Summary of the symposium

These words of wisdom uttered by an internationally recognized expert in the management of carotid arterial occlusive disease reflect the distillation of carefully recorded and interpreted observations based on hundreds of patients over many years. They should be heeded by all who do, or would do, carotid endarterectomy, novice and expert alike. It is a common observation that the great majority of carotid endarterectomy operations are quite successful in bringing relief from transient ischaemic attacks, with an acceptably low perioperative mortality and morbidity. It is probably also a common observation that the dreaded neurological disaster that may follow carotid endarterectomy, despite its rarity, is often a surprise, rarely satisfactorily explained and yields very little substantial information to assist in preventing its reoccurrence. An operative procedure which has been so redefined that mortality is under 1% and its neurological morbidity little more than double that requires the utmost care in the selection ~f every patient and the most meticulous attention to operative technique lest one more death, in a series of, for example, one hundred operations, doubles mortality and morbidity. During a detailed review of our experience with nearly 1000 consecutive carotid endarterectomies, we compared, also from the literature, the best surgical treatment results with the best medical results. We examined a number of surgical series reported in the literature and attempted to identify "practice patterns" common to the best surgical series. We noted methods for the selection and classification of patients, categorization of operative risk, anaesthetic technique and details of the surgical procedure. In each of these series, surgical mortality and morbidity were excellent and nearly identical and in each there were often substantial variations in details of patient management as, for example, general versus local anaesthesia, routine or selective shunting, methods for identification of patients needing a shunt, anaesthet technique, assessment of cardiac risk and other What was common to each of these series, howeve was attention to detail, whatever technique w~ used. The inference from this observation is that tt entire team, neurologist, angiographer, anaesthesi~ logist, cardiologist, etc., and particularly the surgeo~ is of greater importance than a given protocol. A established protocols work well with experts an meticulous attention to every detail yields superk results. The symposium, organized by Professor Fioran amply supports this observation. Cerebral protectic and monitoring are essential to the safe conduct of patient through carotid endarterectomy. Interopen tive embolization, as pointed out by Hans-Marti Becker and Ute Jensen of Munich, Germany, is ce tainly responsible for the majority of cases of neur~ logical deficit during and following surgery. The reminded us, from a study by Bergqvist and assoc ates, that local anaesthesia is associated with actiw tion of the sympathetic nervous system with signit cantly increased levels of plasma adrenaline and no adrenaline. General anaesthesia frequently induc~ hypotensive changes, thus both local and general ai aesthesia have their disadvantages, of importance i patients with increased cardiovascular risk. In tool than 3000 patients routinely receiving general anae,. thesia and routine use of temporary shunts, an monitoring patients with electrocardiogram (EC( and arterial blood pressure, a mortality rate of on] 1.1% was experienced. Half of these were caused b myocardial and half by cerebral infarctions. In a seri~ of 1781 patients, over the course of 7 years, the 30 da transient neurological deficit was 1.4% and perm~ nent defects only 0.6%. These are splendid result~ equal to those reported by any other vascular surgic~ center. Professor Pistolese and his associates point ot