Atherosclerotic plaque components characterization and macrophage infiltration identification by intravascular ultrasound elastography based on b-mode analysis: validation in vivo

Future Perspectives on the Role of Stem Cells and Extracellular Vesicles in Vascular Tissue Regeneration

Vascular tissue engineering is an area of regenerative medicine that attempts to create functional replacement tissue for defective segments of the vascular network. One approach to vascular tissue engineering utilizes seeding of biodegradable tubular scaffolds with stem (and/or progenitor) cells wherein the seeded cells initiate scaffold remodeling and prevent thrombosis through paracrine signaling to endogenous cells. Stem cells have received an abundance of attention in recent literature regarding the mechanism of their paracrine therapeutic effect. However, very little of this mechanistic research has been performed under the aegis of vascular tissue engineering. Therefore, the scope of this review includes the current state of TEVGs generated using the incorporation of stem cells in biodegradable scaffolds and potential cell-free directions for TEVGs based on stem cell secreted products. The current generation of stem cell-seeded vascular scaffolds are based on the premise that cells should be obtained from an autologous source. However, the reduced regenerative capacity of stem cells from certain patient groups limits the therapeutic potential of an autologous approach. This limitation prompts the need to investigate allogeneic stem cells or stem cell secreted products as therapeutic bases for TEVGs. The role of stem cell derived products, particularly extracellular vesicles (EVs), in vascular tissue engineering is exciting due to their potential use as a cell-free therapeutic base. EVs offer many benefits as a therapeutic base for functionalizing vascular scaffolds such as cell specific targeting, physiological delivery of cargo to target cells, reduced immunogenicity, and stability under physiological conditions. However, a number of points must be addressed prior to the effective translation of TEVG technologies that incorporate stem cell derived EVs such as standardizing stem cell culture conditions, EV isolation, scaffold functionalization with EVs, and establishing the therapeutic benefit of this combination treatment.

Intravascular ultrasound elastography analysis of the elastic mechanical properties of atherosclerotic plaque

To assess the elastic mechanical properties of atherosclerotic plaque with different morphological properties by intravascular ultrasound elastography (IVUSE). 30 purebred New Zealand rabbits were fed a high-cholesterol diet; the abdominal aorta endothelium was balloon-injured after 2 weeks; at week 12, 2 plaques with moderate echo from each rabbit were chosen for in situ imaging, and 2 consecutive frames near the end-diastole images in situ were used to construct an IVUS elastogram. Shear strain (SS) and area strain (AS) were greater for eccentric than centripetal plaque (SS: 2.65(2.45)% vs. 1.79 ± 0.97%, p < 0.05; AS: 4.81(4.99)% vs. 3.23 ± 1.75%, p < 0.05) but were lower with low than high plaque burden (SS: 2.14 ± 0.37% vs. 3.40 ± 0.34%, p < 0.05; AS: 3.88 ± 0.60% vs. 5.81 ± 0.54%, p < 0.05). SS and AS were significantly greater for plaque with negative than no remodeling (SS: 3.98 ± 1.53% vs. 1.82(1.40)%, p < 0.017; AS: 6.94 ± 2.24% vs. 2.59(2.87)%, p < 0.017) and were found correlated with eccentric index and plaque burden (R² = 0.365 and R² = 0.359, both p < 0.05). Plaques associated with eccentricity, high plaque burden and negative remodeling showed greater strain than those with centripetalism, low plaque burden and positive remodeling. Eccentric index and plaque burden may be useful to predict the elastic stability of plaque.

Ultrasound Vascular Elastography as a Tool for Assessing Atherosclerotic Plaques - A Systematic Literature Review

Atherosclerosis is a widespread disease that accounts for nearly 3-quarters of deaths due to cardiovascular disease. Ultrasound elastography might be able to reliably identify characteristics associated with vulnerable plaques. There is a need for the evaluation of elastography and its ability to distinguish between vulnerable and stable plaques. The aim of this paper is to provide an overview of the literature on vascular elastography. A systematic search of the available literature for studies using elastography for assessing atherosclerotic plaques was conducted using the MEDLINE, Embase, Cochrane Library and Web of Science databases. A standardized template was used to extract relevant data following the PRISMA 2009 checklist. 20 articles were included in this paper. The studies were heterogeneous. All studies reported that elastography was a feasible technique and provided additional information compared to B-mode ultrasound alone. Most studies reported higher strain values for vulnerable plaques. Ultrasound elastography has potential as a clinical tool in the assessment of atherosclerotic plaques. Elastography is able to distinguish between different plaque types, but there is considerable methodological variation between studies. There is a need for larger studies in a clinical setting to determine the full potential of elastography.

Shear Wave Elastography Quantifies Stiffness in Ex Vivo Porcine Artery with Stiffened Arterial Region

Five small porcine aortas were used as a human carotid artery model, and their stiffness was estimated using shear wave elastography (SWE) in the arterial wall and a stiffened artery region mimicking a stiff plaque. To optimize the SWE settings, shear wave bandwidth was measured with respect to acoustic radiation force push length and number of compounded angles used for motion detection with plane wave imaging. The mean arterial wall and simulated plaque shear moduli varied from 41 ± 5 to 97 ± 10 kPa and from 86 ± 13 to 174 ± 35 kPa, respectively, over the pressure range 20-120 mmHg. The results revealed that a minimum bandwidth of approximately 1500 Hz is necessary for consistent shear modulus estimates, and a high pulse repetition frequency using no image compounding is more important than a lower pulse repetition frequency with better image quality when estimating arterial wall and plaque stiffness using SWE.

Real-time tissue elastography for the detection of vulnerable carotid plaques in patients undergoing endarterectomy: a pilot study

We examined the utility of ultrasonic real-time tissue elastography (RTE) and conventional B-mode ultrasound (US) in the detection of vulnerable carotid atherosclerotic plaques. This prospective study comprised 19 patients scheduled for carotid endarterectomy. Results obtained from pre-operative RTE and B-mode US and post-operative pathology were compared. RTE encoded low, average and high deformability as blue, green and red, respectively. Tissue hardness was scored on a 5-point scale, and relative strains were calculated. The relative strain was 1.12 ± 0.14 for fibrous plaques (n = 4), 0.28 ± 0.07 for atherosclerotic plaques (n = 5), 0.47 ± 0.31 for intraplaque hemorrhage/thrombosis (n = 5) and 0.98 ± 1.04 for complex plaques (n = 5). The sensitivity, specificity and accuracy of detection of vulnerable plaques were 25%, 100% and 84.2% for B-mode US, 50%, 100% and 89.4% for RTE and 62.5%, 100% and 94.7% for the combination. Ultrasonic RTE is a potential candidate for a non-invasive and effective approach to identify vulnerable atherosclerotic plaques in the carotid artery.

Computational approaches for analyzing the mechanics of atherosclerotic plaques: a review

Vulnerable and stable atherosclerotic plaques are heterogeneous living materials with peculiar mechanical behaviors depending on geometry, composition, loading and boundary conditions. Computational approaches have the potential to characterize the three-dimensional stress/strain distributions in patient-specific diseased arteries of different types and sclerotic morphologies and to estimate the risk of plaque rupture which is the main trigger of acute cardiovascular events. This review article attempts to summarize a few finite element (FE) studies for different vessel types, and how these studies were performed focusing on the used stress measure, inclusion of residual stress, used imaging modality and material model. In addition to histology the most used imaging modalities are described, the most common nonlinear material models and the limited number of models for plaque rupture used for such studies are provided in more detail. A critical discussion on stress measures and threshold stress values for plaque rupture used within the FE studies emphasizes the need to develop a more location and tissue-specific threshold value, and a more appropriate failure criterion. With this addition future FE studies should also consider more advanced strain-energy functions which then fit better to location and tissue-specific experimental data.

Uniaxial tensile testing approaches for characterisation of atherosclerotic plaques

The pathological changes associated with the development of atherosclerotic plaques within arterial vessels result in significant alterations to the mechanical properties of the diseased arterial wall. There are several methods available to characterise the mechanical behaviour of atherosclerotic plaque tissue, and it is the aim of this paper to review the use of uniaxial mechanical testing. In the case of atherosclerotic plaques, there are nine studies that employ uniaxial testing to characterise mechanical behaviour. A primary concern regarding this limited cohort of published studies is the wide range of testing techniques that are employed. These differing techniques have resulted in a large variance in the reported data making comparison of the mechanical behaviour of plaques from different vasculatures, and even the same vasculature, difficult and sometimes impossible. In order to address this issue, this paper proposes a more standardised protocol for uniaxial testing of diseased arterial tissue that allows for better comparisons and firmer conclusions to be drawn between studies. To develop such a protocol, this paper reviews the acquisition and storage of the tissue, the testing approaches, the post-processing techniques and the stress-strain measures employed by each of the nine studies. Future trends are also outlined to establish the role that uniaxial testing can play in the future of arterial plaque mechanical characterisation.

Plaque hemorrhage in carotid artery disease: pathogenesis, clinical and biomechanical considerations

Stroke remains the most prevalent disabling illness today, with internal carotid artery luminal stenosis due to atheroma formation responsible for the majority of ischemic cerebrovascular events. Severity of luminal stenosis continues to dictate both patient risk stratification and the likelihood of surgical intervention. But there is growing evidence to suggest that plaque morphology may help improve pre-existing risk stratification criteria. Plaque components such a fibrous tissue, lipid rich necrotic core and calcium have been well investigated but plaque hemorrhage (PH) has been somewhat overlooked. In this review we discuss the pathogenesis of PH, its role in dictating plaque vulnerability, PH imaging techniques, marterial properties of atherosclerotic tissues, in particular, those obtained based on in vivo measurements and effect of PH in modulating local biomechanics.

Intraplaque stretch in carotid atherosclerotic plaque--an effective biomechanical predictor for subsequent cerebrovascular ischemic events

BACKGROUND

Stretch is a mechanical parameter, which has been proposed previously to affect the biological activities in different tissues. This study explored its utility in determining plaque vulnerability.

METHODS

One hundred and six patients with mild to moderate carotid stenosis were recruited in this study (53 symptomatic and 53 asymptomatic). High resolution, multi-sequence magnetic resonance (MR) imaging was performed to delineate various plaque components. Finite element method was used to predict high stretch concentration within the plaque.

RESULTS

During a two-year follow-up, 11 patients in symptomatic group and 3 in asymptomatic group experienced recurrent cerebrovascular events. Plaque stretch at systole and stretch variation during one cardiac cycle was greater in symptomatic group than those in the asymptomatic. Within the symptomatic group, a similar trend was observed in patients with recurrent events compared to those without.

CONCLUSION

Plaques with high stretch concentration and large stretch variation are associated with increased risk of future cerebrovascular events.

Progress in atherosclerotic plaque imaging

Cardiovascular diseases are the primary cause of mortality in the industrialized world, and arterial obstruction, triggered by rupture-prone atherosclerotic plaques, lead to myocardial infarction and cerebral stroke. Vulnerable plaques do not necessarily occur with flow-limiting stenosis, thus conventional luminographic assessment of the pathology fails to identify unstable lesions. In this review we discuss the currently available imaging modalities used to investigate morphological features and biological characteristics of the atherosclerotic plaque. The different imaging modalities such as ultrasound, magnetic resonance imaging, computed tomography, nuclear imaging and their intravascular applications are illustrated, highlighting their specific diagnostic potential. Clinically available and upcoming methodologies are also reviewed along with the related challenges in their clinical translation, concerning the specific invasiveness, accuracy and cost-effectiveness of these methods.

Noninvasive detection of intimal xanthoma using combined ultrasound, strain rate and photoacoustic imaging

BACKGROUND AND MOTIVATION

The structure, composition and mechanics of carotid artery are good indicators of early progressive atherosclerotic lesions. The combination of three imaging modalities (ultrasound, strain rate and photoacoustic imaging) which could provide corroborative information about the named arterial properties could enhance the characterization of intimal xanthoma.

METHODS

The experiments were performed using a New Zealand white rabbit model of atherosclerosis. The aorta excised from an atherosclerotic rabbit was scanned ex vivo using the three imaging techniques: (1) ultrasound imaging of the longitudinal section: standard ultrasound B-mode (74Hz frame rate); (2) strain rate imaging: the artery was flushed with blood and a 1.5Hz physiologic pulsation was induced, while the ultrasound data were recorded at higher frame rate (296Hz); (3) photoacoustic imaging: the artery was irradiated with nanosecond pulsed laser light of low fluence in the 1210-1230nm wavelength range and the photoacoustic data was recorded at 10Hz frame rate. Post processing algorithms based on cross-correlation and optical absorption variation were implemented to derive strain rate and spectroscopic photoacoustic images, respectively.

RESULTS

Based on the spatio-temporal variation in displacement of different regions within the arterial wall, strain rate imaging reveals differences in tissue mechanical properties. Additionally, spectroscopic photoacoustic imaging can spatially resolve the optical absorption properties of arterial tissue and identify the location of lipid pools.

CONCLUSIONS

The study demonstrates that ultrasound, strain rate and photoacoustic imaging can be used to simultaneously evaluate the structure, the mechanics and the composition of atherosclerotic lesions to improve the assessment of plaque vulnerability.

Intravascular ultrasound area strain imaging used to characterize tissue components and assess vulnerability of atherosclerotic plaques in a rabbit model

The purpose of this study was to investigate the association of area strain and tissue components and vulnerability of atherosclerotic plaques in a rabbit model. Forty purebred New Zealand rabbits underwent balloon-induced abdominal aorta endothelium injury, then a high-cholesterol diet for 24 weeks. Intravascular ultrasound (IVUS) images of abdominal aortas were acquired in situ and two consecutive frames near the end-diastole were used to construct an IVUS elastogram. Histologic slices matched with corresponding IVUS images were stained for fatty and collagen components, smooth muscle cells (SMCs) and macrophages. Regions-of-interest (ROIs) in plaques were classified as fibrous, fibro-fatty or fatty according to histologic study. Vulnerability indexes of ROIs were calculated as (fat + macrophage)/(collagen + SMCs). The area strain of these ROIs was calculated by use of an in-house-designed software system with a block-matching-based algorithm. Area strain was significantly higher in fatty ROIs (0.056 ± 0.003) than in fibrous (0.019 ± 0.002, p < 0.001) or fibro-fatty ROIs (0.033 ± 0.003, p < 0.001). The sensitivity and specificity of area strain for fatty ROIs characterization was 75.0% and 80.2% (area under the curve [AUC] 0.858, 95% confidence interval [CI] = 0.800-0.916, p < 0.001) and 75.0% and 75.3% (AUC 0.859, 95% CI = 0.801-0.917, p < 0.001) for fibrous ROIs, as demonstrated by receiver operating characteristic curve analysis. Area strain was positively correlated with vulnerability index (r(2) = 0.495, p < 0.001), fatty components (r(2) = 0.332, p < 0.001) and macrophage infiltration (r(2) = 0.406, p < 0.001); and negatively correlated with collagen and SMC composition (r(2) = 0.115 and r(2) = 0.169, p < 0.001, respectively). Area strain calculation with IVUS elastography based on digital B-mode analysis is feasible and can be useful for tissue characterization and plaque vulnerability assessment.