Document Detail

Predicting embolic potential during carotid angioplasty and stenting: analysis of captured particulate debris, ultrasound characteristics, and prior carotid endarterectomy.
MedLine Citation:
PMID:  20006918     Owner:  NLM     Status:  MEDLINE    
INTRODUCTION: Extracranial carotid stenoses exhibit significant variance in embolic potential, with restenotic lesions having a particularly low propensity for embolization. This study sought to identify characteristics associated with increased generation of embolic debris during carotid angioplasty and stenting (CAS).
METHODS: Captured particulate was available for analysis in 56 consecutive patients. Demographics were mean age, 74 years (range, 60-94 years); mean stenosis, 88% (range, 70%-99%); symptomatic, 27%; prior carotid endarterectomy (CEA), 27%; prior radiotherapy, 7%. Plaque echogenicity, heterogenicity, ulceration, and irregularity were assessed with B-mode duplex ultrasound analysis. Gray scale median (GSM) was calculated from normalized B-mode VHS video recordings. Calcification and degree of stenosis were determined angiographically. Captured particulate debris was evaluated for total number; number >200 microm, >500 microm, >1000 microm; mean and median size. Hematoxylin and eosin, trichrome, and von Kossa stains were used for histologic analysis of captured material.
RESULTS: Restenotic carotid stenoses after prior CEA generated minimal embolic debris compared with primary stenoses. Four of 15 patients (27%) with restenotic lesions demonstrated embolic particles; all debris was <500 microm. All 41 patients with primary stenoses had some embolic debris; particulate size was >200 microm in 91%, >500 microm in 72%, and >1000 microm in 43%. In primary lesions, the number and size of captured particulate correlated with GSM and with the combined ultrasound findings of echogenicity, heterogenicity, and luminal irregularity/ulceration (P < .02, 95% confidence interval, 4.5-27.6). None of these ultrasound factors correlated independently with embolic particulate (P = NS). Patients aged >70 years exhibited more total particles (8.1 vs 2.3, P = .008) and increased mean particle size (370 vs 157 mum, P = .02). No significant correlation was observed between the number and size of captured embolic particulate and any other variable (stenosis percentage, prior radiotherapy, preprocedural symptoms, periprocedural symptoms, and calcification). Histologically, the embolic debris consisted of extensive amorphous, acellular proteinaceous material. Calcium debris in the embolic particulate was associated with heavily and moderately calcified lesions.
CONCLUSIONS: Considerable variation exists in the number and size of embolic particles generated during CAS. Embolic potential is positively correlated with lesion GSM and the combination of lesion echogenicity, heterogenicity, and irregularity. Restenosis after prior CEA is associated with minimal embolic particulate generation, suggesting that embolic protection may not be necessary for CAS of restenotic lesions.
Rajesh K Malik; Gregg S Landis; Scott Sundick; Neal Cayne; Michael Marin; Peter L Faries
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Publication Detail:
Type:  Comparative Study; Journal Article     Date:  2009-12-14
Journal Detail:
Title:  Journal of vascular surgery     Volume:  51     ISSN:  1097-6809     ISO Abbreviation:  J. Vasc. Surg.     Publication Date:  2010 Feb 
Date Detail:
Created Date:  2010-02-09     Completed Date:  2010-03-04     Revised Date:  2012-10-03    
Medline Journal Info:
Nlm Unique ID:  8407742     Medline TA:  J Vasc Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  317-22     Citation Subset:  IM    
Copyright Information:
Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Department of Vascular Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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MeSH Terms
Aged, 80 and over
Angioplasty, Balloon, Coronary* / adverse effects,  instrumentation
Calcinosis / therapy,  ultrasonography
Carotid Stenosis / complications,  radiography,  surgery,  therapy*,  ultrasonography
Embolism / etiology,  prevention & control*,  ultrasonography
Endarterectomy, Carotid* / adverse effects
Filtration* / instrumentation
Middle Aged
Particle Size
Predictive Value of Tests
Risk Assessment
Risk Factors
Severity of Illness Index
Time Factors
Treatment Outcome
Ulcer / therapy,  ultrasonography
Ultrasonography, Doppler, Duplex*

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