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Peripheral arterial disease (PAD) affects more than 10 million people in the United States. The risk factors as- sociated with PAD are similar to those for coronary heart disease (CHD) and cerebrovascular disease (CVD )[4,7]. Medical therapy of PAD must include modification of vascular risk factors with application of strict secondary prevention guidelines [7].

Intraoperative assessment of technical adequacy is a nec- essary part of all arterial reconstructions. Detection of any technical imperfection in the operating room allows the surgeon to provide immediate correction of the abnor- malities that may lead to early thrombosis. Technical im- perfection accounts for about 2.4–26% of all failures ac- cording to different studies [6]. In the past most surgeons used to check the reconstruction through the palpation of a pulse in the vessel distal to the anastomosis; only later was continuous wave (CW) Doppler adopted, providing data on the physiology of the reconstruction (flow veloc- ity). Intraoperative angiography was introduced in the 1970s, thus providing information on the morphology of the by-pass. In recent years duplex scan and colour du- plex scan have been widely used, thus permitting us to check the reconstruction for its physiological and mor- phological parameters (vessel wall and lumen).

The brain’s ability to keep cerebral blood flow (CBF) rela- tively constant despite changes in systemic blood pressure (BP) is due to cerebrovascular autoregulation. The actual cerebral perfusion pressure (CPP) depends on the BP and the intracranial pressure (ICP).

Ischaemic stroke represents a major health problem and an important cause of morbidity and mortality in several western countries [12]. Mortality from stroke ranges be- tween 10% and 30% [61] and its survivors remain at a high annual risk of recurrent ischaemic events and mor- tality both from myocardial infarct and repeated stroke [76]. Atherosclerosis from supra-aortic vessels, especially from the common carotid bifurcation, is the major single aetiology of ischaemic stroke in developed countries as opposed to intracranial occlusive disease and cardioem- bolization.

Carotid endarterectomy (CEA) is well established as a stroke-preventing treatment. Since the 1960s, two differ- ent techniques have evolved, namely conventional and eversion carotid endarterectomy, which is a modified ver- sion of the original method.

Arterial fibromuscular disease encompasses a heteroge- neous group of nonatherosclerotic vascular occlusive and aneurysmal diseases. A principal forum of fibrodysplastic stenoses includes:

Endovascular treatment of carotid stenosis using carotid angioplasty and stenting (CAS) was first implemented ex- perimentally on dogs in 1977 [33]. Since the early 1980s there have been reports of its implementation, mainly on patients suffering from fibromuscular dysplasia [18] and, later on, on patients with atherosclerosis and post-endar- terectomy restenosis [34, 41,57]. Stenting was performed electively in order to treat possible dissection or residual stenosis after the angioplasty procedure. Later this tech- nique was abandoned to a routine stenting procedure. In 1986 Theron introduced a cerebral protection device using an occlusion balloon in the internal carotid artery (ICA) with simultaneous aspiration of possible microem- boli [54–56].

Atherosclerosis is a generalized disease [2,4,9,11,21,22,41]. Therefore, it is of no surprise that simultaneous ath- erosclerotic lesions may exist in the carotid arteries, the coronary arteries, the aorta and the peripheral arteries in the form of unifocal, bifocal and multifocal occlusive or aneurysmal disease [1,14,15,18,26,38,39]. Coexis- tence of severe coronary artery disease with carotid artery stenosis, aortic aneurysm and critical limb ischaemia is a frequent event and the management of these patients is still unclear and in some cases controversial [12,16, 17,24,27,31,32,36,37]. Therefore,multifocal athero- sclerosis remains a challenge for the cardiothoracic and vascular surgeon who has,nowadays, the therapeutic al- ternative of open or endovascular repair.