Karen M. Dente

NEW YORK – Compelling research supports the link between psychological stress and specific skin and allergic disorders, Dr. Rosalind J. Wright said at a dermatology symposium sponsored by Cornell University.

“There is huge biological plausibility to think that there is this psycho-neuro-cutaneous-immunology link to suggest that there is interconnection between these systems, and one important effector organ is the skin,” said Dr. Wright of the department of society, human development, and health at Harvard School of Public Health, Boston.

Atopic dermatitis shows dysregulation of the responsiveness of the hypothalamic-pituitary-adrenal (HPA) axis. “Studies done across the age spectrum show that inpatients with atopic dermatitis seem to have a blunted cortisol response to different types of challenges” when compared with nonatopic dermatitis patients, said Dr. Wright, also of Brigham and Women's Hospital.

Atopic dermatitis is known to start in early childhood. The early experiences shape the stress vulnerability of the older child and adult later in life. “Not only early childhood, but even prenatal exposure to stress is a very critical period of development,” she said.

“There is huge plasticity of the HPA axis early in life. Early experiences in rat experiments–and this has been done in humans as well–also with respect to prenatal stress, show programming of the HPA response in the child postnatally. In animal experiments, social buffering of newborns by the mother seems to dampen the cortisol response,” Dr. Wright said.

In human studies, there seems to be a parallel response. Exposing mothers to stress has been demonstrated to alter the immune function of their children, she noted.

A National Institutes of Health-funded prospective birth cohort study involving a total of 499 mothers recruited at Brigham and Women's at the time of giving birth used asthma to evaluate the external influence of elevated stress on the development of children's immune systems. The patients were genetically predisposed for atopic dermatitis and allergic dermatoses. The question that the investigators hoped to answer was whether stress primed the immune system toward a T helper cell-type pattern of immune response, as is typically seen in allergic dermatoses.

Families with a predisposition to allergic response were followed prospectively every 2 months to see if the children had any clinical manifestations of atopic disease.. “Results indicated that higher caregiver stress predicted a phenotype of early asthma,” Dr. Wright said. Dose-response relationship was seen between a measure of perceived stress over time and the clinical manifestations of wheeze.

Serum IgE, which is a marker for susceptibility to atopic dermatitis, was measured in the blood of children, and high-stress households were associated with elevated levels of IgE expression in their children.

When children were evaluated up to age 6 years, a correlation between stress and eczema was also demonstrated.

“We need to get back to treating the whole patient,” Dr. Wright urged. As a physician, she has seen emotional response and stress affecting the disease process and clinical response to treatment in her patients and said she is fortunate to be able to send patients to the Mind-Body Institute at Beth Israel Deaconess Center in Boston to learn relaxation therapies.

NEW YORK – Compelling research supports the link between psychological stress and specific skin and allergic disorders, Dr. Rosalind J. Wright said at a dermatology symposium sponsored by Cornell University.

“There is huge biological plausibility to think that there is this psycho-neuro-cutaneous-immunology link to suggest that there is interconnection between these systems, and one important effector organ is the skin,” said Dr. Wright of the department of society, human development, and health at Harvard School of Public Health, Boston.

Atopic dermatitis shows dysregulation of the responsiveness of the hypothalamic-pituitary-adrenal (HPA) axis. “Studies done across the age spectrum show that inpatients with atopic dermatitis seem to have a blunted cortisol response to different types of challenges” when compared with nonatopic dermatitis patients, said Dr. Wright, also of Brigham and Women's Hospital.

Atopic dermatitis is known to start in early childhood. The early experiences shape the stress vulnerability of the older child and adult later in life. “Not only early childhood, but even prenatal exposure to stress is a very critical period of development,” she said.

“There is huge plasticity of the HPA axis early in life. Early experiences in rat experiments–and this has been done in humans as well–also with respect to prenatal stress, show programming of the HPA response in the child postnatally. In animal experiments, social buffering of newborns by the mother seems to dampen the cortisol response,” Dr. Wright said.

In human studies, there seems to be a parallel response. Exposing mothers to stress has been demonstrated to alter the immune function of their children, she noted.

A National Institutes of Health-funded prospective birth cohort study involving a total of 499 mothers recruited at Brigham and Women's at the time of giving birth used asthma to evaluate the external influence of elevated stress on the development of children's immune systems. The patients were genetically predisposed for atopic dermatitis and allergic dermatoses. The question that the investigators hoped to answer was whether stress primed the immune system toward a T helper cell-type pattern of immune response, as is typically seen in allergic dermatoses.

Families with a predisposition to allergic response were followed prospectively every 2 months to see if the children had any clinical manifestations of atopic disease.. “Results indicated that higher caregiver stress predicted a phenotype of early asthma,” Dr. Wright said. Dose-response relationship was seen between a measure of perceived stress over time and the clinical manifestations of wheeze.

Serum IgE, which is a marker for susceptibility to atopic dermatitis, was measured in the blood of children, and high-stress households were associated with elevated levels of IgE expression in their children.

When children were evaluated up to age 6 years, a correlation between stress and eczema was also demonstrated.

“We need to get back to treating the whole patient,” Dr. Wright urged. As a physician, she has seen emotional response and stress affecting the disease process and clinical response to treatment in her patients and said she is fortunate to be able to send patients to the Mind-Body Institute at Beth Israel Deaconess Center in Boston to learn relaxation therapies.

NEW YORK – Compelling research supports the link between psychological stress and specific skin and allergic disorders, Dr. Rosalind J. Wright said at a dermatology symposium sponsored by Cornell University.

“There is huge biological plausibility to think that there is this psycho-neuro-cutaneous-immunology link to suggest that there is interconnection between these systems, and one important effector organ is the skin,” said Dr. Wright of the department of society, human development, and health at Harvard School of Public Health, Boston.

Atopic dermatitis shows dysregulation of the responsiveness of the hypothalamic-pituitary-adrenal (HPA) axis. “Studies done across the age spectrum show that inpatients with atopic dermatitis seem to have a blunted cortisol response to different types of challenges” when compared with nonatopic dermatitis patients, said Dr. Wright, also of Brigham and Women's Hospital.

Atopic dermatitis is known to start in early childhood. The early experiences shape the stress vulnerability of the older child and adult later in life. “Not only early childhood, but even prenatal exposure to stress is a very critical period of development,” she said.

“There is huge plasticity of the HPA axis early in life. Early experiences in rat experiments–and this has been done in humans as well–also with respect to prenatal stress, show programming of the HPA response in the child postnatally. In animal experiments, social buffering of newborns by the mother seems to dampen the cortisol response,” Dr. Wright said.

In human studies, there seems to be a parallel response. Exposing mothers to stress has been demonstrated to alter the immune function of their children, she noted.

A National Institutes of Health-funded prospective birth cohort study involving a total of 499 mothers recruited at Brigham and Women's at the time of giving birth used asthma to evaluate the external influence of elevated stress on the development of children's immune systems. The patients were genetically predisposed for atopic dermatitis and allergic dermatoses. The question that the investigators hoped to answer was whether stress primed the immune system toward a T helper cell-type pattern of immune response, as is typically seen in allergic dermatoses.

Families with a predisposition to allergic response were followed prospectively every 2 months to see if the children had any clinical manifestations of atopic disease.. “Results indicated that higher caregiver stress predicted a phenotype of early asthma,” Dr. Wright said. Dose-response relationship was seen between a measure of perceived stress over time and the clinical manifestations of wheeze.

Serum IgE, which is a marker for susceptibility to atopic dermatitis, was measured in the blood of children, and high-stress households were associated with elevated levels of IgE expression in their children.

When children were evaluated up to age 6 years, a correlation between stress and eczema was also demonstrated.

“We need to get back to treating the whole patient,” Dr. Wright urged. As a physician, she has seen emotional response and stress affecting the disease process and clinical response to treatment in her patients and said she is fortunate to be able to send patients to the Mind-Body Institute at Beth Israel Deaconess Center in Boston to learn relaxation therapies.

MIAMI — "The new endovenous techniques such as foam sclerotherapy have made small dysfunctional veins easy to obliterate," said Dr. John J. Bergan of Scripps Memorial Hospital, La Jolla, Calif., who gave a presentation about foam sclerotherapy for the treatment of varicose veins at the annual meeting of the American Venous Forum.

"Foam can be used for nearly anything. Unlike laser radiofrequency treatment, foam will go into any peripheral vein and flow into the accessory saphenous vein," Dr. Bergan said.

"Ultrasound-guided foam sclerotherapy is very good. The small saphenous veins are very easy to close," agreed Dr. Neil S. Sadick of Cornell University in New York.

The foam for the procedure can be made from detergent agents such as Sotradecol and polidocanol at any concentration from 0.25% to 3% with a mixing ratio of 1:4 using room air.

It can be used from the skin down to any vein segment. "One of the easiest procedures there are is the treatment of the tangle of superficial veins underneath ulcers, that can best be treated using foam sclerotherapy," said Dr. Bergan.

Foam heals ulcers in weeks, he explained, referring to this new procedure as a "dramatic change in treatment."

Increasing numbers of patients are appearing who have recurring symptoms after previous laser therapy.

"About one-third of patients with laser therapy will need to have treatment for recurring varices," Dr. Bergan noted. "But about one-third will have a return of symptoms—these can be successfully treated with foam."

Another great advantage of foam sclerotherapy is the avoidance of surgery to the small saphenous vein and prevention of sural nerve injury.

Severe complications that occur as a result of foam sclerotherapy are rare, and can include migraine from bits of foam reaching the extracranial circulation to the brain.

The usual side effects of sclerotherapy include matting, superficial thrombi, and residual pigmentation, he said at the meeting.

Dr. Bergan stressed the need to carefully evaluate for abnormal vein segments in each patient before commencing treatment, especially in those with Turner's or Klippel-Feil syndrome, who have a higher chance of presenting with venous malformations.

"You must also be very careful with other patients who may have other conditions," he cautioned.

"Sclerosant foam is cheap, painless, simple, and not disabling," Dr. Bergan explained.

He stressed the need for standardization of treatment methods with the advent of such new therapies that are being proved efficacious.

MIAMI — "The new endovenous techniques such as foam sclerotherapy have made small dysfunctional veins easy to obliterate," said Dr. John J. Bergan of Scripps Memorial Hospital, La Jolla, Calif., who gave a presentation about foam sclerotherapy for the treatment of varicose veins at the annual meeting of the American Venous Forum.

"Foam can be used for nearly anything. Unlike laser radiofrequency treatment, foam will go into any peripheral vein and flow into the accessory saphenous vein," Dr. Bergan said.

"Ultrasound-guided foam sclerotherapy is very good. The small saphenous veins are very easy to close," agreed Dr. Neil S. Sadick of Cornell University in New York.

The foam for the procedure can be made from detergent agents such as Sotradecol and polidocanol at any concentration from 0.25% to 3% with a mixing ratio of 1:4 using room air.

It can be used from the skin down to any vein segment. "One of the easiest procedures there are is the treatment of the tangle of superficial veins underneath ulcers, that can best be treated using foam sclerotherapy," said Dr. Bergan.

Foam heals ulcers in weeks, he explained, referring to this new procedure as a "dramatic change in treatment."

Increasing numbers of patients are appearing who have recurring symptoms after previous laser therapy.

"About one-third of patients with laser therapy will need to have treatment for recurring varices," Dr. Bergan noted. "But about one-third will have a return of symptoms—these can be successfully treated with foam."

Another great advantage of foam sclerotherapy is the avoidance of surgery to the small saphenous vein and prevention of sural nerve injury.

Severe complications that occur as a result of foam sclerotherapy are rare, and can include migraine from bits of foam reaching the extracranial circulation to the brain.

The usual side effects of sclerotherapy include matting, superficial thrombi, and residual pigmentation, he said at the meeting.

Dr. Bergan stressed the need to carefully evaluate for abnormal vein segments in each patient before commencing treatment, especially in those with Turner's or Klippel-Feil syndrome, who have a higher chance of presenting with venous malformations.

"You must also be very careful with other patients who may have other conditions," he cautioned.

"Sclerosant foam is cheap, painless, simple, and not disabling," Dr. Bergan explained.

He stressed the need for standardization of treatment methods with the advent of such new therapies that are being proved efficacious.

MIAMI — "The new endovenous techniques such as foam sclerotherapy have made small dysfunctional veins easy to obliterate," said Dr. John J. Bergan of Scripps Memorial Hospital, La Jolla, Calif., who gave a presentation about foam sclerotherapy for the treatment of varicose veins at the annual meeting of the American Venous Forum.

"Foam can be used for nearly anything. Unlike laser radiofrequency treatment, foam will go into any peripheral vein and flow into the accessory saphenous vein," Dr. Bergan said.

"Ultrasound-guided foam sclerotherapy is very good. The small saphenous veins are very easy to close," agreed Dr. Neil S. Sadick of Cornell University in New York.

The foam for the procedure can be made from detergent agents such as Sotradecol and polidocanol at any concentration from 0.25% to 3% with a mixing ratio of 1:4 using room air.

It can be used from the skin down to any vein segment. "One of the easiest procedures there are is the treatment of the tangle of superficial veins underneath ulcers, that can best be treated using foam sclerotherapy," said Dr. Bergan.

Foam heals ulcers in weeks, he explained, referring to this new procedure as a "dramatic change in treatment."

Increasing numbers of patients are appearing who have recurring symptoms after previous laser therapy.

"About one-third of patients with laser therapy will need to have treatment for recurring varices," Dr. Bergan noted. "But about one-third will have a return of symptoms—these can be successfully treated with foam."

Another great advantage of foam sclerotherapy is the avoidance of surgery to the small saphenous vein and prevention of sural nerve injury.

Severe complications that occur as a result of foam sclerotherapy are rare, and can include migraine from bits of foam reaching the extracranial circulation to the brain.

The usual side effects of sclerotherapy include matting, superficial thrombi, and residual pigmentation, he said at the meeting.

Dr. Bergan stressed the need to carefully evaluate for abnormal vein segments in each patient before commencing treatment, especially in those with Turner's or Klippel-Feil syndrome, who have a higher chance of presenting with venous malformations.

"You must also be very careful with other patients who may have other conditions," he cautioned.

"Sclerosant foam is cheap, painless, simple, and not disabling," Dr. Bergan explained.

He stressed the need for standardization of treatment methods with the advent of such new therapies that are being proved efficacious.

NEW YORK — Although carotid angioplasty and stenting have emerged as treatment alternative to carotid artery stenosis, there are still unavoidable complications associated with the procedures.

Both embolization and hypotension during the carotid angioplasty and stenting (CAS) have been linked to neurologic injury, and the current standard remains carotid endarterectomy (CEA), said Dr. Peter H. Lin at the Veith symposium on vascular medicine sponsored by Montefiore Medical Center.

Stroke after CAS is assumed to be embolic. “Disruption of atherosclerotic plaque is a disadvantage with carotid stenting. There are eight times more embolizations seen with CAS than with CEA,” said Dr. Lin of Baylor College of Medicine, Houston. “Neurologic deficit remains the most feared of all procedure-related complications.”

Dr. Lin and colleagues conducted a study showing the significance of carotid plaque echomorphology in assessing the embolization risk during CAS. Results from a total of 234 CAS procedures performed in 213 patients with a mean stenosis of 85% showed that the incidence of embolization was increased with hypoechoic plaque. The researchers concluded that that neuroprotective devices should be used in such procedures.

At the session, Dr. Klaus D. Mathias agreed that embolic injury to the brain is the main problem associated with carotid stenting procedures. “Clinically silent embolic showers occur frequently during CAS. Any phase of stenting can produce emboli, which is not good for the brain. There is 3–5 times more embolic material released to the brain with unprotected carotid stenting than with surgery,” said Dr. Mathias of the department of radiology at Klinikum Dortmund (Germany).

According to Dr. Mathias, filter protection is the preferred embolic protective device. A 60% reduction in complications from 3.5% to 1.5% has been reported in previous studies of neuroprotective filters. “The German PROCAS registry showed a 30%–60% reduction in neurologic events with protective filters, but we are still missing prospective trials,” said Dr. Mathias.

Another feared periprocedural complication leading to neurologic injury is hypotension. “Hemodynamic changes are common events during CAS and CEA, occurring in up to 30% of patients,” said Marc van Sambeek, Ph.D., head of the section of vascular surgery at University Hospital, Rotterdam (the Netherlands).

Hypotension, if sufficiently severe, may cause watershed infarction. Lesser degrees of hypotension may render an otherwise inconsequential microembolic shower very relevant if washout is impaired washout, and also lead to a reduction in adequate collateral blood flow to an ischemic territory in the brain.

Hemodynamic instability is well recognized in patients after endarterectomy, where postoperative hypertension has been known to be associated with stroke or death, and studies suggest that CEA is also associated with hypotension. CAS is being investigated as a promising alternative, but despite favorable results from initial series, hemodynamic instability may complicate this procedure,” said Dr. Sambeek.

Hemodynamic instability can be caused by the triggering of baroreceptors of the carotid sinus, as well as the release of catecholamines. “Hemodynamic instability is greater during CAS than in CEA,” said Dr. Sambeek. “Complications are clearly related to hypotension and bradycardia during the procedure.”

In a study presented at the meeting, Dr. Sambeek and colleagues evaluated the patterns of adrenaline and noradrenaline release in CAS, compared with CEA. They found that patterns of catecholamine release were significantly different in patients undergoing CAS and CEA with much higher and more variable surges occurring in CEA patients.

“CAS should be performed with cerebral protection using filter devices,” said Dr. Ron Fairman, chief of the division of vascular surgery at the Hospital of the University of Pennsylvania, Philadelphia, when asked to comment on this article.“In our own series, we have experienced occasional hypotension requiring continuous pharmacologic support for 24–36 hours following CAS. Other troubling phenomenon include troponin “leaks” in association with hypotension, as well as symptoms of cerebral reperfusion which seem to occur with greater frequency than following CEA. Physicians should anticipate these events and be prepared to intervene in order to prevent cardiac and cerebral compromise” he concluded.

NEW YORK — Although carotid angioplasty and stenting have emerged as treatment alternative to carotid artery stenosis, there are still unavoidable complications associated with the procedures.

Both embolization and hypotension during the carotid angioplasty and stenting (CAS) have been linked to neurologic injury, and the current standard remains carotid endarterectomy (CEA), said Dr. Peter H. Lin at the Veith symposium on vascular medicine sponsored by Montefiore Medical Center.

Stroke after CAS is assumed to be embolic. “Disruption of atherosclerotic plaque is a disadvantage with carotid stenting. There are eight times more embolizations seen with CAS than with CEA,” said Dr. Lin of Baylor College of Medicine, Houston. “Neurologic deficit remains the most feared of all procedure-related complications.”

Dr. Lin and colleagues conducted a study showing the significance of carotid plaque echomorphology in assessing the embolization risk during CAS. Results from a total of 234 CAS procedures performed in 213 patients with a mean stenosis of 85% showed that the incidence of embolization was increased with hypoechoic plaque. The researchers concluded that that neuroprotective devices should be used in such procedures.

At the session, Dr. Klaus D. Mathias agreed that embolic injury to the brain is the main problem associated with carotid stenting procedures. “Clinically silent embolic showers occur frequently during CAS. Any phase of stenting can produce emboli, which is not good for the brain. There is 3–5 times more embolic material released to the brain with unprotected carotid stenting than with surgery,” said Dr. Mathias of the department of radiology at Klinikum Dortmund (Germany).

According to Dr. Mathias, filter protection is the preferred embolic protective device. A 60% reduction in complications from 3.5% to 1.5% has been reported in previous studies of neuroprotective filters. “The German PROCAS registry showed a 30%–60% reduction in neurologic events with protective filters, but we are still missing prospective trials,” said Dr. Mathias.

Another feared periprocedural complication leading to neurologic injury is hypotension. “Hemodynamic changes are common events during CAS and CEA, occurring in up to 30% of patients,” said Marc van Sambeek, Ph.D., head of the section of vascular surgery at University Hospital, Rotterdam (the Netherlands).

Hypotension, if sufficiently severe, may cause watershed infarction. Lesser degrees of hypotension may render an otherwise inconsequential microembolic shower very relevant if washout is impaired washout, and also lead to a reduction in adequate collateral blood flow to an ischemic territory in the brain.

Hemodynamic instability is well recognized in patients after endarterectomy, where postoperative hypertension has been known to be associated with stroke or death, and studies suggest that CEA is also associated with hypotension. CAS is being investigated as a promising alternative, but despite favorable results from initial series, hemodynamic instability may complicate this procedure,” said Dr. Sambeek.

Hemodynamic instability can be caused by the triggering of baroreceptors of the carotid sinus, as well as the release of catecholamines. “Hemodynamic instability is greater during CAS than in CEA,” said Dr. Sambeek. “Complications are clearly related to hypotension and bradycardia during the procedure.”

In a study presented at the meeting, Dr. Sambeek and colleagues evaluated the patterns of adrenaline and noradrenaline release in CAS, compared with CEA. They found that patterns of catecholamine release were significantly different in patients undergoing CAS and CEA with much higher and more variable surges occurring in CEA patients.

“CAS should be performed with cerebral protection using filter devices,” said Dr. Ron Fairman, chief of the division of vascular surgery at the Hospital of the University of Pennsylvania, Philadelphia, when asked to comment on this article.“In our own series, we have experienced occasional hypotension requiring continuous pharmacologic support for 24–36 hours following CAS. Other troubling phenomenon include troponin “leaks” in association with hypotension, as well as symptoms of cerebral reperfusion which seem to occur with greater frequency than following CEA. Physicians should anticipate these events and be prepared to intervene in order to prevent cardiac and cerebral compromise” he concluded.

NEW YORK — Although carotid angioplasty and stenting have emerged as treatment alternative to carotid artery stenosis, there are still unavoidable complications associated with the procedures.

Both embolization and hypotension during the carotid angioplasty and stenting (CAS) have been linked to neurologic injury, and the current standard remains carotid endarterectomy (CEA), said Dr. Peter H. Lin at the Veith symposium on vascular medicine sponsored by Montefiore Medical Center.

Stroke after CAS is assumed to be embolic. “Disruption of atherosclerotic plaque is a disadvantage with carotid stenting. There are eight times more embolizations seen with CAS than with CEA,” said Dr. Lin of Baylor College of Medicine, Houston. “Neurologic deficit remains the most feared of all procedure-related complications.”

Dr. Lin and colleagues conducted a study showing the significance of carotid plaque echomorphology in assessing the embolization risk during CAS. Results from a total of 234 CAS procedures performed in 213 patients with a mean stenosis of 85% showed that the incidence of embolization was increased with hypoechoic plaque. The researchers concluded that that neuroprotective devices should be used in such procedures.

At the session, Dr. Klaus D. Mathias agreed that embolic injury to the brain is the main problem associated with carotid stenting procedures. “Clinically silent embolic showers occur frequently during CAS. Any phase of stenting can produce emboli, which is not good for the brain. There is 3–5 times more embolic material released to the brain with unprotected carotid stenting than with surgery,” said Dr. Mathias of the department of radiology at Klinikum Dortmund (Germany).

According to Dr. Mathias, filter protection is the preferred embolic protective device. A 60% reduction in complications from 3.5% to 1.5% has been reported in previous studies of neuroprotective filters. “The German PROCAS registry showed a 30%–60% reduction in neurologic events with protective filters, but we are still missing prospective trials,” said Dr. Mathias.

Another feared periprocedural complication leading to neurologic injury is hypotension. “Hemodynamic changes are common events during CAS and CEA, occurring in up to 30% of patients,” said Marc van Sambeek, Ph.D., head of the section of vascular surgery at University Hospital, Rotterdam (the Netherlands).

Hypotension, if sufficiently severe, may cause watershed infarction. Lesser degrees of hypotension may render an otherwise inconsequential microembolic shower very relevant if washout is impaired washout, and also lead to a reduction in adequate collateral blood flow to an ischemic territory in the brain.

Hemodynamic instability is well recognized in patients after endarterectomy, where postoperative hypertension has been known to be associated with stroke or death, and studies suggest that CEA is also associated with hypotension. CAS is being investigated as a promising alternative, but despite favorable results from initial series, hemodynamic instability may complicate this procedure,” said Dr. Sambeek.

Hemodynamic instability can be caused by the triggering of baroreceptors of the carotid sinus, as well as the release of catecholamines. “Hemodynamic instability is greater during CAS than in CEA,” said Dr. Sambeek. “Complications are clearly related to hypotension and bradycardia during the procedure.”

In a study presented at the meeting, Dr. Sambeek and colleagues evaluated the patterns of adrenaline and noradrenaline release in CAS, compared with CEA. They found that patterns of catecholamine release were significantly different in patients undergoing CAS and CEA with much higher and more variable surges occurring in CEA patients.

“CAS should be performed with cerebral protection using filter devices,” said Dr. Ron Fairman, chief of the division of vascular surgery at the Hospital of the University of Pennsylvania, Philadelphia, when asked to comment on this article.“In our own series, we have experienced occasional hypotension requiring continuous pharmacologic support for 24–36 hours following CAS. Other troubling phenomenon include troponin “leaks” in association with hypotension, as well as symptoms of cerebral reperfusion which seem to occur with greater frequency than following CEA. Physicians should anticipate these events and be prepared to intervene in order to prevent cardiac and cerebral compromise” he concluded.