation (0%, 0.84%, 0.91%, 0.85%, 0%, respectively). 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 (1.03%, 3.6%, 3.67%, 2.56%, 0.5%, respectively). 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.
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.
分析难治性动脉高血压（RAH）患者的收缩压（SBP）动态变化及各类颈动脉内膜切除术（CEE）的结果。
本研究纳入1577例颈内动脉（ICA）存在血流动力学显著狭窄且RAH病程超过3年的患者。患者于2014年1月至2020年12月入组。根据实施的血运重建策略，分为5组：第1组（=289例（18.3%））采用经典CEE并使用补片对重建区域进行整形；第2组（=472例（29.9%））采用翻转式CEE并切除颈动脉体（CG）；第3组（=109例（6.9%））采用新分叉形成术；第4组（=117例（7.4%））采用自体动脉重建术；第5组（=590例（37.4%））采用保留CG的CEE。
术后，各组在死亡率（第1组为0.34%；第2组为0.63%；第3、4和5组为0%）、心肌梗死发生率（分别为0.34%、0.84%、1.83%、0.85%、0.33%）、缺血性卒中发生率（分别为0.34%、1.27%、0.91%、0.85%、0.17%）、出血性转化发生率（分别为0%、0.84%、0.91%、0.85%、0%）方面未观察到显著差异。然而，根据复合终点（死亡+心肌梗死+缺血性卒中+出血性转化）的发生率，在采用经典CEE并使用补片对重建区域进行整形的组和保留CG的CEE组中观察到最低发生率（分别为1.03%、3.6%、3.67%、2.56%、0.5%）。这是由于第1组和第5组患者中不存在不稳定AH和高血压危象病例，这是通过保留颈动脉体（CG）得以保证的。结果，这两组中2级和3级高血压患者的数量在统计学上显著减少。这些手术之后的绝大多数患者实现了稳定的目标SBP。在第2、3和4组中，2级和3级AH患者的数量在统计学上显著增加，这与CG的切除有关。
经典CEE和保留CG的CEE技术能够通过保留CG使RAH患者实现稳定的目标SBP水平。在翻转式CEE、新分叉形成术、自体动脉重建术中对后者的切除或损伤会伴随着不稳定高血压的发生、高血压程度的增加以及脑部出血性转化的高风险。因此，在存在RAH的情况下，最有效且安全的CEE类型是采用补片对重建区域进行整形的经典CEE和保留CG的CEE。
