Carotid artery stenosis (CHA) is a condition manifested by a pathological narrowing (partial or complete) of the vascular lumen, which leads to a decrease in the blood supply to the brain. As a result, his cells lack oxygen and nutrients – this is called ischemia. Such a prolonged deterioration in perfusion over time can cause encephalopathy. In the case of acute blockage, a stroke occurs – the most serious consequence of this disease.
This is a very dangerous disease, because it has a large percentage of complications – in almost 2/3 of cases, there is discirculatory encephalopathy or acute cerebrovascular accident (stroke, stroke). It develops mainly in elderly men.
Atherosclerosis is a polyetiological disease. There are a large number of reasons that can provoke the appearance of an ailment in the human body. Among the entire spectrum of causes of the disease, there are a number of the most common.
The most common causes of the disease are:
- Age over 40 years.
- Men suffer from the deposition of cholesterol plaques four times more often than women.
- Smoking directly leads to severe vascular damage due to changes in the structure of their walls.
- Diabetes mellitus, mainly of the second type.
- Hormonal disorders, including an imbalance in thyroid hormones and the onset of menopause in women.
- Alcohol abuse.
- An important role is played by heredity.
- General disorders of lipid metabolism in the body.
- Deficiency of high density lipoproteins (“good” cholesterol).
- Sedentary lifestyle.
- Metabolic syndrome is a special condition that includes manifestations of hypertension (high blood pressure), excess weight mainly in the abdomen, excess triglycerides, as well as impaired glucose tolerance.
- Frequent stresses, emotional instability.
Damage to the carotid arteries is dangerous for circulatory disorders in the brain, because they carry oxygen-rich blood to its cells and tissues. Initially, minor symptoms may appear, such as memory impairment, frequent mood swings, headaches, decreased intellectual ability, and psychological instability.
If the symptoms characteristic of transient ischemic attacks do not disappear in 24 hours, then another diagnosis is made – a stroke.
A stroke is a necrosis of brain tissue. It can occur due to hypoxia (lack of oxygen) of the brain or due to massive hemorrhage in it.
Tissue hypoxia can occur as a result of hypertension (blood vessels are very narrow, and blood does not flow well) or atherosclerosis (atherosclerotic plaques can significantly protrude into the lumen of the vessel and limit normal blood flow). In this case, the stroke is called ischemic (ischemia – a lack of oxygen-enriched blood).
If hemorrhage occurs in the brain tissue, then its most common cause is vascular aneurysm – thinning and expansion of the vessel wall, as a result of which it loses its elasticity and can easily rupture at any time due to increased load or stress. Aneurysm, in turn, can also develop in the presence of atherosclerosis. A hemorrhage in the brain suggests that the hemorrhagic stroke (hemorrhage – bleeding).
As you can see for yourself, atherosclerosis of the carotid arteries can lead to sad consequences. And worst of all, no one can predict how a stroke will manifest itself. If you do not provide qualified medical care in a timely manner, then a person can permanently remain disabled or even die at all.
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Classification by reason of origin
Immediate causes of stricture in SA are some vascular pathologies:
- obliterating endarteritis is an autoimmune-allergic disease that leads to a gradual narrowing of the lumen of the vessel until it becomes completely blocked due to the accumulation of immune complexes in its wall;
- atherosclerosis is the most common cause of narrowing, occurs against the background of impaired lipid metabolism and leads to the appearance of plaques clogging the vessel;
- nonspecific aortoarteritis (Takayasu syndrome) – an autoimmune disease of mainly the aortic sections, which leads to increased thrombosis;
- congenital malformations;
- fibro-muscular dysplasia is a systemic lesion of the connective tissue of blood vessels, which is manifested by a lack of elastic fibers and increased proliferation of fibrous and muscle.
According to the mechanism of development of ischemic changes, three main forms are distinguished:
- Hemodynamic – a decrease in blood flow due to narrowing of the vessel by more than 75%. It is the main cause of discirculatory encephalopathy.
- Microembolic – separation of microthrombi from an altered vascular wall. Usually clog small vessels, causing transient attacks.
- Thrombotic – the formation of large blood clots that completely block the lumen and lead to extensive strokes. The predominant location is the bifurcation (bifurcation) of the common carotid artery into the internal and external. It is considered the most dangerous form, often ending in death.
Varieties of operations on the carotid arteries
Before doctors determine what kind of operation they will perform in the surgery department, patients need to undergo standard tests: a general blood and urine test, a biochemical blood test, a cardiogram (to exclude heart pathologies), fluorography (a mandatory check for tuberculosis), coagulogram (determination of blood coagulation).
Additional research methods in this case, which we are considering, include carotid artery angiography (angiography is a study of blood vessels using a contrast medium), duplex blood vessels, computed tomography (CT), or magnetic resonance imaging (MRI).
Three main types of surgical interventions on the carotid arteries are distinguished: carotid endarterectomy, vascular stenting, vascular prosthetics.
The choice of the surgical method directly depends on the degree of vascular damage, on the age and general condition of the patient, as well as on the clinic in which the procedure will be performed.
- Carotid enadarterectomy is the most common vascular operation of the above. It consists in the complete removal of cholesterol plaque from the vessel wall, which makes it possible to restore full circulation. Most often it is carried out using general anesthesia, but sometimes local is also possible. It is carried out with atherosclerosis and carotid artery thrombosis, in which there are pronounced clinical manifestations of cerebrovascular accident, or with asymptomatic atherosclerosis, but with significant vascular stenosis. During the operation, an incision is made in the back of the auricle 2 cm below the edge of the lower jaw, it is continued along the sternocleidomastoid muscle for ten centimeters. Then the skin and subcutaneous fatty tissue are dissected. After this, bifurcation (bifurcation) of the common carotid artery is isolated and the internal one is found. Atherosclerotic plaque together with pathologically altered elements of the adjacent vascular wall is completely removed from its lumen. Then this place is washed with physiological solution of sodium chloride. The vascular wall is sutured using a special patch. It can be made from synthetic substances or from the tissues of the patient himself. At the end of the operation, the wound is sutured in layers, leaving a drainage (tube) in the lower part for the outflow of fluid.
- Stenting – at the present time, this operation is increasingly preferred because it is by nature minimally invasive, and, accordingly, less traumatic for humans. For stenting, a constant x-ray control is necessary, in which a contrast agent is delivered to the vessel and its distribution is monitored. The operation is performed under local anesthesia. First, a puncture (puncture) of the carotid artery is performed. Then, under X-ray control, a special balloon is introduced into it, which expands the lumen of the vessel in the required place. After this, a stent is inserted – a metal spring, which will constantly maintain the necessary clearance of the artery. At the end of the operation, the balloon is removed. When stenting, complications such as plaque destruction, carotid artery thrombosis can be observed.
- Prosthetics is perhaps the most difficult method of surgical intervention with the greatest duration. It is used for extensive atherosclerotic lesions, the deposition of calcium salts in the vessel wall, as well as in the presence of tortuosity or excesses of the artery. During prosthetics, the internal carotid artery is cut off, the affected area is completely removed, the vessels are cleaned of deposited plaques and the remaining part of the internal carotid artery is combined with the common carotid artery. A joint is a prosthesis made of synthetic components corresponding to the diameters of the vessels. The last stage is the installation of drainage for the outflow of fluid.
The rehabilitation period after surgery for atherosclerotic plaque in the carotid artery rarely exceeds a week. Complications develop relatively rarely. The outcome of the operation is often favorable. Reviews of the above operations are mostly positive.
Carotid arteriosclerosis is described in a video in this article.
The main types of carotid artery surgery are:
- Carotid – is most often used. Here the autopsy takes place. In America, treatment with this method is carried out more than a hundred a year, in the Russian Federation two times less, but the method is gaining momentum;
- Vascular stenting is not distinguished by a large intervention, and therefore quick recovery after surgery. But for its carrying out considerable skill of the surgeon and the equipment which is not available in each hospital is required;
- Prosthetics are performed for those people who have a large area of the spread of pathology.
Carotid surgery on the carotid artery consists of cutting human tissues and blood vessels in order to extract a pathologically formed plaque from the latter.
Carotid surgery is performed under general anesthesia or under local anesthesia. The surgeon makes an incision behind the auricle down by ten centimeters, spreads the layers of the skin, carefully not touching the nerves, finds the right vessel. After that, he incisions him and takes out an education. In order that the blood does not interfere and its circulation continues, so as not to create a deficiency in the brain, a shunt and a drug are inserted in advance in the artery, which helps to close the walls.
After the vessel is cleaned, it is washed with a special solution that will rid the cavity of the remnants of the plaque. If this is not done, they can clog the smaller arteries. Sewing of the incision is carried out with a special thread, they can put a patch from a previously prepared synthetic or patient’s own tissue. After this, the shunt is removed, the strength of the suture on the vessel is checked, if everything is normal, then the surgeon sutures the layers of tissue, sequentially from the bottom up.
This method is indicated for plaques on the walls of blood vessels, thrombosis, severe narrowing of the vessel without symptoms.
The preparation of the patient for the operation is the same as in the method above. Change during vessel cleaning. After establishing the shunt and administering the drug for gluing the vessels, the desired area is turned on the inside, the plaque is removed, washed with saline solution, and given the original appearance. After carrying out such manipulations, the vessel is sutured, the shunt is removed, the skin is sutured.
The eversion method is much faster than the carotid one, because it is less complex and the risk of doing something wrong is less. Minus – used when removing small plaques that did not fill the entire lumen of the vessel, less than two and a half centimeters.
This method has many advantages that make it more and more popular among others. The smallest intervention of the surgeon in the body cavity, contributes to the rapid recovery of the patient.
The rehabilitation period after stenting lasts no more than a week. But he also has its drawbacks:
- The result is good, but its duration is short and requires subsequent interventions, while the risk of complications increases;
- Complex and expensive equipment, the experience of specialists;
- The method is not able to cope with a large plaque size.
The operation mechanism is as follows:
- The surgeon makes a puncture, and the tube is brought to the right place. With the help of a balloon, the vessel expands, and the metal frame presses the plaque. There is a risk of plaque destruction and the spread of blood clots in the vessel, which is very dangerous. Therefore, they put special filters in the vessel before the introduction of the stent.
The introduction of the stent is carried out in case of atherosclerosis in the elderly, who are forbidden to operate in an open way.
To begin with, the area of damage to the vessel is determined, its cutting off. In its place is a prosthesis, which is made of synthetic material. The diameter and length of the prosthesis is selected individually for each patient. The vessel is washed from the remnants of the plaque, and establish drainage material.
The method is well tolerated by patients, it is considered safe.
Symptoms of the disease
Symptoms of stenosis of the carotid arteries are very nonspecific, most of them are found in other diseases. In accordance with clinical features, 4 main forms can be distinguished, which manifest narrowing of carotid vessels:
- Asymptomatic – despite the fact that the narrowing is present, the manifestations of cerebral ischemia are compensated. This option can only be detected by chance, during surveys;
- Discirculatory encephalopathy is a chronic pathology arising from constant oxygen starvation of brain tissue. It manifests itself with the following symptoms:
- Transient ischemic attack is a temporary violation of cerebral blood flow, which is manifested by focal neurological deficit, depending on the location of the lesion. All symptoms disappear within a day, more often within a few hours.
- Acute cerebrovascular accident (stroke) – ischemia and necrosis of a part of the brain that is manifested by symptoms of a neurological deficit. Most often these are paresis of the muscles of the face, limbs, speech disorders, loss of consciousness.
Operations for stenosis of the carotid artery
Treatment for carotid stenosis can be either conservative or surgical. The first option is acceptable only at the initial stages of pathology, as well as as maintenance therapy for secondary prevention. The most effective drug method for the autoimmune nature of the disease.
However, the only means that can effectively restore normal hemodynamics in the basin of this vessel and prevent critical complications is surgery.
Operations can be open or minimally invasive (endoscopic). Now they prefer to use the second option, since it is more secure.
There are four main types of surgical intervention for narrowing SA:
- Carotid endarterectomy – is necessary to remove the embolus or atherosclerotic lesions on the wall. This is an open operation in which a vessel is cut and the thrombus or plaque is mechanically removed. In some cases, complete removal of the artery site is done.
- Stenting is a minimally invasive intervention, in which a special probe is inserted into the artery through a small incision in the skin. Approaching the place of occlusion, he first widens the lumen, and then sets the prosthesis in the form of a mesh tube. This is the most common and safe treatment. It is carried out under radiographic control
- Prosthetics – if a large area of the vessel is affected, it is removed, and then an artificial prosthesis is installed.
- Reconstructive surgery – used to treat birth defects (usually an abnormal tortuosity). To do this, remove the most deformed portion of the vessel, and the remaining part is straightened and stitched.
All these operations effectively eliminate the obstacle to blood flow, and the patient can feel an improvement almost immediately after leaving anesthesia. However, it should be remembered that surgical intervention only affects the pathogenesis of the disease, and not its causes. Therefore, if the provoking factors of atherosclerosis (or other diseases that led to occlusion) are not eliminated, a relapse is often possible. In addition, prostheses or stents can cause thrombosis, and therefore the patient must constantly take antiplatelet agents.
Prices for such operations vary greatly depending on the clinic. Carotid endarterectomy costs from 30 rubles in a public hospital and from 000 in a private one. The cost of stenting is much higher – in the range of 100 000 – 50 000 p. In some cases, such interventions are performed free of charge, according to the mandatory medical insurance.
Carrying out surgical intervention is carried out only in case of revealing the advanced state of the disease.
In addition, the operation is performed with the low effectiveness of the drug treatment used, which is not able to stabilize the state of health.
Surgical intervention for the treatment of carotid arteriosclerosis has a number of specific, clearly established indications.
Indications are stenosis (narrowing) of the lumen of the carotid artery is stronger than 70%, including those cases where there are no concomitant clinical manifestations; stenosis of the carotid artery is more than half if there are signs of cerebral ischemia, and previously the patient suffered transient cerebrovascular accident (TIA) or strokes.
Also, an operation is prescribed if there is a narrowing of the lumen less than half if cases of TIA and strokes have previously been observed; sudden breakdown of brain functions or the progression of chronic brain ischemia; damage to the left and right carotid arteries; simultaneous damage to the carotid, vertebral and subclavian arteries.
There are also many contraindications to the operation, because in most cases older people come up with similar problems.
For them, such operations are too traumatic, and therefore there are such contraindications to their conduct:
- chronic diseases of the cardiovascular, bronchopulmonary system and kidneys in the period of exacerbation – they are the first problem, because the body under the influence of anesthesia may simply not cope;
- significant depression of consciousness, up to a coma;
- acute stage of stroke;
- hemorrhage into the brain tissue with concomitant foci of ischemia.
Indications for carotid artery surgery include:
- Vasoconstriction by seventy percent, including patients who do not have symptoms;
- Fifty percent narrowing with the presence of symptoms of insufficiency in the brain. Moreover, patients in the past have already dealt with a stroke;
- Narrowing less than fifty percent, in case of insufficiency;
- Bilateral CA violation;
- The complex of pathology, including vertebral, subclavian and carotid main paired vessels.
- The cause of narrowing of the lumen (stenosis) in the vessel may be its bending, venous thrombosis, deposition of cholesterol, protrusion on the arteries.
Contraindications for carotid artery surgery include:
- Diseases of some important organs that prohibit surgery;
- Loss of consciousness, life-threatening;
- Acute failure in the brain;
- Brain hemorrhage, with the death of cells;
- Complete closure of arteries.
Before the operation, the patient is sent for a general examination, which includes: analysis of biological fluids and liquid tissue, an ECG of the heart, fluorographic examinations, tests for the presence of infectious diseases such as hepatitis, syphilis, and human immunodeficiency virus. Other diagnostic methods include ultrasound, Duppler testing, angiography, magnetic resonance imaging, multi-spiral computed tomography.
Possible complications after carotid artery surgery:
- With endarterectomy, nerve damage is possible, which then manifests itself in a change in voice, it will be difficult to swallow, the face becomes asymmetric. Purulent formations when an infection gets into the wound, although this happens quite rarely, subject to all requirements.
- With the introduction of the stent, the plaque can fall apart and its pieces fall into the bloodstream, blockage of the brain vessels, the worst result.
According to statistics, carotid artery surgery guarantees ninety-five percent of good results that do not require repeated intervention.
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