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Agarwal V, Sherwani P, Chauhan U, Kumar B. Assessment of Carotid Plaque Enhancement on Contrast-Enhanced Ultrasound as a Predictor for Severe Coronary Artery Disease. Indian J Radiol Imaging 2024; 34:460-468. [PMID: 38912243 PMCID: PMC11188725 DOI: 10.1055/s-0044-1779522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Background and Aim Contrast-enhanced ultrasound (CEUS) can reliably identify vulnerable plaques. As atherosclerosis is a systemic disease, we evaluated whether contrast enhancement of carotid plaque (CECP) can predict severe coronary artery disease (CAD) by comparing CECP in patients who have had acute coronary syndromes (ACS) recently with asymptomatic individuals. Settings and Design This case-control study was done at a tertiary care center during 2022. Materials and Methods Fourteen participants were recruited in each group, after screening in-patients for carotid plaques and inclusion and exclusion criteria. Those who had history of ACS were enrolled as cases, while those who did not were enrolled as controls. All these patients underwent grayscale, Doppler, and CEUS examination for characterization of the carotid plaque. For cases, findings on CEUS were also compared with the severity of CAD on catheter coronary angiography. Statistical Analysis Diagnostic parameters including sensitivity, specificity, and diagnostic accuracy were calculated and proportions were compared by using Fisher's exact test. Results Eight out of 28 patients showed CECP. CECP and CAD were positively associated with p -Value of 0.033. Eighty-three percent patients with triple vessel disease and 50% patients with double vessel disease on coronary angiography showed CECP. Sensitivity and specificity of CECP for prediction of CAD were 50 and 92.9%, respectively. Conclusion CECP on CEUS can predict CAD and is a more reliable indicator of severe CAD than plaque characteristics on grayscale and Doppler imaging; making it useful for screening of patients at risk of having CAD.
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Affiliation(s)
- Vanshika Agarwal
- Department of Diagnostic and Intervention Radiology, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, India
| | - Poonam Sherwani
- Department of Diagnostic and Intervention Radiology, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, India
| | - Udit Chauhan
- Department of Diagnostic and Intervention Radiology, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, India
| | - Barun Kumar
- Department of Cardiology, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand, India
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Jin J, Zhao Y, Huang P. Combination of HIFU with sulfur hexafluoride microbubbles in the treatment of solitary uterine fibroids: a systematic review and meta-analysis. Eur Radiol 2024; 34:3786-3794. [PMID: 37950765 DOI: 10.1007/s00330-023-10407-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 11/13/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of sulfur hexafluoride microbubbles on ultrasound-guided high-intensity focused ultrasound (HIFU) ablation of uterine fibroids. METHODS Studies that compared HIFU-microbubble combination with HIFU-only in patients with uterine fibroids were searched from inception to April 2022. The standardized mean difference (SMD) or relative risk (RR) with 95% confidence interval (CI) for different outcome parameters was calculated. RESULTS Seven studies were included, with a total of 901 patients (519 in the combination group and 382 in the HIFU-only group). The energy consumption for treating 1 cm3 of the lesion in the combination group was less than that in the HIFU-only group [SMD = - 2.19, 95%CI (- 3.81, - 0.57), p = 0.008]. The use of microbubbles was associated with shortening the duration of the treatment and sonication [SMD = - 2.60, 95%CI (- 4.09, - 1.10), p = 0.0007; SMD = - 2.11, 95%CI (- 3.30, - 0.92), p = 0.0005]. The rates of significant greyscale changes during HIFU were greater in the combination group, as well as the increase of non-perfused volume ratio [RR = 1.26, 95%CI (1.04, 1.54), p = 0.02; SMD = 0.32, 95%CI (0.03, 0.61), p = 0.03]. The average sonication durations to reach significant greyscale changes and for ablating 1 cm3 of the fibroid lesion were shorter in the combination group [SMD = - 1.24, 95%CI (- 2.02, - 0.45), p = 0.002; SMD = - 0.22, 95%CI (- 0.42, - 0.02), p = 0.03]. The two groups had similar post-HIFU adverse effects, while the combination group had fewer intraprocedural adverse events like abdominal pain, sacrum pain, and leg pain. CONCLUSIONS Sulfur hexafluoride microbubbles can be safely used to enhance and accelerate the ablation effects of HIFU in the treatment of uterine fibroids. CLINICAL RELEVANCE STATEMENT The combination of HIFU with sulfur hexafluoride microbubbles offers a promising non-invasive treatment option for patients with uterine fibroids. KEY POINTS • Sulfur hexafluoride microbubbles combined with ultrasound-guided high-intensity focused ultrasound (USgHIFU) has potential advantages in the treatment of uterine fibroids. • Sulfur hexafluoride microbubbles not only enhance the effects of USgHIFU treatment for uterine fibroids but also shorten its duration. • Sulfur hexafluoride microbubbles do not increase the incidence of USgHIFU-related adverse events in the treatment of uterine fibroids.
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Affiliation(s)
- Jin Jin
- Department of Ultrasound in Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China
| | - Yulan Zhao
- Department of Ultrasound in Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China
| | - Pintong Huang
- Department of Ultrasound in Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China.
- Research Center of Ultrasound in Medicine and Biomedical Engineering, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, People's Republic of China.
- Research Center for Life Science and Human Health, Binjiang Institute of Zhejiang University, Hangzhou, 310009, People's Republic of China.
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3
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Boswell-Patterson CA, Hétu MF, Pang SC, Herr JE, Zhou J, Jain S, Bambokian A, Johri AM. Novel theranostic approaches to neovascularized atherosclerotic plaques. Atherosclerosis 2023; 374:1-10. [PMID: 37149970 DOI: 10.1016/j.atherosclerosis.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/05/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023]
Abstract
As the global burden of atherosclerotic cardiovascular disease continues to rise, there is an increased demand for improved imaging techniques for earlier detection of atherosclerotic plaques and new therapeutic targets. Plaque lesions, vulnerable to rupture and thrombosis, are thought to be responsible for the majority of cardiovascular events, and are characterized by a large lipid core, a thin fibrous cap, and neovascularization. In addition to supplying the plaque core with increased inflammatory factors, these pathological neovessels are tortuous and leaky, further increasing the risk of intraplaque hemorrhage. Clinically, plaque neovascularization has been shown to be a significant and independent predictor of adverse cardiovascular outcomes. Microvessels can be detected through contrast-enhanced ultrasound (CEUS) imaging, however, clinical assessment in vivo is generally limited to qualitative measures of plaque neovascularization. There is no validated standard for quantitative assessment of the microvessel networks found in plaques. Advances in our understanding of the pathological mechanisms underlying plaque neovascularization and its significant role in the morbidity and mortality associated with atherosclerosis have made it an attractive area of research in translational medicine. Current areas of research include the development of novel therapeutic and diagnostic agents to target plaque neovascularization stabilization. With recent progress in nanotechnology, nanoparticles have been investigated for their ability to specifically target neovascularization. Contrast microbubbles have been similarly engineered to carry loads of therapeutic agents and can be visualized using CEUS. This review summarizes the pathogenesis, diagnosis, clinical significance of neovascularization, and importantly the emerging areas of theranostic tool development.
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Affiliation(s)
| | - Marie-France Hétu
- Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Canada
| | - Stephen C Pang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Julia E Herr
- Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Canada
| | - Jianhua Zhou
- Department of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
| | - Shagun Jain
- Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Canada
| | - Alexander Bambokian
- Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Canada
| | - Amer M Johri
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada; Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Canada.
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4
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Cui L, Xing Y, Wang L, Liu K, Chen H, Li C, Chen Y. Carotid Intraplaque Neovascularization and Future Vascular Events in Patients With Asymptomatic Carotid Stenosis. Front Pharmacol 2022; 13:804810. [PMID: 35273496 PMCID: PMC8902365 DOI: 10.3389/fphar.2022.804810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/24/2022] [Indexed: 11/27/2022] Open
Abstract
Objective: Intraplaque neovascularization is a marker of plaque vulnerability and is used to predict the risk of future vascular events in patients with symptomatic carotid stenosis; however, its association with asymptomatic carotid stenosis has not been prospectively evaluated. Therefore, this study aimed to explore the association between intraplaque neovascularization assessed using contrast-enhanced ultrasound and the occurrence of future ischemic events in asymptomatic patients diagnosed with carotid stenosis. Methods: We recruited patients with asymptomatic carotid stenosis from our center. Contrast-enhanced ultrasound was performed at baseline. The outcomes were ischemic stroke and cardiovascular events. We plotted Kaplan-Meier survival curves and performed a log-rank test to compare endpoint event probability in patients with and without grade 2 intraplaque neovascularization. Univariate and multivariate Cox proportional hazards models were used to assess predictors of future vascular events. Results: The data of 50 participants were included in the analysis (median follow-up, 43.7 months). Endpoint events occurred in 12 participants (24%). The Kaplan-Meier survival curves showed that patients with grade 2 intraplaque neovascularization had a higher probability of future vascular events than those with grades 0 and 1 (p < .05). Grade 2 intraplaque neovascularization (hazard ratio: 4.530, 95% confidence interval, 1.337–15.343, p < .05) was an independent predictor of future vascular events in patients with asymptomatic carotid stenosis. Conclusion: Grade 2 intraplaque neovascularization assessed using contrast-enhanced ultrasound independently predicted future ischemic events in patients with asymptomatic carotid stenosis, and contrast-enhanced ultrasound may be an effective screening method to identify high-risk subgroups of patients with asymptomatic carotid stenosis.
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Affiliation(s)
- Liuping Cui
- Department of Neurology, the First Hospital of Jilin University, Changchun, China
| | - Yingqi Xing
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Lijuan Wang
- Department of Neurology, the First Hospital of Jilin University, Changchun, China
| | - Kangding Liu
- Department of Neurology, the First Hospital of Jilin University, Changchun, China
| | - Hongxiu Chen
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Diagnostic Center of Vascular Ultrasound, Beijing, China.,Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Cong Li
- Department of Neurology, the First Hospital of Jilin University, Changchun, China
| | - Ying Chen
- Department of Neurology, the First Hospital of Jilin University, Changchun, China
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5
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Huang Z, Cheng XQ, Liu HY, Bi XJ, Liu YN, Lv WZ, Xiong L, Deng YB. Relation of Carotid Plaque Features Detected with Ultrasonography-Based Radiomics to Clinical Symptoms. Transl Stroke Res 2021; 13:970-982. [PMID: 34741749 DOI: 10.1007/s12975-021-00963-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 12/24/2022]
Abstract
Carotid plaque is one of the predominant causes of stroke. We sought to build a nomogram using ultrasonography (US)-based radiomics and clinical features for identification of symptomatic carotid plaques. We prospectively enrolled 548 patients (mean age ± standard deviation, 63 ± 10 years; 373 men) were randomly divided into training and test cohorts. Clinical and conventional US features of carotid plaques were used to generate a clinical and conventional US model. US-based radiomics model was constructed by extracting radiomics features from grayscale and strain elasticity images. Multivariate logistic regression was performed using the radiomics scores together with clinical and conventional US data, and a final nomogram was subsequently developed. The performance of the final nomogram was assessed with respect to discrimination and clinical usefulness in the training of the test cohorts and contrast-enhanced US test cohort. All the radiomics scores were significantly higher in patients with symptomatic carotid plaques. The US-based radiomics model [area under the curve (AUC) = 0.930 and 0.922 for training and test cohorts, respectively] and final nomogram (AUC = 0.927 and 0.919, respectively) outperformed the clinical and conventional US model (AUC = 0.723 and 0.580, respectively). The decision curve analysis indicated that the final nomogram was clinically useful. In patients undergoing the contrast-enhanced US, the prevalence of plaque enhancement was higher in high-risk patients than in low-risk patients based on the final nomogram-score (P = 0.008). Nomogram has a high diagnostic performance for identification of symptomatic carotid plaques.
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Affiliation(s)
- Zhe Huang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Dadao, Wuhan, 430030, China
| | - Xue-Qing Cheng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Dadao, Wuhan, 430030, China
| | - Hong-Yun Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Dadao, Wuhan, 430030, China
| | - Xiao-Jun Bi
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Dadao, Wuhan, 430030, China
| | - Ya-Ni Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Dadao, Wuhan, 430030, China
| | - Wen-Zhi Lv
- Department of Artificial Intelligence, Julei Technology Company, 13 Daxueyuan Road, Wuhan, 430030, China
| | - Li Xiong
- Department of Cardiovascular Ultrasound, Zhongnan Hospital, Wuhan University, 169 East Lake Road, Wuhan, 430071, China.
| | - You-Bin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Dadao, Wuhan, 430030, China.
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6
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Aarli SJ, Thomassen L, Waje-Andreassen U, Logallo N, Kvistad CE, Næss H, Fromm A. The Course of Carotid Plaque Vulnerability Assessed by Advanced Neurosonology. Front Neurol 2021; 12:702657. [PMID: 34489850 PMCID: PMC8417551 DOI: 10.3389/fneur.2021.702657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Carotid artery atherosclerosis is a major risk factor for ischemic stroke. This risk is related to plaque vulnerability and is characterized by plaque morphology, intraplaque neovascularization, and cerebral microembolization. Advanced neurosonology can identify vulnerable plaques and aid in preventing subsequent stroke. We aimed to assess the time course of cerebral microembolization and intraplaque neovascularization during 6 months of follow-up and to explore the utility of advanced neurosonology in patients with acute cerebral ischemia. Methods: Fifteen patients with acute cerebral ischemia and carotid artery plaques underwent comprehensive extra- and intracranial ultrasound examinations, including microemboli detection and contrast-enhanced ultrasound. The examinations were repeated after 3 and 6 months. Results: We examined 28 plaques in 15 patients. The ultrasonographic features of plaque vulnerability were frequent in symptomatic and asymptomatic plaques. There were no significant differences in stenosis degree, plaque composition, plaque surface, neovascularization, or cerebral microembolization between symptomatic and asymptomatic plaques, but symptomatic plaques had a higher number of vulnerable features. None of the patients had recurrent clinical stroke or transient ischemic attack during the follow-up period. We observed a decrease in cerebral microembolization at 6 months, but no significant change in intraplaque neovascularization. Conclusions: In patients with acute cerebral ischemia and carotid artery plaques, cerebral microembolization decreased during 6 months of follow-up, indicating plaque stabilization. Clinical Trial Registration:ClinicalTrial.gov, identifier NCT02759653.
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Affiliation(s)
- Sander Johan Aarli
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ulrike Waje-Andreassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,SESAM - Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Annette Fromm
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
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7
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Mantella LE, Colledanchise KN, Hétu MF, Feinstein SB, Abunassar J, Johri AM. Carotid intraplaque neovascularization predicts coronary artery disease and cardiovascular events. Eur Heart J Cardiovasc Imaging 2020; 20:1239-1247. [PMID: 31621834 DOI: 10.1093/ehjci/jez070] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/25/2019] [Indexed: 11/15/2022] Open
Abstract
AIMS It is thought that the majority of cardiovascular (CV) events are caused by vulnerable plaque. Such lesions are rupture prone, in part due to neovascularization. It is postulated that plaque vulnerability may be a systemic process and that vulnerable lesions may co-exist at multiple sites in the vascular bed. This study sought to examine whether carotid plaque vulnerability, characterized by contrast-enhanced ultrasound (CEUS)-assessed intraplaque neovascularization (IPN), was associated with significant coronary artery disease (CAD) and future CV events. METHODS AND RESULTS We investigated carotid IPN using carotid CEUS in 459 consecutive stable patients referred for coronary angiography. IPN was graded based on the presence and location of microbubbles within each plaque (0, not visible; 1, peri-adventitial; and 2, plaque core). The grades of each plaque were averaged to obtain an overall score per patient. Coronary plaque severity and complexity was also determined angiographically. Patients were followed for 30 days following their angiogram. This study found that a higher CEUS-assessed carotid IPN score was associated with significant CAD (≥50% stenosis) (1.8 ± 0.4 vs. 0.5 ± 0.6, P < 0.0001) and greater complexity of coronary lesions (1.7 ± 0.5 vs. 1.3 ± 0.8, P < 0.0001). Furthermore, an IPN score ≥1.25 could predict significant CAD with a high sensitivity (92%) and specificity (89%). The Kaplan-Meier analysis demonstrated a significantly higher proportion of participants having CV events with an IPN score ≥1.25 (P = 0.004). CONCLUSION Carotid plaque neovascularization was found to be predictive of significant and complex CAD and future CV events. CEUS-assessed carotid IPN is a clinically useful tool for CV risk stratification in high-risk cardiac patients.
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Affiliation(s)
- Laura E Mantella
- Department of Biomedical and Molecular Sciences, Queen's University, 18 Stuart Street, Kingston, Ontario, Canada
| | - Kayla N Colledanchise
- Department of Biomedical and Molecular Sciences, Queen's University, 18 Stuart Street, Kingston, Ontario, Canada
| | - Marie-France Hétu
- Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Steven B Feinstein
- Department of Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL, USA
| | - Joseph Abunassar
- Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Amer M Johri
- Department of Biomedical and Molecular Sciences, Queen's University, 18 Stuart Street, Kingston, Ontario, Canada.,Department of Medicine, Cardiovascular Imaging Network at Queen's (CINQ), Queen's University, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
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8
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Yan H, Wu X, He Y, Staub D, Wen X, Luo Y. Carotid Intraplaque Neovascularization on Contrast-Enhanced Ultrasound Correlates with Cardiovascular Events and Poor Prognosis: A Systematic Review and Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 47:167-176. [PMID: 33213970 DOI: 10.1016/j.ultrasmedbio.2020.10.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/15/2020] [Accepted: 10/23/2020] [Indexed: 02/08/2023]
Abstract
The goal of this meta-analysis is to investigate whether carotid intraplaque neovascularization (IPN) on contrast-enhanced ultrasound (CEUS) correlates with past cardiovascular events (CVEs) and prognosis. The present meta-analysis included 22 studies involving 3232 patients. The pooled analysis revealed that the presence of IPN was significantly associated with a higher incidence of future CVEs (pooled relative risk = 3.28, 95% confidence interval [CI]: 2.28-4.73) and a lower event-free probability (pooled hazard ratio = 2.51, 95% CI: 1.48-4.27). The presence of IPN was significantly associated with higher rates of past cardiac events (odds ratio = 4.25, 95% CI: 2.48-7.29) and past cerebrovascular accidents (odds ratio = 4.83, 95% CI: 2.66-8.78). Our results suggest that carotid IPN on CEUS significantly correlates with past cardiac events and cerebrovascular accidents and can predict future CVEs. Carotid CEUS is useful in CVE risk stratification.
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Affiliation(s)
- Hualin Yan
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Xian Wu
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Ying He
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Daniel Staub
- Department of Angiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Xiaorong Wen
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Luo
- Department of Medical Ultrasound, West China Hospital, Sichuan University, Chengdu, China.
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9
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Schinkel AFL, Bosch JG, Staub D, Adam D, Feinstein SB. Contrast-Enhanced Ultrasound to Assess Carotid Intraplaque Neovascularization. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:466-478. [PMID: 31791553 DOI: 10.1016/j.ultrasmedbio.2019.10.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 06/10/2023]
Abstract
Contrast-enhanced ultrasound (CEUS) is increasingly being used to identify patients with carotid plaques that are vulnerable to rupture, so-called vulnerable atherosclerotic plaques, by assessment of intraplaque neovascularization. A complete overview of the strengths and limitations of carotid CEUS is currently not available. The aim of this systematic review was to provide a complete overview of existing publications on the role of CEUS in assessment of carotid intraplaque neovascularization. The systematic review of the literature yielded 52 studies including a total of 4660 patients (mean age: 66 y, 71% male) who underwent CEUS for the assessment of intraplaque neovascularization. The majority of the patients (76%) were asymptomatic and had no history of transient ischemic attack (TIA) or stroke. The assessment of intraplaque neovascularization was mostly performed using a visual scoring system; several studies used time-intensity curves or dedicated quantification software to optimize analysis. In 17 studies CEUS was performed in patients before carotid surgery (endarterectomy), allowing a comparison of pre-operative CEUS findings with histologic analysis of the tissue sample that is removed from the carotid artery. In a total of 576 patients, the CEUS findings were compared with histopathological analysis of the plaque after surgery. In 16 of the 17 studies, contrast enhancement was found to correlate with the presence and degree of intraplaque neovascularization on histology. Plaques with a larger amount of contrast enhancement had significantly increased density of microvessels in the corresponding region on histology. In conclusion, CEUS is a readily available imaging modality for the assessment of patients with carotid atherosclerosis, providing information on atherosclerotic plaques, such as ulceration and intraplaque neovascularization, which may be clinically relevant. The ultimate clinical goal is the early identification of carotid atherosclerosis to start early preventive therapy and prevent clinical complications such as TIA and stroke.
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Affiliation(s)
- Arend F L Schinkel
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands.
| | - Johan G Bosch
- Department of Biomedical Engineering, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Daniel Staub
- Division of Angiology, Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Dan Adam
- Biomedical Engineering, Israel Institute of Technology, Haifa, Israel
| | - Steven B Feinstein
- Section of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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10
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Song Y, Dang Y, Dang LL, Zhao C, Zheng J, Feng J, Ruan LT. Association between intraplaque neovascularization assessed by contrast-enhanced ultrasound and the risk of stroke. Clin Radiol 2019; 75:70-75. [PMID: 31629485 DOI: 10.1016/j.crad.2019.08.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 08/21/2019] [Indexed: 11/16/2022]
Abstract
AIM To determine the cut-off value of the area ratio under the curve (ARUC) for predicting symptoms of stroke. MATERIALS AND METHODS Contrast-enhanced ultrasound was used to analyse intraplaque neovascularization (IPN). The correlations between the ARUC and risk factors of stroke were examined. A receiver operating characteristic curve was used to determine the cut-off value of the ARUC. RESULTS Using a quantitative analysis method for IPN, the ARUC was significantly higher in the symptomatic group than in the asymptomatic group (p=0.017). The ARUC was positively associated with the homocysteine level (r=0.429, p=0.002) and high-sensitivity C-reactive protein level (r=0.424, p=0.003). Regression analysis showed that the ARUC was a risk factor for symptoms of stroke. The receiver operating characteristic curve showed that the cut-off value for symptoms was 0.24; the sensitivity was 77%, and the specificity was 70%; the positive predictive value was 68%, and the negative predictive value was 78%. CONCLUSION IPN was a risk factor for the occurrence of the clinical symptoms of stroke. Patients with an ARUC of >0.24 had a higher risk of stroke.
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Affiliation(s)
- Y Song
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Y Dang
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - L L Dang
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - C Zhao
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - J Zheng
- The Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - J Feng
- Department of Vascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China.
| | - L T Ruan
- Department of Ultrasound, The First Affiliated Hospital of Xi'an Jiaotong University, No.277 Yanta West Road, Xi'an, Shaanxi 710061, China.
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Choi SW, Kim H, Kim IC, Lee CH, Hwang J, Park HS, Cho YK, Yoon HJ, Nam CW, Han S, Hur SH. Implication of ultrasound contrast-enhancement of carotid plaques in prevalence of acute coronary syndrome and occurrence of cardiovascular outcomes. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:461-466. [PMID: 30306599 DOI: 10.1002/jcu.22638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE Ultrasonographic contrast enhancement of carotid plaque (CECP) has been used to detect neovascularization of vasa vasorum and plaque. However, it is uncertain whether CECP can provide risk stratification of coronary artery disease (CAD). This study aimed to evaluate the relationship between CECP and manifestations of acute coronary syndrome (ACS) in established CAD patients and to explore the prognostic implication of CECP for cardiovascular (CV) clinical outcomes. METHODS A medical record review revealed that contrast-enhanced ultrasonography was performed to evaluate carotid atherosclerosis in 209 coronary artery-stented and 105 non-stented patients. The rate of ACS manifestations was compared depending on contrast uptake patterns: grade 0, absent; grade 1, dot; and grade 2, diffuse pattern. CV primary outcomes were assessed during a mean 7.6 months of follow-up. RESULTS Male sex, smoking, history of old myocardial infarction, intensive medications, and a favorable lipid profile were common in the stented versus non-stented group. Patients with grade 2 CECP had a higher rate of ACS, greater plaque thickness, and class I-II of Gray-Weale plaque echogenicity. During follow-up, 10 coronary revascularizations (nine ACSs), six strokes, and four heart failures occurred. Grade 2 CECP was more closely related with CV primary outcomes and showed a tendency toward more acute CV outcomes. CONCLUSION ACS manifestations were proportionate to CECP grade. Diffuse CECP uptake could be a risk factor for acute CV outcomes.
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Affiliation(s)
- Sang-Woong Choi
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Hyungseop Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - In-Cheol Kim
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Cheol-Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Jongmin Hwang
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Yun-Kyeong Cho
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Hyuck-Jun Yoon
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Chang-Wook Nam
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Seongwook Han
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Seung-Ho Hur
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
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Qin C, Zhang L, Wang X, Duan Y, Ye Z, Xie M. Evaluation of Carotid Plaque Neovascularization in Patients With Coronary Heart Disease on Contrast-Enhanced Ultrasonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:823-831. [PMID: 29027678 DOI: 10.1002/jum.14410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/05/2017] [Accepted: 06/16/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To examine the repeatability of quantitative time-intensity curve analysis of neovascularization within carotid plaques with contrast-enhanced ultrasonography (US) and to investigate carotid plaque neovascularization in patients with coronary heart disease using contrast-enhanced US and the correlation between risk factors and acute coronary syndrome (ACS). METHODS Sixty patients with ACS and 60 with stable coronary artery disease (CAD) underwent conventional carotid and contrast-enhanced US, and plaque enhancement was observed and analyzed quantitatively. Carotid contrast-enhanced US was performed within 1 month of ACS occurrence. Interobserver and intraobserver variability of the measurements was assessed. The peak signal intensity was the maximum number of contrast microbubbles that local tissues could accumulate, reflecting the local microvascular density and representing the capillary volume. RESULTS The ACS group had higher low-density lipoprotein cholesterol (mean ± SD, 3.21 ± 0.75 versus 2.53 ± 0.71 mmol/L; P < .01) and high-sensitivity C-reactive protein (CRP; 3.76 ± 0.19 versus 2. 93 ± 0.15 mg/L; P < .01) levels than the stable CAD group. The proportion of soft plaques in the ACS group (81%) was higher than in the stable CAD group (53%). The proportion of plaque enhancement, peak signal intensity, and plaque-to-carotid lumen enhancement intensity ratio were higher in the ACS group than the stable CAD group. The peak signal intensity was correlated with the high-sensitivity CRP value. Logistic regression analyses indicated that age (65-74 years), high-sensitivity CRP, and enhancement intensity were correlated with the occurrence of ACS. The sensitivity and specificity of the peak signal intensity in carotid plaques were 80.0% and 88.3%, respectively (cutoff value, 9.97 dB; area under the receiver operating characteristic curve, 0.865). The time-intensity curve measurements had good repeatability. CONCLUSIONS Carotid plaque enhancement is a potential independent risk factor for ACS occurrence. These results illustrate the correlation of carotid plaque vulnerability with the coronary artery symptomatic state according to the common pathogenetic mechanism of atherosclerosis.
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Affiliation(s)
- Chuan Qin
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Department of Ultrasound, Central Hospital, Karamay, China
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xinfang Wang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yilian Duan
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Zhou Ye
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Ultrasound, Central Hospital, Karamay, China
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Chistiakov DA, Melnichenko AA, Myasoedova VA, Grechko AV, Orekhov AN. Role of lipids and intraplaque hypoxia in the formation of neovascularization in atherosclerosis. Ann Med 2017; 49:661-677. [PMID: 28797175 DOI: 10.1080/07853890.2017.1366041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
According to the current paradigm, chronic vascular inflammation plays a central role in the pathogenesis of atherosclerosis. The plaque progression is typically completed with rupture and subsequent acute cardiovascular complications. Previously, the role of adventitial vasa vasorum in atherogenesis was underestimated. However, investigators then revealed that vasa vasorum neovascularization can be observed when no clinical manifestation of atherosclerosis is present. Vasa vasorum is involved in various proatherogenic processes such as intimal accumulation of inflammatory leukocytes, intimal thickening, necrotic core formation, intraplaque haemorrhage, lesion rupture and atherothrombosis. Due to the destabilizing action of the intraplaque microenvironment, lesional vasa vasorum neovessels experience serious defects and abnormalities during development that leads to their immaturity, fragility and leakage. Indeed, intraplaque neovessels are a main cause of intraplaque haemorrhage. Visualization techniques showed that presence of neovascularization/haemorrhage can serve as a good indicator of lesion instability and higher risk of rupture. Vasa vasorum density is a strong predictor of acute cardiovascular events such as sudden death, myocardial infarction and stroke. At present, arterial vasa vasorum neovascularization is under intensive investigation along with development of therapeutic tools focused on the control of formation of vasa vasorum neovessels in order to prevent plaque haemorrhage/rupture and thromboembolism. KEY MESSAGE Neovascularization plays an important role in atherosclerosis, being involved in unstable plaque formation. Presence of neovascularization and haemorrhage indicates plaque instability and risk of rupture. Various imaging techniques are available to study neovascularization.
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Affiliation(s)
- Dimitry A Chistiakov
- a Department of Neurochemistry, Division of Basic and Applied Neurobiology , Serbsky Federal Medical Research Center of Psychiatry and Narcology , Moscow , Russia
| | - Alexandra A Melnichenko
- b Laboratory of Angiopathology , Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences , Moscow , Russia
| | - Veronika A Myasoedova
- b Laboratory of Angiopathology , Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences , Moscow , Russia
| | - Andrey V Grechko
- c Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology , Moscow , Russia
| | - Alexander N Orekhov
- b Laboratory of Angiopathology , Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences , Moscow , Russia.,d Institute for Atherosclerosis Research, Skolkovo Innovative Center , Moscow , Russia
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Baud JM, Luong S, Rouyer O, Maurizot A, Gautier C. [Contribution of contrast enhanced ultrasonography in the characterization of carotid lesions]. JOURNAL DE MEDECINE VASCULAIRE 2017; 42:301-314. [PMID: 28964389 DOI: 10.1016/j.jdmv.2017.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/19/2017] [Indexed: 06/07/2023]
Abstract
Harmonic mode ultrasound with injection of a contrast enhancement agent allows visualization of mobile microbubbles in the carotid plaque corresponding to neovessels secondary to an inflammation or hypoxia. These neovessels could be considered "precursor" markers of the vulnerable plaque. The aim of this work was to give an update on ultrasound contrast imaging acquisition in the exploration of carotid artery both for atheromatous lesions and for large vessel vasculitis. A precise description of the material to be used, the image acquisition methodology and the environmental conditions is discussed, emphasizing the pitfalls to be avoided as well as proper image interpretation. Microbubbles in a plaque are significantly associated with an increase in cardiovascular events (infarction and acute coronary syndrome) and ipsilateral cerebral ischemic events. Wall irregularities, microfissures and ulcer plaque detection are facilitated by the use of contrast compared to the CT scan. No studies have yet validated contrast enhanced ultrasound in the exploration of asymptomatic carotid stenosis. Contrast enhanced ultrasound also allows to detect vasculitis of the large vessels active phases by the presence of microbubbles in the carotid wall thickening and to monitor the regression under appropriate medical treatment. Future validation studies or even registries are needed to allow better use of this tool in everyday clinical practice.
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Affiliation(s)
- J M Baud
- Unité de médecine vasculaire, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France.
| | - S Luong
- Département d'imagerie diagnostique et thérapeutique, hôpital Louis-Pradel, hospices Civils de Lyon, 28, avenue Doyen-Lépine, 69500 Bron, France
| | - O Rouyer
- Unité neurovasculaire, hôpital de Hautepierre, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - A Maurizot
- Unité de médecine vasculaire, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - C Gautier
- Unité fonctionnelle de neurosonologie de l'hôpital Roger-Salengro, service des explorations fonctionnelles cardiovasculaires de l'hôpital cardiologique, CHRU de Lille, rue du Professeur Emile-Laine, 59037 Lille cedex, France
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Durymanov M, Kamaletdinova T, Lehmann SE, Reineke J. Exploiting passive nanomedicine accumulation at sites of enhanced vascular permeability for non-cancerous applications. J Control Release 2017. [DOI: 10.1016/j.jconrel.2017.06.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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16
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Correlation of enhancement degree on contrast-enhanced ultrasound with histopathology of carotid plaques and serum high sensitive C-reactive protein levels in patients undergoing carotid endarterectomy. ACTA ACUST UNITED AC 2017; 37:425-428. [DOI: 10.1007/s11596-017-1751-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 01/23/2017] [Indexed: 10/18/2022]
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17
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Johri AM, Herr JE, Li TY, Yau O, Nambi V. Novel Ultrasound Methods to Investigate Carotid Artery Plaque Vulnerability. J Am Soc Echocardiogr 2017; 30:139-148. [DOI: 10.1016/j.echo.2016.11.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Indexed: 11/17/2022]
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18
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The therapeutic effect of bevacizumab on plaque neovascularization in a rabbit model of atherosclerosis during contrast-enhanced ultrasonography. Sci Rep 2016; 6:30417. [PMID: 27452862 PMCID: PMC4958919 DOI: 10.1038/srep30417] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 07/05/2016] [Indexed: 01/06/2023] Open
Abstract
The purpose of the study was to assess the therapeutic effect of the angiogenesis inhibitor bevacizumab on plaques of various stages in rabbit models using contrast-enhanced ultrasonography (CEUS). Abdominal aortic atherosclerosis was induced in 55 rabbits. Thirty-six randomly selected rabbits were divided into 2 groups according to the timing of the bevacizumab injection: an early-stage plaque group (Group ESP) and a later-stage plaque group (Group LSP). The remainder were considered the control group. Standard ultrasonography and CEUS imaging of the abdominal aorta were performed. The animals were euthanized after CEUS, and plaque specimens were harvested for histological staining of CD31. The control group exhibited a substantially higher enhanced intensity, a higher ratio of enhanced intensity in the plaque to that in the lumen, and an increased number of CD31-positive microvessels in the plaque sections than Groups ESP and LSP (P < 0.05 for all). A higher enhanced intensity (P = 0.044), a higher ratio of enhanced intensity in the plaque to that in the lumen (P = 0.023) and more CD31-positive microvessels in the plaque sections (P = 0.006) were found in Group LSP than in Group ESP. Bevacizumab demonstrated more advanced inhibition of neovascularization in early-stage plaques in rabbits.
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19
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Huang R, Abdelmoneim SS, Ball CA, Nhola LF, Farrell AM, Feinstein S, Mulvagh SL. Detection of Carotid Atherosclerotic Plaque Neovascularization Using Contrast Enhanced Ultrasound: A Systematic Review and Meta-Analysis of Diagnostic Accuracy Studies. J Am Soc Echocardiogr 2016; 29:491-502. [PMID: 27038513 DOI: 10.1016/j.echo.2016.02.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intraplaque neovascularization is considered an important indicator of plaque vulnerability. Contrast-enhanced ultrasound (CEUS) of carotid arteries improves imaging of carotid intima-media thickness and permits real-time visualization of neovascularization of the atherosclerotic plaque. The authors conducted a systematic review and meta-analysis to evaluate the accuracy of CEUS-detected carotid atherosclerotic plaque. METHODS A systematic search was performed to identify studies published in the MEDLINE, Embase, Scopus, and Web of Science databases from 2004 to June 2015. Studies evaluating the accuracy of quantitative analysis and qualitative analysis (visual interpretation) for the diagnosis of intraplaque neovascularization compared with histologic specimens and/or clinical diagnosis of symptomatic plaque were included. Parameters evaluated were plaque quantitative CEUS intensity and the visual grading of plaque CEUS. A random-effects meta-analysis was used to pool the likelihood ratios (LRs), diagnostic odds ratios, and summary receiver operating characteristic curves. Corresponding areas under the curves were calculated. RESULTS The literature search identified 203 studies, 20 of which were selected for systematic review; the final meta-analysis included seven studies. For qualitative CEUS, pooled sensitivity was 0.80 (95% CI, 0.72-0.87), pooled specificity was 0.83 (95% CI, 0.76-0.89), the pooled positive LR was 3.22 (95% CI, 1.67-6.18), the pooled negative LR was 0.24 (95% CI, 0.09-0.64), the pooled diagnostic odds ratio was 15.57 (95% CI, 4.94-49.03), and area under the curve was 0.894. For quantitative CEUS, pooled sensitivity was 0.77 (95% CI, 0.71-0.83), pooled specificity was 0.68 (95% CI, 0.62-0.73), the pooled positive LR was 2.34 (95% CI, 1.69-3.23), the pooled negative LR was 0.34 (95% CI, 0.25-0.47), the pooled diagnostic odds ratio was 7.06 (95% CI, 3.6-13.82), and area under the curve was 0.888. CONCLUSIONS CEUS is a promising noninvasive diagnostic modality for detecting intraplaque neovascularization. Standardization of quantitative analysis and visual grading classification is needed to increase reliability and reduce technical heterogeneity.
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Affiliation(s)
- Runqing Huang
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota; Division of Ultrasound, Tongji Hospital, Tongji Medical College, HuaZhong University of Science and Technology, Wuhan, China
| | - Sahar S Abdelmoneim
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Caroline A Ball
- Internal Medicine, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Lara F Nhola
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Ann M Farrell
- Mayo Clinic Libraries, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota
| | | | - Sharon L Mulvagh
- Division of Cardiovascular Diseases, Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, Minnesota.
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Brinjikji W, Huston J, Rabinstein AA, Kim GM, Lerman A, Lanzino G. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg 2016. [DOI: 10.3171/2015.1.jns142452.test] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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21
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van Walraven C, McAlister FA. Competing risk bias was common in Kaplan–Meier risk estimates published in prominent medical journals. J Clin Epidemiol 2016; 69:170-3.e8. [DOI: 10.1016/j.jclinepi.2015.07.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/26/2015] [Accepted: 07/20/2015] [Indexed: 02/07/2023]
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Saha SA, Gourineni V, Feinstein SB. The Use of Contrast-enhanced Ultrasonography for Imaging of Carotid Atherosclerotic Plaques: Current Evidence, Future Directions. Neuroimaging Clin N Am 2015; 26:81-96. [PMID: 26610662 DOI: 10.1016/j.nic.2015.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Contrast-enhanced ultrasonography (CEUS) is a rapidly evolving modality for imaging carotid artery disease and systemic atherosclerosis. CEUS coupled with diagnostic ultrasonography predicts the degree of carotid artery stenosis and is comparable with computed tomography and magnetic resonance angiography. This article reviews the literature on the evolving role of CEUS for the identification and characterization of carotid plaques with an emphasis on detection of intra-plaque neovascularization and related high-risk morphologic features notably present in symptomatic patients. CEUS carotid imaging may play a prominent additive role in risk stratifying patients and serve as a powerful tool for monitoring therapeutic interventions.
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Affiliation(s)
- Sandeep A Saha
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA.
| | - Venu Gourineni
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Steven B Feinstein
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
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van Hinsbergh VWM, Eringa EC, Daemen MJAP. Neovascularization of the atherosclerotic plaque: interplay between atherosclerotic lesion, adventitia-derived microvessels and perivascular fat. Curr Opin Lipidol 2015; 26:405-11. [PMID: 26241102 DOI: 10.1097/mol.0000000000000210] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Neovascularization is a prominent feature in advanced human atherosclerotic plaques. This review surveys recent evidence for and remaining uncertainties regarding a role of neovascularization in atherosclerotic plaque progression. Specific emphasis is given to hypoxia, angiogenesis inhibition, and perivascular adipose tissue (PVAT). RECENT FINDINGS Immunohistochemical and imaging studies showed a strong association between hypoxia, inflammation and neovascularization, and the progression of the atherosclerotic plaque both in humans and mice. Whereas in humans, a profound invasion of microvessels from the adventitia into the plaque occurs, neovascularization in mice is found mainly (peri)adventitially. Influencing neovascularization in mice affected plaque progression, possibly by improving vessel perfusion, but supportive clinical data are not available. Whereas plaque neovascularization contributes to monocyte/macrophage accumulation in the plaque, lymphangiogenesis may facilitate egress of cells and waste products. A specific role for PVAT and its secreted factors is anticipated and wait further clinical evaluation. SUMMARY Hypoxia, inflammation, and plaque neovascularization are associated with plaque progression as underpinned by recent imaging data in humans. Recent studies provide new insights into modulation of adventitia-associated angiogenesis, PVAT, and plaque development in mice, but there is still a need for detailed information on modulating human plaque vascularization in patients.
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Affiliation(s)
- Victor W M van Hinsbergh
- aLaboratory for Physiology, Institute for Cardiovascular Research, VU University Medical Center bDepartment of Pathology, Academic Medical Center, Amsterdam, The Netherlands
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Brinjikji W, Huston J, Rabinstein AA, Kim GM, Lerman A, Lanzino G. Contemporary carotid imaging: from degree of stenosis to plaque vulnerability. J Neurosurg 2015; 124:27-42. [PMID: 26230478 DOI: 10.3171/2015.1.jns142452] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Carotid artery stenosis is a well-established risk factor of ischemic stroke, contributing to up to 10%-20% of strokes or transient ischemic attacks. Many clinical trials over the last 20 years have used measurements of carotid artery stenosis as a means to risk stratify patients. However, with improvements in vascular imaging techniques such as CT angiography and MR angiography, ultrasonography, and PET/CT, it is now possible to risk stratify patients, not just on the degree of carotid artery stenosis but also on how vulnerable the plaque is to rupture, resulting in ischemic stroke. These imaging techniques are ushering in an emerging paradigm shift that allows for risk stratifications based on the presence of imaging features such as intraplaque hemorrhage (IPH), plaque ulceration, plaque neovascularity, fibrous cap thickness, and presence of a lipid-rich necrotic core (LRNC). It is important for the neurosurgeon to be aware of these new imaging techniques that allow for improved patient risk stratification and outcomes. For example, a patient with a low-grade stenosis but an ulcerated plaque may benefit more from a revascularization procedure than a patient with a stable 70% asymptomatic stenosis with a thick fibrous cap. This review summarizes the current state-of-the-art advances in carotid plaque imaging. Currently, MRI is the gold standard in carotid plaque imaging, with its high resolution and high sensitivity for identifying IPH, ulceration, LRNC, and inflammation. However, MRI is limited due to time constraints. CT also allows for high-resolution imaging and can accurately detect ulceration and calcification, but cannot reliably differentiate LRNC from IPH. PET/CT is an effective technique to identify active inflammation within the plaque, but it does not allow for assessment of anatomy, ulceration, IPH, or LRNC. Ultrasonography, with the aid of contrast enhancement, is a cost-effective technique to assess plaque morphology and characteristics, but it is limited in sensitivity and specificity for detecting LRNC, plaque hemorrhage, and ulceration compared with MRI. Also summarized is how these advanced imaging techniques are being used in clinical practice to risk stratify patients with low- and high-grade carotid artery stenosis. For example, identification of IPH on MRI in patients with low-grade carotid artery stenosis is a risk factor for failure of medical therapy, and studies have shown that such patients may fair better with carotid endarterectomy (CEA). MR plaque imaging has also been found to be useful in identifying revascularization candidates who would be better candidates for CEA than carotid artery stenting (CAS), as high intraplaque signal on time of flight imaging is associated with vulnerable plaque and increased rates of adverse events in patients undergoing CAS but not CEA.
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Affiliation(s)
| | | | | | - Gyeong-Moon Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Assessment of carotid plaque neovascularization using quantitative analysis of contrast-enhanced ultrasound imaging is useful for risk stratification in patients with coronary artery disease. Int J Cardiol 2015; 195:113-9. [PMID: 26025869 DOI: 10.1016/j.ijcard.2015.05.107] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 04/13/2015] [Accepted: 05/06/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Contrast-enhanced ultrasound (CEUS) of the carotid artery is a potential technique for imaging plaque neovascularization, a feature of unstable atherosclerotic plaques. This study examined whether assessment of intra-plaque neovascularization of the carotid artery using CEUS provides prognostic information in patients with coronary artery disease (CAD). METHODS A total of 206 patients with stable CAD underwent a CEUS examination of the carotid artery and were followed up prospectively for <38 months or until a cardiac event (cardiac death, non-fatal myocardial infarction (MI), unstable angina pectoris (uAP) requiring unplanned coronary revascularization, or heart failure requiring hospitalization). The degree of contrast signals measured within the carotid plaque was quantified by calculating the mean gray scale level within the region of interest of the carotid plaque, expressed as plaque enhanced intensity. RESULTS During the follow-up period, 31 events occurred (2 cardiac deaths, 7 non-fatal MIs, 16 uAP, and 6 heart failure). Multivariate Cox proportional hazard analysis showed that plaque enhanced intensity was a significant predictor of cardiac events independent of traditional risk factors (HR, 1.13; 95% CI, 1.05-1.21; p<0.001). The addition of the plaque enhanced intensity to traditional risk factors resulted in net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI 0.62, p=0.001; and IDI 0.106, p=0.002). CONCLUSIONS The assessment of carotid plaque neovascularization using quantitative analysis of CEUS may be useful for risk stratification in patients with CAD.
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Picano E, Paterni M. Ultrasound tissue characterization of vulnerable atherosclerotic plaque. Int J Mol Sci 2015; 16:10121-33. [PMID: 25950760 PMCID: PMC4463636 DOI: 10.3390/ijms160510121] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 04/23/2015] [Accepted: 04/24/2015] [Indexed: 11/16/2022] Open
Abstract
A thrombotic occlusion of the vessel fed by ruptured coronary atherosclerotic plaque may result in unstable angina, myocardial infarction or death, whereas embolization from a plaque in carotid arteries may result in transient ischemic attack or stroke. The atherosclerotic plaque prone to such clinical events is termed high-risk or vulnerable plaque, and its identification in humans before it becomes symptomatic has been elusive to date. Ultrasonic tissue characterization of the atherosclerotic plaque is possible with different techniques--such as vascular, transesophageal, and intravascular ultrasound--on a variety of arterial segments, including carotid, aorta, and coronary districts. The image analysis can be based on visual, video-densitometric or radiofrequency methods and identifies three distinct textural patterns: hypo-echoic (corresponding to lipid- and hemorrhage-rich plaque), iso- or moderately hyper-echoic (fibrotic or fibro-fatty plaque), and markedly hyperechoic with shadowing (calcific plaque). Hypoechoic or dishomogeneous plaques, with spotty microcalcification and large plaque burden, with plaque neovascularization and surface irregularities by contrast-enhanced ultrasound, are more prone to clinical complications than hyperechoic, extensively calcified, homogeneous plaques with limited plaque burden, smooth luminal plaque surface and absence of neovascularization. Plaque ultrasound morphology is important, along with plaque geometry, in determining the atherosclerotic prognostic burden in the individual patient. New quantitative methods beyond backscatter (to include speed of sound, attenuation, strain, temperature, and high order statistics) are under development to evaluate vascular tissues. Although not yet ready for widespread clinical use, tissue characterization is listed by the American Society of Echocardiography roadmap to 2020 as one of the most promising fields of application in cardiovascular ultrasound imaging, offering unique opportunities for the early detection and treatment of atherosclerotic disease.
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Affiliation(s)
- Eugenio Picano
- Biomedicine Department, NU School of Medicine, Astana 010000, Kazakistan.
| | - Marco Paterni
- CNR (Consiglio Nazionale Ricerche), Institute of Clinical Physiology, 56124 Pisa, Italy.
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Sun J, Deng YB, Liu K, Wang YB. Effects of noradrenaline and adenosine triphosphate on the degree on contrast enhancement in a rabbit model of atherosclerosis during contrast-enhanced ultrasonography. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:2655-2661. [PMID: 25218451 DOI: 10.1016/j.ultrasmedbio.2014.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 06/04/2014] [Accepted: 06/09/2014] [Indexed: 06/03/2023]
Abstract
The aim of the study is to assess the effects of vasoactive agents on the degree of contrast enhancement in experimental atherosclerotic plaque during contrast-enhanced ultrasonography (CEUS). Abdominal aortic atherosclerosis was induced in 25 New Zealand white rabbits by a combination of cholesterol-rich diet and balloon endothelial denudation. Standard ultrasonography and CEUS were performed at baseline and during intravenous infusion of noradrenaline or adenosine triphosphate (ATP). The degree of contrast enhancement of the plaque after injection of contrast material was quantified by calculating the enhanced intensity in the plaque. The infusion of noradrenaline induced significant increase in systolic blood pressure (84 ± 13 mm Hg vs. 112 ± 20 mm Hg, p = 0.011) and significant decrease in the enhanced intensity in the plaque (7.52 ± 1.32 dB vs. 5.88 ± 1.33 dB, p < 0.001) during CEUS. The infusion of ATP resulted in the significant decrease in systolic blood pressure (80 ± 13 mm Hg vs. 65 ± 11 mm Hg, p = 0.005) and increase in the enhanced intensity in the plaque (7.52 ± 1.32 dB vs. 8.84 ± 1.55 dB, p < 0.001) during CEUS. The degree of contrast enhancement within an experimental atherosclerotic plaque during CEUS can be influenced by vasoactive agents and hemodynamic status.
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Affiliation(s)
- Jie Sun
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - You-Bin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Kun Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu-Bo Wang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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