The development of medical diagnosis and treatment specifications or guidelines is an important measure to improve the effectiveness of diagnosis and treatment, ensure the best prognosis for patients, as well as rationalize economic healthcare expenditures and costs. This guideline on extracranial carotid and vertebral artery disease (ECVD) was revised and upgraded by the ACCF/AHA guideline writing committee based on the previous version, summarizing the relevant literature since May 2010. This article extracts and translates some parts from it for your reference and valuable comments, as well as providing a reference basis for clinical practice. Extracranial vascular lesions and stroke The extracranial vasculature emphasizes the vascular network that affects the blood supply to the brain tissue, which mainly includes the carotid system and the vertebrobasilar system. Extracranial vascular lesions are the main cause of ischemic stroke, and the types of clinicopathology include: atherosclerosis, myofibrillar dysplasia, cystic necrosis of the middle layer of arteries, arteritis, and entrapment. Of these, atherosclerosis is the leading cause, and because atherosclerosis is a systemic disease, patients with extracranial vascular lesions are also at risk for other vascular events such as: ischemic heart disease, and peripheral vascular disease. Ischemic stroke is the 3rd leading disease leading to death after cardiovascular disease and cancer, and the leading cause of disability. In epidemiologic analysis, 7-18% of first ischemic strokes are due to >60% stenosis of the carotid and vertebral basilar arteries. The following are guidelines for the diagnosis and treatment of this condition, primarily atherosclerotic lesions. Screening and Evaluation of Asymptomatic Carotid Artery Stenosis 1. In asymptomatic patients with known or suspected carotid artery stenosis, Doppler ultrasound is recommended as the preferred measure for evaluating the extent of the stenosis and its hemodynamic impact. (I/C) 2. In asymptomatic patients with carotid murmurs, Doppler ultrasound is recommended to screen for stenosis. (IIa/C) 3. For follow-up patients with >50% stenosis, Doppler ultrasound is recommended annually for assessment of lesion change; it is also recommended as a means of assessing response to therapy, and the follow-up time frame can be extended appropriately if follow-up shows lesion stabilization. (IIa/C) 4. For patients with peripheral vascular disease, coronary artery disease, and atherosclerotic aneurysms without symptoms of cerebral ischemia, the application of Doppler ultrasound should be considered for screening of carotid artery stenosis. (IIb/C) 5. Doppler ultrasound screening for carotid artery lesions may be considered in those who are asymptomatic and have no signs of atherosclerosis but have 2 or more risk factors (hypertension, hyperlipidemia, cigarette smoking, history of vascular events in a 1st-degree relative before the age of 60 years, and a history of ischemic stroke); however, there is no evidence of prognostic impact. (IIb/C) 6. Routine application of Doppler ultrasound for carotid artery lesion screening is not recommended for asymptomatic people without risk factors for atherosclerosis and for patients with neurologic injuries due to nonischemic factors, such as tumors (III/C) Diagnosis of Symptomatic Extracranial Vasculopathy 1. Noninvasive imaging is recommended for patients suspected of having transient retinal or neural hemispheric symptoms due to ischemia. screening for ECVD. (I/C) 2. Doppler ultrasound is recommended as a measure to detect symptomatic carotid stenosis. (I/C) 3. If Doppler ultrasound is not suggestive, MRA and CTA are recommended as screening measures for symptomatic carotid stenosis. (I/C) 4. If there are no clear signs of pathology in the intracranial or extracranial vessels to explain neurologic symptoms, echocardiography is recommended to detect the presence of possible cardiogenic emboli. (I/C) 5. When extracranial vascular lesions are detected, evaluation of intracranial vascular lesions by CTA, MRA, or selective cerebral angiography is recommended. (IIa/C) 6. MRA, CTA, and angiography are recommended for patients who may require revascularization. (IIa/C) 7. When noninvasive imaging shows unclear or contradictory findings, angiography is recommended to clarify intracranial/extracranial vascular lesions. (IIa/C) 8, Non-contrast MRA is recommended in patients with severe vascular calcification and renal insufficiency. (IIa/C) 9. If it cannot be ruled out that non-specific neurological symptoms may be caused by cerebral ischemia, Doppler ultrasound screening can be performed (IIb/C) 10. If Doppler ultrasound, MRA, CTA suggest total occlusion of the carotid artery, further action of angiography can be done to understand the lumen of the artery, in order to determine whether revascularization is possible (IIb/C) 11. For patients with renal insufficiency, who need to limit the use of contrast medium, the application of angiography can be considered. For patients who need to limit the use of contrast media due to renal insufficiency, the application of angiography to evaluate single-vessel lesions may be considered (IIb/C) Pharmacological treatment of extracranial vascular lesions The main purpose of pharmacological treatment is to control the various risk factors leading to stroke: 1. For patients with asymptomatic ECVD, it is recommended that blood pressure be controlled at 140/90 mmg or less (I/A); for patients with symptomatic ECVD except in the hyper-acute phase, it is recommended that blood pressure be controlled (140 /90mmg or less) (IIa/C) 2. Smoking cessation is recommended to slow down the process of atherosclerosis to reduce the incidence of stroke (I/A) 3. Application of tatin analogs is recommended to control hyperlipidemia, with an LDL of 100mg/dL or less (I/B); LDL is reduced to 70mg/dL or less in high-risk patients (IIa/B); in patients who are unable to tolerate lipid-lowering therapy, bile acid chelating agent or niacin can be used instead (IIa/B) 4. It is recommended to apply dietary control, exercise, and hypoglycemic therapy to control blood glucose in ECVD patients with comorbid diabetes mellitus (IIa/A); meanwhile, tamsulosin is also applied to control the LDL to less than 70mg/dL (IIa/B) The other key point of medication is antithrombotic therapy: 1. It is recommended to apply aspirin alone (75-325mg/d), clopidogrel (75-325mg/ d), clopidogrel (75mg/d) or combined aspirin and pansentin, rather than aspirin combined with clopidogrel for antithrombotic prophylaxis and treatment (I/B) 2. In ECVD patients with anticoagulant indications such as combined atrial fibrillation and mechanical flaps, it is recommended to apply vitamin K antagonists, and to control the INR at around 2.5 (IIa/C) 3. For patients with stroke or TIA, clopidogrel in combination with clopidogrel within 3 months is not recommended Gray combined with aspirin treatment (III/B); heparin or low molecular heparin anticoagulation is not recommended in patients with acute ischemic stroke and TIA (III/B) Carotid artery revascularization 1. In patients with symptomatic carotid artery stenosis, when non-invasive imaging means suggests stenosis of >70% (I/A) or angiography suggests stenosis of >50% (I/B), carotid endarterectomy is recommended. Carotid endarterectomy (CEA), and the estimated perioperative stroke or mortality rate is less than 6% 2. Carotid artery stenting (CAS) is recommended as a candidate for CEA (I/B) 3. In asymptomatic patients with carotid stenosis of more than 70%, and with a low perioperative stroke and mortality rate, CEA is recommended (IIa/A) 4. In elderly patients, especially those whose vascular conditions are not suitable for interventional therapy, the CEA is recommended to be preferred (IIa/B) 5. CAS is recommended to be preferred in patients with neck conditions unsuitable for surgery (IIa/B) 6. Early revascularization is recommended in the absence of contraindications for TIA or stroke within 2 weeks (IIa/B) 7. Prophylactic CAS may be considered in asymptomatic patients with angiography suggesting 60% carotid stenosis and ultrasound 70% (IIa/B) 8. IIb/B) 8, less than 50% carotid artery stenosis, not recommended sexual revascularization (III/A) 9, chronic total occlusive lesions, not recommended for occlusive lesions vascular reconstruction (III/C) 10, for severe brain dysfunction, not recommended for revascularization (III/C) Perioperative management of carotid artery endarterectomy 1, the recommended application of aspirin (81- 325 mg/d) (I/A) 2. Continuous postoperative application of aspirin (75-325 mg/d), clopidogrel (75 mg/d), or low-dose aspirin combined with Pansentin is recommended (I/B) 3. Good control of blood pressure during the perioperative period is recommended (I/C) 4. Recording of neurological examination results during the preoperative period and within 24 h after the operation is recommended (I/C) 5. It is recommended that when the incision is closed by CEA , application of carotid patch (IIa/B) 6, Recommend application of statins after carotid endarterectomy (IIa/B) 7, Recommend noninvasive imaging follow-up, including contralateral vascularization, at 1 month, 6 months, and annually after carotid endarterectomy until the patient doesn’t need further vascular interventions (IIa/C) Perioperative management of carotid artery stenting 1, Recommend pre-procedural CAS, at least 30 days, dual-anti-treatment with aspirin (81-325 mg/d) + clopidogrel (75 mg/ of) or, if clopidogrel is not tolerated, combined with ticlopidine (250 mg BID) (I/C) 2. Perioperative antihypertensive treatment is recommended for CAS (I/C) 3. Documentation of neurological examination results is recommended preoperatively and for 24 h postoperatively (I/C) 4. Embolic protection device (IIa/C) in CAS (IIa/C) 5. Noninvasive imaging follow-up, including collateral vascularization, is recommended at 1 month, 6 months, and annually after carotid CAS until the patient does not require further vascular intervention (IIa/C) Management of restenosis after carotid artery reconstruction 1. Restenosis is recommended in patients with symptomatic In symptomatic patients, restenosis revascularization is recommended (see original stenosis treatment criteria) (IIa/C) 2. During follow-up, if rapid progression of restenosis is detected that may lead to total vessel occlusion, repeat CEA or CAS is recommended (IIa/C) 3. In asymptomatic patients, restenosis revascularization is considered (see original stenosis treatment criteria) (IIb/C) 4. If the degree of restenosis is <70% and asymptomatic, restenosis is not recommended. CEA or CAS is not recommended for asymptomatic patients (III/C) Vertebral artery vasculopathy: Imaging: 1. CTA or MRA is recommended as a noninvasive imaging tool to assess the posterior circulation in patients with symptomatic subclavian artery tamponade (I/C). 2. Noninvasive imaging is recommended for patients with asymptomatic bilateral carotid artery occlusion, unilateral carotid artery occlusion, or an incomplete circle of Willis. 3. For symptomatic patients, CTA, MRA, rather than Doppler ultrasound is recommended as a noninvasive imaging modality to assess the posterior circulation (I/C) 4. For symptomatic patients, angiography is recommended prior to revascularization (IIa/C) 5. Regular follow-up is recommended for patients who have had vertebral artery revascularization (same as carotid artery revascularization). （For patients who have undergone vertebral artery revascularization, regular follow-up is recommended (IIa/C) Treatment strategy: 1. Recommend appropriate pharmacological and lifelong risk factor control treatment for vertebral artery vascular lesions (I/B) 2. Recommend antiplatelet drugs for patients with vertebral artery stenosis who do not have contraindications to the treatment of vertebral artery stenosis, such as aspirin 81-325mg/d, aspirin combined with Pansanthenol or clopidogrel 75mg (I/B) Subclavian artery and head and arm vascular lesions: 1. Recommend antiplatelet drugs for patients who have vertebral artery stenosis without contraindication. Arterial and head and arm vascular lesions: 1. For posterior circulatory ischemia caused by subclavian artery tapping, cervical-subclavian artery bypass is recommended (IIa/B) 2. For posterior circulatory ischemia caused by subclavian artery tapping, interventional therapy is recommended when surgical risk is high (IIa/C) 3. For symptomatic, head and arm vascular lesions, direct interventional revascularization or bypass surgery is recommended (IIa/C) 4, Direct interventional revascularization or bypass surgery is recommended for upper extremity interstitial claudication due to subclavian artery lesions (IIa/C) 5. Direct interventional revascularization or bypass surgery is recommended for occlusion of the subclavian artery when the ipsilateral internal mammary artery is to be used for coronary artery bridging (IIa/C) 6. Asymptomatic patients with stenosis of the subclavian artery, whether it is unequal blood pressures of the upper extremities, carotid murmur, or vertebral artery reflux, are not recommend revascularization unless the internal mammary artery will be used for coronary artery reconstruction (III/C)