Techniques in Carotid Artery Surgery
Techniques in Carotid Artery Surgery
The major objective in carotid endarterectomy is to achieve safe and complete removal of intimal plaque and provide lasting, nonstenotic closure. Controversy exists as to which technical variation best achieves this. In this paper, the authors review the operative nuances and outcomes with conventional and eversion endarterectomy, with a focus on the latter. The views expressed reflect specific neurosurgical and vascular perspectives in the context of a multi-disciplinary stroke unit, where carotid stenosis is managed with all available open and endovascular means. The neurosurgical approach was almost entirely conventional endarterectomy with primary repair, while the vascular surgeons used the eversion method with few exceptions.
The establishment of extracranial CA surgery as an effective treatment option began with several operations and publications in the early 1950s. Eastcott et al. published their account of carotid surgery for stroke prevention in London. These authors anastomosed the distal ICA to the proximal CCA with good results. At about this time, DeBakey independently performed his technique of carotid arteriotomy and repair. The success of this operation was documented many years later. Adding further validity to carotid surgery was a third publication by 3 neurosurgeons from Argentina who had similarly performed a direct end-to-end anastomosis, but had joined the distal ICA to the proximal ECA. They had read Fisher's report concerning locally treatable carotid disease. Over the next few decades, there were many failures as the techniques were widely and loosely applied. Ultimately, due to persisting complications and deaths associated with the technique, the first randomized controlled trial to define the place that CE had in clinical practice was formulated. Following this, the role of conventional CE was established for symptomatic high-grade stenosis, and became widely accepted and practiced. Although highly effective, some limitations of the technique were noted. Recurrent stenosis was seen, which at times required repeated treatment. Patching of the arteriotomy effectively solved this problem, but had its own unique set of drawbacks.
The concept of everting the diseased vessel rather than subjecting it to full longitudinal exposure was first conceived by DeBakey et al. in 1959. This technique involved everting the CCA from its proximal to its distal end. The procedure was technically difficult and ultimately abandoned. It was not until the late 1980s that Kazprzak and Raithel reexplored the eversion method, this time using the proximal ICA as the transection and eversion point. This procedure was technically much easier and was achieved with good results. The method was subsequently exported to Europe, and more recently returned to the US.
The major objective in carotid endarterectomy is to achieve safe and complete removal of intimal plaque and provide lasting, nonstenotic closure. Controversy exists as to which technical variation best achieves this. In this paper, the authors review the operative nuances and outcomes with conventional and eversion endarterectomy, with a focus on the latter. The views expressed reflect specific neurosurgical and vascular perspectives in the context of a multi-disciplinary stroke unit, where carotid stenosis is managed with all available open and endovascular means. The neurosurgical approach was almost entirely conventional endarterectomy with primary repair, while the vascular surgeons used the eversion method with few exceptions.
The establishment of extracranial CA surgery as an effective treatment option began with several operations and publications in the early 1950s. Eastcott et al. published their account of carotid surgery for stroke prevention in London. These authors anastomosed the distal ICA to the proximal CCA with good results. At about this time, DeBakey independently performed his technique of carotid arteriotomy and repair. The success of this operation was documented many years later. Adding further validity to carotid surgery was a third publication by 3 neurosurgeons from Argentina who had similarly performed a direct end-to-end anastomosis, but had joined the distal ICA to the proximal ECA. They had read Fisher's report concerning locally treatable carotid disease. Over the next few decades, there were many failures as the techniques were widely and loosely applied. Ultimately, due to persisting complications and deaths associated with the technique, the first randomized controlled trial to define the place that CE had in clinical practice was formulated. Following this, the role of conventional CE was established for symptomatic high-grade stenosis, and became widely accepted and practiced. Although highly effective, some limitations of the technique were noted. Recurrent stenosis was seen, which at times required repeated treatment. Patching of the arteriotomy effectively solved this problem, but had its own unique set of drawbacks.
The concept of everting the diseased vessel rather than subjecting it to full longitudinal exposure was first conceived by DeBakey et al. in 1959. This technique involved everting the CCA from its proximal to its distal end. The procedure was technically difficult and ultimately abandoned. It was not until the late 1980s that Kazprzak and Raithel reexplored the eversion method, this time using the proximal ICA as the transection and eversion point. This procedure was technically much easier and was achieved with good results. The method was subsequently exported to Europe, and more recently returned to the US.
