Los inicios de la cirugía carotídea actual / The beginnings of current carotid surgery

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A comparative analysis of transcranial Doppler parameters acquired during carotid stenting and semi-eversion carotid endarterectomy / Uma análise comparativa de parâmetros do Doppler transcraniano adquiridos durante a colocação de stent carotídeo e endarterectomia carotídea por semieversão

Abstract Background Carotid endarterectomy (CEA) and carotid artery stenting (CAS) have both been proposed for treatment of critical atherosclerotic stenosis located at the carotid bifurcation. Monitoring of hyperintense microembolic signals (MES) by transcranial Doppler ultrasound (TCD) is considered a method of quality control, both in CEA and in CAS. Objective To analyze temporal distribution of MES throughout both semi-eversion CEA and CAS procedures and to evaluate changes in mean velocity of blood flow through the ipsilateral middle cerebral artery (MCA). Method Thirty-three procedures (17 CEA and 16 CAS) were prospectively monitored using TCD and the data were related to three different stages of surgery (pre-cerebral protection, during cerebral protection and post-cerebral protection). Chi-square, Mann-Whitney, ANOVA and contrast tests were used for statistical analysis. Results The MES were uniformly distributed in the CEA group, but not in the CAS group (p = 0.208). The number of MES was higher in the CAS group in all stages. The average flow in the MCA was similarly lower in both groups during the protection stage. Conclusion CEA provoked a lower incidence of MES per procedure than CAS in all stages. The behavior of the averages of the mean of blood flow through the MCA was similar in both groups.

Resumo Contexto A endarterectomia carotídea (EC) e a angioplastia carotídea (AC) são propostas para o tratamento de estenoses críticas localizadas na bifurcação carotídea. O monitoramento dos sinais de microembolias (SMs) pela ultrassonografia Doppler transcraniana (UDT) é considerado um método de controle de qualidade para ambas as técnicas. Objetivos Analisar a distribuição temporal dos SMs ao longo de diferentes estágios da EC por semieversão e da AC, e avaliar o significado das mudanças nas médias das velocidades médias do fluxo na artéria cerebral média ipsilateral (ACM). Método Trinta e três procedimentos (17 ECs e 16 ACs) foram monitorados com UDT, e os dados foram coletados prospectivamente para diferenciar os diferentes estágios cirúrgicos (pré, durante e pós-proteção cerebral). Para análise estatística foram usados os testes qui-quadrado, Mann-Whitney, análise de variância (ANOVA) e contraste. Resultados Em ambos os grupos, os SMs foram distribuídos uniformemente (p = 0,208). Em todos os tempos, o número de SMs foi superior no grupo AC. A média das velocidades médias do fluxo na ACM foi menor durante o tempo de proteção em ambos os grupos. Conclusão A EC teve uma menor incidência de SMs que a AC em todos os estágios. A média das velocidades médias na ACM teve comportamento similar em ambos os grupos.

History of carotid surgery: from ancient greeks to the modern era.

A relationship between decreased carotid arterial flow and apoplectic manifestations was already suspected by the ancient Greeks. Early attempts at carotid surgery, however, were limited to emergency arterial ligation in patients with neck trauma. Attempts to suture arterial stumps together to restore blood flow paved the way for Carrel's revolutionary idea of reconstructing the resected or injured arterial segment with an interposition vein graft. DeBakey and Eastcott were the first to perform carotid endarterectomy in North America and the United Kingdom, respectively. In 1959, DeBakey proposed a cooperative study to assess the effectiveness of carotid endarterectomy in the treatment and prevention of ischemic cerebrovascular disease. The study was officially designated the Joint Study of Extracranial Arterial Occlusion and represented the first trial in the United States in which large numbers of patients were randomly allocated to surgical or nonsurgical therapy.

Champ Lyons, Holt McDowell, and the evolution of vascular surgery at the University of Alabama at Birmingham: a personal perspective.

The history of medical centers, hospitals, clinics, and their evolution are important contributions and resources to medical history. Likewise, evolution of specialties within these healthcare centers frequently parallels their growth and development. This contribution depicts the evolution of a specialty, vascular surgery, within a major medical center, the University of Alabama at Birmingham. It recounts the major participants involved and their contributions and pioneering efforts, some of which have received little attention or were overshadowed by other events. Perspectives from participants--a patient and a trainee--provide insight into this process that has supported the growth and development of a major world-class medical center.

In memoriam of Michael Ellis DeBakey. Alternative reconstructions of carotid bifurcation for atherosclerosis: the history and the latest advances.

The paper overviews the history of reconstructive surgery for atherosclerotic lesions of carotid bifurcation, as well as indications for various revascularization procedures for internal carotid artery, based on the experience of the Vascular Surgery Department, A. V. Vishnevsky Institute of Surgery, and in particular, on 205 interventions that were carried out in 2006.

Carotid stenosis--when is revascularization appropriate?

Approximately 15% of ischemic strokes are caused by extracranial carotid stenoses. Revascularization of a symptomatic stenosis is very efficacious in carefully selected patients. This review outlines criteria which help to identify those who will benefit most from carotid endarterectomy (CEA) for symptomatic stenosis. Asymptomatic carotid stenosis is a common condition in the general population over 50 years, but nonetheless associated with a low risk of ischemic stroke. Consequently, the therapeutic yield of CEA is much lower in asymptomatic stenosis and women seem not to benefit at all. In the future, specific morphological MRI features may help to identify stenoses prone to become symptomatic. In addition to their significance for stroke, it has been demonstrated that atherosclerotic lesions can be regarded as an indicator of cardiovascular morbidity which may help to identify high-risk patients for cardiovascular events.

[Historical overview of carotid artery surgical treatment].

Since antiquity, there has been a mystery about the cerebral circulation function. Scientific methods were introduced in research at the end of the nineteenth century. During the first half of the last century, the problem of occlusive carotid disease was defined and the basis for the surgical treatment of carotid disease was established. The first contemporary reconstructive surgical procedures were performed in the middle of the last century, the time when successful surgical treatment of carotid disease began. Today, carotid endarterectomy is one the most frequently performed vascular surgical procedures of all, followed by very low morbidity and mortality rates.

Perspective: carotid stenting and the history of disruptive technology in vascular surgery.

This article defines disruptive technology and discusses such technologies in Vascular Surgery. It considers the question: Is carotid artery stenting (CAS) a disruptive technology? Although CAS will impact positively on the treatment of carotid bifurcation disease, it will probably never displace carotid endarterectomy in the majority of patients. The precise role of CAS remains to be determined.

From Hippocrates to Palmaz-Schatz, the history of carotid surgery.

The extracranial carotid artery is the most common site for peripheral vascular procedures. Although the association of carotid disease and neurologic dysfunction was understood by the ancient Greeks, over 1700 years would pass before the relevant anatomy was described. In the 16th and 17th centuries, attempts at treatment of carotid injury and aneurysm by ligation were met with extremely high rates of stroke and death. It is not until the mid 20th century, with the introduction of carotid angiography and improved vascular surgical techniques, that the era of reconstructive carotid surgery begins. We present a synopsis of the history of carotid surgery from ancient times to present day.

The evolution of extracranial carotid artery surgery as seen by one surgeon over the past 40 years.

Carotid endarterectomy is one of the most common vascular and neurosurgical operations. Controversies regarding its indications and safety have required several decades before general resolution, while its methodology is still debated. The first operations are described with particular emphasis on the epic successful procedure in 1954 by Eastcott and Rob. Early procedures were on patients with frank strokes with poor results. The development of carotid endarterectomy was slow because neurologists were unsure of its effectiveness and safety as the mortality and stroke results recorded by untrained surgeons were unacceptable. It was not until some 35 years after its introduction that randomised controlled trials, both in North America and Europe, defined its indications and demonstrated its benefits for both symptomatic and asymptomatic carotid stenosis. Clamping of the carotid vessels, required during endarterectomy, may result in various degrees of cerebral ischaemia. Methods to determine which patients need shunting are compared. The author has employed local neck block anesthesia since 1972, which is the only method that provides constant neurological assessment for selective shunting during carotid cross clamping. Evidence is presented showing that local anaesthesia also reduces complications of general anaesthesia, especially myocardial infarction. The technique of neck block, conventional endarterectomy and two varieties of eversion endarterectomy for carotid disease are described. Each of these techniques of endarterectomy is advantageous in certain circumstances, suggesting that vascular surgeons should ideally be proficient in each. Likewise, the management of early stroke after operation, stenotic or occluded external carotid the presence of retinal Hollenhorst plaques, and the totally occluded internal carotid, is presented. Finally, observations on some famous figures who suffered from cerebrovascular complications secondary to carotid disease and what effect it may have had on world history is discussed.