A CLINICAL CASE OF ENDOVASCULAR TREATMENT OF THE PATIENT WITH CHRONIC ARTERIAL INSUFFICIENCY OF THE BRAIN WITH CRITICAL ISCHEMIA OF LOWER EXTREMITIES

The article describes the case of one-stage stenting of the internal carotid artery and balloon angioplasty of the tibial arteries in a patient with multifocal atherosclerosis.

patient's blood on an LA 230 platelet aggregation analyzer for clopidogrel resistance, it was found that ADP-dependent platelet aggregation is suppressed to a minimum, which in turn leads to the development of resistance and an increased risk of early thrombotic complications. Clopidogrel (K) was replaced by a new thienopyridine antiplatelet agentprasugrel (P). Its effect occurs earlier and is more pronounced than that of clopidogrel. Prasugrel administration schedule: loading dose of 60 mg with a transition to a maintenance dose of 10 mg / day. The results of the study showed that, 4 hours after taking loading doses in group P, there was a significant decrease in platelet aggregation activity compared to that of group K (88.7% and 28.5%, respectively, p <0.0001). After 24 hours, while taking already supporting doses of clopidogrel and prasugrel, the aggregation ability in group K decreased to 57.8%, and in group P, the degree of suppression of aggregation reached 89.9% (p <0.0001). After 7 days, against the background of taking maintenance doses of thienoperidines in both groups, there was some leveling of aggregation suppression indicators, but with a significantly more significant effect in group P (72.8% versus 60.8%, p <0.0001) (Fig. 1).
The results of general clinical and biochemical blood tests (Table 3) and ultrasound dopplerography data (Tables 1 and 2) are presented below. Considering the above, it was decided to stent the right ICA with transluminal balloon angioplasty of the tibial arteries of the right lower limb. Retrograde left femoral access puncture a. femoralis communis with installation of 6F introducer. After the insertion of the guide-introducer into the lumen of the right CCA, a distal protection system with the subsequent implantation of a self-expanding stent 6.0x9.0x30 was performed through the stenosis of rICA. Before completion of the procedure, post-dilatation of residual stenosis was performed. On the control angiograms there are no signs of distal embolization, the neurological symptoms of the patient are unchanged. The initial carotidography and stenting results are shown below (Fig. 1)

Initially
After Stenting Fig. 2 Arteriography of the right carotid artery before and after endovascular intervention (arrows indicate the area of stenosis) The following puncture was performed on the right a. femoralis communis in the antegrade direction with the installation of a 6F introducer. A multifunctional diagnostic catheter 5F was performed below the popliteal segment before tibial artery bifurcation. A 3.0x100 balloon catheter with dilatation along the entire length was delivered to the coronary conductor in the zone of stenosis of the ATA. The exposure time of the balloon is 5-7min. Similar actions were implemented in the PTA. On the control arteriograms, the restoration of the main contrast of ATA and PTA was noted (Fig. 2).

Initially
After balloon dilatation Fig. 3

Arteriography of the tibial and femoral arteries before and after endovascular intervention (arrows indicate areas of stenosis and occlusion)
Manual hemostasis was performed with a pressure bandage on the puncture area on both sides. After 1 day, there was a positive trend according to the data of ultrasound dopplerography (table. 4,5). On the 2nd day, the physical activity of the patient was resumed. Neurological deficit is not observed. The resting pains were stopped, the skin was warm to the touch, the color of the foot was normal, pulsation along the main arteries of the foot (a.dorsalis pedis et tibialis posterior) was observed. The patient was discharged in satisfactory condition. The necessary recommendations for further treatment are given.