The endovascular revolution stopped at the carotid bifurcation … or did it?
2012; Elsevier BV; Volume: 56; Issue: 6 Linguagem: Inglês
10.1016/j.jvs.2012.10.010
ISSN1097-6809
Autores Tópico(s)Acute Ischemic Stroke Management
ResumoAs the Society for Vascular Surgery (SVS) approaches its 70th anniversary, I am awed and humbled at the great privilege, if somewhat improbable circumstance, of leading the nation's oldest and largest society devoted to the care of patients with vascular disease. My term has been both rewarding and certainly the assemblage of a presidential address has at times daunted me. I have been steered by the wisdom of Presidents past; I learned much from Dr Shumaker's fascinating history of the first 50 years of the SVS,1Shumacker Jr, H.B. The Society for Vascular Surgery: a history.in: The Society for Vascular Surgery, Manchester, MA1984: 1945-1983Google Scholar and I am pleased to report that in follow-up of our 50th anniversary meeting, Drs Jimmy Yao and Norm Rich are leading an effort to chronicle our past 20 years. In deciding on fact or philosophy for this address, I have fundamentally come to the position that I am first and foremost a vascular surgeon and accordingly, my topic this morning, on carotid atherosclerosis, is one of the core components of vascular surgical practice coming into the modern era shortly after the founding of the SVS in 1947. Furthermore, there has been much activity in the carotid arena of late; some of this is actually science, much is not. Also, in such Presidential addresses, tradition must be served, and the great tradition of our society is entwined with certain Boston Pioneers and with the evolution of vascular surgery at the Massachusetts General Hospital (MGH), where I have had the great privilege to spend essentially my entire professional career. From the vision of its 31 Founding Members, the SVS has evolved in stature, size, and influence as among the nation's pre-eminent medical professional organizations. Our recent history has solidified SVS as the representative organization for all vascular surgeons, and today, we stand nearly 4000 members strong, with an annual budget of some 7 million dollars, and an effective force of nearly 300 of our members carrying out the SVS mission in some 30 different councils and committees. In particular, I owe a great deal to my colleagues on the SVS Executive Committee who provided me with both wisdom and the sometimes needed temperance over the past year. Customary in a Presidential address is the acknowledgment of the many in my personal and professional life that made it possible for me to become your 66th president. My professional evolution at the MGH in Boston began only after disillusionment at the prospect of becoming a cardiac surgeon. I went to medical school convinced I would be a cardiac surgeon. I was only dissuaded during my subinternship on cardiac surgery. Accordingly, when I had the great fortune to do a subinternship in vascular surgery at the MGH under the tutelage of my professional godfather, Dr R. Clement Darling, Jr, MD, in September of 1976, I discovered the specialty that seem to suit me so well as the vascular surgeon was the expert in the diagnosis, clinical decision-making, and execution of the surgical treatment of patients afflicted with vascular disease. Perhaps even more impressive, at the time, no other medical or surgical specialty either knew anything about vascular disease nor had any interest in being involved in same. To be sure, a Shangri-La of sorts, but of course, not reality today. The history of vascular surgery at the MGH is intimately entwined with the beginning days of the SVS. Arthur Allen, MD (Fig), was the first vascular surgeon at the MGH. He was, by all accounts, a surgeon for all seasons with the wide range of interests in surgery that crossed gastrointestinal, endrocrine, and vascular surgery. Influenced to a degree by John Homans, also in Boston, he was writing on periarterial sympathectomy in the 1920s in the original Boston Medical and Surgery Journal, which would ultimately become the New England Journal of Medicine. Allen was appointed Chief of the Vascular Clinic at the MGH in 1928, the first such clinic of its kind in the US. It is extraordinary to read some of his early work, such as his report on the use of typhoid vaccine injection to augment the microcirculation in young people with gangrene, likely secondary to what we would refer to today as thromboanginitis obliterans.2Allen W.A. Smithwick R.H. Use of foreign protein in the treatment of peripheral vascular diseases.JAMA. 1928; 91: 1161-1168Crossref Scopus (1) Google Scholar This paper was read before the annual meeting of the American Medical Association in 1928; it contributed to Allen's national stature as a leader in vascular disease management. Allen spent a large part of his professional career investigating the prophylaxis of pulmonary embolism and was the first to promulgate ligation of the superficial femoral vein in the prevention of pulmonary embolism. His paper, on the MGH series of such operations, delivered before the American Surgical Association in 1943,3Allen A.W. Linton R.R. Donaldson G.A. Thrombosis and embolism: review of 202 patients treated by femoral vein interruption.Ann Surg. 1943; 118: 728-739Crossref PubMed Google Scholar positioned him as one of the national leaders in an effort to initiate a surgical professional society devoted to vascular disease management. Accordingly, he was one of a group of six individuals who held an initial organizational meeting in December of 1945 at the Southern Surgical Association; a follow-up meeting occurred the following July, and the SVS was launched. The initial SVS scientific meeting was held on the Steel Pier in Atlantic City, New Jersey, in June of 1947. Allen, who would go on to be the second president of the SVS, succeeding Alton Ochsner, chaired the program committee of that first meeting; the very first paper at the very first SVS meeting was delivered by one Robert R. Linton, MD, whose name is forever associated with the origins of modern vascular surgery, both in Boston and across the nation. Linton, in turn, had catapulted to national fame based on his work with lower extremity venous disease and his sentinel work published in 1938, which was the initial description of the importance of the ligation of incompetent perforating veins in the prevention of the postthrombotic syndrome.4Linton R.R. The communicating veins of the lower leg and the operative technic for their ligation.Ann Surg. 1938; 107: 582-593Crossref PubMed Google Scholar Accordingly, Linton was well positioned to initiate modern arterial reconstructive surgery at the MGH right around the year I was born; his contributions to vascular surgery were many, and his ninth SVS presidential address delivered in 1955 was, in fact, the first of the SVS Presidential addresses to deal with direct arterial reconstructive surgery. In the twilight of his career, Dr Linton was invited to give the prestigious Homan's lecture before the SVS, and his topic was John Homans' impact on Venous Surgery. Interestingly, most of this address centered on the effectiveness of the methods Linton developed (ligation of incompetent perforators), as opposed to radical soft tissue excision and skin grafting espoused by Homans!5Linton R.R. John Homans' impact on diseases of the vein of the lower extremity, with special reference to deep thrombophlebitis and the post-thrombotic syndrome with ulceration.Surgery. 1977; 81: 1-11PubMed Google Scholar Linton was a master technical surgeon and performed the first successful direct repairs of both abdominal aortic aneurysms and autogenous veins bypass surgery in New England. His monumental Atlas of Vascular Surgery, published in the early 1970s, was for many years a vascular surgery bible and a prized possession of graduating MGH Vascular Surgical Trainees. When I received mine, I was the initial Robert R. Linton Research Fellow. The circle is now complete with the inauguration of the Robert R. Linton, MD, professorship in Vascular and Endovascular Surgery at the Harvard Medical School and the Massachusetts General Hospital. To be the first incumbent of this chair is for me the stuff that dreams are made of. Linton's protégé and partner, joining him in practice at the MGH in 1960 after a two-year fellowship with Dr DeBakey, was Dr R. Clement Darling, Jr, who was my principle teacher of vascular surgery. He opened his practice to me in the evolution of our central aortic practice. A few years ago, as president of the New England Society for Vascular Surgery, I had the opportunity to recount in detail Dr Darling's many contributions to vascular surgery.6Cambria R.P. R. Clement Darling Jr, MD, and the evolution of vascular surgery.J Vasc Surgery. 2010; 51: 747-755Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Dr Darling was reporting large series of femoropopliteal vein bypass grafts before the SVS in the mid-1960s; he invented and promulgated the lower extremity arterial noninvasive technique that is widely used across the world today in a sentinel report delivered before the SVS in 1971.7Darling R.C. Raines J.K. Brener B.J. Austen W.G. Quantitative segmental pulse volume recorder: a clinical tool.Surgery. 1972; 72: 873-887PubMed Google Scholar To Dr Darling, I owe an incredible debt, and yes, he was the father of our current SVS treasurer Dr R. Clement Darling, III, from Albany, New York. Although by proxy, Dr E. Stanley Crawford was both my hero and had a profound influence on the development of my aortic surgery practice. Dr Crawford was chief resident at the MGH in 1955, and perhaps the greatest aortic surgeon who ever lived. His autographed picture, which hangs in my office, is signed “best wishes and highest esteem.” By proxy, I mean that Dr Crawford's son, John, who joined him in the authorship of the monumental Crawford's Atlas of Aortic Surgery, was chief resident with me at the MGH in 1984. Dr Crawford, our 42nd president, delivered the Homans lecture in 1991 through his son, John, because at that point, Dr Crawford was disabled with a stroke; his address, entitled “Heroes in Vascular Surgery,” was one of the more inspiring things I have ever heard at a scientific meeting.8Crawford E.S. The seventh John Homans' lecture: heroes in vascular surgery.J Vasc Surg. 1992; 15: 417-423Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar My colleagues in the division of vascular and endovascular surgery at the MGH are my special family. They are the reason I find it so much fun to go to work every day. Our many vascular fellows over the years have contributed to my professional development in a way that they could never know. They have had to endure my intensity and my insistence on perfection passed down from Dr Linton, but they annually renew me with their accomplishments and their own individual outstanding stories. You have heard elements of my personal story from President-Elect Gloviczki. Dr Sanjiv Chopra, who has lectured all over the world on leadership, indicates that all leaders have a story to tell.9Chopra S. Leadership by example. St Martin's Press, New York2012Google Scholar I hope you will indulge me a few moments to hear mine. As a small child, I came under the influence of John Caccamo, my maternal grandfather. He was an outstanding, if typical, representative of the great wave of immigrants who sought a better life in America. Coming to this country from Sicily as a desperately poor 16-year-old in 1904 with little more than an address of certain relatives who settled in Brooklyn, he had to wait 3 weeks in confinement at Ellis Island to be sure that he did not bring tuberculosis into the country. He was a man of great faith, if somewhat stern, but embodied that outstanding quality of the immigrant generation – a fierce tenacity to succeed. He started the family business – John's Meat Market – the butcher shop establishment, which operated for some 70 consecutive years in Elizabeth, New Jersey, where I spent my formative years and where later, my father would teach me many things, including how to carve a side of beef! My father was a perfect example of what Tom Brokaw and Stephen Ambrose termed “the greatest generation this country has ever produced.” Like so many of his generation, many of his prime years were spent in the military service of his country. As a navigator/bombardier on a B-25 in the horror of the Pacific theater in World War II, he was witness to history on August 9, 1945, when he saw the second atom bomb explode over Nagasaki, effectively ending World War II. His influence on me was enormous, but of course it was some years before I recognized this; he taught me humanism and kindness, which I hope to have brought to the care of the thousands of patients I have had the privilege to care for over the past 30 years. In each person's development, there are profound influences, usually early in life, and mine was working side-by-side with my father in the butcher shop beginning when I was 12 years of age. In his book Outliers, Malcolm Gladwell examines the careers of some outstandingly successful people and, in a very learned treatise, ascribes success more to circumstance than to brilliance.10Gladwell M. Outliers: the story of success. Back Bay Books, New York2008Google Scholar The people who stand before kings may look like they did it all by themselves … but, in fact, they are the beneficiaries of hidden advantages and extraordinary opportunities and cultural legacies that allow them to work hard and make sense of the world in ways others cannot. It makes a difference where and when we grew up. The culture we belong to and the legacies passed down by our forebears shape the patterns of our achievement in ways we cannot begin to imagine. Accordingly, I am here before you today as SVS president because my father took me as a young boy to work with him in the butcher shop. It's as simple as all that. My wife, Chris, and my five children have sustained me these past 30 years and continue to do so. They never asked, “Do you have to make rounds today?” My first son, Andy, was born when I was an intern, and now having come full circle, my wife, Chris and I experienced the unbelievable joy of our first grandchild, baby Sadie, born 18 months ago at the MGH and timed perfectly in between cases! I have had many blessings in life, but being baby Sadie's pop-pop is just about the best of them. While supporting me, my wife and children have also kept me grounded. Let me give you an example; my second son, Jay, when he was 16, had a good way of putting it. I had gone to look at a job in Cleveland at some point in midcareer and was chatting about it with the family. My son Jay's comment was, “Dad, we want you to know that if you take that job in Cleveland, you can call home anytime you want.” Needless to say, I stayed in Boston. While I intended to stick to topic, I would be remiss if I failed to report on some of our major developments in the SVS this year, and many of these are in the carotid sphere, thus the rationale for focusing on the carotid disease debate today. Now about a year and a half old, the Vascular Quality Initiative (VQI) has positioned our society and our profession as the leaders in quality improvement efforts relative to vascular procedures. SVS leadership over the past several years felt it entirely appropriate and vitally important for SVS to be in a leadership position in such activities. Modeled on the highly successful and now 9-year-old vascular study group of New England, the VQI has several distinct components, as recently reviewed by our medical director, Jack Cronenwett, in the Journal of Vascular Surgery.11Cronenwett J.L. Kraiss L.W. Cambria R.P. The Society for Vascular Surgery Vascular Quality Initiative.J Vasc Surg. 2012; 55: 1529-1537Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar These include an Agency for Healthcare Research and Quality-certified Patient Safety Organization, which incidentally, was the very first medical profession society to hold such designation, regional quality groups, and a robust procedural data platform with our corporate partner who provides the web-based data platform. This effort has grown exponentially in the past 16 months, and we currently have approximately 200 hospitals and over 50,000 procedures in the database. I encourage all SVS members to join in the VQI effort; it is an important vehicle to advance our specialty and benchmark your practice. A particular effort during my presidency has been to facilitate one of our strategic goals articulated in 2008, namely an increase in the number of newly trained vascular surgeons. Both projections of the total numbers of practicing vascular surgeons, the age demographics of our workforce, and the actual data in our fellowship training programs reveal the relatively flat trajectory in the vascular surgery workforce. While many surgical subspecialties have seen a decrement in the pool of qualified applicants for training programs, the now 5-year-old 0-5 integrated vascular residency training paradigm has been fabulously successful and is among the Accreditation Council for Graduate Medical Education's most avidly sought subspecialty training programs. Bringing quality vascular care to all types of practice settings can only be accomplished by increasing the supply of vascular surgeons. We initiated a vascular fellowship development task force over the past year. I am greatly indebted to the vascular surgery leaders who joined me in this task force: Ronald Dalman, John Eidt, Vivian Gahtan, Jeffrey Jim, Craig Kent, Michel Makaroun, and Jon Matsumura. Our committee was composed of representatives from different geographic regions across the country, and we assembled a list of potential practices and hospitals wherein vascular residencies and/or fellowships could be developed. I am pleased to announce that as a product of this task force, SVS has now made available to prospective fellowship sites a series of programs, tools, and mechanisms to foster the development of new vascular residencies and/or fellowships. These are in the form of a handbook for new fellowship directors, which includes strategies for dealing with department chairs and hospital administrators, a reference list of current fellowship directors to serve as mentors and facilitators, and an SVS-sponsored consultant who will travel to potential sites to help in program development. While all vascular surgeons are aware of the firestorm referable to carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CEA), certain temporal events have caused both the debate and the technology into a waxing and waning posture in recent years. Listed in the Table are some of the important events more recently, which makes a consideration of the carotid paradigm an appropriate topic for today's meeting. After the publication of a number of European-based randomized trials clearly implicating CEA as the preferred treatment (vs CAS) in the management of, in particular, symptomatic patients, the medical community eagerly awaited completion of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST).12Mas J.L. Chatelier G. Beyssen B. Branchereau A. Moulin T. Becquemin J.P. et al.Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis.N Engl J Med. 2006; 355: 1660-1671Crossref PubMed Scopus (1398) Google Scholar, 13Ederle J. Dobson J. Featherstone R.L. Bonati L.H. van der Worp H.B. et al.International Carotid Stenting Study investigatorsCarotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomized controlled trial.Lancet. 2010; 375: 985-997Abstract Full Text Full Text PDF PubMed Scopus (1070) Google Scholar, 14Ringleb P.A. Allenberg J. Brückmann H. Eckstein H.H. Fraedrich G. et al.Space Collaborative Group30-day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial.Lancet. 2006; 368: 1239-1247Abstract Full Text Full Text PDF PubMed Scopus (1324) Google Scholar Both practitioners and regulatory agencies would consider this large well-conducted trial as a sentinel event in the carotid sphere. Soon after publication of the CREST study in mid-2010, these data were incorporated into the promulgation of some five different international practice guidelines published in 2011, which were recently compared in a short Journal of Vascular Surgery review article upon which I had the privilege to comment.15Paraskevas K.I. Mikhailidis D.P. Veith F.J. Comparison of the five 2011 guidelines for the treatment of carotid stenosis.J Vasc Surg. 2012; 55: 1504-1508Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Doubtless you are familiar with the SVS updated practice guidelines that contain the best available/most declarative/evidence-based management guidelines for patients with carotid stenosis.16Ricotta J.J. AbuRahma A.F. Ascher E.A. Eskandari M. Faries P. Lal B.K. Updated guidelines for the management of extracranial carotid stenosis.J Vasc Surg. 2011; 54: e1-e31Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar Also, in 2011, the SVS Clinical Research Council convened a clinical research priorities retreat with 40 experts gathering to hear presentations and otherwise vote in hierarchical fashion on the important clinical research questions in our practice. As a product of that meeting, SVS identified clinical management of asymptomatic carotid stenosis as its number one clinical research priority. This is not to be interpreted as a retribution of any component of the updated 2011 SVS practice guidelines referable to carotid disease, but rather an acknowledgment that further research in characterizing the nature and risk of asymptomatic carotid stenosis is certainly in order. Details of the research priorities retreat will soon be published in JVS.17Kraiss L.W. Conte M.S. Geary R.L. Kibbe M. Ozaki C.K. Setting high impact clinical research priorities for the Society for Vascular Surgery.J Vasc Surg. 2012; (in press)Google ScholarTableCarotid arena: Recent notable events• February/June 2010: Presentation/publication of CREST52Brott T.G. Hobson II, R.W. Howard G. Roubin G.S. Clark W.M. Brooks W. et al.CREST InvestigatorsStenting versus endarterectomy for treatment of carotid-artery stenosis.N Engl J Med. 2010; 363: 11-23Crossref PubMed Scopus (2293) Google Scholar• 2011: Publication of five international practice guidelines• February 2011: Multispecialty ACC/AHA77Brott T.G. Halperin J.L. Abbara S. Bacharach J.M. Barr J.D. Bush R.L. et al.2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery.Circulation. 2011; 124: e54-e130Crossref PubMed Scopus (453) Google Scholar• September 2011: SVS updated practice guidelines16Ricotta J.J. AbuRahma A.F. Ascher E.A. Eskandari M. Faries P. Lal B.K. Updated guidelines for the management of extracranial carotid stenosis.J Vasc Surg. 2011; 54: e1-e31Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar• October 2011: SVS Clinical Research Council convenes clinical research priorities Retreat17Kraiss L.W. Conte M.S. Geary R.L. Kibbe M. Ozaki C.K. Setting high impact clinical research priorities for the Society for Vascular Surgery.J Vasc Surg. 2012; (in press)Google Scholar• January 2012: CMS convenes MEDCAC on carotid atherosclerosis18Cambria R.P. Centers for Medicare and Medicaid Services conducts a medical evidence development and coverage advisory committee meeting on carotid atherosclerosis: executive summary.J Vasc Surg. 2012; 56: 199-200http://www.ncbi.nlm.nih.gov/pubmed/22749277Abstract Full Text Full Text PDF PubMed Scopus (2) Google ScholarACC/AHA, American College of Cardiology and the American Heart Association; CMS, Centers for Medicare and Medicaid Services; CREST, Carotid Revascularization Endarterectomy versus Stenting Trial; MEDCAC, medical evidence discovery and coverage analysis group meeting; SVS, Society for Vascular Surgery. Open table in a new tab ACC/AHA, American College of Cardiology and the American Heart Association; CMS, Centers for Medicare and Medicaid Services; CREST, Carotid Revascularization Endarterectomy versus Stenting Trial; MEDCAC, medical evidence discovery and coverage analysis group meeting; SVS, Society for Vascular Surgery. In anticipation of a reconsideration by Centers for Medicare and Medicaid Services (CMS) of the National Coverage Determination (NCD) for CAS, the SVS board of directors by vote of 21 of its 22 members in June 2011 (repeated in identical manner and result at the June 2012 Board of Directors meeting), voted against any change in SVS position relative to the current CMS coverage determination for CAS. In additional, and at the invitation of CMS, SVS submitted (in May 2012) a detailed position statement opposing any change in the current NCD relative to CAS. Although an application was made to CMS, it was deferred when CMS instead convened a medical evidence discovery and coverage analysis group meeting (MEDCAC) in January of this year. A MEDCAC meeting is different than a reconsideration of coverage and consists of a panel of medical experts who hear both invited testimony and then at-large testimony from interested stake holders. Given the importance of carotid disease as a core component of vascular surgery practice, SVS had a very active role at the January MEDCAC, offering a variety of oral presentations and submitting a comprehensive document addressing the meeting's seven research questions, and this material was recently published in the Journal of Vascular Surgery.18Cambria R.P. Centers for Medicare and Medicaid Services conducts a medical evidence development and coverage advisory committee meeting on carotid atherosclerosis: executive summary.J Vasc Surg. 2012; 56: 199-200http://www.ncbi.nlm.nih.gov/pubmed/22749277Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar The supporting research data in the carotid sphere could occupy a textbook; indeed, the Rutherford textbook of vascular surgery contains some 11 chapters and 200 pages devoted to the management of cerebrovascular disease. Yet, not since SVS 31st President Jesse Thompson Homans' lecture, delivered in 1995 at the 50th anniversary meeting, has there been comprehensive treatment of the carotid story from this podium. Dr Thompson's wonderful treatise, which should be read by all students of carotid surgery, closed with an admonition referable to CAS … and I quote, “mortality and stroke rates are not acceptable when compared to carotid endarterectomy.”19Thompson J.E. Carotid surgery: the past is prologue The John Homans lecture.J Vasc Surg. 1997; 25: 131-140Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar He went on to quote Osler, “…the foolishness of yesterday has become the wisdom of tomorrow.” As I will review with you, 15 years hence, the clinical realities as reviewed in SVS practice guidelines have not changed much. I have chosen to outline this topic beginning with fundamentals of pathogenesis, and proceeding to natural history data before considerations of the efficacy and safety of intervention. What I refer to as the fundamentals of pathology and pathophysiology, while well known to most vascular surgeons, is important to delineate as a foundation for clinical decision making in carotid disease. It is my belief that such considerations are not in the knowledge base of some who seek to manage carotid disease. Any prophylactic treatment, whether it be repair of an abdominal aortic aneurysm or carotid endarterectomy for asymptomatic carotid stenosis is, of course, predicated on a thorough knowledge of the natural history of the lesion without treatment, and an important consideration in the carotid sphere is the role and/or limitations of modern medical therapy in the management of those with asymptomatic carotid stenosis. Where we have come with both CEA and where we hope to potentially go with CAS are important elements of the debate, as is, of course, the available comparative data referable to CEA and CAS. The father of carotid surgery was, in fact, not a surgeon at all. Rather, the original description of the relationship between carotid disease and its causative role in ipsilateral hemispheric stroke was delineated by C. Miller Fisher, MD, a stroke neurologist who spent his career at the MGH. In 1949, the preponderance of thought was that ischemic stroke was largely related to vasospasm and/or spontaneous thrombosis of the middle cerebral artery. In dissecting brains of patients who had died of stroke, Miller Fisher made the observation that there was no trace of vascular blockage in the middle cerebral artery. He took this apparent incongruity during further investigations as a stroke fellow at the Montreal Neurological Institute. He recorded carefully elements of histories of patients who had severe hemispheric stroke, noting that a history of transient monocular blindness on the side contralateral to the stroke was frequently obtained. One such patient, whom he had questioned carefully, died of
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