vascular and endovascular surgery unit san paolo hospital civitavecchia, rome, italy g.marcucci...

Vascular and Endovascular Surgery Unit San Paolo Hospital

Civitavecchia, Rome, Italy

G.Marcucci G.Marcucci

CAROTID PLAQUES AND CEREBRAL CAROTID PLAQUES AND CEREBRAL EMBOLISMEMBOLISM

G.MarcucciG.Marcucci

From histopathologic and vascular biologic studies, plaque composition and vulnerability, rather than

degree of stenosis, have emerged as crucial factors leading to sudden rupture of the plaque surface, usually with superimposed thrombosis, which

underlies the majority of acute occlusions.

CAROTID PLAQUES CAROTID PLAQUES

The link between echo plaque structure and prognosis do not appear to be limited to the carotid arteries but may apply to virtually all vascular districts

G.MarcucciG.Marcucci

Heterogeneous plaques have been correlated with the presence of intra-plaque haemorrhage, ulceration and loose stroma

containing lipids, cholesterol and proteinaceous deposits

Echo-lucency is associated with lipid-rich plaques

CAROTID PLAQUES CAROTID PLAQUES

G.MarcucciG.Marcucci

All of the heterogeneous plaques have a echo-lucent component

(lipid, haemorrhage, thrombi)

A hypo-echoic appearance can also be associated with intra-plaque haemorrhage,

which may be the result of intra-plaque neo-vascularization.

CAROTID PLAQUES CAROTID PLAQUES

G.MarcucciG.Marcucci

G.MarcucciG.Marcucci

These small, fragile vessels could represent the underlying anatomic and pathologic

changes leading to intramural haemorrhages and rupture.

Lipid lakes and intra-plaque haemorrhage are more frequently found in vulnerable

plaques, with greater potential for evolution and complication, and are the dominant

substrate of hypoechoic and heterogeneous plaques

CAROTID PLAQUES CAROTID PLAQUES

G.MarcucciG.Marcucci Cardiovascular Research 2002; 54:36-41

““VULNERABLE PLAQUE” VULNERABLE PLAQUE”

G.MarcucciG.Marcucci

atheroembolization results from disruption of endothelial surface and fibrous cap

AtheroembolizationAtheroembolization

platelet and erytrocyte aggregation to the subendothelial layer

distal embolization of the thrombus and debris from the plaque

G.MarcucciG.Marcucci

CEREBRAL EMBOLIZATION CEREBRAL EMBOLIZATION DURING CEA AND CASDURING CEA AND CAS

Perioperative cerebral embolization during CEA or CAS is a potentially devastting complication

It is correlated with:

- embolic potential of the plaque

- during surgical dissection

- during CAS procedure- postoperative embolization (technical problems)

G.MarcucciG.Marcucci

In the course of monitoring CEA’s with TCD ultrasonography,

it became apparent that during all stages of thisoperation, signals identical to the qualities of

embolic transients could be noticed

Carotid endarterectomy

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an association between multiple cerebral microemboli during dissection and new white matter lesions on magnetic resonance images (MRI) of the brain made after surgery

However, in the majority of these patients the new MRI lesions were clinically silent

JANSEN Stroke, 1994

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microemboli that appeared duringdissection and particularly during

wound closure werestatistically significantly associated with permanent cerebral deficits,

i.e. intraoperative stroke

ACKERSTAFF R. Stroke, 2000

but……

G.MarcucciG.Marcucci

CAS has been criticized on the

grounds that the risk of cerebral embolism during the

procedure may be greater than CEA

Carotid Artery Stenting

G.MarcucciG.Marcucci CRAWLEY Stroke, 1997

In contrast to coronary and peripheral artery angioplasty and stenting, which have been widely adopted, the concern

for cerebral embolisation originally resulted in a understandable reluctance to use these techniques in the carotid

artery territory.

During these peripheral procedures, the risk of embolisation, estimated by

myocardial infarction and clinical distal arterial emboli, ranges from 4% to 5%

G.MarcucciG.Marcucci

true incidence of asymptomatic embolisation may be much higher, and emboli of a size that are asymptomatic in the coronary and peripheral arterial circulations may cause neurological deficits in the cerebral circulation

The National Heart LaBIR N Engl J Med, 1988

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during stent deployment

squeezes plaque material fromthe vessel wall

microembolization

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utilization of neuroprotection devices has the potential to reduce

the intraprocedural cerebral embolic load

and neurological event rate

but……

G.MarcucciG.Marcucci

In conclusion,

CEA is a safe and effective procedure

CAS of the carotid bifurcation is a feasible alternative to CEA, particularly in patients with medical or surgical contraindications to surgery

Nevertheless, CAS results in a significant higher cerebral embolic load and the number of clinically silent lesions on MRI is greater than in CEA

Our aim is not to prove superiority of one technique over other