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• W4385447401 abstract "Stroke is the third leading cause of death and the most common cause of long-term disability. Severe narrowing (stenosis) of the carotid artery is an important cause of stroke. Surgical treatment (carotid endarterectomy) may reduce the risk of stroke and plays a significant role in the treatment. The origin of carotid endarterectomy and its use in clinical practice for the treatment and prevention of stroke almost resemble the script of a drama full of joys and sorrows. Although all the characters of this story achieved fame and honor for their claims and contribution, controversies continued regarding the credits for the first carotid endarterectomy. WHO DID THE FIRST CAROTID ENDARTERECTOMY? The first thought of surgery for carotid diseases owes credit to the neurologist Fischer who noted that carotid disease is localized and thus could conceivably be bypassed or locally excised. In 1951, he stated “It is even conceivable that someday vascular surgery will find a way to bypass the occluded portion of the artery during the period of ominous fleeting symptoms. Anastomosis of the external carotid artery or one of its branches with the internal carotid artery above the area of narrowing should be feasible.”[1] This was the basis of the first successful carotid artery reconstruction for an occlusive disease that took place in Buenos Aires in 1951. Neurosurgeon Raul Carrea et al. admitted a 41-year-old man with aphasia and right hemiparesis to the Institute of Experimental Medicine. Two weeks and two angiographic studies later, Carrea and his team partially resected the diseased portion of the internal carotid artery and re-established flow through an external carotid to distal internal carotid artery anastomosis. The patient did well postoperatively and had normal findings on neurologic examination 39 months later. Two years later, it was then attempted in carotid disease by Strully, Hurwitt, and Blankenberg on January 28, 1953, at the Montefiore Hospital in New York City. Their patient, a 52-year-old man, had a completely occluded internal carotid artery owing to arteriosclerotic stricture with superimposed thrombosis. During the operation, “a piece of the clot with adherent intima was removed… but the retrograde flow of blood could not be obtained.” The procedure was finally terminated by resection of the carotid artery, but the continuity of the carotid circulation was not restored. The authors concluded that “if the diagnosis, in this case, had been made earlier it might have been possible to remove the clot completely”.[2] The first successful carotid endarterectomy was performed by DeBakey on August 7, 1953, in a 53-year-old man with transient ischemic attacks. The diagnosis was made without the benefit of angiography on the basis that “published reports had indicated that such lesions may be well localized at the bifurcation of the common carotid artery.” The left carotid bifurcation was explored, and a “well-localized atheromatous plaque (which) produced severe stenosis at the origin of the internal, as well as the external carotid artery” and a “partially organized fresh clot partially filling the lumen of the common carotid artery” was removed. He claims himself the first one to perform Carotid endarterectomy (CEA) but reported his success story very late in 1975 in the print media. When asked why he waited for 19 years to publish his work, he replied that it was his practice to acquire sufficient clinical data before rushing into print.[3] The operation which gave great impetus to the early development of surgery for carotid occlusion was that performed by Eastcott et al. on May 19, 1954, at St Mary’s Hospital in London and reported in the November issue of the Lancet in the same year.[4] Their patient was a woman with transient ischemic attacks whose left carotid bifurcation was severely narrowed by an arteriosclerotic plaque. In the course of surgery, which was performed in moderate total-body-immersion hypothermia, the external carotid artery was divided and ligated, and the carotid bifurcation containing the occlusive atheroma was resected. The continuity of the carotid circulation was restored by direct anastomosis between the common carotid artery and the stump of the internal carotid artery. The patient fully recovered from the operation and had no further attacks of cerebral ischemia and she lived for nearly 20 years after surgery. Rob and Wheeler published an account in 1957 of 27 additional carotid procedures performed at St Mary’s Hospital in the 2 years after the epic 1954 operation.[5] On July 7, 1954, Denman et al. performed an operation that included carotid artery resection and replacement of the removed segments with lyophilized homografts. Their case is noteworthy not only because the procedure was staged bilaterally but also because, while on one side, the circulation to the internal carotid could not be restored, “the external carotid was patent and an arterial graft was inserted between it at the common carotid. Restoration of the external carotid circulation was considered desirable primarily because of its communication through the ophthalmic artery with the circle of Willis.[6]” In 1956, Doyle et al. at the Madigan Army Hospital in Tacoma, Washington, used an autogenous saphenous vein graft to restore continuity after the resection of a segment of the internal carotid for occlusion.[7] The earliest report in the literature of a successful carotid endarterectomy is that of Cooley et al. on March 4, 1956, at the Methodist Hospital in Houston. “A polyvinyl shunt with needle points at both ends was used to bypass the carotid circulation during the period of occlusion. With the external carotid temporarily occluded, the internal carotid flow was maintained by means of the shunt while the atheromatous plaque was removed from the vessel.[8]” Their report was also the first record of the application of a temporary shunt during carotid endarterectomy. In lectures and at least one subsequent publication, Cooley et al. referred to this procedure as the first successful carotid endarterectomy. The internal carotid artery “stump pressure” (the pressure measured in the internal carotid artery after proximal cross-clamping) as a hemodynamic indicator of collateral cerebral blood flow was described by Crawford et al. in 1960.[9] Indwelling temporary bypass shunting was first applied during carotid reconstruction by Michal et al. and first at the Institute for Experimental Surgery, in Prague, in 1966.[10] They used small plastic tubes inserted through the arteriotomy incision to maintain cerebral perfusion. In the early 1960s, the elective application of temporary shunting was advocated by Thompson et al.[11] Selective application of the shunt on the basis of the measurement of the stump pressure was recommended by Moore et al. in 1969[12] and on the basis of electroencephalographic monitoring by Callow in 1980.[13] In true sense, the authorship of the first carotid endarterectomy has been less clear because of a decades-long rivalry between two pioneering cardiac and vascular surgeons: Cooley et al. and DeBakey. Most of the others reconstructed the carotid artery after excising the diseased segment, rather than endarterectomy, including Felix Eastcott et al. The claim of first carotid endarterectomy continued till 2007 when finally after multiple exchanges of letters, operative notes, and meetings particularly between, Eastcott et al., DeBakey and Cooley et al., it was decided to give the due credit to DeBakey. The feud between DeBakey and Cooley et al. ended and DeBakey accepted a lifetime achievement award from the Denton A. Cooley Cardiovascular Surgical Society. He also received a Congressional Gold Medal for his towering medical achievements. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest." @default.
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• W4385447401 title "Origin of Carotid Endarterectomy: The Contribution, Claims, and Credits" @default.
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