Since the 1950s carotid endarterectomy has been performed in patients with symptomatic carotid artery stenosis, based on suggestive but inconclusive evidence for its effectiveness. Only during the last 5 years have randomized studies clarified the indications for surgery. In preparing this report, panel members used the same rules of evidence used in the previous report1 2 (Table⇓).

View this table:

 Table 1. 
Levels of Evidence and Grading of Recommendations



Few studies have analyzed control of risk factors in a randomized, prospective manner following carotid endarterectomy. However, a wealth of data are available regarding the general relationship between risk factor control and stroke risk. These data provide some guidance for the care of endarterectomy patients.

### Hypertension

Hypertension is the most powerful, prevalent, and treatable risk factor for stroke.3 Both systolic and diastolic blood pressure are independently related to stroke incidence. Isolated systolic hypertension, which is common in the elderly, also considerably increases risk of stroke. Reduction of elevated blood pressure significantly lowers risk of stroke. Meta-analyses of randomized trials found that an average reduction in diastolic blood pressure of 6 mm Hg produces a 42% reduction in stroke incidence.3 4 Treatment of isolated systolic hypertension in people older than 60 years also reduces stroke incidence by 36% without an excessive number of side effects such as depression or dementia.5 Long-term care of patients after endarterectomy should include careful control of hypertension (Grade A recommendation for treatment of hypertension in general; Grade C recommendation for postendarterectomy care).

Perioperative treatment of hypertension after carotid endarterectomy represents a special situation. Poor control of blood pressure after endarterectomy increases risk of cerebral hyperperfusion syndrome.6 7 8 9 This complication is characterized by unilateral headache, seizures, and occasionally altered mental status or focal neurological signs. Neuroimaging may show intracerebral hemorrhages10 11 12 or white …

Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association

Background and Purpose Indications for carotid endarterectomy have engendered considerable debate among experts and have resulted in publication of retrospective reviews, natural history studies, audits of community practice, position papers, expert opinion statements, and finally prospective randomized trials. The American Heart Association assembled a group of experts in a multidisciplinary consensus conference to develop this statement. Methods A conference was held July 16-18, 1993, in Park City, Utah, that included recognized experts in neurology, neurosurgery, vascular surgery, and healthcare planning. A program of critical topics was developed, and each expert presented a talk and provided the chairman with a summary statement. From these summary statements a document was developed and edited onsite to achieve consensus before final revision. Results The first section of this document reviews the natural history, methods of patient evaluation, options for medical management, results of surgical man...

Guidelines for Carotid Endarterectomy A Multidisciplinary Consensus Statement From the Ad Hoc Committee, American Heart Association

Guidelines for carotid endarterectomy: a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association.

Background Baroreflexes originate in the great vessels of the neck and thorax and prevent arterial pressure from rising or falling excessively. Methods This study was undertaken to clarify the cause, clinical spectrum, and therapy of this disorder. We studied 11 patients with baroreflex failure presenting as severe, labile hypertension and hypotension, often with headache, diaphoresis, and emotional instability, and characterized by the failure of exogenous vasoactive substances to alter heart rate. Each underwent hemodynamic monitoring and biochemical, physiologic, and pharmacologic testing. Results The patients' maximal systolic blood pressures ranged from 164 to 280 mm Hg, and their minimal systolic pressures ranged from 58 to 96 mm Hg. Plasma norepinephrine and epinephrine concentrations were sometimes many times normal during blood-pressure surges. All the patients had excessive pressor and tachycardic responses to the mental-arithmetic and cold pressor tests and marked hypersensitivity to clonidine....

The diagnosis and treatment of baroreflex failure.

Background A multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk. Methods A modified Delphi technique was used, evaluating papers published in MEDLINE on associations between preoperative numerical arterial pressure values or cardiovascular medications and perioperative outcomes. The strength of the recommendations was graded by National Institute for Health and Care Excellence guidelines. Results Significant heterogeneity in study design, including arterial pressure measures and perioperative outcomes, hampered the comparison of studies. Nonetheless, consensus recommendations were that (i) preoperative arterial pressure measures may be used to define targets for perioperative management; (ii) elective surgery should not be cancelled based solely upon a preoperative arterial pressure value; (iii) there is insufficient evidence to support lowering arterial pressure in the immediate preoperative period to minimise perioperative risk; and (iv) there is insufficient evidence that any one measure of arterial pressure (systolic, diastolic, mean, or pulse) is better than any other for risk prediction of adverse perioperative events. Conclusions Future research should define which preoperative arterial pressure values best correlate with adverse outcomes, and whether modifying arterial pressure in the preoperative setting will change the perioperative morbidity or mortality. Additional research should define optimum strategies for continuation or discontinuation of preoperative cardiovascular medications.

Perioperative Quality Initiative consensus statement on preoperative blood pressure, risk and outcomes for elective surgery

Hypotension and hypertension as consequences of baroreceptor dysfunction following carotid endarterectomy.

• Forty-eight arterial reconstructions were performed for chronic upper extremity ischemia in 43 patients, aged 31 to 81 years. Diagnostic arterial catheterization was the most frequent cause of symptomatic occlusion, followed by proximal arteriosclerotic lesions and noniatrogenic trauma. Doppler ultrasound evaluation provided important diagnostic and prognostic data that complemented information derived from arteriography. Indications for operation included disabling claudication (39 cases) or digital gangrene (four cases). Restoration of normal extremity function can be anticipated except in instances where poor forearm runoff exists. Autogenous saphenous and basilic interposition vein grafts have proved excellent for axillary-brachial revascularizations. Axillary-axillary bypass procedures for innominate-subclavian artery occlusions appear hemodynamically sound and technically simple. Follow-up, averaging 48 months, extended to 144 months. Late vein graft failure or progressive distal occlusive disease was not encountered. (Arch Surg113:419-423, 1978)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=SURG&articleId=583892&pdfFileName=archsurg_113_4_012.pdf

Chronic Upper Extremity Arterial Insufficiency: Etiology, Manifestations, and Operative Management

Although the popliteal arteries are the most common sites of peripheral arterial aneurysms, their detection often goes unrecognized until complications evolve. Inasmuch as surgical therapy prior to development of complications offers the greatest benefit to patients, early diagnosis becomes an important cornerstone in their management.

https://www.ajronline.org/doi/pdfplus/10.2214/ajr.129.6.1003

Gray Scale Ultrasound Evaluation of Popliteal Artery Aneurysms

Records of 160 emergency department patients with lower extremity complaints were reviewed to determine the economic and therapeutic impact of noninvasive venous impedance testing. Venograms obtained in 86 extremities were used to determine diagnostic accuracy. The incidence of pulmonary thromboembolic events, postphlebitic syndrome and complications of anticoagulation was ascertained. Outflow impedance testing correctly identified all patients with deep venous thrombosis and overall diagnostic accuracy was 95% (41/43 patients). In 123 patients (33 positive results, 90 negative) therapeutic decisions were based solely on impedance test results. Examination required 20 to 30 minutes at a cost of $35. Follow-up ranging from 4 to 60 weeks failed to reveal documented thromboembolic complications or recurrence of lower extremity symptoms. In 37 patients (six positive results, 31 negative) impedance test results were ignored and inpatient workup, including invasive venography, was undertaken. Hospital charges for these patients averaged $1,500. In addition to its ease of performance and high degree of accuracy, comparison with inpatient evaluation documents its cost effectiveness. Impedance testing for emergency department evaluation of suspected deep vein thrombosis appears appropriate.

Therapeutic and economic implications of emergency department evaluation for venous thrombosis

Thirty-eight patients were studied because of symptoms thought to be vascular in origin. In 18 patients in whom angiography was performed, the presence or absence of hemodynamically significant vascular occlusive lesions was predicted correctly by Doppler ultrasound techniques. Normal Doppler studies in the remaining 20 patients expedited nonvascular diagnostic evaluation and treatment and helped to avoid unnecessary angiography. Studies required 15 to 20 minutes and no complications occurred. Noninvasive Doppler evaluation is inexpensive, free of risk, and provides an accurate means of determining alterations in upper extremety hemodynamics.

William S. Gross

Papers

Hypotension and hypertension as consequences of baroreceptor dysfunction following carotid endarterectomy.

Chronic Upper Extremity Arterial Insufficiency: Etiology, Manifestations, and Operative Management

Gray Scale Ultrasound Evaluation of Popliteal Artery Aneurysms

Therapeutic and economic implications of emergency department evaluation for venous thrombosis

Doppler hemodynamic assessment of obscure symptomatology in the upper extremity.