Introduction

Ischaemic stroke represents a major health problem and an important cause of morbidity and mortality in several western countries [12]. Mortality from stroke ranges between 10% and 30% [61] and its survivors remain at a high annual risk of recurrent ischaemic events and mortality both from myocardial infarct and repeated stroke [76]. Atherosclerosis from supra-aortic vessels, especially from the common carotid bifurcation, is the major single aetiology of ischaemic stroke in developed countries as opposed to intracranial occlusive disease and cardioem-bolization.

The association between internal carotid artery occlusion and severe ischaemic stroke was first credited to Savory [82], obtained from the autopsy of a woman

Fig. 2.2.1 First cerebral arteriogram performed by Egas Moniz

with a history of monocular blindness and contralateral hemiplegia and occlusion of the left carotid artery associated with bilateral subclavian occlusions. Subsequent descriptions were reported [33, 87] and in 1914 Ramsey Hunt published an important paper, which correlated the presence of diminished cervical carotid pulsations with intermittent neurological symptoms and drew attention to the need for "careful examination of the neck vessels" in such patients [49]. With the introduction of angiography, Egas Moniz [62] provided the first demonstration in vivo of occlusion of the internal carotid and stroke (Fig. 2.2.1) and also described the correlation between transient strokes and carotid bifurcation stenosis [63]. His observations were confirmed in subsequent studies using angiography [18, 51], although the established ar-teriographic technique routinely practised often failed to visualize the extracranial vessels [13, 42].

Embolization from carotid bifurcation lesions was suggested by Miller Fisher [35, 36] to be the pathogenic mechanism of ischaemic brain symptoms associated with extracranial carotid disease and led to the possibility of preventing stroke by eventual surgical correction of the diseased arteries.

The most frequent lesion is stenosis at the common carotid bifurcation and origin of the internal carotid artery; however, atheroma of the aortic arch protruding into the ostia of the innominate and left common carotid arteries may cause severe flow-reducing stenosis and act as a source of cerebral embolization.

Reconstructive surgery for chronic arterial occlusive disease started in Lisbon in 1947, with the introduction of endarterectomy by Joâo Cid dos Santos [19], a technique conceived to be used for the obliteration of limb occlusive disease ideally in short segmental obstructions.

The first carotid intervention was performed in Buenos Aires in 1951 by Carrea, Mollins and Murphy [17], consisting of resection of the proximal internal carotid segment and re-establishment of flow by anastomosing the external carotid to the distal internal carotid.

DeBakey [24] described the first carotid disoblit-eration in 1953, in a patient with a complete occlusion, which succeeded in restoring flow. Eastcott, in 1954 [27], performed the first successful elective carotid operation on a patient with internal carotid stenosis and multiple transient ischaemic attacks (TIAs) in order to prevent stroke, resulting in the patient remaining asymptomatic for more than 30 years.

Successful endarterectomy of the innominate artery with a 2-year follow-up was described in 1956 [21], followed by several reports of correction of proximal and/or ostial lesions at the aortic arch through by-pass procedures.

The development of arterial catheterization for arteriography [83] and its widespread use provided easier diagnosis of extracranial disease as a major cause of brain ischaemia and set the stage for the generalized use of carotid surgery, aiming to restore arterial perfusion to the brain and avoid distal atheroembolization to prevent severe ischaemic syndromes.

The 80 multicentre cooperative studies, in both Europe and the USA [29, 70], provided level 1 evidence for the benefit of carotid endarterectomy (CEA) in patients with transient neurological symptoms (TIAs) and reversible stroke; for carotid stenosis it was greater than 70%, contributing to a more appropriate and rational use of CEA.

Reduction of surgical risk and the need for specific accreditation of surgeons and institutions for the treatment of extracranial carotid disease were recognized [64] in order to ensure greater benefit from CEA. The selection of patients for surgical treatment, and the need to reduce overall morbidity and mortality in patient management, both for symptomatic and asymptomatic patients, must be considered; the impact of the new endovascular surgical procedures requires careful re-evaluation of established concepts, to offer the best available treatment for each patient, and to provide guidelines for institutions and individual practitioners dealing with extracranial carotid disease.

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