Contrast-enhanced carotid ultrasonography and MRI plaque imaging to identify patients developing in-stent intimal hyperplasia after carotid artery stenting

Abstract

Aim: In-stent intimal hyperplasia (ISH) observed after carotid artery stenting (CAS) may lead to in-stent restenosis. We aimed to investigate whether contrast-enhanced carotid ultrasonography (CEUS) and magnetic resonance imaging (MRI) plaque imaging prior to CAS are predictive for ISH at 6 months after CAS.Material and method: A total of 14 patients (13 men, 1 woman; mean age, 74.2 years) were prospectively enrolled. CEUS and MRI plaque imaging were performed before CAS. ISH was diagnosed by carotid angiography at 6 months after CAS. Patients were divided into two groups based on the thicknessof ISH and age, risk factors, enhancement in CEUS, MRI plaque imaging and number of replaced stents were compared between groups.Results: Carotid angiography at 6 months after CAS revealed ISH in 10 patients. Plaque enhancement on CEUS was observed in 6 patients, all of whom showed ISH. A significant association was seen between plaque enhancement on CEUS and development of ISH (χ2 test, CEUS enhancement (+) 100% vs. CEUS enhancement (-) 50% p=0.040). Carotid plaques in 12 patients were diagnosed as unstable by MRI plaque imaging. Presence of ISH was significantly associated with unstable plaque diagnosed by MRI plaque imaging (χ2 test, unstable 83% vs. stable 0%; p=0.016).Conclusion: Carotid plaque MRI and CEUS may be useful to predict ISH after CAS.

Anatomical Considerations for Endovascular Intervention for Extracranial Carotid Disease: A Review of the Literature and Recommended Guidelines

“…We conducted a systematic literature review without meta-analysis per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [8]. Nineteen studies were identified that discussed perioperative risk in the context of relevant anatomy [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] (Table 1) in addition to fourteen studies [28][29][30][31][32][33][34][35][36][37][38][39][40][41] (Table 2) and fifteen case reports/series [42][43][44][45][46][47][48][49][50][51][52][53][54]…”

“…Recent trial data comparing the two was found to be equivocal for short and long-term primary endpoints, and continued analysis in pooled studies reported increased risk of AIS in the first month following CAS [70][71][72]. As such, early guidelines recommended CAS to be reserved as an alternative to CEA in anatomically favorable scenarios [1,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. Anatomic factors often dictate treatment outside of CAS, such as during emergent EVT and PTA in the context of AIS secondary to LVO or intima dissection [73].…”

“…Additional challenges exist in so-called vulnerable plaque morphologies [25,27,42,52]. The Stary classification divides plaque grading into six categories, with type V (fibroatheroma) and VI (complicated) lesions considered vulnerable [91][92][93][94].…”

“…Such lesions may rupture and shower atheromatous debris [27] with minimal stimulation, induce formation of occlusive intraluminal mobile flaps [52] or free floating thrombi (FFT) [42], and trigger in-stent stenosis via thrombosis or intimal hyperplasia following CAS [25]. Furthermore, flexible open-cell stents suitable to navigating tortuous anatomy have been reported to risk a scissoring effect following stent expansion and collapse in vulnerable plaques, in which individual threads of the stent shear embolic material [27].…”

Intraplaque neovascularisation is associated with ischaemic events after carotid artery stenting: an observational prospective study

“… 9 In addition, another study with a small sample size showed that plaques detected by contrast-enhanced ultrasound (CEUS) were significantly correlated with in-stent intimal hyperplasia. 10 CEUS can observe IPN through the degree of microbubble enhancement and can be used as a screening method to detect plaque vulnerability. However, to our knowledge, the predictive value of carotid plaque characteristics assessed using CEUS for ischaemic events in patients after CAS has not been discussed.…”