Carotid Plaque Surface Irregularity Predicts Cerebral Embolism during Carotid Artery Stenting

Object: We investigated possible associations among the presence of cholesterol crystals in embolic debris, the proportions of debris components, and postoperative cerebral embolism in patients undergoing carotid artery stenting (CAS). Methods: Sixty-seven consecutive procedures were performed for internal carotid artery stenosis with CAS at our hospital between November 2015 and February 2018. Procedures for emergency CAS for stroke in evolution or crescendo transient ischemic attack were excluded (n = 12). The embolic debris from remaining procedures (n = 55) was stained with hematoxylin-eosin and the red blood cells, white blood cells, and fibrin were quantified by color-based segmentation. Cholesterol crystals and calcification were examined histopathologically. Diffusion-weighted imaging (DWI) was performed 1–3 days after CAS, and the images were used to classify procedures according to the presence of new lesions. Results: Of the 55 CAS procedures, new DWI lesions were identified after 32. One patient had symptomatic cerebral embolism. Higher proportions of patients with cholesterol crystals in embolic debris (17 vs. 78%, p < 0.001) and higher proportion of white blood cells (mean 2.3 [0–9.9] vs. 4.2% [0–29.9%], p < 0.01) were observed in the embolic debris of procedures with and without new DWI lesions. Conclusions: Cholesterol crystals were common in the embolic debris from patients with postoperative ischemic lesions after CAS. These results suggest that inflammatory destabilization of the intraplaque lipid component is related to postprocedural DWI lesions.

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Management of Mobile Floating Carotid Plaque Using Carotid Artery Stenting

Journal of Endovascular Therapy ◽

10.1177/152660280301000336 ◽

2003 ◽

Vol 10 (3) ◽

pp. 653-656 ◽

Cited By ~ 12

Author(s):

Elie Y. Chakhtoura ◽

Jonathan E. Goldstein ◽

Robert W. Hobson

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Carotid Plaque ◽

Case Reports ◽

Duplex Ultrasound ◽

Carotid Stenting ◽

Clinical Results ◽

Unique Nature ◽

Risk Patients ◽

Ischemic Attack

Purpose: To present management techniques for dealing with mobile floating carotid plaque (MFCP), which represents an indeterminate risk of embolic cerebrovascular events. Case Reports: Two high-risk patients with a history of carotid endarterectomy were diagnosed with MFCP by duplex ultrasound scanning. One patient had a left hemispheric transient ischemic attack while the other was asymptomatic with a moderate stenosis. Both were successfully treated with carotid artery stenting, achieving complete coverage of the MFCP. Their outcomes were uneventful, and sustained patency of the stented arteries has been observed during an event-free survival of 32 and 44 months, respectively. Conclusions: Based upon the unique nature of these lesions and our satisfactory clinical results, we believe that carotid stenting may be a viable option for the treatment of MFCP.

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What Have We Learned from the Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) Study?

Vascular ◽

10.1258/rsmvasc.12.1.62 ◽

2004 ◽

Vol 12 (1) ◽

pp. 62-68 ◽

Cited By ~ 6

Author(s):

Giorgio M. Biasi ◽

Alberto Froio ◽

Gaetano Deleo ◽

Claudia Piazzoni ◽

Valter Camesasca

Keyword(s):

Risk Factor ◽

Clinical Practice ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Carotid Plaque ◽

Independent Risk Factor ◽

Carotid Stenting ◽

Computer Assisted ◽

Carotid Angioplasty ◽

Cerebral Embolization

Carotid artery stenting (CAS) is used widely to treat carotid lesions. Indication to CAS is mostly based, both in trial and in clinical practice, on the percentage of stenosis and the presence or absence of preprocedural neurologic symptoms, whereas the features of the plaque are somehow disregarded and ignored. The most severe complication of CAS is stroke, related to cerebral embolization from carotid plaque. Several studies showed that echolucent plaques generate a higher number of embolic particles following carotid stenting. Echolucency can be measured using the gray scale median, which is an objective and quantitative computer-assisted grading of the echogenicity of carotid plaques. As previously demonstrated in the ICAROS study, carotid plaque echolucency is an independent risk factor for stroke in carotid stenting. Carotid plaque echolucency is one of the parameters that should be mandatory to be considered for indication to treatment.

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Relationship between carotid plaque characteristics and new ischemic lesions after stenting detected by computed tomography angiography

Acta Radiologica ◽

10.1177/0284185119852732 ◽

2019 ◽

Vol 61 (1) ◽

pp. 47-55

Author(s):

Hongying Qu ◽

Xiaokun Zhang ◽

Miao Zhang ◽

Yongan Gao ◽

Jie Lu

Keyword(s):

Risk Factors ◽

Computed Tomography ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Carotid Plaque ◽

Diffusion Weighted Imaging ◽

Irregular Surface ◽

Irregular Surfaces ◽

Diffusion Weighted ◽

Peripheral Position

Background Although carotid artery stenting achieves definite benefits, it carries a higher rate of embolization compared with carotid endarterectomy. The incidence of embolization may be related to plaque stability. Purpose To assess for any relationship between plaque characteristics and cerebral emboli following carotid artery stenting. Material and Methods Sixty-three patients with severe carotid stenosis underwent carotid artery stenting. They were divided into two groups according to whether new ischemic lesions were detected on diffusion-weighted imaging after carotid artery stenting. We evaluated the types and locations of calcification in plaques and extent of calcification. We then assessed for a correlation between each of these factors and occurrence of new lesions on diffusion-weighted imaging after carotid artery stenting. Results The locations of calcification, percentage of plaque enhancement, and the number of plaques with irregular surface or ulceration were significantly different between the two groups. A peripheral position of calcification (close to the adventitia), enhancing plaques, and plaques with irregular surfaces or ulceration were statistically significant predictors of intracerebral embolization after carotid artery stenting. No significant differences in type of plaque or degree of calcification were found between two groups. Conclusion Peripheral calcification, enhancing plaques, and plaques with irregular surfaces were risk factors for intracerebral embolization after carotid artery stenting. These plaque characteristics should be considered when choosing the optimal treatment for patients.

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Associations between Cerebral Embolism and Carotid Intraplaque Hemorrhage during Protected Carotid Artery Stenting

American Journal of Neuroradiology ◽

10.3174/ajnr.a4576 ◽

2015 ◽

Vol 37 (4) ◽

pp. 686-691 ◽

Cited By ~ 14

Author(s):

G.H. Chung ◽

J.Y. Jeong ◽

H.S. Kwak ◽

S.B. Hwang

Keyword(s):

Carotid Artery ◽

Carotid Artery Stenting ◽

Cerebral Embolism ◽

Intraplaque Hemorrhage

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Abstract 957: Elevated Levels of Neopterin are Associated with Carotid Complex Plaques in Patients with Stable Angina Pectoris

Circulation ◽

10.1161/circ.118.suppl_18.s_636 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Kenichi Sugioka ◽

Takahiko Naruko ◽

Takeshi Hozumi ◽

Shoichi Ehara ◽

Takuhiro Okuyama ◽

...

Keyword(s):

Angina Pectoris ◽

Carotid Artery ◽

Stable Angina ◽

Carotid Plaque ◽

Coronary Vessels ◽

Surface Irregularity ◽

Stable Angina Pectoris ◽

Carotid Artery Plaque ◽

Plaque Score ◽

Carotid Plaques

Background: Neopterin is produced by activated macrophages and serves as an activation marker for monocytes/macrophages. Serum levels of neopterin have been shown to be associated with the presence of complex coronary lesions in unstable angina pectoris. However, the relationship between neopterin levels and complex carotid lesions is still unknown. We investigated the association between plasma neopterin levels and the characteristics of carotid plaques in patients with stable angina pectoris (SAP). Moreover, we immunohistochemically studied the presence of neopterin in carotid endarterectomy specimens. Methods: We studied 65 SAP patients who were scheduled coronary angiography. In all patients, plasma neopterin levels were measured and carotid ultrasound was performed for evaluation of carotid artery plaque score (PS) defined by the sum of plaque thickness, plaque number (PN) and plaque surface irregularity. Frozen tissue of 40 endarterectomy specimens for extracranial high-grade carotid stenosis were immunohistochemically examed with antibodies against macrophages and neopterin. Results: There was no significant correlation between plasma neopterin levels and PS (P=0.38) or PN (P=0.49). On the other hand, plasma neopterin levels were significantly higher in patients with carotid plaque surface irregularity compared with patients without it (25.4 ± 13.5 nmol/L vs.16.9 ± 6.5 nmol/L, P=0.0015). Carotid plaque irregularity was detected more frequently in patients with higher neopterin levels (>=18.5 nmol/L median) compared with those with lower neopterin levels (41.9% vs. 16.1%, P=0.025). Using multivariate analyses, nepopterin levels (OR, 1.11; 95%CI, 1.01 to 1.21; P=0.023) and the number of diseased coronary vessels (OR, 2.51; 95%CI, 1.01 to 6.22; P=0.047) are independently associated with carotid plaque irregularity. Immunohistochemical staining showed abundant neopterin-positive macrophages in the unstable carotid plaques. Conclusions: Neopterin levels are associated with carotid complex plaques rather than the severity of carotid atherosclerotic change. Neopterin can be considered as one of the significant markers of plaque destabilization in not only coronary artery but carotid artery atherosclerotic lesions.

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Computed Tomography Texture Analysis of Carotid Plaque as Predictor of Unfavorable Outcome after Carotid Artery Stenting: A Preliminary Study

Diagnostics ◽

10.3390/diagnostics11122214 ◽

2021 ◽

Vol 11 (12) ◽

pp. 2214

Author(s):

Davide Colombi ◽

Flavio Cesare Bodini ◽

Beatrice Rossi ◽

Margherita Bossalini ◽

Camilla Risoli ◽

...

Keyword(s):

Computed Tomography ◽

Carotid Artery ◽

Carotid Artery Stenting ◽

Carotid Plaque ◽

Independent Predictor ◽

Multiple Logistic Regression Analysis ◽

Unfavorable Outcome ◽

Textural Features ◽

Roc Curve Analysis ◽

Density Histogram

Novel biomarkers are advocated to manage carotid plaques. Therefore, we aimed to test the association between textural features of carotid plaque at computed tomography angiography (CTA) and unfavorable outcome after carotid artery stenting (CAS). Between January 2010 and January 2021, were selected 172 patients (median age, 77 years; 112/172, 65% men) who underwent CAS with CTA of the supra-aortic vessels performed within prior 6 months. Standard descriptors of the density histogram were derived by open-source software automated analysis obtained by CTA plaque segmentation. Multiple logistic regression analysis, receiver operating characteristic (ROC) curve analysis and the area under the ROC (AUC) were used to identify potential prognostic variables and to assess the model performance for predicting unfavorable outcome (periprocedural death or myocardial infarction and any ipsilateral acute neurological event). Unfavorable outcome occurred in 17/172 (10%) patients (median age, 79 years; 12/17, 70% men). Kurtosis was an independent predictor of unfavorable outcome (odds ratio, 0.79; confidence interval, 0.65–0.97; p = 0.029). The predictive model for unfavorable outcome including CTA textural features outperformed the model without textural features (AUC 0.789 vs 0.695, p = 0.004). In patients with stenotic carotid plaque, kurtosis derived by CTA density histogram analysis is an independent predictor of unfavorable outcome after CAS.

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