key: cord-0851076-f3yudwof
authors: Kazantsev, A.N.; Karkayeva, M.R.; Tritenko, A.P.; Korotkikh, A.V.; Zharova, A.S.; Chernykh, K.P.; Bagdavadze, G.SH.; Lider, R.YU.; Kazantseva, Ye.G.; Zakharova, K.L.; Shmatov, D.V.; Kravchuk, V.N.; Peshekhonov, K.S.; Zarkua, N.E.; Lutsenko, V.A.; Sultanov, R.V.; Artyukhov, S.V.; Kharchilava, E.; Solotenkova, K.N.; Zakeryayev, A.B.
title: CAROTID ENADRTERECTOMY FOR INTERNAL CAROTID THROMBOSIS IN PATIENTS WITH COVID-19
date: 2022-05-13
journal: Curr Probl Cardiol
DOI: 10.1016/j.cpcardiol.2022.101252
sha: e722407a89ea6757c2c036b6d8e16c0b44b527a5
doc_id: 851076
cord_uid: f3yudwof

GOAL: 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 (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: 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. 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.

It has been more than two years since the new coronavirus infection reached pandemic status. The clinical spectrum of this pathology varies from an asymptomatic form to a severe disease characterized by hypoxemic respiratory failure, community-acquired polysegmental pneumonia, septic shock, and systemic multiple organ failure [1, 2] . COVID-19 is often accompanied by hypercoagulability, micro-and macrovascular thrombotic angiopathy [3] . This conclusion is confirmed by the laboratory profile observed in these patients, with a significant increase in Ddimer, prothrombin, fibrinogen [4] . In addition, a aggravating factor is systemic hyperinflammation with an increase in pro-inflammatory cytokines (tumor necrosis factor, interleukin-6, interleukin-1β), which can contribute to the development of intravascular coagulopathy [5] . In a study by Klok F.A. et al. reported a cumulative incidence of thrombotic complications in 49% of patients with COVID-19 in infectious hospitals [6] . According to a systematic review by Cheruiyot I et al., 27 studies described arterial thrombosis of various locations in patients with COVID-19. Among them, special emphasis was placed on the carotid arteries, the proportion of which was 24% [7] . It should be noted that in patients without COVID-19, thrombosis of the internal carotid artery is quite rare (about 1.6% of the total). In 92% of cases, as a rule, neurological symptoms are observed. In 17.1%, a repeated ischemic event is recorded within 30 days after the manifestation [8] . Thus, a significant increase in the frequency of diagnosing this condition has raised the question of choosing effective and safe methods of treatment.

Thrombosis of the internal carotid artery in patients with COVID-19 most often develops against the background of hemodynamically significant stenosis and unstable atherosclerotic plaque [8] . However, among patients who do not suffer from a new coronavirus infection, this condition rarely manifests itself in occlusive thrombosis. This pattern is explained by aggravating factors that accompany the course of COVID-19: endothelitis and hypercoagulability [8] . Due to the lack of sufficient experience in the treatment of this pathology, the optimal tactics of revascularization has not yet been developed. However, there are reports that in case of peripheral arterial thrombosis, open thrombectomy, endovascular thromboextraction, thrombolysis are accompanied by a high frequency of repeated thrombosis and limb amputations [1] . Thus, the use of these techniques in the treatment of patients with occlusive thrombosis of the internal carotid artery will be associated with the risk of new thrombosis and acute cerebrovascular accident. But it must be borne in mind that the listed methods of treatment do not "turn off" one of the main components of the development of this process -the inflamed endothelium. If it is possible to cope with hypercoagulability due to medical support, then within the framework of thrombosis of the internal carotid artery, the most optimal method of revascularization is the removal of the thrombus and the adjacent atherosclerotic plaque along with the endothelium through carotid endarterectomy [9, 10] . Thus, within the framework of this pathology, we should talk about the effectiveness of carotid endarterectomy in the most acute period of ischemic stroke in patients with COVID-19.

The criteria for selecting patients for emergency CEE in "non-covid" surgery have been repeatedly put forward and substantiated: unstable atherosclerotic plaque with a high risk of distal embolization; the diameter of the ischemic focus in the brain, not exceeding 2.5 cm; the absence of a pronounced neurological deficit (stupor, coma); hemorrhagic stroke; hemorrhagic transformation; acute coronary syndrome [8, 11, 12, 13, 14] . But in the absence of an alternative, these parameters can be used in the context of COVID-19 as well. There were no other indications/contraindications for revascularization in this cohort of patients to date. In the world literature, there are only a few reports of individual clinical cases of effective / ineffective attempts of cerebral revascularization against the background of COVID-19 [8, 15, 16, 17, 18] . Thus, due to the lack of large studies on the results of emergency carotid endarterectomy in the acute period of ischemic stroke in patients with a new coronavirus infection, the optimal treatment strategy has not yet been developed.

The aim of this study was to analyze the hospital results of emergency carotid endarterectomy against the background of thrombosis of the internal carotid artery in the acute period of ischemic stroke in patients with COVID-19. To visualize the affected area of the internal carotid artery, computed tomography with angiography of the precerebral arteries was performed. The choice of treatment tactics was carried out by a multidisciplinary consultation (cardiovascular surgeon, endovascular surgeon, neurosurgeon, cardiologist, neurologist, infectious disease specialist, anesthesiologist-resuscitator).

The operation was performed under local anesthesia. In both groups, eversion carotid endarterectomy was performed with preservation of the carotid glomus.

The anastomosis was performed using a 6/0 polypropylene suture. Wound drainage was performed with the installation of two active drains in the paravasal space and subcutaneous fat.

Under the conditions of COVID-19, the operating team performed CEE in a specialized outfit: a surgical suit, protective overalls, a disposable surgical gown, two pairs of disposable gloves, antiviral goggles or a visor, and an FFP3 respirator. 

The groups were comparable in many respects. The vast majority corresponded to old age.

Males predominated in the total sample. For every fourth patient, this acute cerebrovascular accident has become repeated. However, it should be noted that chronic obstructive pulmonary disease was more often diagnosed among patients with COVID-19, which demonstrated a greater adherence of these patients to the disease of a new coronavirus infection (Table 1) . According to laboratory parameters, it should be noted that in the "pre-Covid period" the measurement of ferritin, D-dimer, interleukin-6 was not included in the study standards. In a cohort of patients with COVID-19, there was a pronounced coagulopathy (with an increase in D-dimer, fibrinogen, prothrombin), an inflammatory syndrome (an increase in ferritin, C-reactive protein, interleukin-6, leukocytosis) ( Table 2) . The groups were comparable in terms of severity of stenotic lesions of the internal carotid artery and the time of arterial clamping during carotid endarterectomy (Table 3) . In the hospital postoperative period, the groups were also comparable in terms of the incidence of all adverse cardiovascular events. However, due to severe coagulopathy with ongoing anticoagulant/antiplatelet therapy, patients with COVID-19 were more likely to develop bleeding at the surgical site (Table 4) . [19, 20] .

Also, the course of COVID-19 is associated with hypercoagulability (increased D-dimer, prothrombin, fibrinogen), which, as a result, reduces the time of clot formation and increases its maximum density [21] . It is believed that increased blood viscosity is the result of systemic extrapulmonary hyperinflammation and hypercytokinemia, which activate the coagulation cascade [5] . Endothelitis and hypercoagulation, together with prolonged immobilization of COVID-19 patients (prone position), complete the Virchow triad, providing an explanation for the mechanisms of arterial thrombosis.

Our results showed that all cases of thrombosis of the internal carotid artery were recorded during the stay of patients in the infectious diseases hospital, 5.5±1.5 days after admission. The Another issue relates to the urgency of the intervention. The course of the infectious process with severe respiratory failure and polysegmental pneumonia could serve as contraindications for emergency carotid endarterectomy. However, planned hospitalization in a cardiovascular hospital could only be implemented a few weeks after the patient was discharged from the institution and received two negative PCR tests for COVID-19. Another difficulty is related to the conversion of medical organizations, including those providing routine angiosurgical care to the population, into infectious diseases hospitals [1] . Thus, patients were faced with the inability to receive planned revascularization in the shortest possible time due to the long queue for hospitalization in available cardiovascular hospitals. However, patients with thrombosis of the internal carotid artery are characterized by a high risk of recurrent ischemic stroke [7, 8] . Ultimately, the combination of these circumstances was the reason for the emergency carotid endarterectomy.

It should be noted that an important factor in achieving a successful outcome of emergency carotid endarterectomy was the use of local anesthesia during the operation. It was previously reported that patients with polysegmental viral pneumonia are characterized by an increased risk of developing pneumothorax, pneumomediastinum, emphysema when using mechanical ventilation [1] . Thus, the refusal of artificial lung ventilation under local anesthesia prevents the formation of the listed pathology.

Speaking about the choice of the type of carotid endarterectomy, it is necessary to note the importance of the glomus-sparing eversion technique. The rejection of the classical technique with patch implantation is justified by the reduction in the duration of the operation and the risk of restenosis in the mid-term follow-up period [22, 23] . Preservation of the carotid glomus during carotid endarterectomy made it possible to control blood pressure at the level of normotonia in the early postoperative period. According to the literature, in case of damage to the carotid glomus, against the background of anticoagulant / antiplatelet therapy and hypertensive crisis, the formation of hemorrhagic transformation / intracerebral hematoma is possible with a negative prognosis for the further course of the disease [24, 25, 26] . Thus, the chosen revascularization technique in favor of eversion glomus-sparing carotid endarterectomy has become an important condition for successful revascularization.

Of additional interest may be the method of draining the wound. In elective "non-covid" surgery, we repeatedly used two drains for patients with severe hypoaggregation and hypocoagulation [27] . A separate emphasis should be placed on the range of hospital complications received. As noted above, in view of the fact that the majority of medical institutions turned out to be converted into infectious diseases hospitals, most patients could not receive the necessary therapeutic assistance in a timely manner [1] . Ultimately, patients hospitalized for COVID-19 often had decompensated cardiac and other pathologies [1] . As part of our work, two patients were diagnosed with myocardial infarction, which in one case became fatal. These patients were unable to receive the planned myocardial revascularization (percutaneous coronary intervention), which caused coronary circulatory failure with further consequences. In a single case, a recurrent ischemic stroke was diagnosed with regression on the background of conservative treatment. The cause of the condition was a distal embolism during clamping of the common carotid artery with areas of calcification.

The presented work is the first study with a sample of 43 patients, which has no analogues in the world literature. The experience of our medical institution, converted into an infectious diseases hospital, has shown that emergency carotid endarterectomy in the acute period of ischemic stroke is characterized by a low risk of adverse cardiovascular events. Anticoagulant/antiplatelet therapy in combination with removal of the inflamed endothelium during carotid endarterectomy makes it possible to exclude the formation of repeated thrombosis in this group of patients. Thus, glomussparing eversion carotid endarterectomy may be the revascularization of choice for patients with COVID-19 in the acute period of ischemic stroke against the background of internal carotid artery thrombosis.

Emergency carotid endarterectomy in the most acute period of ischemic stroke is an effective and safe method of brain revascularization in case of thrombosis of the internal carotid artery under conditions of COVID-19.

Declarations of interest none' in the template.

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