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

The Cardiothoracic Surgeon volume 31, Article number: 6 (2023) Cite this article

Abstract

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.

Background

Carotid endarterectomy (CEA) is the most elegant operation in modern angiosurgery. There are two popular techniques of this reconstruction—classic with patch implantation and eversion [1,2,3,4,5]. The current guidelines specified strict indications for CEA implementation and adopted certain “quality standards,” including the acceptable rate of postoperative cardiovascular complications [6]. And today, after more than half a century of history, CEA has established itself as the “gold standard” for the treatment of patients with hemodynamically significant stenoses of the internal carotid arteries (ICA) [6,7,8,9,10].

With the development of endovascular technologies, carotid angioplasty and stenting (CAS) has become a serious competitor for open surgery [11,12,13,14,15]. According to a number of studies, in-hospital and long-term results of CEA and CAS have already reached comparable values [4, 16,17,18,19]. More often, we can observe that the choice in favor of one or another type of revascularization is determined not only by indications, but also by the patient’s preference. The guidelines allow performing CAS in cases where CEA is associated with a high risk of surgical complications or when restenosis of the ICA is involved [6]. Redo carotid surgery is almost always combined with trauma of the surrounding nerves, closely adherent scar tissue to the vessels of this area [7, 20, 21]. Therefore, stent implantation in these conditions will be the most preferable option to avoid the negative consequences of neuropathy [6, 7, 20, 21].

However, the injury of the hypoglossal and glossopharyngeal nerves also occurs during primary CEA [6]. In the opinion of some authors, this is due to the need for surgical manipulations in the area where these structures are localized: (1) in view of “high” location of the carotid bifurcation; (2) with continuing intimal detachment in the ICA, requiring extended arteriotomy; and (3) with extended atherosclerotic plaque in the ICA, spreading above the mentioned nerves [2, 3, 22, 23]. As a rule, the second situation cannot be predicted by preoperative angiography (AG) data. In the first situation, guided by imaging techniques, it is possible to avoid open surgery and cranial nerve injury (CNI) by referring the patient for CAS [4, 6, 11, 14, 15]. Even though most cases of CN neuropathy are reversible, in some situations, they become irreparable, accompanied by laryngeal paresis, dysphagia, etc. [3, 4, 6, 7, 24]. These consequences undoubtedly reduce the patient’s quality of life [3, 4, 6, 7, 24]. However, the current guidelines do not suggest acceptable limits for the incidence of cranial nerve injury at any particular facility and do not consider such a term as “high bifurcation” in order to refer a patient for CAS, thus avoiding open surgery with the risk of hypoglossal and glossopharyngeal neuropathy [6]. Also, despite the fact that there are references in the literature about high localization of the carotid bifurcation as an unfavorable predictor of the listed complications for CEA, there is no unified definition of this term today [24, 25]. Some practicing surgeons still try to focus on the topography of the carotid arteries relative to the mandible or cervical vertebrae [25, 26]. In the first situation, due to the mobility of the os mandibula, this method is minimally informative. In the case of the vertebrae, however, no classifications to determine the boundaries of high, medium, and low carotid bifurcation have been published to date.

The aim of this multicenter study was to develop a new classification of the types (high, medium, and low) of carotid bifurcations (based on the level of cervical vertebrae) with an analysis of CEA results depending on the type.

Methods

This retrospective multicenter study included 7148 patients who underwent CEA between 2010 and 2021. In 2362 (33%) cases, classical CEA with patch angioplasty was performed; in 4786 (67%), eversion CEA was performed. Based on the results of AG/multislice computed tomography (MSCT) angiography depending on the projection of the carotid sinus to the cervical vertebrae, 3 types of carotid bifurcation were identified:

  • Type I (high)—from the upper edge of the body of the II cervical vertebra to the lower edge of the intervertebral disc located between the 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

  • 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 vertebra

Type I was detected in 1329 (18.6%) patients, type II in 4652 (65.1%), and type III in 1167 (16.3%).

Rationale for the boundaries between the types

The boundary between types I and II was established because the hypoglossal nerve and glossopharyngeal nerve in different variants are localized strictly within type I (from the upper edge of the body of II cervical vertebra to the lower edge of the intervertebral disc located between III and IV cervical vertebrae). The boundary between types II and III was established due to the fact that strictly within type III, the anterior surface of the carotid arteries is concealed by the sternocleidomastoid muscle, the superior belly of the omohyoid muscle, and the sternohyoid muscle (when the arteries are isolated, it becomes necessary to cross/partially cross one or two of the last listed muscles to visualize them).

The criteria for inclusion in the study are (1) the absence of acute periods of ischemic stroke, (2) indications for CEA according to the current international recommendations, and (3) the presence of imaging results of AG/MSCT of the brachiocephalic artery.

Non-inclusion criteria are (1) the presence of pathology limiting the patient’s long-term follow-up (oncology, etc.).

The operative risk was calculated according to the EuroSCORE II interactive calculator. In the presence of clinical signs of angina, coronary angiography with calculation of coronary atherosclerosis severity according to the SYNTAX score was performed after consultation with a cardiologist. The degree of ICA stenosis was determined on the basis of MSCT AG/AG data (The North American Symptomatic Carotid Endarterectomy Trial (NASCET)). Prior to CEA, all patients underwent the marking of the intervention area with the support of color duplex scanning (CDS).

The choice of treatment tactics was made by a multidisciplinary council (cardiovascular surgeon, endovascular surgeon, cardiologist, neurologist, resuscitator, and anesthesiologist). The decision to place a temporary shunt was based on invasive measurement of retrograde ICA pressure (when it decreased by 60% or more of the systemic arterial pressure). The study involved those medical centers in which the tactics are unified, only this. According to Russian recommendations and standards, this is a strict regulation that cannot be ignored. So it is the same everywhere.

In the postoperative period, all patients underwent control CDS of the reconstructed area. Also, all patients were examined daily by a neurologist during the pre- and postoperative follow-up periods.

The end points were fatal outcome, myocardial infarction (MI), acute cerebrovascular accident (ACVA), transient ischemic attack (TIA), Bleeding Academic Research Consortium (BARC) type 3b or more, ICA thrombosis, Horner syndrome, hypoglossal neuropathy, glossopharyngeal neuropathy, and combined end point (Horner syndrome + hypoglossal neuropathy + glossopharyngeal neuropathy).

Statistical analysis

The type of distribution was determined using the Kolmogorov-Smirnov test. Groups were compared using Pearson’s chi-square and Kruskal-Wallis tests and Pearson’s chi-square with Yates correction for pairwise comparison of groups. If there were values in only two groups, Fisher’s exact test was used to compare them. Differences were evaluated as significant at p < 0.05. The results were processed using the GraphPad Prism software package (www.graphpad.com).

Ethical review

All patients signed a written consent to the use of their data in scientific research. The work was carried out in accordance with the standards of good clinical practice (Good Clinical Practice) and the principles of the Declaration of Helsinki and did not contradict the Federal Law of the Russian Federation of November 21, 2011, No. April 1, 2016, N 200n “On approval of the rules of good clinical practice” Conclusion of the Local Ethics Committee (extract from protocol No. 5 dated December 6, 2021): the study was performed in compliance with the ethical principles of scientific medical research involving humans.

The cohorts of patients of each type were completely comparable in terms of age, sex, comorbid pathology, frequency of surgical interventions in history, and risk of postoperative complications according to the EuroSCORE II scale (Table 1).

Table 1 Comparative clinical and anamnestic characteristics of patient groups
Full size table

Results

There were no statistically significant differences between the groups according to stenosis degree and coronary atherosclerosis severity (SYNTAX score). There were no cases of extended atherosclerotic plaque in carotid bifurcation type I (high) (at the stage of revascularization strategy selection by the multidisciplinary council, taking into account AG/MSCT AG data, such patients were referred for CAS) (Table 2).

Table 2 Angiographic and perioperative characteristics
Full size table

Intraoperatively, the time of ICA clamping most often did not exceed 30 min. The need for placing a temporary shunt appeared in every sixth case. In the vast majority of cases, the eversion technique of CEA was used. In types II and III of the carotid bifurcation, there was no need for the removal of the styloid process (Table 2).

In the postoperative period, there were no significant intergroup differences in the incidence of fatal outcomes and MI. The highest number of ACVA/TIA (n = 15; 1.1%) was detected in type I (high) carotid bifurcation, which was associated with a statistically higher incidence of ICA thrombosis (n = 8; 0.6%) in this cohort against the background of intimal detachment behind the endarterectomy zone (Table 3).

Table 3 Hospital outcomes
Full size table

In 2 cases of type I (high), after insertion of an inaccurately calibrated temporary shunt (it was impossible to accurately assess the ICA diameter due to low visualization behind the tissue above the hypoglossal nerve), ICA dissection occurred. After the clamp was removed and blood flow started, from the depth of the upper wound edge, bleeding developed. Further tissue dissection and removal of the styloid process did not allow us to identify the “uninjured area of the artery” (the dissection continued up to the entry of the ICA into the skull), which resulted in the necessity of ICA ligation. Both patients developed ischemic ACVA with an irreversible neurological deficit at the hospital stage.

In other cases, the cause of ACVA/TIA (in all types) was distal embolization either due to manipulations during arterial isolation in the presence of an unstable atherosclerotic plaque area or after a temporary shunt.

Most bleedings of type 3b or more on the BARC scale with the formation of acute hematomas of the intervention area were recorded in type III (low) carotid bifurcation (n = 14; 1.2%). During revision, we found that in 9 cases the source of bleeding was an “erupted” suture between sections of the dissected omohyoid muscle; in 5 cases, there was diffuse bleeding along this suture (without signs of “eruption”).

In 1 case of type III (low) carotid bifurcation (left), no antegrade blood flow was obtained after inserting a temporary shunt, completing the reconstruction, and removing the clamp from the common carotid artery (CCA). Due to the absence of pulsation in the entire accessible section of the CCA (up to the entrance to the thorax), it was decided to transport the patient to the radiology room. According to the angiography, the dissection of the CCA with its thrombotic occlusion was visualized, without damage to the aorta. Recanalization of the CCA with stenting was performed. A satisfactory angiographic result was obtained. According to the control CDS, the blood flow along the CCA/ICA was normal and the arteries had no signs of thrombosis/stenosis. The patient was discharged on the 10th day after the operation without the symptoms of ACVA/TIA.

The greatest number of cases of neuropathy of the hypoglossal nerve, glossopharyngeal nerve, Horner syndrome, and the combined endpoint was revealed in type I (high) carotid bifurcation, which was caused by the localization of the mentioned structures in this area above the anterior wall of the ICA. The need for dissection of the latter with the removal of the styloid process in case of ICA dissection or detachment of the intima behind the endarterectomy zone was always accompanied by the development of irreversible neuropathy of the listed nerves.

Discussion

The presented multicenter study demonstrated that type II (medium) carotid bifurcation (from the upper edge of the IV cervical vertebra to the lower edge of the V cervical vertebra) is the most favorable topographic variant for CEA implementation. The hypoglossal and glossopharyngeal nerves are not localized in this area, which prevents their injury with subsequent neuropathy.

It is also possible to perform CEA with a satisfactory postoperative outcome in the presence of type III (low) carotid bifurcation (from the upper edge of the intervertebral disc located between the V and VI cervical vertebrae to the lower edge of the VII vertebra body). But it should be borne in mind that crossing of the muscles of this area even after their integrity has been restored by means of suturing may be accompanied by defective work of the latter due to disconnection of the continuous structure by the scar tissue with subsequent atrophy. Such a feature, firstly, will be characterized by the formation of a cosmetic defect expressed as asymmetry of the neck. Secondly, the weakened functionality of the ipsilateral muscles and the preserved activity of the contralateral group can lead to destabilization in the cervical spine with the subsequent development of osteochondrosis, cervicalgia, etc. Therefore, despite the convincing clinical result of revascularization, the patient should be warned about possible mid-term and long-term effects in the postoperative period. Thus, CAS in the presence of carotid bifurcation types I and III would probably help to avoid the listed adverse events.

Additionally, it should be reported that in conditions of high and low bifurcation imaging, it is difficult to insert a temporary shunt (if indicated). Its implantation in the distal direction (into the ICA) in type I virtually eliminates the visualization of the arterial segment in which the balloon is inflated. In the case of the development of ICA dissection with a temporary balloon shunt of this area, further manipulations will be possible if the length of the wound is continued towards the temporal bone with incision of nerves with styloidectomy, which will be manifested by irreversible neurological complications [27,28,29]. If we are talking about type III carotid bifurcation, the placement of a temporary shunt in the proximal direction (into the common carotid artery (CCA) with balloon inflation and dissection) can lead to the continuation of dissection (depending on anatomy) to the aorta, brachiocephalic trunk, and subclavian artery with subsequent unfavorable prognosis.

Another fact that we were able to establish as part of our study was that CEA in type III conditions is statistically more frequently accompanied by the development of acute hematoma with the need for wound revision (p = 0.0017). This is primarily due to the traumatic nature of access to the arteries with the incision of muscular structures. Muscle fibers are known to be richly vascularized, and in subsequent postoperative management, against the background of anticoagulant/antiplatelet therapy, this factor can lead to diffuse bleeding of the muscle incision site (regardless of the suture). It should also be pointed out that the muscle tissue is very soft and when the neck moves (after surgery), the suture connecting the crossed fibers can break, which will lead to bleeding and hematoma formation.

Another observation was that in type I carotid bifurcation a statistically higher number of ICA thrombosis (p < 0.0001) and associated ACVA/TIA were diagnosed (p = 0.0001). In all cases, the ICA thrombosis developed against the background of intimal detachment behind the endarterectomy zone, which could not be identified intraoperatively due to the lack of visualization of this arterial segment (the artery is located behind and above the hypoglossal nerve).

Thus, summarizing the results of our work, CEA can be recommended in the presence of type II (medium) carotid bifurcation. In other types (II and III), open intervention will be accompanied by a greater risk of neurological and hemorrhagic complications.

Conclusions

Type II (medium) carotid bifurcation may be the most preferred for CEA. Type I (high) carotid bifurcation when performing CEA is statistically more often combined with the need for styloidectomy, postoperative neuropathy of the hypoglossal nerve, glossopharyngeal nerve, Horner syndrome, ICA thrombosis, and ACVA/TIA. Type III (low) carotid bifurcation is characterized by statistically frequent development of acute hematoma after CEA. Types I (high) and III (low) of carotid bifurcation may be the least preferable for temporary shunt placement due to the risks of dissection of non-visualized arterial sections.

Availability of data and materials

All study data are included in the All-Russian multicenter register of carotid endarterectomy.

Abbreviations

ACVA:

Acute cerebrovascular accident

AG:

Angiography

BARC:

Bleeding Academic Research Consortium

CAS:

Carotid angioplasty and stenting

CCA:

Common carotid artery

CDS:

Color duplex scanning

CEA:

Carotid endarterectomy

CN:

Cranial nerve

CNI:

Cranial nerve injury

ICA:

Internal carotid arteries

MI:

Myocardial infarction

MSCT:

Multislice computed tomography

NASCET:

The North American Symptomatic Carotid Endarterectomy Trial

TIA:

Transient ischemic attack

References

  1. Kazantsev AN, Lider RY, Korotkikh AV, Kazantseva EG, Bagdavadze GS, Kravchuk VN, Shmatov DV, Lebedev OV, Lutsenko VA, Zakeryaev AB, Artyukhov S, Palagin PD, Sirotkin AA, Sultanov RV, Taits D, Taits B, Snopova EV, Zharova AS, Zarkua N, Zakharova K, Belov Y (2022) Effects of different types of carotid endarterectomy on the course of resistant arterial hypertension. Vascular.:17085381221140620. https://doi.org/10.1177/17085381221140620

  2. Akchurin RS, Shiryaev AA, Galyautdinov DM, Vlasova EE, Vasiliev VP, Ismagilov BR, Balakhonova TV (2017) Immediate results of simultaneous coronary artery bypass grafting and carotid endarterectomy. Cardiol Cardiovasc Surg 10(6):4–8. (In Russ)]. https://doi.org/10.17116/kardio20171064-8

    Article  Google Scholar 

  3. Kazantsev AN, Chernyavsky MA, Vinogradov RA, Kravchuk VN, Shmatov DV, Sorokin AA, Artyukhov SV, Matusevich VV, Porkhanov VA, Khubulava GG (2021) Implantation of a long biological patch during classical carotid endarterectomy for extended atherosclerotic lesions. Long-term results. Bull Transplantol Artif Organs 23(1):112–124. (In Russ). https://doi.org/10.15825/1995-1191-2021-1-112-124

    Article  Google Scholar 

  4. Vinogradov RA, Pykhteev VS, Lashevich KA (2017) Long-term results of open surgical and endovascular treatment of stenosis of the internal carotid arteries. Angiology and Vascular. Surgery. 23(4):164–170 (In Russ)]

    CAS  Google Scholar 

  5. Kazantsev AN, Korotkikh AV, Lider RY, Mukhtorov OS, Palagin PD, Sirotkin AA, Lebedev OV, Kazantsva EG (2022) Computer modeling of carotid endarterectomy with the different shape patches and prediction of the atherosclerotic plaque formation zones. Curr Probl Cardiol 48(2):101505. https://doi.org/10.1016/j.cpcardiol.2022.101505

    Article  Google Scholar 

  6. (2013) National guidelines for the management of patients with brachiocephalic artery disease. Angiol Vasc Surg 19(2):4–68 (In Russ)

  7. Kazantsev AN, Tarasov RS, Burkov NN, Shabaev AR, Leader RY, Mironov AV (2018) Carotid endarterectomy: three-year follow-up in a single-center registry. Angiol Vasc Surg 24(3):101–108 (In Russ)

    CAS  Google Scholar 

  8. Kazantsev AN, Korotkikh AV, Lider RY, Lebedev OV, Sirotkin AA, Palagin PD, Mukhtorov OS, Shmatov DV, Sergey A (2023) Mathematical model for the choice of tactics of revascularization in case of combined lesions of the carotid and coronary arteries. Curr Probl Cardiol 48(1):101436. https://doi.org/10.1016/j.cpcardiol.2022

    Article  Google Scholar 

  9. Babayan GB, Zorin RA, Pshennikov AS, Suchkov IA, Yudin VA, Zhadnov VA, Egorov AA, Zhdanov AI (2019) Predictors of neurological deficit in hemodynamically significant stenosis of the carotid and vertebral arteries. Sci Young (Eruditio Juvenium) 7(4):533–540 (In Russ)]

    Article  Google Scholar 

  10. Fokin AA, Traiger GA, Vladimirsky VV (2017) Using the method of rhythmocardiography to assess the effectiveness of sinus-sparing modification of carotid endarterectomy. Angiol Vasc Surg 23(S2):478–480 (In Russ)

    Google Scholar 

  11. Kazantsev AN, Tarasov RS, Burkov NN, Volkov AN, Grachev KI, Yakhnis EY, Leader RY, Shabaev AR, Barbarash LS (2019) Hospital results of percutaneous coronary intervention and carotid endarterectomy in hybrid and phased modes. Angiol Vasc Surg 25(1):101–107. (In Russ). https://doi.org/10.33529/angio2019114

    Article  CAS  Google Scholar 

  12. Kazantsev AN, Abdullaev IA, Danilchuk LB, Shramko VA, Korotkikh AV, Chernykh KP, Bagdavadze G, Zharova AS, Kharchilava EU, Lider R, Kazantseva Y, Zakeryayev AB, Shmatov DV, Kravchuk VN, Zakharova KL, Artyukhov SV, Bhand HK, Chernyavtsev IA, Erofeev AA, Khorkova SM, Kulikov KA, Lutsenko VA, Matusevich VV, Morozov D, Peshekhonov KS, Sultanov RV, Zarkua NE, Khasanova DD, Serova NY, Shaikhutdinova RA, Gavrilova OO, Alekseeva EO, Kleschenogov AS, Sukhoruchkin PV, Taits DB, Taits BM, Palagin PD, Lebedev OV, Alekseev MV, Belov Y (2022) CAROTIDSCORE.RU-the first Russian computer program for risk stratification of postoperative complications of carotid endarterectomy. Vascular.:17085381221124709. https://doi.org/10.1177/17085381221124709

  13. Kazantsev AN, Zharova AS, Sokolova EV, Korotkikh AV (2022) Stenting of the artery of Dr A.N. Kazantsev in the acute period of ischemic stroke. Radiol Case Rep 17(10):3699–3708. https://doi.org/10.1016/j.radcr.2022.07.034

    Article  Google Scholar 

  14. Belov YV, Kazantsev AN, Kravchuk VN, Vinogradov RA, Korotkikh AV, Shmatov DV, Chernykh KP, Zakeryaev AB, Sukhoruchkin PV, Matusevich VV, Yu Lider R, Kazantseva EG, Zakharova CL, Sh Bagdavadze G, Zharova AS, Artyukhov SV, Lutsenko VA, Sultanov RV (2022) Features of carotid endarterectomy in Russia. How do we resolution issues? Curr Probl Cardiol 47(9):101272. https://doi.org/10.1016/j.cpcardiol.2022.101272

    Article  Google Scholar 

  15. Kazantsev AN, Burkov NN, Bayandin MS, Guselnikova YI, Leader of the Republic of Yugoslavia, Yakhnis EY, Volkov AN, Ruban EV, Shabaev AR (2020) Hospital results of carotid artery stenting in patients with multifocal atherosclerosis. Cardiology and Cardiovascular. Surgery. 13(3):224–229. (In Russ). https://doi.org/10.17116/kardio202013031224

    Article  Google Scholar 

  16. Bazylev VV, Shmatkov MG, Morozov ZA, Pyanzin AI, Allenov AA, Smagin DV (2019) Predictors of complications in the early postoperative period after carotid artery stenting and carotid endarterectomy. Angiol Vasc Surg 25(S2):46–47 (In Russ)

    Google Scholar 

  17. Kazantsev AN, Karkayeva MR, Tritenko AP, Korotkikh AV, Zharova AS, Chernykh KP, Bagdavadze GS, Lider RY, Kazantseva YG, Zakharova KL, Shmatov DV, Kravchuk VN, Peshekhonov KS, Zarkua NE, Lutsenko VA, Sultanov RV, Artyukhov SV, Kharchilava EU, Solotenkova KN, Zakeryayev AB (2022) Carotid enadrterectomy for thrombosis of the internal carotid artery in patients with COVID-19. Curr Probl Cardiol:101252. https://doi.org/10.1016/j.cpcardiol.2022.101252

  18. Korotkikh AV, Babunashvili AM, Kazantsev AN, Tarasyuk ES, Annaev ZS (2022) Distal radial artery access in noncoronary procedures. Curr Probl Cardiol:101207. https://doi.org/10.1016/j.cpcardiol.2022.101207

  19. Belov YV, Kazantsev AN, Vinogradov RA, Korotkikh AV (2022) Long-term outcomes of eversion and conventional carotid endarterectomy: a multicenter clinical trial. Vascular:17085381221084803. https://doi.org/10.1177/17085381221084803

  20. Klimov AB, Kokov LS, Ryabukhin BE, Matveev PD (2017) Carotid stenting in patients with atherosclerosis of the internal carotid artery and restenosis after endarterectomy. Int J Interv Cardioangiol 48-49:50–51 (In Russ)

    Google Scholar 

  21. Kazantsev AN, Chernykh KP, Bagdavadze GS, Bayandin MS (2021) Redo-surgery of the carotid arteries in patients with contraindications for carotid angioplasty with stenting. Angiology and Vascular. Surgery. 27(2):92–98. (In Russ). https://doi.org/10.33529/ANGIO2021217

    Article  CAS  Google Scholar 

  22. Ignatenko PV, Gostev AA, Novikova OA, Saaya SB, Rabtsun AA, Popova IV, Cheban AV, Zeidlitz GA, Klevanets YE, Starodubtsev VB, Karpenko AA (2020) Dynamics of hemodynamic parameters in different types of carotid endarterectomy in the immediate and late postoperative period in patients with stenosing carotid atherosclerosis. Cardiovasc Ther Prev 19(5):83–91. (In Russ). https://doi.org/10.15829/1728-8800-2020-2381

    Article  Google Scholar 

  23. Kazantsev AN, Khubulava GG, Kravchuk VN, Erofeev AA, Chernykh KP (2020) Evolution of carotid endarterectomy. Literature review. Circ Pathol Cardiac Surg 24(4):22–32. (In Russ). https://doi.org/10.21688/1681-3472-2020-4-22-32

    Article  Google Scholar 

  24. Nikulnikov PI, Ratushnyuk AV, Guch AA, Liksunov AV, Cheburakhin NV (2010) Management of patients with extended and high lesions of the carotid arteries. Herald Emerg Restor Med 11(3):385–386 (In Russ)

    Google Scholar 

  25. Pirtskhalaishvili ZK, Lavrentiev AV, Darvish NA, Churakova AV, Seleznev AI, Al Madvakhi NY (2003) Selection of the optimal reconstruction of the internal carotid artery in patients with high bifurcation. Bulletin of NTSSSH them. A.N. Bakuleva RAMS. Cardiovasc Dis 4(6):71 (In Russ)

    Google Scholar 

  26. Dalibaldyan VA, Lukyanchikov VA, Shalumov AZ, Polunina NA, Tokarev AS, Shatokhina YI, Stepanov VN (2016) Temporary subluxation of the lower jaw during interventions for high atherosclerotic lesions of the extracranial part of the internal carotid artery. Neurosurgery. 1:60–67 (In Russ)

    Google Scholar 

  27. Gavrilenko AV, Kuklin AV, Skrylev SI, Agafonov IN (2007) Indications for the use of an intraluminal temporary shunt in operations on the carotid arteries. Angiol Vasc Surg 13(4):105–112 (In Russ)

    CAS  Google Scholar 

  28. Mikhailov IV, Gusinsky AV, Shlomin VV, Orlova OV, Rakhmatillaev TB, Mohan P (2015) Efficiency of classical carotid endarterectomy using a temporary shunt. Bull Surg II Grekov 174(6):13–16 (In Russ)

    Article  CAS  Google Scholar 

  29. Zholkovsky AV, Ermolenko VV, Abuazab BS, Zhukova NP, Kolbov EC, Dudanov IP (2011) Intraluminal shunting for carotid endarterectomy. Med Acad J 11(3):100–104 (In Russ.)

    Google Scholar 

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Authors and Affiliations

  1. Kostroma Regional Clinical Hospital named after E.I. Korolev, 114, Mira Ave, Kostroma, Kostroma region, 156013, Russian Federation

    Anton N. Kazantsev, Oleg V. Lebedev, Alexey A. Sirotkin, Petr D. Palagin, Otabek Sh. Mukhtorov, Goderzi Sh. Bagdavadze & Mikhail A. Khetagurov

  2. Clinic of Cardiac Surgery of the Amur State Medical Academy of the Ministry of Health of Russia, st. Gorky, 95, Blagoveshchensk, Amur Region, 675000, Russian Federation

    Alexander V. Korotkikh

  3. Kemerovo State Medical University of the Ministry of Health of the Russian Federation, st. Voroshilov 22a, Kemerovo, 650056, Russian Federation

    Roman Yu. Lider & Elizaveta G. Kazantseva

  4. Clinic of High Medical Technologies named after N.I. Pirogov St. Petersburg State University, Embankment of the Fontanka River, 154, St. Petersburg, 190103, Russian Federation

    Dmitriy V. Shmatov

  5. North-Western State Medical University named after I.I. Mechnikov, Piskarevsky pr., 47, Saint Petersburg, 195067, Russian Federation

    Artyukhov Sergey & Ludmila V. Roshkovskaya

  6. First Moscow State Medical University named after I.M. Sechenov, 2, building 4, st. Bolshaya Pirogovskaya, Moscow, 119435, Russian Federation

    Shuowen Wang

  7. Kostroma Clinical Oncology Center, Nizhnyaya Debrya street, 19, Kostroma, 156005, Russian Federation

    Vladimir M. Unguryan

  8. Clinical Hospital of the Administration of the President of the Russian Federation, Open highway, block 40, Moscow, 107143, Russian Federation

    Maxim P. Chernyavin

  9. First St. Petersburg State Medical University, st. Leo Tolstoy, d. 6-8, Saint Petersburg, 197022, Russian Federation

    Okenu Gloria Nonye

  10. Russian Scientific Center of Surgery named after Academician B.V. Petrovsky, Abrikosovsky per., 2, Moscow, 119991, Russian Federation

    Yuri V. Belov

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  1. Anton N. Kazantsev
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  4. Oleg V. Lebedev
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Contributions

ANK—execution of operations and article writing. AVK—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. RYL—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. OVL—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. AAS—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. PDP—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. MOS—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. DVS—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. SVA—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. EGK—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. GShB—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. WS—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. LVR—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. MAK—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. VMU—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. MPC—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. OGN—execution of operations, collection of primary information, registration of the database, entering data into the register, statistical analysis, and approval of the final version of the article. YVB—execution of operations, concept and design, and article writing. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Anton N. Kazantsev.

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The work was carried out in accordance with the standards of good clinical practice (Good Clinical Practice) and the principles of the Declaration of Helsinki and did not contradict the Federal Law of the Russian Federation of November 21, 2011, No. April 1, 2016, N 200n “On approval of the rules of good clinical practice” Conclusion of the Local Ethics Committee (extract from protocol No. 5 dated December 6, 2021): the study was performed in compliance with the ethical principles of scientific medical research involving humans.

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All patients signed a written consent to the use of their data in scientific research.

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Kazantsev, A.N., Korotkikh, A.V., Lider, R.Y. et al. An alternative anatomical classification for carotid bifurcation and impact on outcome of carotid endarterectomy: a multicenter study. Cardiothorac Surg 31, 6 (2023). https://doi.org/10.1186/s43057-023-00097-8

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