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. 2023 Apr 20;63(7):283–294. doi: 10.2176/jns-nmc.2022-0362

History of Carotid Artery Reconstruction around the World and in Japan

Masaaki UNO 1
PMCID: PMC10406461  PMID: 37081650

Abstract

Since ancient times, physicians have been aware of correlations between the carotid artery and consciousness; however, carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke. In 1658, Wepfer described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology. In 1951, Fisher reported details of the symptoms and pathological findings and emphasized that cervical atheromatous lesions induced cerebral infarction with various symptoms. The beginning of carotid artery surgery was ligation of the carotid artery for neck or head injury, but surgeons were aware that this operation induced cerebral symptoms due to lack of blood supply. Carotid endarterectomy (CEA) was first reported by Eastcott et al. in 1954, and in Japan, Kimoto performed a successful CEA in 1962. In 1979, percutaneous transluminal angioplasty (PTA) was performed for patients with fibromuscular dysplasia, and then, carotid artery stenting (CAS) was first performed in 1989 by Mathias. In Japan, Kuwana et al. were the first to perform carotid PTA, in 1981, whereas Yamashita et al. performed the first CAS in 1997. Yoshimura et al. proposed staged carotid stenting to prevent hyperperfusion syndrome. Some issues in carotid reconstruction are still debated today, which include conventional (standard) CEA versus the eversion technique, CEA versus CAS versus medical therapy, and medical economic problems. In the future, we must continue to develop more effective, safer, and less expensive therapeutic methods to prevent carotid stroke, carrying on the efforts of the ancient peoples who pioneered this research.

Keywords: history, carotid endarterectomy, carotid ligation, surgical treatment

Introduction

Carotid artery reconstruction is one of the most common operations in the neurosurgical field, and carotid endarterectomy (CEA) is the basic operation for carotid reconstruction. In 2015, over 80,000 CEAs were performed in the United States, and over 4,000 were performed in Japan.1,2) Since ancient times, physicians have been aware of correlations between carotid artery and consciousness, but carotid stenosis was only recently identified as the cause of atherothrombotic ischemic stroke.3) Vascular reconstruction for carotid lesions is also a relatively new operation, both worldwide and in Japan. An understanding of the relationship between carotid artery lesions and cerebral infarction and an appreciation of the history of carotid reconstruction are valuable for neurosurgeons. In this report, I review historical papers on carotid stroke and carotid reconstruction globally and in Japan.

Relationships between Carotid Artery Lesions and Cerebral Infarction

The term carotid is derived from the Ancient Greek verb “karos” (κάρος), which means “to stupefy”.4,5) Hippocrates first stated that the sudden-onset of paralysis and aphasia were signs of apoplexy.4,6) Rufus suggested that the word “karos” was used because superficial compression of this artery induced stupefaction.3,5,6) The metope of the Parthenon in Athens portrays a centaur gripping the neck and compressing the carotid artery of a Lapith during the legendary Centauromachy.3,4,7) Galen ascribed the loss of consciousness to compression not of the carotid arteries per se but of “sensitive nerves” located on the vessels and noticed that arterial occlusion was the cause of apoplexy.4,5)

Wepfer, a Swiss pathologist, described the first suggestion of a link between symptoms of cerebral arterial insufficiency and carotid pathology in 1658.4,5,8-10) He postulated that interruption of the blood supply to the brain was the cause of apoplexy.4,5,8-10) In 1664, the clinical importance of the cerebral arterial circle was confirmed by Willis, who reported the cases of two patients with right internal carotid artery (ICA) occlusion that remained asymptomatic due to the presence of collateral supply.4,5,9,11)

In 1754, the hypothesis of emboli arising from the artery was put forward by van Swieten.9,12) In 1765, Petit discovered an aneurysm of the carotid artery bifurcation in a patient and noted total occlusion of the common carotid artery (CCA) 7 years later on autopsy, but the patient had experienced no stroke.4,9,13) In 1856, Virchow published his seminal work, in which he coined the terms “thrombosis,” “ischemia,” and “embolus,” as well as reviving the expression “arteriosclerosis”.14) He also described embolus within the carotid artery as being associated with ipsilateral monocular blindness.4,5,14)

In 1881, Penzoldt published the case of a patient who exhibited sudden-onset blindness of the right eye with delayed contralateral hemiplegia.4,5,15) The autopsy revealed a thrombotically obstructed right CCA.4,5,15) Hultquist reported thromboembolism of the carotid system in approximately 3% of routine autopsies.16,17) In 1905, Chiari developed the thromboembolic hypothesis based on work on ulcerated plaques and surface thrombus.6,16-19) His findings were the first to show the atherosclerotic carotid bifurcation as a prominent source of stroke-inducing cerebral emboli.6,16,17,19) Moreover, in 1914, an examination of autopsy cases by Hunt identified that both occlusion and stenosis of the carotid artery could induce cerebral syndromes.4,5,20) They proposed examining the carotid vessels at autopsy as a cause of stroke,17,20) even though this advice has long been disregarded.17) In 1937, Moniz and colleagues showed cases with occlusion of the cervical portion of the ICA on angiography, along with the clinical details of those cases.4,17,21) In 1951, Jonson and Walker reported 107 cases of carotid thrombosis diagnosed angiographically and emphasized that carotid occlusion was far more common than generally recognized.4,22)

Moreover, in 1951, Fisher described eight cases with occlusive lesions of the carotid artery and reported detailed symptoms and pathological findings. He emphasized that cervical atheromatous lesions induced cerebral infarction with various transient or permanent symptoms.4,5,17,23,24) This landmark article by Fisher brought major attention to the carotid arteries as the pathological substrate for stroke, and the idea of surgical reconstruction of the carotid arteries came into being.4)

After the 1950s, several CEAs had been performed and elucidation of the etiologies of postoperative complications continued to advance. In 1963, Bruetman et al. reported six cases of postoperative intracerebral hemorrhage. Patients consistently showed clinical improvements after CEA; then, hemorrhages suddenly occurred.25) Bland et al. reported intracerebral hemorrhage soon after CEA in patients with postoperative hypertension but did not suggest any etiology for this hemorrhagic complication.26) Sundt et al. in 1981 and Bernstein et al. in 1984 reported hyperperfusion syndrome after CEA.27,28) Both reports mentioned that this phenomenon resembled breakthrough perfusion such as postoperative arteriovenous malformation in patients who had severe postoperative hypertension.27,28) Subsequent to these reports, neurologists and neurosurgeons investigated the mechanisms and frequency of hyperperfusion syndrome.29-31) A great deal of hard work was put into preventing hyperperfusion syndrome, which was a severe postoperative complication.29,32) Table 1 summarizes the historical evolution of ideas on the relationship between carotid artery lesions and cerebral infarction.

Table 1.

Relationships between CA lesion and cerebral infarction, and history of CA reconstruction worldwide

Year Authors Relationships between CA lesion and cerebral infarction History of carotid artery reconstruction worldwide
BC 460-370 Hippocrates4,5) Stated that sudden onset of paralysis and aphasia were signs of apoplexy
100 Rufus3,5,6) Suggested that the word “karos” was used because superficial compression of CAs induced stupefaction
131-201 Galen4,5) Noticed that arterial occlusion was the cause of apoplexy
1552 Pare9,33) Performed carotid ligation to control bleeding from an epee wound
1658 Wepfer4,5,8-10) Postulated that interruption of blood supply to the brain was the cause of apoplexy
1664 Willis4,5,9,11) Reported two patients with asymptomatic right ICA occlusion and with collateral supply
1754 Swieten9,12) Reported the hypothesis of emboli arising from the artery
1765 Petit4,9,13) Found asymptomatic complete occlusion of CA by thrombus
1775 Warner9,35) Ligated the CA when removing a massive lipoma
1793 Hebenstreit4,5,7,9,36) Used carotid ligation to control bleeding resulting from operative removal of a scirrhous tumor
1798 Abernathy4,5,7,9) Performed elective CCA ligation for a patient with traumatic injury of the CA in a goring by a cow
1803 Fleming4,9,38) Exposed and ligated the CA proximal to the rupture site in an injury caused by the patient
1805 Cooper39,40) First attempted ligation of a CA for a patient with cervical aneurysm
1809 Travers4,9) Successfully ligated the CA for a patient with carotid-cavernous fistula
1856 Virchow4,5,14) Described embolus within the CA as associated with ipsilateral monocular blindness
1881 Penzoldt4,5,15) Published the case of a patient who exhibited sudden-onset blindness in the right eye with delayed contralateral hemiplegia
1885 Horsley4,33,41,42) Successfully performed CA ligation for a patient with intracranial aneurysm
1905 Chiari6,16-19) Developed the thromboembolic hypothesis based on work on ulcerated plaques and surface thrombus
1914 Hunt4,5,20) Identified that both occlusion and stenosis of the CA could induce cerebral syndromes
1937 Moniz4,17,21) Indicated cases with occlusion of the cervical portion of the ICA on angiography, along with clinical details of cases
1951 Fisher4,5,17,23,24) Emphasized that cervical atheromatous lesions induced cerebral infarction with various temporary or permanent symptoms
1951 Carrea4,5,47) Partially resected the atheromatous portion of the CA, then re-established flow through an ECA-to-distal ICA anastomosis
1952 Conley and Pack43) Reported end-to-end anastomosis after resection of a neoplasm around the CA system
1953 Conley4,44) Reported using an interposition graft to reconstruct a resected cervical artery after tumor surgery using superficial femoral or saphenous vein
1953 DeBakey3-5,48) Performed CEA with primary closure; patient survived 19 years
1954 Eastcott4,49,50) First published report of CEA
1959 DeBakey51) Reported the original eversion technique
1963 Bruetman25) Reported six cases of postoperative intracerebral hemorrhage after CEA
1979 Mathias66) Performed PTA for patients with fibromuscular dysplasia
1980 Mullan70) Reported PTA for web-like ICA stenosis
1981 Sundt27) Reported a mechanism of hyperperfusion syndrome after CEA
1983 Bockenheimer and Mathias66,72) Performed successful PTA for proximal atherosclerotic ICA stenosis
1983 Wiggli and Gratzl71) Performed successful PTA for proximal atherosclerotic ICA stenosis
1984 Bernstein28) Reported the mechanism and histopathology of hyperperfusion syndrome after CEA
1987 Theron77,78) Developed the balloon-type distal protection system
1989 Mathias66) Placed a self-expanding stent in a carotid atherosclerotic lesion as rescue treatment
1994 Marks75) Performed stent placement for ICA dissection
1996 Roubin76) Reported CAS for a total of 210 procedures in 152 CAs
1996 Kachel79) Expressed the new concept of flow reversal in the ICA resulting from blockade of the ECA and CCA
2000 Parodi81,82) Developed a new device and protection system using Kachel’s idea
2001 Yaday83) Demonstrated the concept of the filter protection device
2004 Leipzig84) Developed a clamping device system using flow reversal
2006 Alexandrescu89,90) Reported good outcomes from transcarotid artery revascularization
2009 Yoshimura106) Developed staged angioplasty as a method for preventing postoperative hyperperfusion from CAS
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CA, carotid artery; ICA, internal carotid artery; CEA, carotid endarterectomy; CCA, common carotid artery; ECA, external carotid artery; PTA, percutaneous transluminal angioplasty; CAS, carotid artery stenting

History of Carotid Artery Reconstruction

1) Carotid artery ligation

The beginning of carotid artery surgery was ligation of the carotid artery (Fig. 1). Pare performed the first such ligation in 1552,9,33) which was aimed at controlling bleeding from an epee wound to the patient, a soldier; however, aphasia and hemiplegia were seen subsequently.9,33) In those times, vessel ligations were performed using silk or catgut threads.34) Warner ligated the carotid artery when removing a massive lipoma in 1775.9,35) Hebenstreit injured a carotid artery during the operative removal of a scirrhous tumor in 1793 and controlled the resulting bleeding by carotid ligation.4,5,7,9,36) This patient survived for a long time following the operation.4,9,36) In 1798, Abernathy performed elective CCA ligation for a patient with traumatic injury of the carotid artery in a goring by a cow, but the patient died 30 h later.4,5,7,9) By the beginning of the 19th century, several reports had described successful ligation of the carotid artery.4,5,7,9,37) In 1803, Fleming exposed the carotid artery proximal to a rupture site and ligated the carotid artery, which had been injured by the patient himself; his assistant Coley reported this case in 1817.4,9,38)

Fig. 1.

Fig. 1

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The first surgeries on the carotid artery involved ligation of the carotid artery for patients with head or neck trauma to control massive bleeding.

In 1805, Cooper first attempted ligation of a carotid artery for a patient with a cervical aneurysm, but the patient died 21 days postoperatively.39) After that unsuccessful case, he successfully ligated the carotid artery to treat a cervical aneurysm in 1808.40)

In 1809, Travers diagnosed and successfully ligated the carotid artery for a patient with carotid-cavernous fistula.4,9) Horsley successfully performed carotid artery ligation for a patient with an intracranial aneurysm in 1885.4,33,41,42) Following that report, surgeons continued to perform carotid ligation for patients with intracranial aneurysm until the advent of direct surgery for this pathology.42) In 1868, Pilz identified 600 descriptions of carotid ligations for cervical aneurysm or hemorrhage, although the mortality rate after surgery was 43%.4,5)

2) Anastomosis of the carotid artery

In 1952, Conley and Pack reported end-to-end anastomosis after resection of a neoplasm around the carotid artery system.43) They concluded that such anastomosis was safe and useful in the resection of the carotid artery.43) The following year, Conley reported the interposition graft to reconstruct a resected cervical artery after tumor surgery using superficial femoral or saphenous vein.4,44)

3) Carotid endarterectomy

Des Santos performed thromboendarterectomy in a peripheral artery before CEA in 1946,45) whereas Wylie removed atherosclerotic plaque from the aortoiliac artery before CEA.46)

After Fisher's landmark articles,17,23,24) the mood regarding carotid artery reconstruction was positive. There is no dispute that the first successful carotid artery reconstruction for occlusive disease occurred in Buenos Aires in 1951.3-5,47) The neurosurgeon Carrea and his colleagues diagnosed left ICA stenosis angiographically, partially resected the atheromatous portion of the artery, and then re-established flow through an external carotid artery-to-distal ICA anastomosis.4,5) Nevertheless, the report of this surgery was not published until 4 years later.47) The first successful CEA was performed by DeBakey in 1953, using a primary closure.3-5) Although the patient survived 19 years without neurological events, the case was not reported until 1975.48) In that paper, DeBakey described that the artery was sutured using silk.48)

The first published report of CEA was made by Eastcott et al. in 1954.4,49) They resected an atheromatous region of the ICA and performed end-to-end reconstruction of the ICA and CCA under hypothermic general anesthesia.4,49,50) Since that report, several methods for resecting carotid atherosclerotic plaque and anastomosing carotid vessels have been described. DeBakey et al. reported the original eversion technique,51) whereas Etheredge and Raithel et al. developed further eversion techniques,52,53) although conventional CEA is still considered to be the standard operation.2,4,6) In terms of historical changes in the suture materials applied to CEA, silk was used first, with monofilament, nonabsorbable polypropylene entering commonly used subsequently.54) Additionally, polytetrafluoroethylene and hexafluoropropylene-VDF are currently in use, as is monofilament, absorbable suture material.55)

CEA has been reported for the prevention of fatal and disabling strokes, but the indications for CEA remain to be debated. DeBakey proposed an international co-operative study of CEA efficacy, leading to a joint study. The results of that randomized study, which included 2400 operations, were published in 1968 and 1969,56,57) with an overall surgical mortality rate of 4%.57) After those reports, the use of CEA exploded in North America.58,59) Further randomized studies performed in the 1990s statistically confirmed the effectiveness of CEA.60,61)

Table 1 summarizes the history of carotid artery reconstructions worldwide, and Fig. 2 depicts the historical transitions of surgical reconstructions for the carotid artery.

Fig. 2.

Fig. 2

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Historical transitions in surgical reconstruction of the carotid artery.

A: Illustration of carotid artery stenosis due to atherosclerotic plaque.

B: DeBakey et al. performed carotid endarterectomy with a primary closure.

C: Eastcott et al. resected an atheromatous lesion in the internal carotid artery (ICA) and performed end-to-end reconstruction of the ICA and common carotid artery.

D: Patch angioplasty as initially performed using the saphenous vein and then later using an artificial vascular membrane.

E: The original eversion technique as first described by DeBakey et al., which involved cutting the carotid bifurcation and resecting the plaque.

CCA: common carotid artery; ICA: internal carotid artery; ECA: external carotid artery; P: plaque. *Resected an atheromatous region of ICA.

4) Carotid artery reconstruction by endovascular surgery

In 1964, Dotter and Judkins first reported percutaneous transluminal angioplasty (PTA) for patients with stenosis of the superficial femoral artery.62) Gruntzig and Hopt introduced the balloon dilatation catheter as a PTA tool in 1974.63) After these two reports, angioplasty started to be performed for peripheral vessels or other brachiocephalic branches in addition to the coronary arteries.64-66) In cases of ICA stenosis among patients with fibromuscular dysplasia, PTA was performed by Mathias in 1979,66) Hasso et al. in 1981,67) and Garrido and Montaya in 1981.68) In 1980, Kerber et al. performed PTA for proximal stenosis of the CCA during distal CEA,66,69) and Mullan et al. reported PTA for web-like ICA stenosis that same year.70) In 1983, Bockenheimer and Mathias and another group of Wiggli and Gratzl performed the first successful PTAs for proximal atherosclerotic ICA stenosis.66,71,72) After these reports, PTA for CCA or ICA stenosis increased during the 1980s.72-74)

In 1989, Mathias placed a self-expanding stent (Wallstent for the iliac artery; Schneider, Minneapolis, MN, USA) in a carotid atherosclerotic lesion. In that case, PTA was performed first, but dissection occurred at the lesion so the stent was placed as a rescue treatment.66) In 1994, stent placement for the ICA was performed by Marks et al. in two patients with ICA dissection.75) They used Palmaz stents (Johnson & Johnson, Warren, NJ, USA), and the lesions were successfully resolved.75) In 1996, Roubin et al. reported carotid artery stenting (CAS) for a total of 210 procedures in 152 carotid arteries.76) After these initial reports, the application of CAS increased with the development of new stent devices, such as the Palomaz stent, Wallstent, Precise stent (Cordis, Santa Clara, CA, USA), and closed cell stent. Finer closed stents are currently being developed.

In the endovascular treatment of carotid artery lesions, protection against distal embolism is a crucial issue. In 1981, Mathias developed a mesh-type protection device, but commercial manufacture was never achieved.66) In 1987, Theron et al. developed a balloon-type distal protection system that later evolved into the triaxial system.77,78) This idea was later commercialized as the “PercuSurge” device (Bait, Montmorency, France).79,80) In 1996, Kachel expressed the new concept of flow reversal in the ICA resulting from the blockade of the external carotid artery and CCA.79) In 2000, Parodi et al. developed a new device and protection system using the ideas expressed by Kachel.81,82) Yaday described the concept of filter protection devices and Jaeger et al. reported results for filter-protected CAS in 2001.83) In 2004, the Leipzig group developed a clamping device (INVATEC s.r.1., Roncadelle, Italy) system by applying the principles of flow reversal.84)

As another problem associated with embolic complications, the access route itself affects the risk of embolism.85) Passing the aortic arch is dangerous in elderly patients undergoing transfemoral procedures during CAS,85) so transbrachial artery or transcarotid (cervical) artery access was chosen in patients with a dangerous aortic arch.86-88) Recently, transcarotid artery revascularization using flow reversal was proposed and showed good outcomes in elderly patients with carotid artery stenosis.89,90) Fig. 3 demonstrates the historical transitions in endovascular reconstructions of the carotid artery.

Fig. 3.

Fig. 3

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Historical transitions in the endovascular reconstruction of the carotid artery.

A: Percutaneous transluminal angioplasty for patients with atherosclerotic carotid artery stenosis, initially without distal protection against embolism.

B: Percutaneous transluminal angioplasty for patients with atherosclerotic carotid artery stenosis with a distal protection balloon to prevent embolism.

C: Carotid artery stenting for patients with atherosclerotic carotid artery stenosis with distal protection balloon for the embolus.

D: Carotid artery stent for patients with atherosclerotic carotid artery stenosis with distal filter protection device to protect against embolism.

E: Carotid artery stenting for patients with atherosclerotic carotid artery stenosis using flow reversal methods with proximal common carotid and external carotid artery balloons.

CCA: common carotid artery; ICA: internal carotid artery; ECA: external carotid artery; B: balloon; C: catheter; S: stent; DPB: distal protective balloon; F: distal filter protection device; PPB: proximal protection balloon; PB: protection balloon at the external carotid artery

History of Carotid Surgery in Japan

The first successful performance of CEA in Japan appears to have been in 1962, by Professor Kimoto and colleagues in the Department of Surgery at Tokyo University.91) They performed CEA for a patient with symptomatic left ICA stenosis using a vein patch. During ICA clamping, they used an external shunt.91) The next CEA in Japan was by Ogata et al. in 1964, for a patient with left ICA stenosis.92) They resected the affected region and performed reconstruction using a Tetoron graft.92) Kageyama et al. performed CEA for a patient with left ICA occlusion in 1965,93) then, in 1969, Takaku et al. reported four cases of CEA with resection of sympathetic nerves around the carotid artery. They used hypothermic anesthesia during CEA and warfarin after CEA.94) Following these operations, energetic Japanese neurosurgeons performed CEA in various institutes: Ono at Nagasaki University,95) Ueda at Tokushima University,96) and Professor Endo at Toyama University.97) However, the number of CEAs was quite small compared to the situation in North America. Professor Mori from Nagasaki University examined the number of CEAs performed in Japan using a questionnaire survey and estimated the total number of CEA performed in 1987 as approximately 500.98) This represented an annual rate of CEA for the Japanese population less than 1% of that of the United States.98) The author undertook a questionnaire survey of the number of CEAs performed in Japan in 1993, identifying 531 CEAs in 260 institutes.99) Professor Endo et al. found that 395 institutes performed 1336 CEAs in 2000 and 1427 CEAs in 2001.100) However, in those days, the number of CEAs performed by a single institute was very small.98-100) Since the beginning of 2000, the use of CEA has gradually increased, but with the widespread use of carotid stenting at the same time, the number of CEAs performed increased only slightly and has remained around 4,000 for the last 4-5 years.2)

Endovascular reconstruction of the carotid artery began slightly later in Japan than in Europe. In 1981, Kuwana et al. performed PTA for a patient with extracranial ICA stenosis, with the case reported in Japanese in 1985.101) At the beginning of 1990, PTA for extracranial ICA stenosis was established in Japan, and several reports of PTA for extracranial ICA stenosis have been published, with balloon protection used in a few cases during PTA.102,103)

After reports of CAS by Marks et al. and other endovascular surgeons,75,76) Yamashita et al. reported CAS as a rescue therapy for a patient with iatrogenic ICA dissection in 1997.104) After that report, CAS for extracranial ICA stenosis started to be performed more frequently in Japan from the late 1990s and the beginning of the 2000s.105) Nowadays, almost 10,000 patients undergo CAS in Japan each year.2)

As mentioned above, hyperperfusion after carotid artery reconstruction is a crucial complication. Thus, endovascular neurosurgeons should prevent this complication. In 2009, Yoshimura et al. developed staged angioplasty as a method for preventing postoperative hyperperfusion from CAS.106) The effectiveness of this method was confirmed in subsequent studies.107,108)

Problems and Future Issues in Carotid Reconstruction

Discussions of which methods are superior for carotid revascularization are still ongoing, including 1) conventional (standard) CEA versus eversion technique;109,110) 2) primary closure versus patch angioplasty,2,111-113) 3) general anesthesia versus local anesthesia,114,115) and 4) non-shunting versus selective shunting versus routine shunting.2,116) We have described and discussed these issues previously.2,116-118) Additionally, the superiority of treatments for carotid artery lesions must be discussed in terms of CEA versus CAS versus medical therapy.119-121) Table 2 summarizes randomized studies on the treatment of carotid artery lesions, including medical treatments.56,57,60,61,122-130) Long-term follow-up results of randomized controlled trials as secondary analyses have now been published.131-133) New information on the treatment of carotid artery lesions becomes available on an almost daily basis.

Table 2.

Randomized studies of the treatment of carotid artery lesions, including medical treatments

Year Study Results
1968 Joint study of extracranial arterial occlusion56,57) Although surgical mortality was 4%, outcomes of CEA in TIA patients with more than 50% stenosis were better than those of medical therapy
1991 North American Symptomatic Carotid Endarterectomy Trial Collaborators (NASCET)60) In symptomatic patients with more than 70% stenosis, CEA showed absolute benefit compared to medical treatment
1995 Asymptomatic Carotid Atherosclerosis Study: endarterectomy for asymptomatic carotid artery stenosis (ACAS)61) In asymptomatic patients with more than 60% stenosis, CEA showed absolute benefit compared to medical treatment
1998 MRC European Carotid Surgery Trial (ECST)122) In symptomatic patients with more than 70% stenosis, CEA showed absolute benefit compared to medical treatment
2001 Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS)123) Endovascular treatment showed similar major risks and effectiveness in prevention of stroke during 3 years compared with carotid surgery
2004 Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy trial (SAPPHIRE)124) Among patients with severe carotid artery stenosis (more than 50%) and coexisting conditions, CAS was not inferior to CEA
2004 Asymptomatic Carotid Surgery Trial (ACST)125) In asymptomatic patients with more than 60% stenosis, CEA showed absolute benefit compared to medical treatment
2006 Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis (EVA-3S)126) In symptomatic patients with more than 60% stenosis, rates of death and stroke at 1 and 6 months were lower with CEA than with CAS
2006 Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy trial (SPACE)127) This study failed to prove non-interiority of CAS compared with CEA in symptomatic patients with more than 50% stenosis
2010 Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (ICSS)128) In symptomatic patients with more than 50% stenosis, CEA was safer than CAS
2010 Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)129) In symptomatic or asymptomatic patients with more than 50% stenosis, outcomes did not differ significantly between CAS and CEA
2016 Asymptomatic Carotid Trial (ACT) I130) In asymptomatic patients with more than 70% stenosis who were not at high risk of surgical complications, CAS was noninferior to CEA
2016 Long-term results of stenting versus endarterectomy for carotid-artery stenosis (CREST)131) In symptomatic or asymptomatic patients with more than 50% stenosis, outcomes did not differ significantly between CAS and CEA over 10 years of follow-up
2021 Second Asymptomatic Carotid Surgery Trial (ACST-2)132) In asymptomatic patients with more than 60% stenosis, protective effects of CAS and CEA were similar for at least the first few years
2022 Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis (SPACE-2)133) In symptomatic patients with more than 50% stenosis, CEA plus BMT or CAS plus BMT were not found to be superior to BMT alone
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TIA, transient ischemic attack; CEA, carotid endarterectomy; CAS, carotid artery stenting; BMT, best medical treatment

Complication and recurrence rates have not reached zero, irrespective of the maneuvers or pharmacotherapies. Although randomized studies and meta-analyses have been conducted as described above, conclusive results have not been established. Furthermore, as techniques for carotid reconstruction by endovascular surgery become more complicated and as new medicines are developed, medical costs will continue to increase.1,134) Indications for carotid reconstruction in super-aging patients remain controversial worldwide and in Japan.135)

In the future, we must develop more effective, safer, and less expensive therapeutic methods for preventing carotid stroke, which will repay the efforts of our great antecedents.

Conclusion

In this report, I have reviewed both the evolution of the concept of how carotid artery lesions affect cerebral infarction and the history of carotid artery reconstructions worldwide and in Japan.

Conflicts of Interest Disclosure

The author has no conflicts of interest to declare regarding this study or its findings.

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