Welcome to the past, present, and future of carotid stenosis. My name is Scott Simon, and I'm an associate professor of neurosurgery at Penn State College of Medicine in Hershey, Pennsylvania, where I sub-specialize in cerebrovascular and endovascular neurosurgery. I have nothing to disclose. The modern history of carotid stenosis began in 1951 when C. Miller Fisher published post-mortem studies that showed plaque buildup at the carotid bifurcation. He hypothesized that the buildup would continue until eventual occlusion could cause an ipsilaterals in ischemic stroke or infarction. He did not specifically hypothesize the risk of thromboemboli. In 1953, Dr. DeBakey performed the first CEA based on Dr. Fisher's work. Interestingly, he did not publish the fact that he did this in 1953 until 1978, and therefore the credit for the first proper CEA in the United States is debated. In 1969, the joint study of extracranial arterial occlusion looked at 2,400 carotid surgeries at 24 centers from 1961 to 1968. Morbidity was a sobering 2 to 36%, but it did decrease over the eight years of the study. In 1971, 15,000 carotid endarterectomies were performed in the United States, and by 1985, this had climbed to 107,000. In 1986, there was a slight drop after a series of reports demonstrated perioperative stroke risk might be as high as 21%. In 1991, NASIT demonstrated benefit in the treatment of symptomatic disease in a randomized double-blinded fashion. And this was augmented by the ACAS study in 1994, which demonstrated benefit in treatment of asymptomatic disease with a similarly robust investigational method. In 1995, there were 132,000 carotid endarterectomies performed annually in the United States. Since that time, we have enjoyed the benefit of the development of carotid artery stenting. This graph demonstrates that between 1998 and 2004, the number of carotid endarterectomies generally and slowly decreased, while the number of carotid artery stenting cases increased. Subsequent publications have proved this to be a durable phenomenon. Now that we know where we have been, and perhaps have a better idea of where we are, this still raises interesting questions about the future. Will advancing radiologic, genetic, or other testing redefine what is symptomatic and what is asymptomatic? Will advancing technology change the comparative risk of carotid endarterectomy versus carotid endarterectomy? Will advances in medical management of risk factors change the comparative risk of either intervention? And how do we approach the patient with an occluded carotid, either in the acute situation, such as a thrombectomy for acute stroke or large vessel occlusion, or in the chronic setting? I hope you enjoy the following series of lectures examining these questions.

carotid stenosis

plaque buildup

carotid artery

strokes

carotid endarterectomy