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.