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Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 312-314

Evolution of extracranial carotid artery disease treatment: From opinion to evidence

Department of Vascular and Endovascular Surgery, CARE Outpatient Centre, Hyderabad, Telangana, India

Date of Submission26-Nov-2019
Date of Acceptance27-Nov-2019
Date of Web Publication20-Dec-2019

Correspondence Address:
Dr. Pritee Sharma
Department of Vascular and Endovascular Surgery, CARE Outpatient Centre, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_99_19

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How to cite this article:
Sharma P. Evolution of extracranial carotid artery disease treatment: From opinion to evidence. Indian J Vasc Endovasc Surg 2019;6:312-4

How to cite this URL:
Sharma P. Evolution of extracranial carotid artery disease treatment: From opinion to evidence. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Sep 27];6:312-4. Available from:

The fact that some blood vessels in the neck supply brain has been known since antiquity. The ancient Greek literature has description about how occlusion of the carotid artery led to deranged neurologic function. Around fourth century BC, Hippocrates coined the term “apoplexy” and gave a detailed description about prodromal symptoms, transient ischemic attack (TIA), and occurrence of contralateral hemiplegia due to carotid artery occlusion.[1]

Rufus of Ephesus, around 100 AD, noticed that compressing blood vessels in the neck caused loss of consciousness – “deep sleep.” Hence, the artery was named “carotid,” Greek meaning is “to stun, stupefy, or fall asleep.” The Greek warriors were also aware of this fact. In Athens on the southern side of Parthenon, the 31st metope shows a centaur compressing the carotid artery of enemy in a fight with Thessalian.[2]

It was believed that loss of consciousness was curse of God and so attempts to treat were not successful. Initial operative procedures included ligation of common carotid arteries as described by Ambroise Pare in 1552 wherein he ligated the common carotid artery in trauma patients who postoperatively developed aphasia and hemiplegia.[3] John Abernathy, pupil of John Hunter, published the first case in English literature of operation on carotid artery for carotid artery injury by horns of cow.[4],[5] After couple of futile postoperative outcomes, Sir Astley Paston Cooper on June 22, 1809, ligated the carotid artery in aneurysm case and the patient lived for 13 years.[6]

Ligation of carotid artery was the treatment option for carotid artery trauma, carotid aneurysms and cerebral ischemia for some period of time. In 1938, Chao et al. applied Leriche principles of arterectomy and excised the occluded thrombosed segment of carotid artery.[7] In 1960, Hurwitt et al. concluded that by excising the thrombosed segment, symptoms improved because of cessation of embolic shower from the stenosed and ulcerated segment.[8] In 1948, Sciaroni published his case series of four patients in whom side-to-side anastomosis between common carotid artery and the internal jugular vein was created. He introduced the concept of “reversal of the circulation of the brain.”[9]

Approximately 363 patients in United States and Europe underwent Sciaroni's procedure from 1949 to 1953. However, due to frequent and severe complications such as pulsating exophthalmos, raised spinal pressures, and cardiomegaly, the procedure was discontinued.[10]

In the 19th century, the concept of restoring blood supply to brain by excising the disease segment and reconstructing continuity by either end-to-end anastomosis or vein graft was being proven on experimental basis. Carrel in his “experimental surgery” mentions about transplanting segment of jugular vein into dog's carotid artery. After 8 months, when he extirpated the carotid artery, he found that the vein had adapted to arterial function.[11]

Surgical oncologists have a significant contribution in the treatment of carotid artery disease. Harry Sloan in 1920 reported in English literature about carotid reconstruction using Carrel's original method of suturing while operating on recurrent carcinoma lip with cervical metastases.[12]

John J. Conley, surgical oncologists practicing at Saint Vincent's Hospital in New York in the early 1950s, started the procedure of end-to-end anastomosis between the distal stumps of internal and external carotid artery and at times replaced the diseased segment with autogenous saphenous vein. In 1952, he presented a case series of 11 patients in whom he had successfully done the procedure.[13] Nonetheless, he was way ahead of his time and has made a very important contribution in carotid surgery.

Until now, oncologists successfully demonstrated carotid reconstruction and this experience was extrapolated to occlusive carotid artery disease. In 1951, Carrea, Molina and Murphy repaired occluded internal carotid artery via end-to-end anastomosis in a 41-year-old male who had presented with right hemiparesis.[14]

In 1947, Dos Santos introduced the technique of endarterectomy for aortoiliac atherosclerotic occlusion.[15] On August 7, 1953, DeBakey performed the first successful carotid endarterectomy in a 53-year-old male who had presented with TIA.[16],[17] After the success of carotid endarterectomy by DeBakey, many eminent surgeons like Eastcott et al.,[18] Moore, Baker, and Wylie[19] and Ehrenfeld performed this procedure[18],[19] and the number of carotid surgeries rose to approximately 85,000/year by 1987.[20] This alarming rise in the number of procedures led to questions about patient selection, stroke risk, and death risk related to surgery. In 1987, Patterson reviewed the results of joint study of extracranial disease and Shaw et al.'s study and concluded that carotid surgery is beneficial in symptomatic patients with high-grade stenosis and severe ulceration.[21] In 1988, Winslow et al. conducted health program of Rand Corporation found that only 35% of patients had the operation done for appropriate reason, and carotid surgeries were substantially overperformed with high postoperative complication rate (10%).[22]

Due to emerging conflicting reports, the need aroused to conduct well-planned randomized control trials. In 1996 the European Carotid Surgery Trial[23] and in 1991 the North American Symptomatic Carotid Endarterectomy Trial[24] showed that the outcome of surgery is better as compared to medical management in symptomatic patients with high-grade stenosis (70%–99%). The management of asymptomatic patients was based on the Asymptomatic Carotid Atherosclerosis Study[25] conducted in 1995 and the Asymptomatic Carotid Surgery Trial,[26] which suggested surgery in asymptomatic patients with stenosis more than 60% in centers that have death and stroke rate not exceeding 3%.

In the late 19th century, where studies were being conducted to assess the effectiveness of carotid surgeries, various improvised techniques were being experimented. On March 4, 1956, Cooley performed successful carotid endarterectomy using a polyvinyl shunt with needle pointing at both ends to maintain internal carotid flow when the artery was temporary occluded during plaque removal.[27] In 1966, at the Institute of Experimental Surgery in Prague, Mical et al. used small plastic tubes as temporary shunts to maintain cerebral perfusion during temporary occlusion of artery.[28] Crawford et al. in 1960 discussed in detail the hemodynamic changes that occur in patients with cerebral arterial insufficiency before and after surgery.[29] They suggested measurement of stump pressure to assess the collateral cerebral circulation. Thompson et al. in their series of 592 patients followed up to 13 years advocated elective application of shunts.[30] Moore et al., however, suggested selective use of shunt based on stump pressure measurement.[31]

With the advent of endovascular procedures, there was further controversy in the treatment of carotid artery disease. DeBakey et al. in 1967 used open technique of gradual dilatation of carotid lesions using biliary dilators for 12 patients with fibromuscular dysplasia.[32] A German interventional radiologist, Mathias in 1977, did the first percutaneous transluminal carotid angioplasty.[33] Later in 1994, Marks et al. used Palmaz stent in spontaneous carotid dissection patients.[34] Diethrich et al. performed carotid angioplasty and stenting in 110 patients with clinical success of 89% and stroke rate of 10.9% that which much higher as compared to open surgery. Therefore, they recommended angioplasty and stenting in selective high-risk patients at experienced neuroradiology centers.[35]

As carotid endarterectomy underwent improvisation, carotid angioplasty also underwent various levels of improvisation in the next decade. The introduction of nitinol crush resistant stents and embolic protection devices made a significant difference in the outcome of carotid angioplasty and stenting. The next decade had various trials comparing carotid endarterectomy with carotid artery stenting.

The Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE-2004) trial showed that in patients with symptomatic carotid artery stenosis, the cumulative incidence of the primary endpoint at 1 year was 16.8% among those who received a stent, as compared with 16.5% among those who underwent endarterectomy (P = 0.95). SAPPHIRE trial concluded that carotid stenting with the use of an emboli protection device is not inferior to carotid endarterectomy.[36]

The International Carotid Stenting Study (ICSS), a randomized controlled trial, enrolled 1710 patients with symptomatic carotid stenosis. The number of fatal or disabling strokes (52 vs. 49) and cumulative 5-year risk did not differ significantly between the stenting and endarterectomy groups (6·4% vs. 6·5%; P = 0·77). ICSS concluded that long-term functional outcome and risk of fatal or disabling stroke are similar for stenting and endarterectomy for symptomatic carotid stenosis.[37]

The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)[38] enrolled 2502 patients with symptomatic or asymptomatic carotid stenosis and showed that primary study endpoint (within 30 days) was 5.2% for stenting group and 4.5% for endarterectomy group. The estimated 4-year rate of primary endpoint was 7.2% for stenting group and 6.8% for endarterectomy group. CREST concluded that among patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, myocardial infarction, or death did not differ significantly in the group undergoing carotid artery stenting and the group undergoing carotid endarterectomy. During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy.

The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is an ongoing two-parallel multicenter randomized, observer-blinded endpoint clinical trial, which is likely to end by December 2020.[39]

The treatment for carotid artery disease started with ligation of vessel and then as importance of restoring the blood supply to brain was understood various ways of carotid artery revascularization got added to the armamentarium of vascular and endovascular surgeon. Till today the treatment of carotid artery disease is evolving.

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  References Top

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Thompson JE. The development of carotid artery surgery. Arch Surg 1973;107:643-8.  Back to cited text no. 2
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