Ex vivo human carotid artery bifurcation stenting: Correlation of lesion characteristics with embolic potential

Ohki, Takao; Marin, Michael L.; Lyon, Ross T.; Berdejo, George L.; Soundararajan, Krish; Ohki, Mika; Yuan, John G.; Faries, Peter L.; Wain, Reese A.; Sánchez, Luis A.; Suggs, William D.; Veith, Frank J.

doi:10.1016/s0741-5214(98)70321-0

Cited by 237 publications

(126 citation statements)

References 24 publications

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“…22 Several authors have broadened the investigation of atheromatous plaque and embolization phenomena in the carotid, coronary, and peripheral vascular systems through the direct analysis of particles captured by the filter, trying to corroborate their atherosclerotic origin and establish an association between the volume and composition of the filter particles and postprocedural clinical events and MR imaging findings. 21,[25][26][27] In our study, 58.2% of the filters contained debris. Ultrastructural analysis revealed fibrin and platelets, foam macrophages, cellular debris, cholesterol crystals, collagen fibers, smooth muscle fibers, calcium, unidentified fibrillate, and amorphous material.…”

Section: Discussionmentioning

confidence: 42%

Volume and Composition of Emboli in Neuroprotected Stenting of the Carotid Artery

Piñero¹,

González²,

Martínez³

et al. 2008

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE:Periprocedural microembolization is a major and permanent risk for patients treated by angioplasty and stent placement of high-grade carotid stenoses. Little is known however about the characteristics and significance of these embolized particles. Our aim was to assess the volume and composition of debris captured by filters during carotid angioplasty and stent placement (CAS) of severe internal carotid artery (ICA) stenoses.

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Section: Discussionmentioning

confidence: 42%

Volume and Composition of Emboli in Neuroprotected Stenting of the Carotid Artery

Piñero¹,

González²,

Martínez³

et al. 2008

AJNR Am J Neuroradiol

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“…6 -9 The occurrence of periprocedural stroke for CAS has been proposed to be closely related to plaque manipulation with intra-arterial devices resulting in plaque rupture, subsequent superimposed thrombus formation, and embolization of plaque debris. 10,11 Disruption of carotid plaques during manipulation in stenting procedures is more likely to occur in so-called vulnerable plaques with large lipid cores and thin fibrous caps. 12 Only a few studies have reported on histological carotid plaque characteristics in relation to age.…”

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confidence: 99%

Atherosclerotic Plaque Vulnerability as an Explanation for the Increased Risk of Stroke in Elderly Undergoing Carotid Artery Stenting

Lammeren

Reichmann

Moll

et al. 2011

Stroke

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Background and Purpose-Recent randomized trials showed an increased periprocedural risk for stroke with increasing age in patients undergoing carotid artery stenting. Manipulation of atherosclerotic plaques during carotid artery stenting can result in plaque rupture with subsequent superimposed thrombus formation, embolization, and cerebrovascular events. We hypothesized that atherosclerotic plaques become more unstable with increasing age and thereby might provide insight into the age-related increased risk of cerebrovascular events during carotid artery stenting. Methods-Carotid atherosclerotic plaques were harvested from 1385 consecutive patients undergoing carotid endarterectomy between 2002 and 2010. Carotid plaques were quantitatively analyzed for macrophages, smooth muscle cells, and microvessels; and semiquantitatively analyzed for collagen, calcifications lipid cores, and intraplaque hemorrhages.Patients were divided in 4 groups by age: Ͻ60, 60 to 69, 70 to 79, and Ն80 years. Measures of association between age as a continuous variable and histological characteristics were also calculated. Results-Increasing age was associated with a decrease in the amount of smooth muscle cells in the carotid plaque. More plaques with large atheroma and heavy plaque calcifications were observed among elderly patients. After correction for baseline differences, risk factors, and medication use, age was independently associated with a more vulnerable carotid plaque composition. Conclusion-Plaque stability decreases gradually with age. Older patients with carotid stenosis have relatively unstable plaques with low smooth muscle cell content, a high amount of large lipid cores, and more calcified plaques as compared with younger patients. The underlying vulnerable plaque composition in the elderly might be an important contributing factor to the increased risk of stroke for older patients undergoing carotid artery stenting. (Stroke. 2011;42:2550-2555.)Key Words: age Ⅲ angioplasty & stenting Ⅲ atherosclerosis Ⅲ carotid stenosis Ⅲ plaque composition Ⅲ risk factors C arotid endarterectomy (CEA) reduces the risk of ischemic stroke in patients with a recently symptomatic, significant carotid artery stenosis. 1 Subgroup analysis revealed a high benefit from surgery, particularly for patients Ͼ75 years, due to the relatively high risk for a secondary event and therefore a relatively low number needed to treat to prevent 1 ipsilateral stroke. 2 Besides the favorable number needed to treat, overall life expectancy is rising, indicating that CEA in the "intellectually intact" elderly can be highly beneficial. 3 From observational studies, the periprocedural risk for the elderly undergoing CEA has been reported to be comparable to the risk for younger patients. 3-5 Nevertheless, subgroup analyses for age in several randomized trials revealed that periprocedural risk of stroke, myocardial infarction, and death after carotid artery stenting (CAS) increases with age. 6 -9 The occurrence of periprocedural stroke for CAS has been propos...

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“…2,31 Balloon angioplasty, both before and after stent insertion, releases significant amounts of embolic debris 20,24,26,28,33 and often results in significant hemodynamic instability, defined as bradycardia (< 60 beats/min) and hypotension (systolic blood pressure < 90 mm Hg).…”

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confidence: 99%

“…10 Every pass of a device through an atherosclerotic stenosis generates distal emboli. 2,31 Balloon angioplasty, both before and after stent insertion, releases significant amounts of embolic debris 20,24,26,28,33 and often results in significant hemodynamic instability, defined as bradycardia (< 60 beats/min) and hypotension (systolic blood pressure < 90 mm Hg). 27 Some major centers now rarely perform prestent balloon angioplasty, deliberately undersize poststent angioplasty balloons, or completely omit poststent angioplasty to decrease the potential for embolic events and hemodynamic depression.…”

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confidence: 99%

Plaque morphology (the PLAC Scale) on CT angiography: predicting long-term anatomical success of primary carotid stenting

Pelz¹,

Lownie²,

Lee³

et al. 2015

JNS

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C arotid angioplasty and stenting (CAS) has evolved into an alternative to carotid endarterectomy (CEA) for the treatment of atherosclerotic carotid stenosis, particularly since the publication of the Carotid Revascularization Endarterectomy versus Stent Trial (CREST) in 2010. 4 In the CREST, as in most other randomized controlled trials and large case series, the standard technical protocols include the use of embolic protection devices (EPDs), self-expanding stents (SESs), and balloons preand postdilation. It has, however, been shown that EPDs do not catch all debris generated by balloons and that these expensive devices may cause complications themselves. 10Every pass of a device through an atherosclerotic stenosis generates distal emboli.2,31 Balloon angioplasty, both before and after stent insertion, releases significant amounts of embolic debris 20,24,26,28,33 and often results in significant hemodynamic instability, defined as bradycardia (< 60 beats/min) and hypotension (systolic blood pressure < 90 mm Hg).27 Some major centers now rarely perform prestent balloon angioplasty, deliberately undersize poststent abbreviatioNs CAS = carotid angioplasty and stenting; CEA = carotid endarterectomy; CREST = Carotid Revascularization Endarterectomy versus Stent Trial; CTA = CT angiography; EPD = embolic protection device; NASCET = North American Symptomatic Carotid Endarterectomy Trial; PCS = primary carotid stenting; PLAC = Predicting Long-term outcome with Angioplasty of the Carotid artery; PSV = peak systolic velocity; SES = self-expanding stent. obJect Carotid angioplasty and stenting has emerged as an alternative to carotid endarterectomy for the treatment of atherosclerotic carotid stenosis. Primary carotid stenting, performed using self-expanding stents alone without deliberate use of embolic protection devices and balloon angioplasty, has been shown to be effective and faster, cheaper, and potentially safer than conventional techniques. However, the long-term morphological results of this technique have not been established. The aim of this study was to determine whether preprocedural carotid plaque imaging at the site of maximal stenosis by using CT angiography (CTA) could predict the long-term morphological outcome of primary carotid stenting. methods One hundred eighty-one patients were treated over an 11-year period. Preprocedural CTA was performed in 102 of these. A morphological scale (the Predicting Long-term outcome with Angioplasty of the Carotid artery [PLAC] Scale), with grades from 0 to 4 and A or B, was used to evaluate the circumferential degree of plaque calcification, and the presence or absence of soft plaque. All patients were followed using duplex carotid ultrasound and plain radiographs. Satisfactory morphological outcome was defined as a peak systolic velocity < 120 cm/s and internal carotid artery/common carotid artery ratio < 1.4. results The average follow-up duration was 29.7 months (median 24.5 months, range 0.3-87 months). Univariate logistic regression demonstrated that a low ca...

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Ex vivo human carotid artery bifurcation stenting: Correlation of lesion characteristics with embolic potential

Cited by 237 publications

References 24 publications

Volume and Composition of Emboli in Neuroprotected Stenting of the Carotid Artery

Volume and Composition of Emboli in Neuroprotected Stenting of the Carotid Artery

Atherosclerotic Plaque Vulnerability as an Explanation for the Increased Risk of Stroke in Elderly Undergoing Carotid Artery Stenting

Plaque morphology (the PLAC Scale) on CT angiography: predicting long-term anatomical success of primary carotid stenting

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