1. CAROTID PLAQUES AND CEREBRAL EMBOLISM G.Marcucci
Vascular and Endovascular Surgery Unit
San Paolo Hospital
Civitavecchia, Rome, Italy

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Abstract
Background
Carotid plaque severity and morphology can affect cardiovascular prognosis.
We evaluate both the importance of echographically assessed carotid artery plaque geometry and morphology as predictors of death in hospitalised cardiological patients.
Methods
541 hospitalised patients admitted in a cardiological division (age = 66 ± 11 years, 411 men), have been studied through ultrasound Duplex carotid scan and successively followed-up for a median of 34 months. Echo evaluation assessed plaque severity and morphology (presence of heterogeneity and profile).
Results
361 patients showed carotid stenosis (67% with <50% stenosis, 18% with 50–69% stenosis, 9% with >70% stenosis, 4% with near occlusion and 2% with total occlusion). During the follow-up period, there were 83 all-cause deaths (15% of the total population). Using Cox's proportional hazard model, age (RR 1.06, 95% CI 1.03–1.09, p = 0.000), ejection fraction > 50% (RR = 0.62, 95% CI 0.4–0.96, p = 0.03), treatment with statins (RR = 0.52, 95% CI 0.29–0.95, p = 0.34) and the presence of a heterogeneous plaque (RR 1.6; 95% CI, 1.2 to 2.14, p = 0.002) were independent predictors of death. Kaplan – Meier survival estimates have shown the best outcome in patients without plaque, intermediate in patients with homogeneous plaques and the worst outcome in patients with heterogeneous plaques (90% vs 79% vs 73%, p = ).
Conclusion
In hospitalised cardiological patients, carotid plaque presence and morphology assessed by ultrasound are independent predictors of death.
Non-invasive carotid artery ultrasound is a well established and valid method which allows to both visualize and quantify atherosclerotic lesions. Ultrasound and autopsy studies have shown that the presence and extent of carotid atherosclerosis correlates with atherosclerosis elsewhere in the circulation, including coronary arteries [1-4]. Several studies have found that the presence of carotid stenosis is a strong predictor of death in the general population [5,6].
Moreover, there is evidence that ultrasonographic B-mode characterization of plaque morphology may be useful in the assessment of the vulnerability of the atherosclerotic lesions [7-10].
Atherosclerotic plaque composition appears to be more important than plaque size in determining adverse events [11]. In particular, lipids and haemorrhages are associated with a more active plaque [12,13], which appear to be more vulnerable to rupture. Ultrasonically assessed plaque morphology provides an insight into the plaque composition and structure as shown by both in vitro [14-18] and in vivo [19-23] studies. Echo-lucent carotid plaques are lipid-rich and have a greater potential for clinical complications [7,10]. Heterogeneous plaques have a hypoechoic component and are associated with the presence of intra-plaque haemorrhage, ulceration and lipids, more likely to result in adverse events [8,21,22].
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CAROTID PLAQUES
From histopathologic and vascular biologic studies, plaque composition and vulnerability, rather than degree of stenosis, have emerged as crucial factors leading to sudden rupture of the plaque surface, usually with superimposed thrombosis, which underlies the majority of acute occlusions.
The link between echo plaque structure and prognosis do not appear to be limited to the carotid arteries but may apply to virtually all vascular districts
G.Marcucci
Research
Christina Petersen     
, Patricia B Peçanha     
, Lucia Venneri     
, Emilio Pasanisi     
, Lorenza Pratali     
and Eugenio Picano     
CNR, Institute of Clinical Physiology, Pisa, Italy
     author     
corresponding author
Cardiovascular Ultrasound 2006, 4:16doi: /
The electronic version of this article is the complete one and can be found online at:
Received:
11 January 2006
Accepted:
24 March 2006
Published:
© 2006 Petersen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

3. Echo-lucency is associated with lipid-rich plaques
CAROTID PLAQUES
Heterogeneous plaques have been correlated with the presence of intra-plaque haemorrhage, ulceration and loose stroma containing lipids, cholesterol and proteinaceous deposits
Echo-lucency is associated with lipid-rich plaques
G.Marcucci

4. CAROTID PLAQUES
All of the heterogeneous plaques have a echo-lucent component
(lipid, haemorrhage, thrombi)
A hypo-echoic appearance can also be associated with intra-plaque haemorrhage, which may be the result of intra-plaque neo-vascularization.
G.Marcucci

5. G.Marcucci

6. CAROTID PLAQUES
These small, fragile vessels could represent the underlying anatomic and pathologic changes leading to intramural haemorrhages and rupture.
Lipid lakes and intra-plaque haemorrhage are more frequently found in vulnerable plaques, with greater potential for evolution and complication, and are the dominant substrate of hypoechoic and heterogeneous plaques
G.Marcucci

7. “VULNERABLE PLAQUE”
Cardiovascular Research 2002; 54:36-41
G.Marcucci

8. Atheroembolization
atheroembolization results from disruption of endothelial surface and fibrous cap
platelet and erytrocyte aggregation to the subendothelial layer
distal embolization of the thrombus and debris from the plaque
G.Marcucci

9. CEREBRAL EMBOLIZATION DURING CEA AND CAS
Perioperative cerebral embolization during CEA or CAS is a potentially devastting complication
It is correlated with:
- embolic potential of the plaque
- during surgical dissection
- during CAS procedure
- postoperative embolization (technical problems)
G.Marcucci

10. Carotid endarterectomy
In the course of monitoring CEA’s
with TCD ultrasonography,
it became apparent that during all stages of this
operation, signals identical to the qualities of embolic transients could be noticed
G.Marcucci

11. an association between multiple cerebral microemboli during dissection and new white matter lesions on magnetic resonance images (MRI) of the brain made after surgery
However, in the majority of these patients the new MRI lesions were clinically silent
JANSEN Stroke, 1994
G.Marcucci

12. microemboli that appeared during
but……
microemboli that appeared during
dissection and particularly during wound closure were
statistically significantly associated with permanent cerebral deficits, i.e. intraoperative stroke
ACKERSTAFF R. Stroke, 2000
G.Marcucci

13. Carotid Artery Stenting
CAS has been criticized on the
grounds that the risk of cerebral embolism during the
procedure may be greater than CEA
G.Marcucci

14. In contrast to coronary and peripheral artery angioplasty and stenting, which have been widely adopted, the concern for cerebral embolisation originally resulted in a understandable reluctance to use these techniques in the carotid artery territory.
During these peripheral procedures, the risk of embolisation, estimated by myocardial infarction and clinical distal arterial emboli, ranges from 4% to 5%
CRAWLEY Stroke, 1997
G.Marcucci

15. true incidence of asymptomatic embolisation may be much higher, and emboli of a size that are asymptomatic
in the coronary and peripheral arterial circulations may cause neurological deficits in the cerebral circulation
The National Heart LaBIR N Engl J Med, 1988
G.Marcucci

16. during stent deployment
squeezes plaque material from
the vessel wall
microembolization
G.Marcucci

17. and neurological event rate
but……
utilization of neuroprotection devices has the potential to reduce the intraprocedural cerebral embolic load
and neurological event rate
G.Marcucci

18. Our aim is not to prove superiority of one technique over other
In conclusion,
Our aim is not to prove superiority of one
technique over other
CEA is a safe and effective procedure
CAS of the carotid bifurcation is a feasible
alternative to CEA, particularly in patients with
medical or surgical contraindications to surgery
Nevertheless, CAS results in a significant higher
cerebral embolic load and the number of clinically
silent lesions on MRI is greater than in CEA
G.Marcucci