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Huang Y, Sun X, Ding X, Tan S, Yu Z, Shi X, Li X, Ge H. Pathological Intraplaque Hemorrhage as the Gold Standard to Assess the Efficacy of Ultrasound in Predicting Vulnerable Carotid Plaque Rupture. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38962941 DOI: 10.1002/jum.16518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 05/27/2024] [Accepted: 06/14/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE To assess the clinical utility of ultrasound in predicting the risk of carotid vulnerable plaque rupture using pathological intraplaque hemorrhage as the gold standard. METHODS A total of 118 patients who underwent endarterectomy due to symptomatic carotid artery stenosis were enrolled. Conventional ultrasound assessed the plaque thickness, area stenosis rate, echo, and surface morphology. Neovascularization were assessed by contrast-enhanced ultrasound (CEUS) and tracing intraplaque nonenhanced areas. According to neovascularization grade (0-4), plaques were classified as low-, intermediate-, and high risk. Fresh intraplaque hemorrhage within the pathology was adopted as the gold standard for diagnosing plaque rupture risk. Thus, we divided patients into ruptured risk and nonruptured risk groups to assess the value of crucial factors for plaque rupture risk using ultrasound. RESULTS Of the 118 patients, hypertension accounted for 71.2%, hyperlipidemia 68.6%, diabetes 52.5%, and statin history 64.4%. In the rupture risk group, diabetes, smoking, and stenosis rate were significantly higher than the nonrupture risk group (P < .001); plaque thickness ≥4 mm (P > .05); and mainly hypoechoic with irregular surface morphology (P < .001), nonenhanced areas in the plaques (P < .001), and neovascularization >grade 2 (P < .001). Compared with the low-risk group, plaque rupture risk was 7.219 times higher in the medium-risk group and 18.333 times higher in the high-risk group. The kappa value of the interobserver consistency of crucial ultrasound parameters was >0.75, and the intraclass correlation coefficient was 0.919 (P < .01). CONCLUSIONS Both conventional ultrasound and CEUS have significant clinical importance in the prediction of rupture risk in vulnerable carotid plaques, thereby enabling stroke risk stratification and the assessment of plaque rupture risk.
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Affiliation(s)
- Yaping Huang
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of Ultrasound, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Xinping Sun
- Department of Ultrasound, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Xu Ding
- Department of Vascular Surgery, Chuiyangliu Hospital Affiliated to Tsinghua University, Beijing, China
| | - Shuping Tan
- Department of Vascular Surgery, Beijing Hospital, Beijing, China
| | - Zexing Yu
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xue Shi
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xin Li
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Huiyu Ge
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Wang LJ, Zhai PQ, Xue LL, Shi CY, Zhang Q, Zhang H. Machine learning-based identification of symptomatic carotid atherosclerotic plaques with dual-energy computed tomography angiography. J Stroke Cerebrovasc Dis 2023; 32:107209. [PMID: 37290153 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107209] [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: 01/28/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE This study aimed to develop and validate a machine learning model incorporating both dual-energy computed tomography (DECT) angiography quantitative parameters and clinically relevant risk factors for the identification of symptomatic carotid plaques to prevent acute cerebrovascular events. METHODS The data of 180 patients with carotid atherosclerosis plaques were analysed from January 2017 to December 2021; 110 patients (64.03±9.58 years old, 20 women, 90 men) were allocated to the symptomatic group, and 70 patients (64.70±9.89 years old, 50 women, 20 men) were allocated to the asymptomatic group. Overall, five machine learning models using the XGBoost algorithm, based on different CT and clinical features, were developed in the training cohort. The performances of all five models were assessed in the testing cohort using receiver operating characteristic curves, accuracy, recall rate, and F1 score. RESULTS The shapley additive explanation (SHAP) value ranking showed fat fraction (FF) as the highest among all CT and clinical features and normalised iodine density (NID) as the 10th. The model based on the top 10 features from the SHAP measurement showed optimal performance (area under the curve [AUC] .885, accuracy .833, recall rate .933, F1 score .861), compared with the other four models based on conventional CT features (AUC .588, accuracy .593, recall rate .767, F1 score .676), DECT features (AUC .685, accuracy .648, recall rate .667, F1 score .678), conventional CT and DECT features (AUC .819, accuracy .740, recall rate .867, F1 score .788), and all CT and clinical features (AUC .878, accuracy .833, recall rate .867, F1 score .852). CONCLUSION FF and NID can serve as useful imaging markers of symptomatic carotid plaques. This tree-based machine learning model incorporating both DECT and clinical features could potentially comprise a non-invasive method for identification of symptomatic carotid plaques to guide clinical treatment strategies.
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Affiliation(s)
- Ling-Jie Wang
- Department of Radiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, PR China.
| | - Pei-Qing Zhai
- Department of Radiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, PR China.
| | - Li-Li Xue
- Department of Radiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, PR China.
| | - Cai-Yun Shi
- Department of Radiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, PR China.
| | - Qian Zhang
- Department of Radiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, PR China.
| | - Hua Zhang
- Department of Radiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province 030001, PR China.
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Wang B, Zhao P, Zhang P, Hu J, Liu Y, Xie M, He Y. 3D-printed tortuous vessels with Photodissociable and morphology-controllable ink. J Biomater Appl 2023:8853282231183984. [PMID: 37485893 DOI: 10.1177/08853282231183984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Acute ischemic stroke (AIS) is a high mortality cerebrovascular disease associated with vessel curvature. However, the relevant mechanism remains unclear due to a lack of appropriate tortuous vascular models to investigate and validate. This study explores the combination of projection-based 3D bioprinting (PBP) with photo-stimulus-responsive techniques to fabricate a sodium alginate (SA)/acrylamide (AAM) hydrogel vascular scaffold capable of bending deformation. The coordination of Fe3+ ions with carboxylate groups in the alginate chains of the vascular scaffold acts as a molecular switch, which can be dissociated through photoreduction to enable the deformation response. Fourier Transform Infrared (FTIR) and X-ray Photoelectron Spectroscopy (XPS) results verified the deformation principle. By subjecting the scaffold to UV light exposure, Fe3+ is reduced to Fe2+ in spatially selected regions, resulting in the release of strain and subsequent deformation. Furthermore, it also controlled the degree and direction of curvature of the vessels. The cell seeding experiment verified that the vascular scaffold showed excellent biocompatibility. Overall, our approach could be used to generate an in vitro model of curved vascular pathology to investigate the pathogenesis and provide new directions for the diagnosis and treatment of vascular diseases in the future.
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Affiliation(s)
- Biling Wang
- School of Mechatronics & Vehicle Engineering, East China Jiaotong University, Nanchang, China
- Engineering for Life Group (EFL), Suzhou, China
| | - Pengcheng Zhao
- School of Mechatronics & Vehicle Engineering, East China Jiaotong University, Nanchang, China
| | - Peng Zhang
- Engineering for Life Group (EFL), Suzhou, China
| | - Jun Hu
- School of Mechatronics & Vehicle Engineering, East China Jiaotong University, Nanchang, China
| | - Yande Liu
- School of Mechatronics & Vehicle Engineering, East China Jiaotong University, Nanchang, China
| | - Mingjun Xie
- Plastic and Reconstructive Surgery Center, Department of Plastic and Reconstructive Surgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yong He
- School of Mechatronics & Vehicle Engineering, East China Jiaotong University, Nanchang, China
- Engineering for Life Group (EFL), Suzhou, China
- State Key Laboratory of Fluid Power and Mechatronic Systems, School of Mechanical Engineering, Zhejiang University, Hangzhou, China
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4
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Advances in Noninvasive Carotid Wall Imaging with Ultrasound: A Narrative Review. J Clin Med 2022; 11:jcm11206196. [PMID: 36294515 PMCID: PMC9604731 DOI: 10.3390/jcm11206196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2022] Open
Abstract
Carotid atherosclerosis is a major cause for stroke, with significant associated disease burden morbidity and mortality in Western societies. Diagnosis, grading and follow-up of carotid atherosclerotic disease relies on imaging, specifically ultrasound (US) as the initial modality of choice. Traditionally, the degree of carotid lumen stenosis was considered the sole risk factor to predict brain ischemia. However, modern research has shown that a variety of other imaging biomarkers, such as plaque echogenicity, surface morphology, intraplaque neovascularization and vasa vasorum contribute to the risk for rupture of carotid atheromas with subsequent cerebrovascular events. Furthermore, the majority of embolic strokes of undetermined origin are probably arteriogenic and are associated with nonstenosing atheromas. Therefore, a state-of-the-art US scan of the carotid arteries should take advantage of recent technical developments and should provide detailed information about potential thrombogenic (/) and emboligenic arterial wall features. This manuscript reviews recent advances in ultrasonographic assessment of vulnerable carotid atherosclerotic plaques and highlights the fields of future development in multiparametric arterial wall imaging, in an attempt to convey the most important take-home messages for clinicians performing carotid ultrasound.
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5
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Identification Markers of Carotid Vulnerable Plaques: An Update. Biomolecules 2022; 12:biom12091192. [PMID: 36139031 PMCID: PMC9496377 DOI: 10.3390/biom12091192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/02/2022] Open
Abstract
Vulnerable plaques have been a hot topic in the field of stroke and carotid atherosclerosis. Currently, risk stratification and intervention of carotid plaques are guided by the degree of luminal stenosis. Recently, it has been recognized that the vulnerability of plaques may contribute to the risk of stroke. Some classical interventions, such as carotid endarterectomy, significantly reduce the risk of stroke in symptomatic patients with severe carotid stenosis, while for asymptomatic patients, clinically silent plaques with rupture tendency may expose them to the risk of cerebrovascular events. Early identification of vulnerable plaques contributes to lowering the risk of cerebrovascular events. Previously, the identification of vulnerable plaques was commonly based on imaging technologies at the macroscopic level. Recently, some microscopic molecules pertaining to vulnerable plaques have emerged, and could be potential biomarkers or therapeutic targets. This review aimed to update the previous summarization of vulnerable plaques and identify vulnerable plaques at the microscopic and macroscopic levels.
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6
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Li Y, Zheng S, Zhang J, Wang F, Liu X, He W. Advance ultrasound techniques for the assessment of plaque vulnerability in symptomatic and asymptomatic carotid stenosis: a multimodal ultrasound study. Cardiovasc Diagn Ther 2021; 11:28-38. [PMID: 33708475 DOI: 10.21037/cdt-20-876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Advanced carotid ultrasound techniques may be useful in characterizing plaque vulnerability, but comprehensive studies are still lacking. The aim of this study was to identify factors associated with vulnerable plaques using advanced ultrasound techniques. Methods This is a prospective observational study of patients with >50% internal carotid stenosis (ICA). All patients underwent conventional ultrasound, superb microvascular imaging (SMI) and shear wave elastography (SWE) examinations. Plaque size, echogenicity, stiffness and intraplaque neovascularization (IPN) were assessed and compared between symptomatic and asymptomatic groups. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic performance of SWE and SMI of the vulnerable plaques. Results The final analysis included 123 patients (78.9% male; mean age, 66±8 years), 65 were enrolled in the symptomatic group, and 58 were enrolled in the asymptomatic group. The mean elasticity was 78.1±25.4 kPa for asymptomatic and 51.5±18.3 kPa for symptomatic plaques. Symptomatic plaques showed higher visual IPN grades on SMI than asymptomatic plaques (P<0.001). Multivariate regression analysis showed that plaque stiffness (PS) (OR 0.95, 95% CI, 0.919-0.974) and IPN level (OR 4.17, 95% CI, 2.008-8.664) were independently associated with symptomatic plaques. The combination of the two factors had a preferable accuracy to discriminate symptomatic plaques (AUC 0.89, 95% CI, 0.827-0.944). Conclusions Advanced carotid ultrasound techniques can identify plaque characteristics that are associated with ischemic events and may be potentially indicative of plaque vulnerability. These factors may ultimately be used in the clinical management of carotid stenosis.
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Affiliation(s)
- Yi Li
- Department of Ultrasound, Capital Medical University, Beijing, China.,Department of Ultrasound, Beijing Tiantan Hospital, Beijing, China
| | - Shuai Zheng
- Department of Ultrasound, Capital Medical University, Beijing, China.,Department of Ultrasound, Beijing Tiantan Hospital, Beijing, China
| | - Jinghan Zhang
- Department of Ultrasound, Capital Medical University, Beijing, China.,Department of Ultrasound, Beijing Tiantan Hospital, Beijing, China
| | - Fumin Wang
- Department of Ultrasound, Capital Medical University, Beijing, China.,Department of Ultrasound, Beijing Tiantan Hospital, Beijing, China
| | - Xinyao Liu
- Department of Ultrasound, Capital Medical University, Beijing, China.,Department of Ultrasound, Beijing Tiantan Hospital, Beijing, China
| | - Wen He
- Department of Ultrasound, Capital Medical University, Beijing, China.,Department of Ultrasound, Beijing Tiantan Hospital, Beijing, China
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7
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Li Z, Wang Y, Wu X, Liu X, Huang S, He Y, Liu S, Ren L. Studying the Factors of Human Carotid Atherosclerotic Plaque Rupture, by Calculating Stress/Strain in the Plaque, Based on CEUS Images: A Numerical Study. Front Neuroinform 2020; 14:596340. [PMID: 33324188 PMCID: PMC7721669 DOI: 10.3389/fninf.2020.596340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 09/11/2020] [Indexed: 01/08/2023] Open
Abstract
Carotid plaque neovascularization is one of the major factors for the classification of vulnerable plaque, but the axial force effects of the pulsatile blood flow on the plaque with neovessel and intraplaque hemorrhage was unclear. Together with the severity of stenosis, the fibrous cap thickness, large lipid core, and the neovascularization followed by intraplaque hemorrhage (IPH) have been regarded as high-risk features of plaque rupture. In this work, the effects of these factors were evaluated on the progression and rupture of the carotid atherosclerotic plaques. Five geometries of carotid artery plaque were developed based on contrast-enhanced ultrasound (CEUS) images, which contain two types of neovessel and IPH, and geometry without neovessel and IPH. A one-way fluid-structure interaction model was applied to compute the maximum principal stress and strain in the plaque. For that hyper-elastic and non-linear material, Yeoh 3rd Order strain energy density function was used for components of the plaque. The simulation results indicated that the maximum principal stress of plaque in the carotid artery was higher when the degree of the luminal stenosis increased and the thickness of the fibrous cap decreased. The neovessels within the plaque could introduce a 2.5% increments of deformation in the plaque under the pulsatile blood flow pressure. The IPH also contributed to the increased risk of plaque rupture that a gain of stress was 8.983, 14.526, and 34.47 kPa for the plaque with 50, 65, and 75%, respectively, when comparing stress in the plaque with IPH distributed at the middle to the shoulder of the plaque. In conclusion, neovascularization in the plaque could reduce the stability of the plaque by increasing the stress within the plaque. Also, the risk of plaque rupture increased when large luminal stenosis, thin fibrous cap, and IPH were observed.
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Affiliation(s)
- Zhenzhou Li
- Department of Ultrasound, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Yongfeng Wang
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
| | - Xinyin Wu
- Department of Ultrasound, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Xin Liu
- Guangdong Academy Research on Virtual Reality (VR) Industry, Foshan University, Foshan, China
| | - Shanshan Huang
- Department of Ultrasound, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Yi He
- Department of Neurosurgery, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
| | - Shuyu Liu
- School of Pharmacy, Sun Yat-sen University, Guangzhou, China
| | - Lijie Ren
- Department of Neurology, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, China
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8
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Chung H, Kim BY, Kim HS, Kim HO, Lee JM, Woo JS, Kim JB, Kim WS, Kim KS, Kim W. Long-Term Clinical Effects of Carotid Intraplaque Neovascularization in Patients with Coronary Artery Disease. Korean J Radiol 2020; 21:900-907. [PMID: 32524790 PMCID: PMC7289693 DOI: 10.3348/kjr.2019.0550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/20/2019] [Accepted: 02/09/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate the predictive value of intraplaque neovascularization (IPN) for cardiovascular outcomes. Materials and Methods We evaluated 217 patients with coronary artery disease (CAD) (158 men; mean age, 68 ± 10 years) with a maximal carotid plaque thickness ≥ 1.5 mm for the presence of IPN using contrast-enhanced ultrasonography. We compared patients with (n = 116) and without (n = 101) IPN during the follow-up period and investigated the predictors of major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction, coronary artery revascularization, and transient ischemic accident/stroke. Results During the mean follow-up period of 995 ± 610 days, the MACE rate was 6% (13/217). Patients with IPN had a higher maximal thickness than those without IPN (2.86 ± 1.01 vs. 2.61 ± 0.84 mm, p = 0.046). Common carotid artery-peak systolic velocity, left ventricular mass index (LVMI), and ventricular-vascular coupling index were significantly correlated with MACE. However, on multivariate Cox regression analysis, increased LVMI was independently related to MACE (p < 0.05). The presence of IPN could not predict MACE. Conclusion The presence of IPN was related to a higher plaque thickness but could not predict cardiovascular outcomes better than conventional clinical factors in patients with CAD.
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Affiliation(s)
- Hyemoon Chung
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Bu Yong Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Hyun Soo Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Hyung Oh Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Jung Myung Lee
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Jong Shin Woo
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Jin Bae Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Woo Shik Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Kwon Sam Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea
| | - Weon Kim
- Cardiovascular Division, Department of Internal Medicine, Kyung Hee University Medical Center, Kyung Hee University, Seoul, Korea.
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Saba L, Zucca S, Gupta A, Micheletti G, Suri JS, Balestrieri A, Porcu M, Crivelli P, Lanzino G, Qi Y, Nardi V, Faa G, Montisci R. Perivascular Fat Density and Contrast Plaque Enhancement: Does a Correlation Exist? AJNR Am J Neuroradiol 2020; 41:1460-1465. [PMID: 32732275 DOI: 10.3174/ajnr.a6710] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/18/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Inflammatory changes in the fat tissue surrounding the coronary arteries have been associated with coronary artery disease and high-risk vulnerable plaques. Our aim was to investigate possible correlations between the presence and degree of perivascular fat density and a marker of vulnerable carotid plaque, namely contrast plaque enhancement on CTA. MATERIALS AND METHODS One-hundred patients (76 men, 24 women; mean age, 69 years) who underwent CT angiography for investigation of carotid artery stenosis were retrospectively analyzed. Contrast plaque enhancement and perivascular fat density were measured in 100 carotid arteries, and values were stratified according to symptomatic (ipsilateral-to-cerebrovascular symptoms)/asymptomatic status (carotid artery with the most severe degree of stenosis). Correlation coefficients (Pearson ρ product moment) were calculated between the contrast plaque enhancement and perivascular fat density. The differences among the correlation ρ values were calculated using the Fisher r-to-z transformation. Mann-Whitney analysis was also calculated to test differences between the groups. RESULTS There was a statistically significant positive correlation between contrast plaque enhancement and perivascular fat density (ρ value = 0.6582, P value = .001). The correlation was stronger for symptomatic rather than asymptomatic patients (ρ value = 0.7052, P value = .001 versus ρ value = 0.4092, P value = .001). CONCLUSIONS There was a positive association between perivascular fat density and contrast plaque enhancement on CTA. This correlation was stronger for symptomatic rather than asymptomatic patients. Our results suggest that perivascular fat density could be used as an indirect marker of plaque instability.
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Affiliation(s)
- L Saba
- From the Departments of Radiology (L.S., S.Z., G.M., A.B., M.P.), Pathology (G.F.), and Vascular Surgery (R.M.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy; Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
| | - S Zucca
- From the Departments of Radiology (L.S., S.Z., G.M., A.B., M.P.), Pathology (G.F.), and Vascular Surgery (R.M.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy; Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
| | - A Gupta
- Stroke Diagnosis and Monitoring Division (J.S.S.), AtheroPoint (TM), Roseville, California
| | - G Micheletti
- From the Departments of Radiology (L.S., S.Z., G.M., A.B., M.P.), Pathology (G.F.), and Vascular Surgery (R.M.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy; Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
| | - J S Suri
- Stroke Diagnosis and Monitoring Division (J.S.S.), AtheroPoint (TM), Roseville, California
| | - A Balestrieri
- From the Departments of Radiology (L.S., S.Z., G.M., A.B., M.P.), Pathology (G.F.), and Vascular Surgery (R.M.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy; Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
| | - M Porcu
- From the Departments of Radiology (L.S., S.Z., G.M., A.B., M.P.), Pathology (G.F.), and Vascular Surgery (R.M.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy; Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
| | - P Crivelli
- Department of Radiology (P.C.), Azienda Ospedaliero Universitaria, Sassari, Italy
| | - G Lanzino
- Department of Neurologic Surgery (G.L., V.N.), Mayo Clinic, Rochester, Minnesota
| | - Y Qi
- Xuanwu Hospital (Y.Q.), Capital Medical University Beijing, China
| | - V Nardi
- Department of Neurologic Surgery (G.L., V.N.), Mayo Clinic, Rochester, Minnesota
| | - G Faa
- From the Departments of Radiology (L.S., S.Z., G.M., A.B., M.P.), Pathology (G.F.), and Vascular Surgery (R.M.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy; Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
| | - R Montisci
- From the Departments of Radiology (L.S., S.Z., G.M., A.B., M.P.), Pathology (G.F.), and Vascular Surgery (R.M.), Azienda Ospedaliero Universitaria, Monserrato (Cagliari), Italy; Department of Radiology (A.G.), Weill Cornell Medicine, New York, New York
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10
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Wang LF, Li Y, Landsittel DP, Reis SE, Levesque MC, Jones DM, Gartland R, Avolio J, Shoushtari A, Qi Z, Dezfulian C, Moreland LW, Liang KP. Identifying Vulnerable Plaque in Rheumatoid Arthritis Using Novel Microbubble Contrast-Enhanced Carotid Ultrasonography and Serum Biomarkers. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2020. [DOI: 10.1177/8756479320922512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Rheumatoid arthritis (RA) is associated with increased risk of cardiovascular disease. Adventitial vasa vasorum density (aVVD), the vessel density of the vasa vasorum, is a surrogate measure for atherosclerotic plaque vulnerability. The purpose of this study was to compare the adventitial vasa vasorum density (aVVD) in RA and non-RA control participants using novel carotid artery contrast-enhanced ultrasound (CEUS). In addition, we investigate associations of aVVD with traditional cardiovascular (CV) risk factors, vascular and inflammatory biomarkers, and RA disease activity. Methods: The study was a cross-sectional analysis of patients with RA and control participants without RA or other autoimmune disease. CV disease risk, biomarkers, and CEUS images were collected on all patients. Results: aVVD was quantified in 86 patients with RA and 95 non-RA control participants. Nitrite, CD40L, E-selectin, matrix metalloproteinase 9, intercellular adhesion molecule 1, vascular cell adhesion molecule 1, myeloperoxidase (MPO), high-sensitivity C-reactive protein (hsCRP), and erythrocyte sedimentation rate were measured. Median aVVD was higher in patients with RA (0.59 [0.47–0.69] vs 0.64 [0.54–0.62]; P = .02). In patients with RA, MPO was lower (253.5 [153.2–480] vs 470.8 [274.2–830.1] ng/mL; P = .0002) and ESR was higher (15.5 [11–25] vs 13 [9–20] mm/h; P = .02). aVVD was correlated with MPO ( r = −0.33, P = .001) and hsCRP ( r = 0.25, P = .02) in control participants only, associations that remained significant after adjusting for number of CV risk factors and age. No significant correlations were found between aVVD and RA disease activity measures. Conclusions: Using a novel application of CEUS, we found that aVVD, an early measure of plaque vulnerability, was significantly higher in RA than control subjects, even after adjusting for CV risk factors. Differences in correlation of aVVD with vascular biomarkers and CV risk factors suggest RA-related differences in atherosclerotic progression.
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Affiliation(s)
- Linda F. Wang
- School of Medicine, University of Pittsburgh, Pittsburgh PA, USA
| | - Yaming Li
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh PA, USA
| | | | - Steven E. Reis
- Division of Cardiology, University of Pittsburgh, Pittsburgh PA, USA
| | - Marc C. Levesque
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh PA, USA
| | - Donald M. Jones
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh PA, USA
| | - Rachel Gartland
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh PA, USA
| | - Jennifer Avolio
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh PA, USA
| | - Ali Shoushtari
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh PA, USA
| | - Zengbiao Qi
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh PA, USA
| | - Cameron Dezfulian
- Vascular Medicine Institute and Critical Care Medicine, University of Pittsburgh, Pittsburgh PA, USA
| | - Larry W. Moreland
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh PA, USA
| | - Kimberly P. Liang
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh PA, USA
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Abstract
Atherosclerosis is a chronic inflammatory vascular disease and the predominant cause of heart attack and ischemic stroke. Despite the well-known sexual dimorphism in the incidence and complications of atherosclerosis, there are relatively limited data in the clinical and preclinical literature to rigorously address mechanisms underlying sex as a biological variable in atherosclerosis. In multiple histological and imaging studies, overall plaque burden and markers of inflammation appear to be greater in men than women and are predictive of cardiovascular events. However, while younger women are relatively protected from cardiovascular disease, by the seventh decade, the incidence of myocardial infarction in women ultimately surpasses that of men, suggesting an interaction between sex and age. Most preclinical studies in animal atherosclerosis models do not examine both sexes, and even in those that do, well-powered direct statistical comparisons for sex as an independent variable remain rare. This article reviews the available data. Overall, male animals appear to have more inflamed yet smaller plaques compared to female animals. Plaque inflammation is often used as a surrogate end point for plaque vulnerability in animals. The available data support the notion that rather than plaque size, plaque inflammation may be more relevant in assessing sex-specific mechanisms since the findings correlate with the sex difference in ischemic events and mortality and thus may be more reflective of the human condition. Overall, the number of preclinical studies directly comparing plaque inflammation between the sexes is extremely limited relative to the vast literature exploring atherosclerosis mechanisms. Failure to include both sexes and to address age in mechanistic atherosclerosis studies are missed opportunities to uncover underlying sex-specific mechanisms. Understanding the mechanisms driving sex as a biological variable in atherosclerotic disease is critical to future precision medicine strategies to mitigate what is still the leading cause of death of men and women worldwide.
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Affiliation(s)
- Joshua J. Man
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, MA
| | - Joshua A. Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN
| | - Iris Z. Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA
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12
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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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13
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Molecular imaging of carotid artery atherosclerosis with PET: a systematic review. Eur J Nucl Med Mol Imaging 2019; 47:2016-2025. [PMID: 31786626 DOI: 10.1007/s00259-019-04622-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/14/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE To conduct a systematic review of articles on PET imaging of carotid atherosclerosis with emphasis on clinical usefulness and comparison with other imaging modalities. METHODS Research articles reporting carotid artery PET imaging with different radiotracers until 30 November 2018 were systematically searched for in Medline/PubMed, Scopus, Embase, Google Scholar, and Cochrane Library. Duplicates were removed, and editorials, case studies, and investigations on feasibility or reproducibility of PET imaging and of patients with end-stage diseases or immunosuppressive medications were omitted. After quality assessment of included articles using Joanna Briggs Institute checklists, all eligible articles were reviewed. RESULTS Of 1718 primary hits, 53 studies comprising 4472 patients, aged 47-91 years (78.8% males), were included and grouped under the following headlines: diagnostic performance, risk factors, laboratory findings, imaging modalities, and treatment. 18F-fluorodeoxyglucose (FDG) (49/53) and 18F-sodium fluoride (NaF) (5/53) were the most utilized tracers to visualize carotid wall inflammation and microcalcification, respectively. Higher carotid FDG uptake was demonstrated in patients with than without symptomatic carotid atherosclerosis. Normal carotid arteries presented with the lowest FDG uptake. In symptomatic atherosclerosis, carotid arteries ipsilateral to a cerebrovascular event had higher FDG uptake than the contralateral carotid artery. FDG uptake was significantly associated with age, male gender, and body mass index in healthy individuals, and in addition with arterial hypertension, hypercholesterolemia, and diabetes mellitus in patients. Histological assessment indicated a strong correlation between microcalcification and NaF uptake in symptomatic patients. Histological evidence of calcification correlated inversely with FDG uptake, which was associated with increased macrophage and CD68 count, both accounting for increased local inflammatory response. CONCLUSION FDG-PET visualizes the inflammatory part of carotid atherosclerosis enabling risk stratification to a certain degree, whereas NaF-PET seems to indicate long-term consequences of ongoing inflammation by demonstrating microcalcification allowing discrimination of atherosclerotic from normal arteries and suggesting clinically significant carotid atherosclerosis.
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14
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Neovascularization of Carotid Atherosclerotic Plaque and Quantitative Methods of Its Dynamic Assessment in Vivo. Bull Exp Biol Med 2018; 165:521-525. [DOI: 10.1007/s10517-018-4208-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Indexed: 10/28/2022]
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15
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Demeure F, Bouzin C, Roelants V, Bol A, Verhelst R, Astarci P, Gerber BL, Pouleur AC, Pasquet A, Meester CD, Vanoverschelde JLJ, Vancraeynest D. Response by Demeure et al to Letter Regarding Article, "Head-to-Head Comparison of Inflammation and Neovascularization in Human Carotid Plaques: Implications for the Imaging of Vulnerable Plaques". Circ Cardiovasc Imaging 2018; 10:CIRCIMAGING.117.007012. [PMID: 29021262 DOI: 10.1161/circimaging.117.007012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Fabian Demeure
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Caroline Bouzin
- IREC Imaging Platform, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Véronique Roelants
- Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Belgium.,Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Anne Bol
- Pôle d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Belgium.,Division of Nuclear Medicine, Internal Medicine Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Robert Verhelst
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Parla Astarci
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bernhard L Gerber
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Anne-Catherine Pouleur
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Agnès Pasquet
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Christophe de Meester
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-Louis J Vanoverschelde
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - David Vancraeynest
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Cardiovascular Department, Institut Cardiovasculaire, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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16
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Evdokimenko AN, Anufriev PL, Kulichenkova KN, Gulevskaya TS, Tanashyan MM. [Morphometric characteristics of neovascularization of carotid atherosclerotic plaques]. Arkh Patol 2018; 80:24-29. [PMID: 29697668 DOI: 10.17116/patol201880224-29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE to identify the relationship between the magnitude of neovascularization of an atherosclerotic plaque and its other processes, such as atheromatosis, macrophage responses, hemorrhages, and calcification. MATERIAL AND METHODS 48 carotid atherosclerotic plaques all their way underwent morphopathological examination, by assessing the magnitude of neovascularization (total vessel density per plague cm2; density of vessels of different diameters; localization in section), atheromatosis (a volume fraction), foam cells (a score of 0 to 5), hemorrhages (a score of 0 to 4), and calcification (a score of 0 to 4). The Mann-Whitney U test and the Spearman correlation coefficient with p<0.05 were used in the statistical analysis. RESULTS There was a substantial variability in vessel diameters and densities in the plaque with a drastic predominance of vessels smaller than 20 µm in diameter (69.8±14.3%). The vessels with a diameter as large as 20 µm were more frequently located in the area of accumulation of foam cells or organizing hemorrhages (p<0.03), unlike those with a diameter of more than 40 µm, which were more common in the areas of connective tissue, especially adjacent to large calcifications, and in the foci of organized hemorrhages (p<0.008). Intensified calcification was accompanied by the higher density of vessels having a diameter of more than 40 µm (p<0.038) and particularly of those with a diameter of more than 60 µm (p=0.006). The degree of hemorrhages and the number of foam cells were unrelated to the density of vessels, but these increased with their localization in the surface areas of a plaque (p=0.000342). With the increasing severity of atheromatosis, there was a decrease in the density of vessels larger than 20 µm in diameter (p=0.00042). CONCLUSION The number, diameter, and location of vessels in the plaque serve as a dynamic reflection of its destructive and reparative processes; and a larger number of vessels having a diameter of more than 40 µm can be an indicator for the activation of reparative processes.
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17
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Chung H, Kim W. Letter by Chung and Kim Regarding Article, “Head-to-Head Comparison of Inflammation and Neovascularization in Human Carotid Plaques: Implications for the Imaging of Vulnerable Plaques”. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006995. [DOI: 10.1161/circimaging.117.006995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hyemoon Chung
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Weon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Korea
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18
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Affiliation(s)
- Marc R Dweck
- From the British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (M.R.W.); and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY (Z.A.F.).
| | - Zahi A Fayad
- From the British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (M.R.W.); and Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY (Z.A.F.)
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