Correlation between plaque instability and presence of preoperative - - PowerPoint PPT Presentation

Correlation between plaque instability and presence of preoperative ischemic brain lesions in patients undergoing carotid endarterectomy

M.L. Rots, D.P.V. de Kleijn, G. Pasterkamp, M.M. Brown, L.H. Bonati, G.J. de Borst

I do not have any potential conflict of interest

Carotid Artery Disease

Vulnerable Plaques Thrombo-embolisms  Stroke / TIA

Background

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Intraplaque hemorrhage (IPH)

• Associated with higher risk of ipsilateral

stroke1-2

• IPH more common in symptomatic patients3
• Symptomatic patients with IPH increased

chance of recurrent events4

1 Turc et al, Relationships between recent intraplaque hemorrhage and stroke risk factors in patients with carotid stenosis: The HIRISC study, Aterioscler. Throm. Vasc. Biol. 2012 2 Takaya et al, Association between Carotid Plaque Characteristics and Subsequent Ischemic Cerebrovascular Events, Stroke, 2006 3 Gao et al, Correlation between carotid intraplaque hemorrhage and clincal symptoms: sytematic review of observational studies. Stroke, 2007 4 Altaf et al, Carotid intraplaque hemorrhage predicts recurrent symptoms in patients with high-grade carotid stenosis, Stroke, 2007

Background

5 Gensicke, Ischemic brain lesions after carotid artery stenting increase future cerebrovascular risk. J Am Coll Cardiol. 2015

Patients with instable plaques: High risk interval period Development of asymptomatic ischemic brain lesions in waiting period? Magnetic Resonance Diffusion Weighted Imaging (MR-DWI) lesions

• Surrogate marker for cerebral ischemia
• Clinically relevant: associated with increased chance of future cerebrovascular events5

INDEX EVENT REVASCULARIZATION

Aim: To investigate the correlation between intraplaque hemorrhage and presence of fresh pre-operative ischemic brain lesions in carotid stenosis patients

Plaque Characteristics (histology)

• Intraplaque hemorrhage
• Large lipid core
• Calcifications
• Collagen
• Microvessels
• Macrophage staining
• Smooth muscle cell staining

Retrospective study on prospectively collected data

METHODS

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ICSS – MRI substudy

(81% of CEA patients >14 days between last symptom and surgery)

Athero-Express biobank (UMC Utrecht)

Atherosclerotic plaques of CEA patients

MRI 1-7 days prior to surgery Ipsilateral DWI lesions (appearing hypo-/isointense on ADC)  Lesion 0-10 days old 6

Index event revascularization t MRI

1-7 days 1-10 days

82% of patients > 14 days waiting time

6 Allen et al, Sequence-specific MR Imaging Findings That Are Useful in dating Ischemic Stroke . RadioGraphics 2012

Recurrent thrombo-embolism

RESULTS

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DWI – (n=40) DWI + (n=13) p-value Age 68.2 (8.6) 69.3 (8.4) 0.673 Male gender 70% 85% 0.299 Hypertension 65% 83% 0.227 Diabetes Mellitus 23% 23% 0.966 Hypercholersterolemia 64% 63% 0.977 Smoking 38% 25% 0.425 BMI 25.8 (3.7) 25.0 (2.9) 0.520 History of CAD 30% 41% 0.450 Stenosis > 70% 93% 100% 0.218 Index event stroke 33% 39% 0.693 Waiting time in days (IQR) 45 (24-66) 34 (18-50) 0.179

Inclusion of 53 patients No ipsilateral DWI lesions n=40 ≥1 ipsilateral DWI lesion n=13 Ipsilateral DWI – (n=40) DWI + (n=13) OR (adjusted) p-value multivariate

Intraplaque hemorrhage 60% 92% 10 (1.2-100) 0.036 Lipid core ≥40% 58% 23% 0.18 (0.04-0.836) 0.028 Moderate/heavy calcifications 43% 39% 0.82 (0.22-3.04) 0.770 Moderate/heavy collagen 78% 54% 0.34 (0.09-1.267) 0.107

DWI – (n=40) DWI + (n=13) Β (adjusted) p-value multivariate

% Microvessels 9.15 (5.22) 9.00 (8.00) 1.07 (0.420-2.639) 0.890 % Macrophage staining 0.63 (1.40) 0.74 (1.68) 1.10 (0.286-4.264) 0.886 % Smooth muscle cell staining 1.16 (2.40) 0.91 (1.58) 0.74 (0.217-2.520) 0.630

Multivariate analysis corrected for age and type of index event

Patients with intraplaque hemorrhage have an increased risk for recurrent ischemic lesions after the index event Detection of intraplaque hemorrhage can be helpful in prioritizing patients for timing of revascularization Low number of patients ↔ first study relating histological plaque features to preprocedual risk of (recurrent) ischemic lesions Reliable methods for in vivo detection needed Thank You For Your Attention!

DISCUSSION

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