ИСТИНА

Introduction Possibilities of endovascular treatment of large and giant cerebral aneurysms are limited by severe carotid tortuosity, which complicates intravascular manipulation on aneurysm and stent delivery through the deformation. In such cases open surgical or hybrid interventions are seen as reasonable approach to solve this problem. Methods 20 patients with large and giant aneurysm of C4 (11 cases) C5 (5 cases) and C6-C7 (4 cases) segments of ICA with combined severe tortuosity of extracranial carotid arteries underwent staged surgery from 2016 to 2018. Carotid deformations were presented with Metz-3 kinking of C1 segment (11 cases), coiling with Metz 2-3 kinking of C1 ICA segment (6 cases),proximal kinking of CCA (3 cases). At first stage we performed surgical dissection and straightening of carotid artery followed by resection of vessel redundancy and end-by-side reimplantation in CCA bifurcation (17 cases) or end-by-end anastomosis for CCA reconstructions. Endovascular intervention was planned 3-4 months after carotid reconstruction: in 16 patients flow-diverters were placed, in 4 patients - aneurysm coiling with stent assistance. Control CTA examination we performed 6-10 months after endovascular operation. Mean follow-up period was 8 month. Results In all cases we achieved complete aneurysm embolization, confirmed by control CTA. Open surgical carotid reconstruction prepared convenient endovascular access to cerebral aneurysm in 19 cases. In 1 patients residual stenosis at the place of severe deformation needed additional angioplasty and stenting. 2 patients (10%) were intolerant to temporary carotid clamping, revealed during intraoperative TCD and cerebral oximetry monitoring – we used temporary indwelling shunt. We didn’t notice any bleeding problems due to antiplatelets therapy, characteristic to hybrid “cut-down” approaches. No ischemic and hemorrhagic cerebral complications of carotid reconstructions were registered as perioperative, as during the whole period before endovascular intervention. 1 patient had transitory peripheral nerve deficit with full regress 3 months after surgery. During follow up in 1 case we diagnosed asymptomatic carotid occlusion. Overall morbidity was 5% - 1 patient suffered from minor ischemic stroke after flow-diverter placement. Conclusions Staged open surgical reconstruction of carotid arteries is efficient and relative save method, which can solve the problem of complex endovascular approach due to severe tortuosity of brachiocephalic arteries.