Contemporary Management of Carotid Bifurcation Atherosclerosis for Stroke Prevention: Management Options and Patient Selection

Abstract

There are few areas in vascular surgery more extensively studied than the role of carotid bifurcation stenosis in stroke treatment. In 1951, C. M. Fisher identified the relationship of carotid bifurcation atheroma and stroke. Within a year or two, surgeons in 3 continents successfully treated carotid bifurcation lesions in patients with ongoing cerebrovascular insufficiency. Their initial hope that removal or bypass of these lesions would reverse the clinical stroke syndrome proved unfounded in the majority of cases. Within a decade of the first successful carotid reconstructions, the Joint Study on Extracranial Arterial Occlusive Disease was undertaken. This study, which involved surgeons, internists, and neurologists, prospectively randomized 5000 patients with lesions of the extracranial carotid and vertebral arteries. The lessons learned served as the basis to define the role of surgery of the carotid and vertebral arteries for stroke prevention. The model of critical prospective multidisciplinary analysis has been applied over subsequent decades to evaluate carotid endarterectomy in Europe and North America for both symptomatic and asymptomatic patients and is currently being used to evaluate a new technology—carotid angioplasty and stenting. The next 2 issues of Perspectives in Vascular Surgery and Endovascular Therapy provide a comprehensive summary of the contemporary management of extracranial carotid disease for stroke prevention by a multidisciplinary group of experts. Dr Mackey provides a comprehensive review of the role carotid revascularization plays in contemporary stroke prevention. Dr Shields et al describe contemporary medical management of patients with carotid bifurcation stenosis. Because carotid interventions are essentially prophylactic in nature, selecting the appropriate patients for intervention, whether by open or endovascular means, is of paramount importance. Dr Rocman addresses the issue of intervention in the asymptomatic patient, whereas Drs Jeffrey and Sicard address the management of patients with comorbidities that increase the risk of endarterectomy. There has been renewed interest in the management of carotid bifurcation stenosis in patients with acute stroke, a topic well covered by Dr Lanzino et al. This issue is designed to provide a solid base for the subject of our subsequent issue that addresses the relative roles of carotid endarterectomy and carotid stenting in contemporary interventional management.