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Ugusman A, Hisam NSN, Othman NS, Anuar NNM, Hamid AA, Kumar J, Razmi MM, Aminuddin A. Pharmacological interventions for intraplaque neovascularization in atherosclerosis. Pharmacol Ther 2024; 261:108685. [PMID: 38977083 DOI: 10.1016/j.pharmthera.2024.108685] [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: 03/02/2024] [Revised: 06/29/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024]
Abstract
Advanced atherosclerosis is linked to plaque instability, which can result in rupture and the onset of a heart attack. Evidence gathered from human atheroma plaques indicates that intraplaque neovascularization poses a risk to plaque stability and may lead to plaque hemorrhage. Hence, targeting the neovascularization within the atheroma plaque has the potential to mitigate the plaque's vulnerability. While neovascularization has been extensively explored in the context of cancer, research on pharmacological inhibition of this phenomenon in atherosclerosis remains limited. This systematic review aimed to comprehensively assess current and emerging pharmacological interventions for inhibiting intraplaque neovascularization in preclinical settings. Electronic databases (Web of Science, PubMed, Scopus, and Ovid) were searched from January 2013 until February 1, 2024. Preclinical studies reporting the effect of any pharmacological interventions targeting intraplaque neovascularization were included. A total of 10 articles involving in vivo animal studies were eligible for inclusion, with five of them incorporating in vitro experiments to complement their in vivo findings. The pharmacological interventions studied were axitinib, ghrelin, K5, rosuvastatin, atorvastatin, 3PO, everolimus, melatonin, Si-Miao-Yong-A, and protocatechuic aldehyde. All the interventions showed a positive impact in inhibiting intraplaque neovascularization in various atherosclerotic animal models through various signaling pathways. This review provides valuable insights into pharmacological approaches to attenuate intraplaque neovascularization that could serve as a promising therapeutic avenue to enhance plaque stability.
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Affiliation(s)
- Azizah Ugusman
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia.
| | - Nur Syahidah Nor Hisam
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia; Programme of Biomedical Science, Centre for Toxicology & Health Risk Studies, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Nur Syakirah Othman
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Nur Najmi Mohamad Anuar
- Programme of Biomedical Science, Centre for Toxicology & Health Risk Studies, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Adila A Hamid
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Jaya Kumar
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia
| | - Maisarah Md Razmi
- Programme of Biomedical Science, Centre for Toxicology & Health Risk Studies, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - Amilia Aminuddin
- Department of Physiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia.
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Takeshita S, Inoue K, Ogata T, Ishii A, Uesugi N, Hamasaki M, Abe H, Tsugawa J. Impact of distribution of carotid intraplaque neovessels on plaque vulnerability. J Stroke Cerebrovasc Dis 2024; 33:107859. [PMID: 38997050 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/06/2024] [Accepted: 07/10/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND AND PURPOSE Intraplaque neovessels (INVs) are considered important contributors to carotid plaque vulnerability. The purpose of this study was to examine whether differences in INV distribution affect plaque vulnerability. METHODS The study cohort comprised 110 patients with significant stenosis of the carotid artery who had undergone carotid endarterectomy. The distribution of INVs within carotid plaques was assessed by immunohistochemical studies using anti-CD-34 antibody as a marker for endothelial cells. First, we divided the patients into M group and S group depending on the numbers of INVs in middle and shoulder region. Next, we categorized carotid plaques into four categories according to the distributions of INVs: Shoulder, Middle, Mixed, and Scarce. We then compared total area of intraplaque hemorrhage, cholesterol, and calcification, width of thinnest fibrous cap, and number of INVs between the four categories of plaque. RESULTS The area of intraplaque hemorrhage was significantly larger in the M group than in the S group (P = 0.011). Meanwhile, symptomatic carotid stenosis was significantly more frequently associated with the Middle and Mixed than the Shoulder and Scarce categories (P < 0.01). The area of intraplaque hemorrhage was significantly different between the four groups (P = 0.022). Rupture of the fibrous cap was more frequently detected in the Middle and Mixed than the other categories (P = 0.002). CONCLUSIONS INVs in the middle region of carotid plaques are strongly associated with symptomatic carotid stenosis, intraplaque hemorrhage, and rupture of the fibrous cap. Our findings indicate that the distribution of INVs may affect plaque vulnerability.
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Affiliation(s)
- Sho Takeshita
- Department of Neurology, Fukuoka University, Fukuoka, Japan.
| | - Kenichi Inoue
- Department of Neurology, Fukuoka University, Fukuoka, Japan
| | - Toshiyasu Ogata
- Department of Neurology, Fukuoka University, Fukuoka, Japan; Department of Neurology, Japan Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Ayako Ishii
- Department of Neurology, Fukuoka University, Fukuoka, Japan
| | - Noriko Uesugi
- Department of Pathology, Fukuoka University, Fukuoka, Japan
| | | | - Hiroshi Abe
- Department of Neurosurgery, Fukuoka University, Fukuoka, Japan
| | - Jun Tsugawa
- Department of Neurology, Fukuoka University, Fukuoka, Japan
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Goudot G, Jimenez A, Mohamedi N, Sitruk J, Wang LZ, Khider L, Bruneval P, Messas E, Pernot M, Mirault T. Vasa vasorum interna in the carotid wall of active forms of Takayasu arteritis evidenced by ultrasound localization microscopy. Vasc Med 2024; 29:296-301. [PMID: 38488572 DOI: 10.1177/1358863x241228262] [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] [Indexed: 03/22/2024]
Abstract
Introduction: Takayasu arteritis (TA) is associated with microvascularization of the wall of large arteries and is related to inflammation. Ultrasound localization microscopy (ULM), combining ultrafast ultrasound imaging with microbubble (MB) injection, can track the path of MBs within the arterial wall and thus provide imaging of the vasa vasorum. From the analysis of MB tracks in the common carotid arteries of patients with active TA, we report the presence of microvessels in connection with the carotid lumen (i.e., vasa vasorum interna [VVI]). Methods: ULM maps were obtained on five patients with active disease in the observational single-center series of the TAK-UF study. MB tracks connected to the carotid lumen were automatically identified, allowing the reconstruction of VVI. Results: MB tracking allows us to observe a microvascular network on the inner part of the wall, with some vessels in communication with the carotid lumen. This type of vessel was identified in all patients with active TA (n = 5) with a median of 2.2 [1.1-3.0] vessels per acquisition (2D longitudinal view of 3 cm of the common carotid artery). The blood flow within these vessels is mainly centrifugal; that is, toward the adventitia (88% [54-100] of MB tracks with flow directed to the outer part of the wall). Conclusion: VVI are present in humans in the case of active TA and emphasize the involvement of the intima in the pathological process. ClinicalTrials.gov Identifier: NCT03956394.
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Affiliation(s)
- Guillaume Goudot
- Université Paris Cité, INSERM U970 PARCC, Paris, France
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Anatole Jimenez
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Nassim Mohamedi
- Université Paris Cité, INSERM U970 PARCC, Paris, France
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Jonas Sitruk
- Université Paris Cité, INSERM U970 PARCC, Paris, France
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Louise Z Wang
- Université Paris Cité, INSERM U970 PARCC, Paris, France
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lina Khider
- Université Paris Cité, INSERM U970 PARCC, Paris, France
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Patrick Bruneval
- Cardiology Department, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Emmanuel Messas
- Université Paris Cité, INSERM U970 PARCC, Paris, France
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Mathieu Pernot
- Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Tristan Mirault
- Université Paris Cité, INSERM U970 PARCC, Paris, France
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
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Uchihara Y, Saito K, Motoyama R, Ishibashi-Ueda H, Yamaguchi E, Hatakeyama K, Tanaka A, Kataoka H, Iihara K, Sugie K, Koga M, Toyoda K, Nagatsuka K, Ihara M. Neovascularization From the Carotid Artery Lumen Into the Carotid Plaque Confirmed by Contrast-Enhanced Ultrasound and Histology. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:1798-1803. [PMID: 37202244 DOI: 10.1016/j.ultrasmedbio.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/30/2023] [Accepted: 04/09/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE This study was aimed at assessing intraplaque neovessels, focusing on neovascularization from the vascular luminal side using contrast-enhanced ultrasound (CEUS) and determining that this contrast effect indicates that the neovessel is connected to the vessel lumen histopathologically. Whether plaque vulnerability can be assessed more accurately was also investigated. METHODS We enrolled consecutive patients with internal carotid artery stenosis who underwent carotid endarterectomy (CEA) and pre-operative CEUS with perflubutane of the carotid arteries. We graded the contrast effect semi-quantitatively from the vascular luminal and adventitial sides. We compared the contrast effect with the pathological findings, especially the neovascularization of the CEA specimens. RESULTS In total, 68 carotid arterial atheromatous plaques (47 symptomatic) were analyzed. Symptomatic plaques were significantly correlated with stronger contrast effects from the luminal side than from the adventitial side (p = 0.0095). Microbubbles from the luminal side appeared to flow mainly into the plaque shoulder. The contrast effect value for the plaque shoulder and neovessel density were significantly correlated (ρ = 0.35, p = 0.031). Neovessel density was significantly higher in symptomatic than in asymptomatic plaques (56.2 ± 43.7/mm2 and 18.1 ± 15.2/mm2, respectively, p < 0.0001). Serial histological sections of CEA specimens in a symptomatic plaque with a strong contrast effect from the luminal side revealed multiple neovessels fenestrated to the vessel lumen with endothelial cells, consistent with the CEUS findings. CONCLUSION Contrast-enhanced ultrasound can be used to evaluate neovessels originating from the luminal side, histopathologically confirmed in serial sections. Symptomatic vulnerable plaque is correlated more significantly with intraplaque neovascularization from the luminal side than with neovascularization from the adventitia.
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Affiliation(s)
- Yuto Uchihara
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology, Nara Medical University, Nara, Japan.
| | - Kozue Saito
- Department of Neurology, Nara Medical University, Nara, Japan; Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Rie Motoyama
- Department of Neurology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | | | - Eriko Yamaguchi
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kinta Hatakeyama
- Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akito Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Neurology, Nara Medical University, Nara, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuma Sugie
- Department of Neurology, Nara Medical University, Nara, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuyuki Nagatsuka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
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Gu SY, Zhang LN, Chen J, Li F, Yao MH, Jia CX, Wu R. Associations of plaque morphology and location with Intraplaque neovascularization in the carotid artery by contrast-enhanced ultrasound imaging. Front Neurol 2023; 14:1097070. [PMID: 37251224 PMCID: PMC10213664 DOI: 10.3389/fneur.2023.1097070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 04/25/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Intraplaque neovascularization (IPN) is a known indicator of plaque vulnerability, and is thus considered a predictor of stroke. The morphology and location of the carotid plaque may be correlated with plaque vulnerability. Therefore, our study aimed to examine the associations of carotid plaque morphology and location with IPN. Methods A total of 141 patients with carotid atherosclerosis (mean age, 64.99 ± 10.96 years) who underwent carotid contrast-enhanced ultrasound (CEUS) between November 2021 and March 2022 were retrospectively analyzed. IPN was graded according to the presence and location of microbubbles within the plaque. The association of IPN grade with carotid plaque morphology and location was evaluated using ordered logistic regression. Results Of the 171 plaques, 89 (52%) were IPN Grade 0, 21 (12.2%) were Grade 1, and 61 (35.6%) were Grade 2. IPN grade significantly associated with both plaque morphology and location, with higher grades observed among Type III morphology and common carotid artery plaques. Significant negative association was further shown between IPN grade and serum high-density lipoprotein cholesterol (HDL-C) level. Plaque morphology and location, and HDL-C remained significantly associated with IPN grade after adjusting for confounding factors. Conclusion The location and morphology of carotid plaques were significantly associated with the IPN grade on CEUS, and therefore show potential as biomarkers for plaque vulnerability. Serum HDL-C was also identified as a protective factor against IPN, and may play a role in the management of carotid atherosclerosis. Our study provided a potential strategy for identification of vulnerable carotid plaques and elucidated the important imaging predictors of stroke.
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Zhang M, Xie Z, Long H, Ren K, Hou L, Wang Y, Xu X, Lei W, Yang Z, Ahmed S, Zhang H, Zhao G. Current advances in the imaging of atherosclerotic vulnerable plaque using nanoparticles. Mater Today Bio 2022; 14:100236. [PMID: 35341094 PMCID: PMC8943324 DOI: 10.1016/j.mtbio.2022.100236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/13/2022] [Accepted: 03/05/2022] [Indexed: 01/29/2023]
Abstract
Vulnerable atherosclerotic plaques of the artery wall that pose a significant risk of cardio-cerebral vascular accidents remain the global leading cause of morbidity and mortality. Thus, early delineation of vulnerable atherosclerotic plaques is of clinical importance for prevention and treatment. The currently available imaging technologies mainly focus on the structural assessment of the vascular wall. Unfortunately, several disadvantages in these strategies limit the improvement in imaging effect. Nanoparticle technology is a novel diagnostic strategy for targeting and imaging pathological biomarkers. New functionalized nanoparticles that detect hallmarks of vulnerable plaques are promising for advance further control of this critical illness. The review aims to address the current opportunities and challenges for the use of nanoparticle technology in imagining vulnerable plaques.
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Li Y, Zheng S, Zhang J, Wang F, He W. Multimodal ultrasound parameters aided carotid plaque risk stratification in patients with asymptomatic carotid stenosis. Acta Radiol 2022; 63:278-286. [PMID: 33525913 DOI: 10.1177/0284185121989189] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Risk stratification of asymptomatic carotid plaque remains an issue in stroke prevention in clinical practice. PURPOSE To investigate whether a multimodal ultrasound (MMU) model would help plaque risk stratification in patients with asymptomatic carotid stenosis. MATERIAL AND METHODS A prospective study was conducted of symptomatic and asymptomatic patients with > 50% proximal internal carotid artery (ICA) stenosis. All patients underwent MMU examination. Multivariable regression analyses were performed to identify parameters associated with ischemic vascular events (IVE). These parameters were used to develop a scoring nomogram to assess the probability of IVE. We elaborated the diagnostic performance of the MMU nomogram using receiver operating characteristic (ROC) curves. RESULTS From December 2018 to December 2019, 98 patients (75 men, mean age 67 ± 8 years) were included; 50 were symptomatic and 48 were asymptomatic. Multivariable regression analyses revealed that plaque surface morphology (PSM) (odds ratio [OR] 2.99, 95% confidence interval [CI] 1.26-7.12, P = 0.013), intraplaque neovascularization (IPN) grades (OR 3.23, 95% CI 1.77-5.89, P<0.001), and carotid stenosis degree (CSD) (OR 4.12, 95% CI 1.47-11.55, P = 0.007) were independently associated with IVE. For the nomogram, the area under the ROC curve was 0.85 (95% CI 0.77-0.92) and the Hosmer-Lemeshow test P value was 0.822. CONCLUSIONS In patients with proximal ICA > 50%, PSM, IPN grades, and CSD were independent variables associated with IVE. The MMU nomogram provided favorable value to risk stratification of IVE. Future large-scale studies with long-term follow-up are needed to validate these findings.
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Affiliation(s)
- Yi Li
- Capital Medical University, Beijing, PR China
- Department of Ultrasound, Beijing Tiantan Hospital, Beijing, PR China
| | - Shuai Zheng
- Capital Medical University, Beijing, PR China
- Department of Ultrasound, Beijing Tiantan Hospital, Beijing, PR China
| | - Jinghan Zhang
- Capital Medical University, Beijing, PR China
- Department of Ultrasound, Beijing Tiantan Hospital, Beijing, PR China
| | - Fumin Wang
- Capital Medical University, Beijing, PR China
- Department of Ultrasound, Beijing Tiantan Hospital, Beijing, PR China
| | - Wen He
- Capital Medical University, Beijing, PR China
- Department of Ultrasound, Beijing Tiantan Hospital, Beijing, PR China
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Donners SJA, Toorop RJ, de Kleijn DPV, de Borst GJ. A narrative review of plaque and brain imaging biomarkers for stroke risk stratification in patients with atherosclerotic carotid artery disease. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1260. [PMID: 34532397 PMCID: PMC8421959 DOI: 10.21037/atm-21-1166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
Objective In this narrative review, we aim to review imaging biomarkers that carry the potential to non-invasively guide stroke risk stratification for treatment optimization. Background Carotid atherosclerosis plays a fundamental part in the occurrence of ischemic stroke. International guidelines select the optimal treatment strategy still mainly based on the presence of clinical symptoms and the degree of stenosis for stroke prevention in patients with atherosclerotic carotid plaques. These guidelines, based on randomized controlled trials that were conducted three decades ago, recommend carotid revascularization in symptomatic patients with high degree of stenosis versus a conservative approach for most asymptomatic patients. Due to optimization of best medical therapy and risk factor control, it is suggested that a subgroup of symptomatic patients is at lower risk of stroke and may not benefit from revascularization, whereas a selective subgroup of high-risk asymptomatic patients would benefit from this procedure. Methods A literature search was performed for articles published up to December 2020 using PubMed, EMBASE and Scopus. Based on the literature found, change in stenosis degree and volume, plaque echolucency, plaque surface, intraplaque haemorrhage, lipid-rich necrotic core, thin fibrous cap, inflammation, neovascularization, microembolic signals, cerebrovascular reserve, intracranial collaterals, silent brain infarcts, diffusion weighted imaging lesions and white matters lesions have the potential to predict stroke risk. Conclusions The applicability of imaging biomarkers needs to be further improved before the potential synergistic prognostic ability of imaging biomarkers can be verified on top of the clinical biomarkers. In the future, the routine and combined assessment of both plaque and brain imaging biomarkers might help to improve optimization of treatment strategies in individual patients with atherosclerotic carotid artery disease.
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Affiliation(s)
- Simone J A Donners
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Raechel J Toorop
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dominique P V de Kleijn
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, Division of Surgical Specialties, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Nishida T, Hiro T, Takayama T, Sudo M, Haruta H, Fukamachi D, Hirayama A, Okumura Y. Clinical significance of microvessels detected by in vivo optical coherence tomography within human atherosclerotic coronary arterial intima: a study with multimodality intravascular imagings. Heart Vessels 2021; 36:756-765. [PMID: 33403471 DOI: 10.1007/s00380-020-01756-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
The significance of microvessels within atherosclerotic plaques is not yet fully clarified. Associated with plaque vulnerability. The aim of this study is to examine tissue characteristics of plaque with microvessels detected by optical coherence tomography (OCT) by use of a commercially available color-coded intravascular ultrasound (IVUS) and coronary angioscopy (CAS). The subjects examined comprised of 44 patients with stable angina pectoris who underwent percutaneous coronary intervention. Microvessels were defined as a tiny tubule with a diameter of 50-300 µm detected over three or more frames in OCT. We compared the total volume of microvessels with tissue component such as fibrotic, lipidic, necrotic, and calcified volume and the number of yellow plaque. In IVUS analysis, % necrotic volume and % lipidic volume were significantly correlated and % fibrotic volume was inversely significantly correlated with the total volume of microvessel (r = 0.485, p = 0.0009; r = 0.401, p = 0.007; r = - 0.432, p = 0.003, respectively). The number of plaque with an angioscopic yellow grade of two or more was significantly correlated with the total volume of microvessel (r = 0.461, p = 0.002). The greater the luminal volume of microvessels, the more the percent content of necrotic/lipidic tissue volume within plaque and the more the number of yellow plaques. These data suggested that microvessels within coronary plaque might be related to plaque vulnerability.
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Affiliation(s)
- Toshihiko Nishida
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Tadateru Takayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Mitsumasa Sudo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Hironori Haruta
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Daisuke Fukamachi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
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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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Immune-Mediated Inflammation in Vulnerable Atherosclerotic Plaques. Molecules 2019; 24:molecules24173072. [PMID: 31450823 PMCID: PMC6749340 DOI: 10.3390/molecules24173072] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 01/16/2023] Open
Abstract
Atherosclerosis is a chronic long-lasting vascular disease leading to myocardial infarction and stroke. Vulnerable atherosclerotic (AS) plaques are responsible for these life-threatening clinical endpoints. To more successfully work against atherosclerosis, improvements in early diagnosis and treatment of AS plaque lesions are required. Vulnerable AS plaques are frequently undetectable by conventional imaging because they are non-stenotic. Although blood biomarkers like lipids, C-reactive protein, interleukin-6, troponins, and natriuretic peptides are in pathological ranges, these markers are insufficient in detecting the critical perpetuation of AS anteceding endpoints. Thus, chances to treat the patient in a preventive way are wasted. It is now time to solve this dilemma because clear results indicate a benefit of anti-inflammatory therapy per se without modification of blood lipids (CANTOS Trial, NCT01327846). This fact identifies modulation of immune-mediated inflammation as a new promising point of action for the eradication of fatal atherosclerotic endpoints.
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Saba L, Saam T, Jäger HR, Yuan C, Hatsukami TS, Saloner D, Wasserman BA, Bonati LH, Wintermark M. Imaging biomarkers of vulnerable carotid plaques for stroke risk prediction and their potential clinical implications. Lancet Neurol 2019; 18:559-572. [PMID: 30954372 DOI: 10.1016/s1474-4422(19)30035-3] [Citation(s) in RCA: 260] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/15/2023]
Abstract
Stroke represents a massive public health problem. Carotid atherosclerosis plays a fundamental part in the occurence of ischaemic stroke. European and US guidelines for prevention of stroke in patients with carotid plaques are based on quantification of the percentage reduction in luminal diameter due to the atherosclerotic process to select the best therapeutic approach. However, better strategies for prevention of stroke are needed because some subtypes of carotid plaques (eg, vulnerable plaques) can predict the occurrence of stroke independent of the degree of stenosis. Advances in imaging techniques have enabled routine characterisation and detection of the features of carotid plaque vulnerability. Intraplaque haemorrhage is accepted by neurologists and radiologists as one of the features of vulnerable plaques, but other characteristics-eg, plaque volume, neovascularisation, and inflammation-are promising as biomarkers of carotid plaque vulnerability. These biomarkers could change current management strategies based merely on the degree of stenosis.
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Affiliation(s)
- Luca Saba
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy.
| | - Tobias Saam
- Department of Radiology, University Hospital Munich, Ludwig-Maximilians-University Munich, Munich, Germany; Radiologisches Zentrum Rosenheim, Rosenheim, Germany
| | - H Rolf Jäger
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | - Chun Yuan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | - David Saloner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Bruce A Wasserman
- The Russell H Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA, USA
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Crombag GAJC, Schreuder FHBM, van Hoof RHM, Truijman MTB, Wijnen NJA, Vöö SA, Nelemans PJ, Heeneman S, Nederkoorn PJ, Daemen JWH, Daemen MJAP, Mess WH, Wildberger JE, van Oostenbrugge RJ, Kooi ME. Microvasculature and intraplaque hemorrhage in atherosclerotic carotid lesions: a cardiovascular magnetic resonance imaging study. J Cardiovasc Magn Reson 2019; 21:15. [PMID: 30832656 PMCID: PMC6398220 DOI: 10.1186/s12968-019-0524-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/04/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The presence of intraplaque haemorrhage (IPH) has been related to plaque rupture, is associated with plaque progression, and predicts cerebrovascular events. However, the mechanisms leading to IPH are not fully understood. The dominant view is that IPH is caused by leakage of erythrocytes from immature microvessels. The aim of the present study was to investigate whether there is an association between atherosclerotic plaque microvasculature and presence of IPH in a relatively large prospective cohort study of patients with symptomatic carotid plaque. METHODS One hundred and thirty-two symptomatic patients with ≥2 mm carotid plaque underwent cardiovascular magnetic resonance (CMR) of the symptomatic carotid plaque for detection of IPH and dynamic contrast-enhanced (DCE)-CMR for assessment of plaque microvasculature. Ktrans, an indicator of microvascular flow, density and leakiness, was estimated using pharmacokinetic modelling in the vessel wall and adventitia. Statistical analysis was performed using an independent samples T-test and binary logistic regression, correcting for clinical risk factors. RESULTS A decreased vessel wall Ktrans was found for IPH positive patients (0.051 ± 0.011 min- 1 versus 0.058 ± 0.017 min- 1, p = 0.001). No significant difference in adventitial Ktrans was found in patients with and without IPH (0.057 ± 0.012 min- 1 and 0.057 ± 0.018 min- 1, respectively). Histological analysis in a subgroup of patients that underwent carotid endarterectomy demonstrated no significant difference in relative microvessel density between plaques without IPH (n = 8) and plaques with IPH (n = 15) (0.000333 ± 0.0000707 vs. and 0.000289 ± 0.0000439, p = 0.585). CONCLUSIONS A reduced vessel wall Ktrans is found in the presence of IPH. Thus, we did not find a positive association between plaque microvasculature and IPH several weeks after a cerebrovascular event. Not only leaky plaque microvessels, but additional factors may contribute to IPH development. TRIAL REGISTRATION NCT01208025 . Registration date September 23, 2010. Retrospectively registered (first inclusion September 21, 2010). NCT01709045 , date of registration October 17, 2012. Retrospectively registered (first inclusion August 23, 2011).
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Affiliation(s)
- Geneviève A. J. C. Crombag
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Floris H. B. M. Schreuder
- Department of Neurology & Donders Institute for Brain Cognition & Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raf H. M. van Hoof
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Martine T. B. Truijman
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicky J. A. Wijnen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Stefan A. Vöö
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Patty J. Nelemans
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Sylvia Heeneman
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan-Willem H. Daemen
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mat J. A. P. Daemen
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Werner H. Mess
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Clinical Neurophysiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J. E. Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Robert J. van Oostenbrugge
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M. Eline Kooi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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Pereira T, Betriu A, Alves R. Non-invasive imaging techniques and assessment of carotid vasa vasorum neovascularization: Promises and pitfalls. Trends Cardiovasc Med 2018; 29:71-80. [PMID: 29970286 DOI: 10.1016/j.tcm.2018.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 12/17/2022]
Abstract
Carotid adventitia vasa vasorum neovascularization (VVn) is associated with the initial stages of arteriosclerosis and with the formation of unstable plaque. However, techniques to accurately quantify that neovascularization in a standard, fast, non-invasive, and efficient way are still lacking. The development of such techniques holds the promise of enabling wide, inexpensive, and safe screening programs that could stratify patients and help in personalized preventive cardiovascular medicine. In this paper, we review the recent scientific literature pertaining to imaging techniques that could set the stage for the development of standard methods for quantitative assessment of atherosclerotic plaque and carotid VVn. We present and discuss the alternative imaging techniques being used in clinical practice and we review the computational developments that are contributing to speed up image analysis and interpretation. We conclude that one of the greatest upcoming challenges will be the use of machine learning techniques to develop automated methods that assist in the interpretation of images to stratify patients according to their risk.
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Affiliation(s)
- T Pereira
- Institute for Biomedical Research in Lleida Dr. Pifarré Foundation, Catalonia, Spain; Departament de Ciències Mèdiques Bàsiques, University of Lleida, Catalonia, Spain.
| | - A Betriu
- Unit for the Detection and Treatment of Atherothrombotic Diseases, Hospital Universitari Arnau de Vilanova de Lleida, Catalonia, Spain; Vascular and Renal Translational Research Group - IRBLleida, Catalonia, Spain
| | - R Alves
- Institute for Biomedical Research in Lleida Dr. Pifarré Foundation, Catalonia, Spain; Departament de Ciències Mèdiques Bàsiques, University of Lleida, Catalonia, Spain
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Xu Y, Li D, Yuan C, Zhou Z, He L, Li R, Cui Y, Li Q, Zheng Z, Zhao X. Association of severity between carotid and intracranial artery atherosclerosis. Ann Clin Transl Neurol 2018; 5:843-849. [PMID: 30009201 PMCID: PMC6043773 DOI: 10.1002/acn3.590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023] Open
Abstract
Objective This study sought to investigate the relationship of atherosclerosis between intracranial and extracranial carotid arteries using three‐dimensional multicontrast magnetic resonance (MR) vessel wall imaging. Methods Patients with recent cerebrovascular symptoms in anterior circulation were recruited and underwent MR vessel wall imaging for intracranial and extracranial carotid arteries. The plaque burden, including maximum wall thickness (Max WT) and stenosis, and presence of intraplaque hemorrhage (IPH) were assessed. The correlation of the plaque characteristics between intracranial and extracranial carotid arteries was determined. Results In total, 107 patients (mean age: 57.0 ± 11.1 years, 69 males) were recruited. In discriminating intracranial severe stenosis (≥50% stenosis), the odds ratio (OR) of Max WT of extracranial carotid arteries was 1.41 (95% confidence interval [CI], 0.94–2.11, P = 0.095) and 1.72 (95% CI, 1.04–2.83, P = 0.034) before and after adjusting for confounding factors, respectively. The OR of stenosis of extracranial carotid arteries with increment of 10% was 1.26 (95% CI, 0.99–1.60, P = 0.054) and 1.37 (95% CI, 1.03–1.82, P = 0.033) before and after adjusting for confounding factors, in discriminating intracranial severe stenosis respectively. Receiver operating characteristic analysis revealed that the area under the curve (AUC) of Max WT, stenosis, and IPH of extracranial carotid artery plaques was 0.641, 0.605, and 0.603 in discriminating intracranial severe stenosis, respectively. After adjusting for confounding factors, the AUC of Max WT, stenosis, and presence of IPH in extracranial carotid artery plaques increased to 0.812, 0.817 and 0.781, respectively. Interpretation Carotid artery plaque burden is significantly associated with severe intracranial artery stenosis, suggesting that extracranial carotid plaque burden might be an independent indicator for severity of intracranial artery atherosclerosis.
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Affiliation(s)
- Yilan Xu
- Department of RadiologyBeijing Tsinghua Changgung HospitalSchool of Clinical MedicineTsinghua UniversityBeijingChina
| | - Dongye Li
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
- Center for Brain Disorders ResearchCapital Medical University and Beijing Institute for Brain DisordersBeijingChina
| | - Chun Yuan
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
- Department of RadiologyUniversity of WashingtonSeattleWashington
| | - Zechen Zhou
- Philips Research North AmericaCambridgeMassachusetts
| | - Le He
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
| | - Rui Li
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
| | - Yuanyuan Cui
- Department of RadiologyPLA General HospitalBeijingChina
| | - Qing Li
- Department of NeurologyPeople's Hospital of Xinjiang Vygur Autonomous RegionUrumqiChina
| | - Zhuozhao Zheng
- Department of RadiologyBeijing Tsinghua Changgung HospitalSchool of Clinical MedicineTsinghua UniversityBeijingChina
| | - Xihai Zhao
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
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Guo M, Cai Y, Yao X, Li Z. Mathematical modeling of atherosclerotic plaque destabilization: Role of neovascularization and intraplaque hemorrhage. J Theor Biol 2018; 450:53-65. [PMID: 29704490 DOI: 10.1016/j.jtbi.2018.04.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/29/2018] [Accepted: 04/23/2018] [Indexed: 01/03/2023]
Abstract
Observational studies have identified angiogenesis from the adventitial vasa vasorum and intraplaque hemorrhage (IPH) as critical factors in atherosclerotic plaque progression and destabilization. Here we propose a mathematical model incorporating intraplaque neovascularization and hemodynamic calculation with plaque destabilization for the quantitative evaluation of the role of neoangiogenesis and IPH in the vulnerable atherosclerotic plaque formation. An angiogenic microvasculature is generated by two-dimensional nine-point discretization of endothelial cell proliferation and migration from the vasa vasorum. Three key cells (endothelial cells, smooth muscle cells and macrophages) and three key chemicals (vascular endothelial growth factors, extracellular matrix and matrix metalloproteinase) are involved in the plaque progression model, and described by the reaction-diffusion partial differential equations. The hemodynamic calculation of the microcirculation on the generated microvessel network is carried out by coupling the intravascular, interstitial and transvascular flow. The plasma concentration in the interstitial domain is defined as the description of IPH area according to the diffusion and convection with the interstitial fluid flow, as well as the extravascular movement across the leaky vessel wall. The simulation results demonstrate a series of pathophysiological phenomena during the vulnerable progression of an atherosclerotic plaque, including the expanding necrotic core, the exacerbated inflammation, the high microvessel density (MVD) region at the shoulder areas, the transvascular flow through the capillary wall and the IPH. The important role of IPH in the plaque destabilization is evidenced by simulations with varied model parameters. It is found that the IPH can significantly speed up the plaque vulnerability by increasing necrotic core and thinning fibrous cap. In addition, the decreased MVD and vessel permeability may slow down the process of plaque destabilization by reducing the IPH dramatically. We envision that the present model and its future advances can serve as a valuable theoretical platform for studying the dynamic changes in the microenvironment during the plaque destabilization.
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Affiliation(s)
- Muyi Guo
- School of Biological Sciences and Medical Engineering, Southeast University, Nanjing 210096, China
| | - Yan Cai
- School of Biological Sciences and Medical Engineering, Southeast University, Nanjing 210096, China
| | - Xinke Yao
- School of Biological Sciences and Medical Engineering, Southeast University, Nanjing 210096, China
| | - Zhiyong Li
- School of Biological Sciences and Medical Engineering, Southeast University, Nanjing 210096, China; School of Chemistry, Physics and Mechanical Engineering, Queensland University of Technology, Brisbane, QLD 4001, Australia.
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Kolodgie FD, Yahagi K, Mori H, Romero ME, Trout HH, Finn AV, Virmani R. High-risk carotid plaque: lessons learned from histopathology. Semin Vasc Surg 2017; 30:31-43. [DOI: 10.1053/j.semvascsurg.2017.04.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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