HISTORICAL VIGNETTES IN VASCULAR SURGERY Norman M. Rich, MD, Section Editor
The first carotid endarterectomy Steven G. Friedman, MD, MBA, New York, NY
There is no dispute that the first successful carotid artery reconstruction for occlusive disease took place in Buenos Aires in 1951. Neurosurgeon Raul Carrea and his colleagues admitted a 41-year-old man with aphasia and right hemiparesis to the Institute of Experimental Medicine. Two weeks and two angiographic studies later, Carrea and his team partially resected the diseased portion of the internal carotid artery and re-established flow through an external carotid to distal internal carotid artery anastomosis (Fig 1). The patient did well postoperatively and had normal findings on neurologic examination 39 months later. Authorship of the first carotid endarterectomy has been less clear because of a decades-long rivalry between two pioneering cardiac and vascular surgeons: Denton Cooley and Michael DeBakey. DeBakey claimed that he performed the first carotid endarterectomy in August 1953; however, he did not report the case until 1975. In an article in JAMA entitled “Successful Carotid Endarterectomy for Cerebrovascular Insufficiency: Nineteen-Year Follow-up,” DeBakey described the case of a 53-year-old male bus driver with a more than 2-year history of transient ischemic attacks.1 Because DeBakey had had favorable experiences with endarterectomies of arteries in other parts of the body, he was confident that the risk of carotid endarterectomy would be slight. DeBakey performed this procedure with a primary closure, and his patient survived for 19 years without a neurologic event. In March 1956, Cooley admitted a 71-year-old man to Methodist Hospital for complaints of a “swishing” noise in his left ear for 4 months. The patient denied neurologic symptoms and an angiogram revealed a carotid bifurcation stenosis. At surgery, the patient’s head was immersed in From the Department of Surgery, Weill Cornell Medical College. Author conflict of interest: none. Additional material for this article may be found online at www.jvascsurg.org. Reprint requests: Steven G. Friedman, MD, MBA, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065 (e-mail: stf3001@med. cornell.edu). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;60:1703-8 0741-5214 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.08.059
Fig 1. The first carotid artery reconstructions.
crushed ice and a polyvinyl shunt with needles at both ends was used to bypass the carotid bifurcation. An endarterectomy was performed through a transverse incision at the bifurcation, and it was repaired primarily. Postoperatively, the patient stated that the noises were gone, but he was aphasic and had right hemiparesis. One month later, these symptoms were improving.2 In lectures and at least one subsequent publication, Cooley referred to this procedure as the first successful carotid endarterectomy.3 In a 2001 interview with Cooley, he reaffirmed his belief that the carotid endarterectomy performed at Methodist Hospital was the first of its kind. In support of this, Cooley shared a letter from Felix Eastcott requesting Cooley’s thoughts about this surgical first (Fig 2). Eastcott was preparing for a lecture at the Mayo Clinic about famous vascular operations and wished to acknowledge Cooley’s carotid endarterectomy in addition to the modified Carrea 1703
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Fig 2. Eastcott letter to Cooley.
procedure Eastcott had performed in 19544 (Fig 1). Cooley responded with a detailed description of his case and confessed to misgivings about performing carotid surgery in a patient without neurologic symptoms as well as the use of external brain cooling (Fig 3 and Supplementary Fig 1, online only). Cooley recalled having assisted DeBakey earlier in 1956, in an attempted endarterectomy of an occluded carotid artery, and he recounted this case to me as well. In the original report of the procedure, the carotid artery was clamped for 9 minutes.2 In the letter to Eastcott, carotid occlusion lasted 8 minutes. Cooley also provided 6-month follow-up, at which time his patient had normal findings on neurologic examination. In his cover letter to me, Cooley reiterated doubt about the validity of DeBakey’s 1975 article in JAMA (Fig 4). Shortly after this correspondence with Cooley, DeBakey was asked if he could resolve this discrepancy.
He was specifically asked why he waited 19 years to report his carotid endarterectomy. In a November 2001 letter, DeBakey claimed that it was his practice to acquire sufficient clinical data before rushing into print (Fig 5). He also claimed that he had described this case during a number of visiting lectures after the operation and in publications before the report in JAMA.5,6 Cooley was a coauthor of one of these papers.5 DeBakey also provided a copy of the original operative note, thereby establishing his carotid endarterectomy as the first (Fig 6; Supplementary Fig 2, online only). The feud between DeBakey and Cooley ended in 2007, several days after DeBakey received a Congressional Gold Medal for his towering medical achievements, including innovative operations, creation of mobile army surgical hospital (MASH) units, and
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Fig 3. Cooley response to Eastcott. Complete letter available online at www.jvascsurg.org.
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Fig 4. Cooley letter to Friedman.
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Fig 5. DeBakey letter to Friedman.
helping with the development of the Veterans Administration medical system. In a ceremony at St. Luke’s Episcopal Hospital in Houston, DeBakey accepted a lifetime achievement award from the Denton A. Cooley Cardiovascular Surgical Society. While presenting the award, Cooley reportedly joked, “It must be a heavy burden for one person to be honored by a Congressional Gold Medal and membership in the Cooley Society all in one week.” Less than a year later, Cooley was inducted into the Michael E. DeBakey International Surgery Society. DeBakey expressed relief that they were colleagues and friends again. In 2005, at the age of 97, DeBakey underwent surgical repair of a thoracic aortic dissection, a procedure he had
pioneered decades earlier. He survived the operation and was able to attend the groundbreaking of the Michael E. DeBakey Library and Museum at the Baylor College of Medicine the following year. DeBakey died in 2008 at the age of 99. During his illustrious career, Cooley founded and is Surgeon-in-Chief and President Emeritus of the Texas Heart Institute; he is Chief of Cardiovascular Surgery at the St. Luke’s Episcopal Hospital, and he is a Clinical Professor of Surgery at the University of Texas Health Science Center in Houston. His numerous awards include the Medal of Freedom, the René Leriche Prize, the National Medal of Technology, and the Boukalev Premium, Russia’s highest award for
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Fig 6. DeBakey operative note.
cardiovascular surgery. In April 2013, Cooley was appointed Distinguished Emeritus Professor at the Baylor College of Medicine (in the Michael E. DeBakey Department of Surgery). Cooley is 93 years old. REFERENCES 1. DeBakey ME. Successful carotid endarterectomy for cerebrovascular insufficiency: nineteen-year follow-up. JAMA 1975;233:1083-5. 2. Cooley DA, Al-Naaman YD, Carton CA. Surgical treatment of arteriosclerotic occlusion of common carotid artery. J Neurosurg 1956;13: 500-6. 3. Cooley DA. Carotid endarterectomy: from first recorded case to present. Texas Heart Inst J 1988;15:139-41.
4. Eastcott HH, Pickering GW, Rob C. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954;2:994-6. 5. DeBakey ME, Crawford ES, Morris GC Jr, Cooley DA. Surgical consideration of occlusive disease of the innominate, carotid, subclavian, and vertebral arteries. Ann Surg 1961;154:698-725. 6. Crawford ES, DeBakey ME. Surgery for strokes. In: Page IH, editor. Strokes. New York: Dutton and Co; 1961. p. 132-53.
Submitted Jul 16, 2014; accepted Aug 6, 2014.
Additional material for this article may be found online at www.jvascsurg.org.
JOURNAL OF VASCULAR SURGERY Volume 60, Number 6
Supplementary Fig 1 (online only). Remainder of letter in Fig 3.
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Supplementary Fig 1 (online only). (continued).
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Supplementary Fig 1 (online only). (continued).
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Supplementary Fig 2 (online only). Remainder of operative note in Fig 6.
The first carotid endarterectomy Steven G. Friedman, MD, MBA, New York, NY
There is no dispute that the first successful carotid artery reconstruction for occlusive disease took place in Buenos Aires in 1951. Neurosurgeon Raul Carrea and his colleagues admitted a 41-year-old man with aphasia and right hemiparesis to the Institute of Experimental Medicine. Two weeks and two angiographic studies later, Carrea and his team partially resected the diseased portion of the internal carotid artery and re-established flow through an external carotid to distal internal carotid artery anastomosis (Fig 1). The patient did well postoperatively and had normal findings on neurologic examination 39 months later. Authorship of the first carotid endarterectomy has been less clear because of a decades-long rivalry between two pioneering cardiac and vascular surgeons: Denton Cooley and Michael DeBakey. DeBakey claimed that he performed the first carotid endarterectomy in August 1953; however, he did not report the case until 1975. In an article in JAMA entitled “Successful Carotid Endarterectomy for Cerebrovascular Insufficiency: Nineteen-Year Follow-up,” DeBakey described the case of a 53-year-old male bus driver with a more than 2-year history of transient ischemic attacks.1 Because DeBakey had had favorable experiences with endarterectomies of arteries in other parts of the body, he was confident that the risk of carotid endarterectomy would be slight. DeBakey performed this procedure with a primary closure, and his patient survived for 19 years without a neurologic event. In March 1956, Cooley admitted a 71-year-old man to Methodist Hospital for complaints of a “swishing” noise in his left ear for 4 months. The patient denied neurologic symptoms and an angiogram revealed a carotid bifurcation stenosis. At surgery, the patient’s head was immersed in From the Department of Surgery, Weill Cornell Medical College. Author conflict of interest: none. Additional material for this article may be found online at www.jvascsurg.org. Reprint requests: Steven G. Friedman, MD, MBA, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065 (e-mail: stf3001@med. cornell.edu). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg 2014;60:1703-8 0741-5214 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.08.059
Fig 1. The first carotid artery reconstructions.
crushed ice and a polyvinyl shunt with needles at both ends was used to bypass the carotid bifurcation. An endarterectomy was performed through a transverse incision at the bifurcation, and it was repaired primarily. Postoperatively, the patient stated that the noises were gone, but he was aphasic and had right hemiparesis. One month later, these symptoms were improving.2 In lectures and at least one subsequent publication, Cooley referred to this procedure as the first successful carotid endarterectomy.3 In a 2001 interview with Cooley, he reaffirmed his belief that the carotid endarterectomy performed at Methodist Hospital was the first of its kind. In support of this, Cooley shared a letter from Felix Eastcott requesting Cooley’s thoughts about this surgical first (Fig 2). Eastcott was preparing for a lecture at the Mayo Clinic about famous vascular operations and wished to acknowledge Cooley’s carotid endarterectomy in addition to the modified Carrea 1703
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Fig 2. Eastcott letter to Cooley.
procedure Eastcott had performed in 19544 (Fig 1). Cooley responded with a detailed description of his case and confessed to misgivings about performing carotid surgery in a patient without neurologic symptoms as well as the use of external brain cooling (Fig 3 and Supplementary Fig 1, online only). Cooley recalled having assisted DeBakey earlier in 1956, in an attempted endarterectomy of an occluded carotid artery, and he recounted this case to me as well. In the original report of the procedure, the carotid artery was clamped for 9 minutes.2 In the letter to Eastcott, carotid occlusion lasted 8 minutes. Cooley also provided 6-month follow-up, at which time his patient had normal findings on neurologic examination. In his cover letter to me, Cooley reiterated doubt about the validity of DeBakey’s 1975 article in JAMA (Fig 4). Shortly after this correspondence with Cooley, DeBakey was asked if he could resolve this discrepancy.
He was specifically asked why he waited 19 years to report his carotid endarterectomy. In a November 2001 letter, DeBakey claimed that it was his practice to acquire sufficient clinical data before rushing into print (Fig 5). He also claimed that he had described this case during a number of visiting lectures after the operation and in publications before the report in JAMA.5,6 Cooley was a coauthor of one of these papers.5 DeBakey also provided a copy of the original operative note, thereby establishing his carotid endarterectomy as the first (Fig 6; Supplementary Fig 2, online only). The feud between DeBakey and Cooley ended in 2007, several days after DeBakey received a Congressional Gold Medal for his towering medical achievements, including innovative operations, creation of mobile army surgical hospital (MASH) units, and
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Fig 3. Cooley response to Eastcott. Complete letter available online at www.jvascsurg.org.
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Fig 4. Cooley letter to Friedman.
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Fig 5. DeBakey letter to Friedman.
helping with the development of the Veterans Administration medical system. In a ceremony at St. Luke’s Episcopal Hospital in Houston, DeBakey accepted a lifetime achievement award from the Denton A. Cooley Cardiovascular Surgical Society. While presenting the award, Cooley reportedly joked, “It must be a heavy burden for one person to be honored by a Congressional Gold Medal and membership in the Cooley Society all in one week.” Less than a year later, Cooley was inducted into the Michael E. DeBakey International Surgery Society. DeBakey expressed relief that they were colleagues and friends again. In 2005, at the age of 97, DeBakey underwent surgical repair of a thoracic aortic dissection, a procedure he had
pioneered decades earlier. He survived the operation and was able to attend the groundbreaking of the Michael E. DeBakey Library and Museum at the Baylor College of Medicine the following year. DeBakey died in 2008 at the age of 99. During his illustrious career, Cooley founded and is Surgeon-in-Chief and President Emeritus of the Texas Heart Institute; he is Chief of Cardiovascular Surgery at the St. Luke’s Episcopal Hospital, and he is a Clinical Professor of Surgery at the University of Texas Health Science Center in Houston. His numerous awards include the Medal of Freedom, the René Leriche Prize, the National Medal of Technology, and the Boukalev Premium, Russia’s highest award for
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Fig 6. DeBakey operative note.
cardiovascular surgery. In April 2013, Cooley was appointed Distinguished Emeritus Professor at the Baylor College of Medicine (in the Michael E. DeBakey Department of Surgery). Cooley is 93 years old. REFERENCES 1. DeBakey ME. Successful carotid endarterectomy for cerebrovascular insufficiency: nineteen-year follow-up. JAMA 1975;233:1083-5. 2. Cooley DA, Al-Naaman YD, Carton CA. Surgical treatment of arteriosclerotic occlusion of common carotid artery. J Neurosurg 1956;13: 500-6. 3. Cooley DA. Carotid endarterectomy: from first recorded case to present. Texas Heart Inst J 1988;15:139-41.
4. Eastcott HH, Pickering GW, Rob C. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet 1954;2:994-6. 5. DeBakey ME, Crawford ES, Morris GC Jr, Cooley DA. Surgical consideration of occlusive disease of the innominate, carotid, subclavian, and vertebral arteries. Ann Surg 1961;154:698-725. 6. Crawford ES, DeBakey ME. Surgery for strokes. In: Page IH, editor. Strokes. New York: Dutton and Co; 1961. p. 132-53.
Submitted Jul 16, 2014; accepted Aug 6, 2014.
Additional material for this article may be found online at www.jvascsurg.org.
JOURNAL OF VASCULAR SURGERY Volume 60, Number 6
Supplementary Fig 1 (online only). Remainder of letter in Fig 3.
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Supplementary Fig 1 (online only). (continued).
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Supplementary Fig 1 (online only). (continued).
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Supplementary Fig 2 (online only). Remainder of operative note in Fig 6.
