Our experience on surgical treatment of patients with multiple atherosclerotic lesions of carotid arteries

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Xodjiakbar K. Alidjanov, Candidate of Medical Sciences, Head of

Department, Republican Specialized Center of Surgical Angioneurology,

Uzbekistan

Abdurasul A. Yulbarisov, Doctor of Medical Sciences, Deputy Director,

Republican Specialized Center of Surgical Angioneurology, Uzbekistan.

Rustam T. Muminov, Candidate of Medical Sciences, Vascular Surgeon,

Republican Specialized Center of Surgical Angioneurology, Uzbekistan.

Alimjon M. Axmatov, Candidate of Medical Sciences, Neurologist,

Republican Specialized Center of Surgical Angioneurology, Uzbekistan.

Victoria E. Tsay, Assistant of Department of faculty and hospital surgery

№1, Tashkent Medical Academy, Uzbekistan.

OUR EXPERIENCE ON SURGICAL TREATMENT OF PATIENTS WITH

MULTIPLE ATHEROSCLEROTIC LESIONS OF CAROTID ARTERIES

X.K. Alidjanov, A.A. Yulbarisov, R.T. Muminov, A.M. Axmatov, V.E. Tsay

Abstract: The objective of study was improvement of results of surgical

treatment of patients with bilateral atherosclerotic defeats of carotid
arteries. Studied results of treatment of 180 patients with bilateral
atherosclerotic defeats of the carotid arteries in 2014-2019 y. Patients were
divided into the first (60 patients) and the second (120 patients) groups
depending on tactic of surgical treatment. In the 1

st

group of patients: first

stage of CEA performed on the side with greater degree of stenosis and on
the side where stroke happened. Terms of СEA on the opposite side varied
from 2 weeks till 2 years. Complications in the 1

st

group were (5.0 %). At

patients of the second group was applied to revealing of carotid pool of
primary importance. To 120 patients performed 200 carotid
reconstructions. Performance terms of CEA on the opposite side varied from
45 days till 3 months. Total percentage of complications in the 2

nd

group was

1.7 %. It is important to do CEA stage by stage. According to our data it is
ideal to perform CEA on the opposite side in period from 2 to 3 months.

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Choosing the side of primary importance for bilateral atherosclerotic lesions
determines the results of treatment.

Keywords: bilateral lesions, carotid arteries, side of primary

importance, stage of operations, time-frame of operations.

Atherosclerotic defeats of brachiocephalic arteries are one of the main

reasons of acute and transient brain circulation disorders [1-4]. Bilateral
atherosclerotic defeats are more usual then isolated [5, 6]. The most saved
and effective method of preventing the stroke which is caused by
atherosclerosis of carotid arteries is carotid endarterectomy [13, 15]. It is
steel important, to research hemodynamic in brain vessels before planning
intervention [11-14]. According to some authors it is necessary to orientate
not only on the degree of stenosis but mainly on properties of
atherosclerotic plaque (ASP) [8-9].

Although, some questions are not solved yet: on which criteria we

should relay for determining surgical tactic, staging, sequence of the
operations and intervals between them [7, 12].

It is very important to protect the brain from ischemia during operation

in the patients with bilateral atherosclerotic lesions of carotid arteries.

Besides this lop-sided approach, that considers only hemodynamic

importance of lesion or carotid pool with prevalent carotid symptoms, is
hopeless and fraught with serious consequences [10].

In connection with this it is necessary to have particular tactic of

choosing side of primary importance for performing carotid reconstruction.

Taking into account everything mentioned above, the aim was

optimization of the results of the treatment of patients with bilateral lesions
of carotid arteries, by means of revealing time-frame and staging of
performing carotid reconstruction and protecting brain from ischemia.

MATERIAL AND METHODS
Analyzed results of 2140 patients, treated in our hospital, 180 of them

were with bilateral atherosclerotic defeats of carotid arteries in period
2014-2019.

Patients were divided into the first and the second groups, depending

on tactic of surgical treatment. 1

st

group included 60 (33,3%) patients who

undergone carotid reconstruction step-by-step on both sides. 2

nd

group

included 120 (66,7%) patients with bilateral atherosclerotic defeats of
carotid arteries, to whom at the first stage performed carotid reconstruction
on the side of primary importance. Patients of both groups did not mainly
differ by their age and sex. Age of the patients varied form 42 to 82. Average
age was 59±5.6 years, (р<0,005).

To all patients performed duplex imagining. For duplex scanning used

ultrasound machine «Medison X6» (Korea 2008). Measured the diameter of
CCA, ICA, ECA, vertebral arteries, thickness of complex media-intima, linear

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and volumetric velocity of blood, pulsation index and index of resistance in
the vessels. Degree of stenosis calculated by diameter of the vessel by ЕCSET
methodic [3, 4]. Also were paid attention for the structure of plaques, speed
and direction of the blood flow. All patients underwent duplex imagining
investigation with identification of stenosis percentage, speed of the blood
flow and the structure of plaques. For description of ASP was used
supplemented classification of Gray-Weale [1]. Volumetric bloodstream in
brachiocephalic arteries was measured at extracranial and intracranial
levels. By adding data was calculated average volumetric blood speed at the
right and left side in every patient. Studying hemodynamic in the
intracranial arteries used analogical methodic with calculating average
volumetric blood speed. Performing transcranial duplex imagining we paid
attention for direction and speed of the blood flow in the MCA, and carried
out compression tests for estimating communicant arteries.

For estimating tolerance of the brain for ischemia we used compressing

test, and during this test we studied as neurological status of the patient as
blood flow in MCA.

Nature and localization of failure of the brain was estimated with

computer tomography (CT).

All patients as a rule were examined by neurologist before and after

intervention and also at near and long postoperative term. For estimating
neurological symptoms considered signs of disorders of coordination,
vision, sense, noise in the ears and in the head, fatigability, degradation, and
also emotional status of the patients.

For the quantitative revealing neurological deficit (ND) at the patients

who suffered stroke or TIA and its dynamic was used scale of Hachinsky
(1985) [2, 15].

RESULTS AND DISCUSSION
According to the classification of A.V. Pokrovskiy (1979) patients of

both groups were divided in reference to stages of chronic cerebral-vascular
insufficiency (CCVI) (table 1).

Table 1

Structure of the patients by the stages of CCVI

Stages of CCVI

Number of the patients

Total
%

I group
(n=60)

II group
(n=12)

Asymptome current

3 (5,0%)

7 (5,8%)

5,6

TIA

12 (20,0%)

23 (19,2%)

19,4

Discirculator encephalopathy

20 (33,3%)

42 (35,0%)

34,4

Condition after ischemic stroke

25 (41,7 %)

48 (40,0%)

40,6

Total

180

100

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In both groups dominated patients who suffered stroke.
According to the type of performed carotid reconstructions patients of

both groups were similar (р<0,01). In total were performed 275 CEA.
Besides this in both groups technical moments of the operations were
identical (table 2).

Table 2

Reconstructions of carotid arteries

Name of operation

Quantity of procedures
1 group (n=120) 2 group (n=200) Total

(n=320)

1 stage 2 stage 1 stage 2 stage

CEA with patch

30

33

41

59

166

Eversion CEA

21

24

44

41

130

Grafting of ICA

1

-

-

-

1

Plastic of ECA

8

-

15

23

Patients of the first group underwent carotid endarteactomy on both

sides. In revealing side where carotid reconstruction should be performed
first at the patients with stroke preference was given to that carotid pool.
Besides this the degree of stenosis played secondary role. 22 (36.7%)
patients underwent CEA on side where ischemic episode had been occurred.
In 23 (38.3%) cases, at patients with discirculatory encephalopathy and
asymptomatic patients CEA performed on the side with higher degree of
stenosis. Patients with TIA at first stage underwent for CEA on the side
where ischemic episode occurred regardless of degree of stenosis on the
contralateral side. In this group, in 12 cases (20.0%) detected unstable ASP.
In patients with occlusion of ICA first of all carotid CEA on the side of
occlusion in 8 (13.3%) cases regardless of degree of stenosis on the
contralateral side and ischemic episode at current carotid pool. 3 (5.0%)
patients underwent for carotid reconstruction on the side opposite to
occluded ICA, in means of suffered stroke in that carotid pool.

Time-frame of carotid endarterectomy on the opposite side varied from

2 weeks to 2 years, and at the average period was 5.2 months. Besides this
32 (53.3%) patients of the 1

st

group underwent for the procedure in period

of 6 months.

Analyses showed that there is relativity of clinical effect of the operation

among initial level of neurological deficit, time-frame of suffered stroke and
time-frame of the second stage of carotid reconstruction. At the first stage of
CEA 14 (56.0%) patients had 1

st

level of ND, 6 (24.0%) had 2

nd

level of ND

and at 5 (20.0%) patients registered 3

rd

level of ND.

Absolute rising in units among different levels of ND was not the same.

That is the most rate of involution of ND was observed in patients with 1

st

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and 2

nd

levels of ND, who were operated in period of 6 months after stroke

and also in patients who underwent the procedure on the opposite side in
period of 2 or 3 months. Besides this rising in units by Hachinsky scale in
that category of patients was 29.2, 17.1 and 4.4 units respectively,
depending on initial level of ND.

Common quantity of complications, in the 1

st

group were (5,0%). In

period of first 30 days one patient had stroke in operated carotid pool on the
first stage of CEA. During 15 days ND totally disappeared. On the opposite
side carotid endarterectomy performed after 2 months and patient was
discharged in tolerable condition. One patient got stroke during the
operation having occluded ICA on the opposite side. 1 (1.7%) patient with
local occlusion of the left and total occlusion of the right ICA underwent for
carotid reconstruction in time-frame of 2 weeks, because of frequent TIA in
the opposite carotid pool. This patient sustained hemorrhagic stroke after
the 2

nd

stage of CEA. We suppose it depended on irregular receiving of

hypotensive drugs and developing of hyper perfusion syndrome after
discharging from the hospital.

In patients of the 2

nd

group the differentiated approach used for

identification of the side of primary importance to define the indication to
the reconstruction. The significance of the defeat of the carotid pool was
taken into the attention. The particular attention was made to summary
stenosis of the carotid arteries, volume circulation in the extra- and
intracranial arteries of the brain accounting its adapted redistribution and
tolerance of the brain to ischemia. The structure, surface and duration of the
plaque by the data of DS and MSCTA were also considered. The terms of the
ischemic episode, severity and speed of the regress of the neurologic deficit
were taken to the attention in patients with the stroke in anamnesis. So in
patients with occlusion of the ICA and contralateral severe stenosis the side
of occlusion was preferable for performing the first stage of CEA.

We worked out the estimation scale of the severity of the carotid

artery’s defeat for the objective estimation of defeat of the carotid pool
(table 3) [15]. Every parameter was estimated in points. 1

st

stage of CEA

performed at the side with more points, so that corresponded to the more
defeated carotid pool.

Table 3

Estimation scale of the severity of the defeat of the carotid pool

Estimation of the severity of the defeat of the carotid pool
On the right

Points

On the left

Points

1.Degree of stenosis:
55 -70%
70 – 99%

1
2

1.Degree of stenosis:
55 -70%
70 – 99%

1
2

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Occlusion

3

Occlusion

3

2. Stroke (terms):
TIA
To 6 months
After 6 months

3
2
1

2. Stroke (terms):
TIA
To 6 months
After 6 months

3
2
1

3. Neurologic deficit:
Permanent
Hidden
Progressing

1
2
3

3. Neurologic deficit:
Permanent
Hidden
Progressing

1
2
3

4. Number of the
strokes (in the
anamnesis):
1 time
2 times
Many times

1
2
3

4. Number of the
strokes (in the
anamnesis):
1 time
2 times
Many times

1
2
3

5. CT of the brain
(sizes of the focus):
To 3 sm
to 6 sm
more then 6 sm

3
2
1

5. CT of the brain
(sizes of the focus):
To 3 sm
to 6 sm
more then 6 sm

3
2
1

6. Features of the
ASP:
Stabile
Occlusion
Embologenous

1
2
3

6. Features of the
ASP:
Stabile
Occlusion
Embologenous

1
2
3

7. Deficit of the
summary circulation
of the brain:
1 degree
2 degree
3 degree

1
2
3

7. Deficit of the
summary circulation
of the brain:
1 degree
2 degree
3 degree

1
2
3

8. Compensation in
the MBA
crossclamping
(estimation of the
communicant
arteries):
bad
satisfactory
good

1
2
3

8. Compensation in
the MBA
crossclamping
(estimation of the
communicant
arteries):
bad
satisfactory
good

1
2
3

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200 CEA performed to 120 patients, every of which considered as

separated case.

Terms of performing of the CEA at the contralateral side varied from 45

days to 3 months.

The clinic effect of the operation significantly increased because of

keeping the tactic of the identification of the most defeated carotid pool and
optimal terms of performing CEA on the opposite side. Also in 22 (18.3%)
patients with low tolerance of brain to ischemia and severe defeats of
carotid arteries on the both sides and in patients with stroke we used intra-
arterial temporary shunt. In the cases of using temporary shunt time of
ischemia in average was equal to 7±2 min, necessary for performing
endarterectomy, introducing the shunt and for finishing making
anastomosis. It showed in the faster regress of the neurologic deficit
comparing with the patients of the 1

st

group.

At the first stage of the CEA 20 (41.6%) patients had the neuroligic

deficit (ND) 1

st

degree, 22 (45.8%) patients had ND 2

nd

degree and 6

(12.5%) patients had ND 3

rd

degree. The full regress of the neurologic

symptoms marked in 16 (33.3%) patients after the CEA on the contralateral
side, 3 (6.2%) patients passed from the group of ND 2

nd

degree to the group

of ND 1

st

degree. The ND stayed at the same level in 6 (12.5%) patients

because of the terms of suffered stroke.

The percentage of the complications in the 2

nd

group was 1.7%. In 1

patient (1.7%) after 5 months after CEA developed an ischemic stroke at the
second stage. By our opinion it is connected with the stopping of taking of
the hypotensive drugs and antiplattelates. It is necessary to underline, that
we hadn’t marked such complications as stroke and mortality in the period
up to 30 days in this group of the patients.

Identification of the most important side for the CEA with the

identification of the severity of the carotid pool’s defeat helped to reduce the
complications in the period up to 6 months connected with the stroke from
5% to 1.7% (table 4).

Table 4

Character of complications

Character of complications

Complications

1 – Group

2- Group

Total

Stroke at the ipsilateral side

2 (3,3%)

1 (0,83%)

3 (1,7%)

Stroke at the contralateral side 1 (1,7%)

1 (0,83%)

1 (0,5%)

“Stroke+mortality”

1 (1,7%)

-

1 (0,5%)

Total

3(5,0%)

2 (1,7%)

4 (2,2%)

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Differentiated approach for identification the side for the first CEA is

important. Our experience shows that the intervals between CEA on both
sides should not exceed three months and shall not be less than 3 weeks.
This tactic will not only reduce mortality and complications, but also
significantly improve the quality of life of patients by promoting rapid
regression of neurological deficit. So it is very important to determine the
thoroughness of phasing and timing of carotid reconstruction. Adequate
choosing the side of primary importance for bilateral atherosclerotic lesions
determines the results of treatment. Choosing the side of carotid
reconstruction with the express carotid lesions contributed to the reduction
of complications associated with stroke from 5.0% to 1.7%.

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Takhir Burkhanov, The Academy of Armed Forces of the Republic of

Uzbekistan, Senior Lecturer, Department of Humanities

ANALYSIS OF NATIONAL AND UNIVERSAL SPIRITUAL VALUES

T. Burkhanov

Abstract: This article is devoted to the analysis of the national and

universal spiritual values.

Keywords: Values, national values, universal values, religion tolerance,

conscience, faith, ideology.

Analysis of national and universal spiritual values

Universal human values are not separate aspects of spiritual and social

development of humanity. Universal human values are a generalized
reflection of national and regional values. Universal human values are built
and developed on the basis of the values typical to humanity, and they also
serve to bring together and develop all national values.

The word “value” should refer to the set of phenomena came from the

blessings of nature and society, which serves the interests and goals of
nations, folks and social groups that are important to human beings and
humanity, which are therefore appreciated and valued by them.

For everyone, for every family and community, for every nation and