History of Carotid Artery Surgery

Vascular Surgery

History of Carotid Artery Surgery Jesse E. Thompson, M.D. *

Concepts in etiology and management of ischemic stroke syndromes have changed during the past thirty years. With these changes has come an increasing interest in surgery of the carotid artery; so much so that carotid endarterectomy has become the most commonly performed operation in peripheral vascular surgery in the United States. My remarks will be limited largely to surgery for cerebrovascular insufficiency. The word "carotid" is derived from the Greek, meaning to stupefy or plunge into a deep sleep. Figure 1 shows the 31st metope from the south side of the Parthenon in Athens. The ancient Greeks were aware of the significance of the carotid artery as evidenced by the centaur applying left carotid compression to the neck of a Lapith warrior. Ambroise Pare in the 16th century has recounted this phenomenon as follows: "The two branches they call carotides or soparales, the sleepy arteries, because they being obstructed or any way stopt we presently fall asleep."22 According to Dandy,5 Hippocrates and Galen were aware that hemiplegia resulted from a lesion in the opposite side of the brain. The first operations on the carotid artery were ligation procedures for trauma. Hebenstreit of Germany in 1793 did the first ligation for injury, although John Abernathy in England credited with the first deliberate ligation following control of hemorrhage by direct compression. Abernathy's patient had a torn left carotid artery from a gorging injury by the horn of a cow in 1798,14 Sir Astley Cooper was the first to ligate the carotid artery for a cervical aneurysm in 1805. The patient died of sepsis but in 1808 Cooper repeated the operation, this time successfully. The patient lived until 1821. 4 In 1809, Benjamin Travers first ligated the common carotid artery for a carotidcavernous fistula, and in 1885 Victor Horsley first ligated the cervical carotid artery for non-fistulous intracranial aneurysm. By 1868 Pilz had

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*Chief of Surgery, Baylor University Medical Center; Clinical Professor of Surgery, University of Texas Southwestern Medical School, Dallas, Texas This material originally appeared as a chapter in Greenhalgh, R. M., and Rose, F. C. (eds.): Progress in Stroke Research. Volume 2. London, Pitman Press, 1983. It is reprinted here by permission of R. M. Greenhalgh and Pitman Publishing Ltd.

Surgical Clinics of North America-Vol. 66, No.2, April 1986

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Figure 1. The 31st metope from the Parthenon, showing a centaur applying left carotid compression to the neck of a Lapith warrior. (Photo taken by the author in the British Museum.)

been able to collect 600 recorded cases of carotid ligation for hemorrhage or cervical aneurysm with a mortality of 43%.14 Until recently the prevailing notion held by most physicians was that strokes were caused by intracranial vascular disease. William Osler, in his Textbook of Medicine in the 7th edition of 1909 (the last edition which he himself wrote), attributed apoplectic stroke largely to cerebral hemorrhage. No mention is made of extracranial occlusive disease. In the section dealing with cerebral softening, where embolism and thrombosis are mentioned, emphasis is upon blockage of intracranial vessels. This is somewhat curious in view of the fact that Gull in 1855, Savoy in 1856,25 Broadbent in 1871,1 and Penzoldt in 1881 23 had all described occlusive lesions in the extracranial segments of the main arteries supplying the brain, and noted their association with symptoms of cerebral ischemia. In 1905 Chiari described the ulcerating plaque. He stated that emboli could break away from carotidsinus-area plaques and cause strokes. 3 A most significant article was that of Ramsay Hunt of New York City in 1914, who called attention to the importance of extracranial occlusions in cerebrovascular disease. He recognized that both partial and complete occlusions of the innominate and carotid arteries could be responsible for cerebral syndromes of vascular origin. He even used the term "cerebral intermittent claudication. "15 The next significant contribution was the report of Egas Moniz of Portugal, who in 1927 first described the technique of cerebral arteriography.19 The first report of carotid thrombosis demonstrated by arteriography was that of Sjoqvist in 1936. 26 The following year (1937) Moniz, Lima, and de Lacerda20 reported four patients with occlusion of the cervical

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portion of the internal carotid artery diagnosed by arteriography. By 1951, Johnson and Walker16 were able to collect from the literature 101 cases of carotid thrombosis all diagnosed by this technique. In the same year {1951} and again in 1954, Dr. Miller Fisher published two important papers. 11. 12 Fisher re-emphasized the relationship between disease of the carotid artery in the neck and cerebrovascular insufficiency. He defined the basic nature of the lesion as atherosclerosis, and noted partial and complete occlusions. He described several syndromes. He also observed that with severe stenosis at the carotid bifurcation, the distal vessels could be entirely free of disease. He realized the importance of these observations and stated: "It is even conceivable that some day 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." Fisher's prophecy of surgical reconstruction of the carotid artery in the neck as therapy for occlusive disease was soon fulfilled. The first successful surgical reconstruction of a carotid artery was performed by Carrea, Molins, and Murphy in Buenos Aires on October 20, 1951, after reading Fisher's article. It was reported in 1955. 2 The patient had a stroke and stenosis of the left internal carotid in the neck. They performed an anastomosis between the external carotid and the distal internal carotid arteries after partial resection of the stenosed area. The patient made an uneventful recovery. In 1951, E. J. Wylie 29 introduced into the United States the procedure of thromboendarterectomy for the removal of atherosclerotic plaques in the aortoiliac segment, but it was not used on the carotid artery. On January 28, 1953, Strully, Hurwitt, and Blankenberg27 first attempted thromboendartererctomy of the cervical internal carotid artery but were unable to obtain retrograde flow. They suggested that endarterectomy should be feasible in such cases when the distal vasculature was patent. The first successful carotid endarteterctomy was performed by Dr. Michael DeBakey on August 7, 1953. 6 The patient had a frank stroke and total occlusion of the left carotid artery. Thromboendarterectomy was carried out with good retrograde flow from the internal carotid artery. An arteriogram performed postoperatively on the operating table showed the internal carotid artery to be patent in both its extracranial and intracranial portions. This patient lived for 19 years without having further strokes and died in 1972 of emphysema. The operation which gave the greatest impetus to the development of surgery for carotid occlusive disease was that of Eastcott, Pickering, and Rob performed at St. Mary's Hospital in London on May 19, 1954 and reported in November 1954. 8 This case was a woman suffering recurrent transient ischemic attacks with stenosis of the left carotid bifurcation. She underwent resection of the bifurcation with restoration of blood flow by end-to-end anastomosis between the common carotid and distal internal carotid arteries. Hypothermia was used as a protective mechanism during carotid clamping. The patient was completely relieved of her symptoms and was alive and well at age 86.

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With increasing experience, the various procedures listed above were abandoned, with the exception of endarterectomy, which has become the standard operation. Table 1 lists in chronological order the early carotid procedures performed for the treatment of extracranial cerebrovascular disease. A fascinating aspect of this subject is the study of famous people who have had strokes. Louis Pasteur had a series of transient ischemic attacks, involving largely his speech area, before he finally died. Several intriguing reports have speculated on the fate of nations as affected by strokes occurring in their leaders. One world-famous figure who suffered from and eventually died of cerebrovascular deterioration was Marshal Paul von Hindenburg. Certainly his action in authorizing Hitler to form a cabinet in 1933 was a decision that altered the course of history. Whether or not anyone could have stopped Hitler at this time is subject to speculation, but in his senile and demented state, Hindenburg refused or was unable to involve himself in trouble or controversy. His mental status was so deteriorated that his Secretary of State had to write word for word the questions put to any callers. In Russia, V. I. Lenin also suffered from cerebrovascular ischemia. He experienced several transient ischemic episodes, finally had a complete right hemiplegia and died of his third stroke at the early age of 54. Prior to his illness, Lenin had been responsible for elevating Joseph Stalin to several important positions in the government, but in the last years of his life he had grave doubts about Stalin and wanted Leon Trotsky to assume the more important posts. Had Lenin lived to make Trotsky his heir apparent instead of Stalin, who knows what the course of modern history might have been. 9 , 13 In the United States, no less than ten American Presidents have suffered from or died of cerebrovascular insufficiency, 10. 24 A very dramatic example is the case of Woodrow Wilson, who had multiple transient ischemic attacks which finally resulted in near-total incapacitation. It has been stated by those who have studied the President's illness in detail that Wilson's cerebrovascular disease significantly contributed to the defeat of the United States' support for the League of Nations. The illness of Franklin D. Roosevelt is well known. In 1943 he reportedly had severe symptoms of cerebrovascular insufficiency. How this disease affected the Yalta agreements of 1945 and the subsequent Cold War is a matter of speculation. His sudden death at the Georgia Warm Springs was said to be due to a massive cerebral hemorrhage. The most recent cerebrovascular episodes in a Chief Executive were experienced by President Dwight D. Eisenhower. His "little strokes" were said to be due to intracranial disease. His death came ultimately from complications of heart disease rather than stroke. By contrast, the late Mayor Richard Daley of Chicago, after having transient cerebral ischemia, was subjected to bilateral carotid endarterectomies, with complete success and restoration of brain function to normal. Most patients with generalized atherosclerosis die from coronary artery disease and not strokes. For these patients morbidity may be more important than mortality. It is for this reason that emphasis is placed on

Partial

February 24, 1956

August 9, 1956

Partial

February 6, 1956

Lyons & Galbraith l'

Partial Total

December 1955

Murphey & Miller'l

Subclavian-carotid nylon bypass graft

Thromboendarterectomy

Thromboendarterectomy

Resection with saphenous vein graft

Yes

Lin, Javid, & Doyle17

Yes

Resection with homograft

Partial Total

2. June 1954

July 14, 1954

Denman, Ehni, & Duty7

End-to-end anastomosis common carotid to internal carotid Thromboendarterectomy

Partial

1. May 19, 1954

Eastcott, Pickering, & Rob'

Yes

Yes

Yes

Yes

Yes

Yes

Thromboendarterectomy

Total

August 7, 1953

DeBakey"

No

Thromboendarterectomy followed by ligation and resection

Total

January 28, 1953

Yes

RESTORATION OF FLOW

End-to-end anastomosis external carotid to internal carotid

PROCEDURE

Strully, Hurwitt, & Blankenberg27

Partial

DEGREE OF STENOSIS

October 20, 1951

DATE OF OPERATION

Carrea, Molins, & Murphy'

AUTHOR

Table 1. The First Carotid Reconstructions for Cerebrovascular Insufficiency, Listed in Chronological Order

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the role of carotid endarterectomy for stroke prevention.28 The quality of survival is as important as survival itself.

REFERENCES 1. Broadbent, W. H.: Absence of pulsation in both radial arteries, vessels being full of blood. Trans. Clin. Soc., 8:165-168, 1875. 2. Carrea, R. M. E., Molins, M., and Murphy, G.: Surgical treatment of spontaneous thrombosis of the internal carotid artery in the neck, carotid-carotideal anastomosis; report ofa case. Acta Neurol Lationam., 1:71-78,1955. 3. Chiari, H.: Uber des verhalten des teilungswinkels der carotis communis bei der endarteriitis chronica deformans. Verh. Dtsch. Ges. Pathol., 9:326-330, 1905. 4. Cooper, A.: Account of the first successful operation performed on the common carotid artery for aneurysm in the year 1808 with the postmortem examination in the year 1821. Guy Hosp. Rep., 1:53, 1836. 5. Dandy, W. E.: Surgery of the Brain. Hagerstown, MD; W. F. Prior Company, 1945, p. 671. 6. DeBakey, M. E.: Successful carotid endarterectomy for cerebrovascular insufficiency. Nineteen-year followup. J.A.M.A., 233:1083-1085, 1975. 7. Denman, F. R., Ehni, G., and Duty, W. S.: Insidious thrombotic occlusion of cervical carotid arteries, treated by arterial graft; case report. Surgery, 38:569-577, 1955. 8. Eastcott, H. H. G., Pickering, G. W., and Rob, C. G.: Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet, 2:994-996, 1954. 9. Fishbein, M.: Strokes: 1. Some literary descriptions. Postgrad. Med., 37:194-198, 1965. 10. Fishbein, M.: Strokes: 2. American presidents who had strokes. Postgrad. Med., 37:200208, 1965. 11. Fisher, M.: Occlusion of the internal carotid artery. A.M.A. Arch. Neurol. Psychiatr., 65:346-377, 1951. 12. Fisher, M.: Occlusion of the carotid arteries, further experiences. A. M.A. Arch. Neurol. Psychiatr., 72:187-204, 1954. 13. Friedlander, W. J.: About 3 old men: An inquiry into how cerebral arteriosclerosis has altered world politics. A neurologist's view. (Woodrow Wilson, Paul von Hindenburg, and Nikolai Lenin) Stroke, 3:467-473, 1972. 14. Hamby, W. B.: Intracranial aneurysms. Springfield, Illinois, Charles C Thomas, Publisher, 1952, p. 564. 15. Hunt, J. R.: The role of the carotid arteries, in the causation of vascular lesions of the brain, with remarks on certain special features of the symptomatology. Am. J. Med. Sci., 147:704-713, 1914. 16. Johnson, H. C., and Walker, A. E.: Angiographic diagnosis of spontaneous thrombosis of the internal and common carotid arteries. J. Neurosurg., 8:631-659, 1951. 17. Lin, P. M., Javid, H., and Doyle, E. J.: Partial internal carotid artery occlusion treated by primary resection and vein graft; report of a case. J. Neurosurg., 13:650-655, 1956. 18. Lyons, C., and Galbraith, G.: Surgical treatment of atherosclerotic occlusion of the internal carotid artery. Ann. Surg., 146:487-498, 1957. 19. Moniz, E.: L' encephalographie arterielle son importance dans la localisation des tumeurs cerebrales. Rev. Neurol., 2:72-90, 1927. 20. Moniz, E., Lima, A., and de Lacerda, R.: Hemiplegies par thrombose de la carotide interne. Presse Med., 45:977-980, 1937. 21. Murphey, F., and Miller, J. H.: Carotid insufficiency--diagnosis and treatment. J. Neurosurg., 23:156, 1965. 22. Pare, A.: The workes of that. famous chirugion Ambrose Parey: Translated out of Latine and compared with the French, by Thomas Johnson. From the first English edition, London, 1634. New York, Milford House Inc., 1968. 23. Penzoldt, F.: Uber Thrombose (autochtone oder embolische) der Carotis. Dtsch. Arch. Klin. Med., 28:80-93, 1881. 24. Robertson, C. W.: Some observations on presidential illnesses. Boston. Med. Q., 8:3343, 76-86, 1957.

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25. Savory, W. S.: Case of a young woman in whom the main arteries of both upper extremities and of the left side of the neck were throughout completely obliterated. Med. Chir. Trans., 39:205-219, 1856. 26. Sjoqvist, 0.: Uber intrakranielle aneurysmen der arteria carotis und deren beziehung zur ophthalmoplegischen migraine. Nervenarzt, 9:233-241, 1936. 27. Strully, K. J., Hurwitt, E. S., and Blankenberg, H. W.: Thromboendarterectomy for thrombosis of the internal carotid artery in the neck. J. Neurosurg., 10:474-482, 1953. 28. Thompson, J. E., Patman, R. D., and Talkington, C. M.: Carotid surgery for cerebrovascular insufficiency. Curro Probl. Surg., 15:1-68, 1978. 29. Wylie, E. J., Kerr, E., and Davies 0.: Experimental and clinical experiences with use of fascia lata applied as a graft about major arteries after thrombo-end-arterectomy and aneurysmorrhaphy. Surg. Gynecol. Obstet., 93:257-272, 1951. Suite 505 3600 Gaston Avenue Dallas, Texas 75246