Echolucent or predominantly echolucent femoral plaques predict early restenosis after eversion carotid endarterectomy

Abstract

Objective: Although the association between vulnerable lesions and cardiovascular events is well established, little is known about their relationship to postsurgery restenosis. To address this issue, we initiated a prospective, nonrandomized study to examine the femoral plaques on both sides in patients who were undergoing eversion carotid endarterectomy (CEA) and were longitudinally followed-up for early restenosis development. Methods: The final analysis enrolled 321 patients (189 women) with a median age of 67.0 years (interquartile range, 59.0-73.0 years), who underwent eversion CEA (2005 to 2007). Using duplex ultrasound scanning, we evaluated 321 common femoral atherosclerotic lesions on the day before CEA. A quantitative scale was used to grade the size of plaques as grade 1, one or more small plaques (<20 mm 2 ); grade 2, moderate to large plaques; and grade 3, plaques giving flow disturbances. The plaque morphology in terms of echogenicity was graded as echolucent, 1; predominantly echolucent, 2; predominantly echogenic, 3; echogenic 4; or calcified, 5. The plaque surface was categorized as smooth, irregular, or ulcerated. The patients underwent carotid duplex ultrasound imaging at 6 weeks and at 6, 12, and 24 months after CEA. Mann-Whitney U test, 2 test, and multivariate logistic regression were used for statistical evaluation. Results: Internal carotid artery restenosis of >50% was detected in 33 patients (10.28%) in the operated region. Neither the size (grade 1, P ‫؍‬ .793; grade 2, P ‫؍‬ .540; grade 3, P ‫؍‬ .395) nor the surface characteristics of the femoral plaques (smooth, P ‫؍‬ .278; irregular, P ‫؍‬ .281; ulcerated, P ‫؍‬ .934) were significantly different between the patients with and without carotid restenosis. Echolucent-predominantly echolucent femoral lesions were an independent predictor of recurrent carotid stenosis (adjusted odds ratio, 5.63; 95% confidence interval, 2.14-10.89; P < .001). Conclusion: Ultrasound evaluation of femoral plaque morphology before CEA can be useful for identifying patients at higher risk for carotid restenosis. ( J Vasc Surg 2010;51:345-50.)Eversion endarterectomy of the carotid artery (CEA) is a generally accepted elective surgical method in both symptomatic and asymptomatic patients with significant internal carotid artery (ICA) stenosis. Despite of the best surgical care, recurrent stenosis has been reported to occur in 1% to 36% of patients. 1 Stoney and String 2 were the first to classify carotid restenoses into two distinct types: lesions occurring Յ2 years after CEA were attributed to intimal hyperplasia and thereafter, to recurrent atherosclerosis.Multiple inflammatory mediators, including growth factors and cytokines, have been postulated to play different roles to trigger the neointimal response. 3 Similarly, inflammation is involved in all stages of the atherosclerotic process, from the initiation of the fatty streak to the final stage of plaque rupture. 4 Histologic findings have revealed that high-risk vulnerable lesions have a thin fibrous ca...

Middle and Distal Common Carotid Artery Stenting: Long-Term Patency Rates and Risk Factors for In-Stent Restenosis

“…Corresponding to other studies [ 30 , 31 ], we also evaluated several possible risk factors and found hyperlipidemia to be significantly more common among patients with ISR. The role of hyperlipidemia in the formation of neointimal hyperplasia has also been demonstrated by other research groups [ 32 – 36 ]. Hyperlipidemia increases the entry of low-density lipoprotein (LDL) into the intima and its progressive oxidative alteration in the subendothelial space.…”

“…Hyperlipidemia increases the entry of low-density lipoprotein (LDL) into the intima and its progressive oxidative alteration in the subendothelial space. Oxidized LDL results in further lipid infiltration across the intact endothelium, where it aggregates and activates the release of mitogens from platelets, macrophages, and endothelial cells; this, in turn, stimulates smooth muscle cell proliferation, thereby leading to neointima formation [ 32 , 33 ].…”

High frequency of brachiocephalic trunk stent fractures does not impair clinical outcome

“…Innominate artery stenting protocol. The preprocedural work-up included clinical data collection (symptoms, risk factors, which were described in detail previously, 13 and medical history), radial pulse palpation and blood pressure measurement in both arms, neurologic evaluation, and duplex scan of the neck arteries. In recent years, computed tomography (CT) or magnetic resonance angiography have become part of the preprocedural imaging protocol in patients with multivessel supra-aortic disease to evaluate which lesion should be treated first.…”

Imaging Carotid Atherosclerosis Plaque Ulceration: Comparison of Advanced Imaging Modalities and Recent Developments

“…25 The plaque surface can be defined as smooth and regular, mildly irregular, or ulcerated in the case of a variation in height between 0.4 and 2 mm on the contour of the plaque. 26 An example of ulceration in Doppler sonography is shown in Fig 3A. However, it is difficult to detect plaque ulceration by sonography due to various limitations. First, the overall accuracy of using B-mode sonography against criterion standard techniques (DSA or histopathology) is not high (sensitivity and specificity ranges from 39% to 89% and 72% to 87%, respectively).…”