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Letters to the Editor

there is unilateral or bilateral disease, and, on occasion, whether there is intracerebral disease as well. The data obtained from these studies will elicit a figure which one may also consider as stump pressure when properly elicited. However, the most important feature of the operative planning involves an arteriogram which is the blueprint for the surgeon. This will delineate the extent of the disease extracranially as well as intracranially, the possible bilaterality of involvement of the carotids as well as the vertebrals. Then the decision as to the operation can be made. We have for some time eschewed, along with others, notably Thompson and more recently Rich, the almost routine use of the intraoperative shunt during any form of carotid endarterectomy procedure. In certain instances we have resorted to and would advocate the use of hypothermia when extensive disease of the contralateral carotid and the vertebral arteries is involved. This may be an over-embellishment, but we consider it quite an important adjunct. The use of the arterial shunt eliminates the need for athetoid movements by the surgeon and his assistants in their haste to extract the plug, it provides continuous perfusion during the operative procedure and allows a meticulous surgical exercise to take place.* Additionally, we have long espoused the use of a patch graft repair when an extensive endarterectomy has been carried out. This because (a) we feel that the incision should be carried well up into the internal carotid beyond the site of pathology, and (b) from past studies and experience, we are aware that end-arterectomized vessels, like all other traumatized tissue, will gradually cicatrize so that the ultimate lumen size may be less than optimal. We have had no cause to regret this. One of the hallmarks of the careful surgeon is to recognize the fact that when an ulcerated plaque has been demonstrated, it is possible to dislodge a clot or piece of detritus during the operation which will lead to an intraoperative stroke. This can be avoided by careful dissection above and below the bifurcation, taking immediate pains to insert a shunt before completely freeing up the region of the bifurcation itself. What we are suggesting, then, is that a fairly stereotyped form of attack be planned for every patient selected for carotid endarterectomy. Also, that operative procedures be subjected to a checklist before, during and ending, much as the captain of an airliner does before beginning his takeoff roll. This paper reflects no cohesiveness in thought, planning or attack, of the various surgeons on many aspects of carotid surgery, but rather points out the disastrous results from a jumbled mass of data which do not lend themselves to appropriate statistical analysis. These remarks are made in a constructive sense and hopefully will allay the apprehension and anxiety which many of the neurologists and other physicians involved in this disease process may experience after having read this article. In a series which now approximates some 200 cases involving every possible type of carotid disease, our