IMAGO 2010
Massaio k 3 de Setembro
Caracterização de placa e
espessamento da artéria carótida:
justificativa e objetivo
ergio X. Salles Cunha, PhD, RVT
Objective
Carotid plaques
• To demonstrate utility of
• Intima-Media Thickness (IMT)
and
• Carotid plaque characterization
Outline
Carotid plaques
• IMT
• pubmed.org
• medical applications
• technical hints
• comments
•
Summary
Carotid plaques
• Screening with US for carotid plaque or CIMT
uncovers cardiovascular risk in young to middle-age...
Pubmed.org
IMT
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
1 yr 2yrs 3 yrs 5yrs 10 yrs total
Stents
IMT
Pubmed.org
IMT
0
200
400
600
800
1000
1200
1400
1600
IMT
Medical applications
IMT
Medical applications
IMT
• Screening
• Treatment monitoring
• Scare tactics
Technical hints
IMT
Technical hints
IMT
Technical hints
IMT
Technical hints
IMT
Technical hints
IMT
Trchnical hints
IMT
0
0.2
0.4
0.6
0.8
1
1.2
1.4
25 30 35 40 45 55 65 75 85
women
man
Comments
IMT
• Computer super processing
• Core lab is fundamental
• Drug research
• progression: same location
• progress...
Outline
Carotid plaques
• US historical perspective
Velocity measurements
Imaging: percent stenosis
• US plaque characteri...
US velocities
Carotid plaques
• Duplex Doppler US
US velocities
Carotid plaques
• 1980’s
PSV > 125 cm/s
X-ray arteriography luminography
US high sensitivity
US high PPV
Uni...
US velocities
Carotid plaques
• 1980’s
EDV > 140 cm/s
Carotid Endarterectomy
US high PPV
US poor sensitivity
University of...
US velocities
Carotid plaques
• 1980’s
EDV > 100 cm/s
Carotid Endarterectomy
US high PPV
US high sensitivity
everybody else
US velocity ???
Carotid plaques
• Measurement error/variability
PSV = 125 = 100-150 cm/s
EDV = 100 = 80-120 cm/s
Salles-Cu...
US velocity ???
Carotid plaques
• Affected by
gain
angle of insonation
instrument design
US velocity ???
Carotid plaques
• Kinks, tortuosities
• Long plaques
• Contralateral occlusion
• Critical stenosis: low ve...
US velocity ???
Carotid plaques
You should see how bad
and turbulent that
carotid stenosis was !
US imaging
Carotid plaques
You should see how tight
and how ugly that
carotid plaque was !
US imaging
Carotid plaques
• US > 80% diameter stenosis
XR NASCET > 70%
• US < 50% diameter stenosis
XR < 50%
• US 50-70% ...
US imaging ???
Carotid plaques
• Non-circular lumen
US imaging ???
Carotid plaques
• Non-circular lumen
US imaging ???
Carotid plaques
• Non-circular lumen
US imaging ???
Carotid plaques
• Non-circular lumen
US focus
Carotid plaques
• Carotid endarterectomy
Less than 10% of vascular laboratory patients
• Medical treatment
• Prev...
US plaque characterization
Carotid plaques
• Methods
• Present results
US plaque characterization
Carotid plaques
• Heterogeneous plaques had higher incidence of late
strokes, TIA and progressi...
US plaque characterization
Carotid plaques
• Stroke rate in asymptomatic patients, 65 years or
older, with internal caroti...
US plaque characterization
Carotid plaques
• Symptomatic plaques are more hypoechoic than
asymptomatic plaques
J Vasc Surg...
US plaque characterization
Carotid plaques
• Hypoechoic plaque, not degree of stenosis,
predicted presence of non-lacunar ...
US ICAROS
Carotid plaques
Stroke Rate post Carotid Stenting
Condition GSM < 25 GSM > 25
overall 7.1 % 1.5 %
70-84 % stenos...
US ICAROS
Carotid plaques
Stroke Rate post Carotid Stenting
Logistic Multivariate Model
Condition Odds Ratio P
GSM < 25 7....
US plaque characterization
Carotid plaques
• Grayscale: blood-adventitia: 0-190
• Red: hemorrhage: 0-4
• Yellow: lipid: 8-...
US plaque characterization
Carotid plaques
• Sergio’s dogmas
• Worst part of the plaque
• Plaque outside the stent
• Medic...
US plaque characterization
Carotid plaques
US plaque characterization
Carotid plaques
• Plaque characterization: GSM = 78
US plaque characterization
Carotid plaques
• Plaque characterization: GSM = 25
US plaque characterization
Carotid plaques
US plaque characterization
Carotid plaques
• Conclusion
• Indicative of stenting
complications/results
• Follow-up of medi...
IMAGO 2010
Massaio k 3 de Setembro
Atlas
Curso de ultrassom em Natal
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Slide 1 - IMAGO 2010

  1. 1. IMAGO 2010 Massaio k 3 de Setembro
  2. 2. Caracterização de placa e espessamento da artéria carótida: justificativa e objetivo ergio X. Salles Cunha, PhD, RVT
  3. 3. Objective Carotid plaques • To demonstrate utility of • Intima-Media Thickness (IMT) and • Carotid plaque characterization
  4. 4. Outline Carotid plaques • IMT • pubmed.org • medical applications • technical hints • comments •
  5. 5. Summary Carotid plaques • Screening with US for carotid plaque or CIMT uncovers cardiovascular risk in young to middle-aged patients with a low Framingham risk score (FRS). • Carotid US proved better than coronary artery calcium (CAC) score via CT to predict risk 2 studies in the August issue of the Journal of the American Society of Echocardiography.
  6. 6. Pubmed.org IMT 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 1 yr 2yrs 3 yrs 5yrs 10 yrs total Stents IMT
  7. 7. Pubmed.org IMT 0 200 400 600 800 1000 1200 1400 1600 IMT
  8. 8. Medical applications IMT
  9. 9. Medical applications IMT • Screening • Treatment monitoring • Scare tactics
  10. 10. Technical hints IMT
  11. 11. Technical hints IMT
  12. 12. Technical hints IMT
  13. 13. Technical hints IMT
  14. 14. Technical hints IMT
  15. 15. Trchnical hints IMT 0 0.2 0.4 0.6 0.8 1 1.2 1.4 25 30 35 40 45 55 65 75 85 women man
  16. 16. Comments IMT • Computer super processing • Core lab is fundamental • Drug research • progression: same location • progression: worst IMT •Garrincha: seu Feola, o senhor conversou com o tecnico do outro time e ele concorda que a gente pode fazer isso ?
  17. 17. Outline Carotid plaques • US historical perspective Velocity measurements Imaging: percent stenosis • US plaque characterization Method Present results Sergio’s dogmas
  18. 18. US velocities Carotid plaques • Duplex Doppler US
  19. 19. US velocities Carotid plaques • 1980’s PSV > 125 cm/s X-ray arteriography luminography US high sensitivity US high PPV University of Washington
  20. 20. US velocities Carotid plaques • 1980’s EDV > 140 cm/s Carotid Endarterectomy US high PPV US poor sensitivity University of Washington
  21. 21. US velocities Carotid plaques • 1980’s EDV > 100 cm/s Carotid Endarterectomy US high PPV US high sensitivity everybody else
  22. 22. US velocity ??? Carotid plaques • Measurement error/variability PSV = 125 = 100-150 cm/s EDV = 100 = 80-120 cm/s Salles-Cunha et al DAHOS
  23. 23. US velocity ??? Carotid plaques • Affected by gain angle of insonation instrument design
  24. 24. US velocity ??? Carotid plaques • Kinks, tortuosities • Long plaques • Contralateral occlusion • Critical stenosis: low velocity
  25. 25. US velocity ??? Carotid plaques You should see how bad and turbulent that carotid stenosis was !
  26. 26. US imaging Carotid plaques You should see how tight and how ugly that carotid plaque was !
  27. 27. US imaging Carotid plaques • US > 80% diameter stenosis XR NASCET > 70% • US < 50% diameter stenosis XR < 50% • US 50-70% diameter stenosis Do what you want to do Salles-Cunha et al JVC
  28. 28. US imaging ??? Carotid plaques • Non-circular lumen
  29. 29. US imaging ??? Carotid plaques • Non-circular lumen
  30. 30. US imaging ??? Carotid plaques • Non-circular lumen
  31. 31. US imaging ??? Carotid plaques • Non-circular lumen
  32. 32. US focus Carotid plaques • Carotid endarterectomy Less than 10% of vascular laboratory patients • Medical treatment • Preventive medicine • Stenting
  33. 33. US plaque characterization Carotid plaques • Methods • Present results
  34. 34. US plaque characterization Carotid plaques • Heterogeneous plaques had higher incidence of late strokes, TIA and progression than homogeneous plaques in patients with 60% to 69% carotid stenosis J Vasc Surg 2002; 36:437
  35. 35. US plaque characterization Carotid plaques • Stroke rate in asymptomatic patients, 65 years or older, with internal carotid stenosis greater than 50% (PSV >150 cm/sec) – Hypoechoic plaque: 5 % per year – Hyperechoic plaque: < 2 % per year Cardiovascular Health Study Radiology 1998; 208:649
  36. 36. US plaque characterization Carotid plaques • Symptomatic plaques are more hypoechoic than asymptomatic plaques J Vasc Surg 2000; 31:39
  37. 37. US plaque characterization Carotid plaques • Hypoechoic plaque, not degree of stenosis, predicted presence of non-lacunar silent CT-brain infarcts (GSM=11) J Vasc Surg 2001; 33:334
  38. 38. US ICAROS Carotid plaques Stroke Rate post Carotid Stenting Condition GSM < 25 GSM > 25 overall 7.1 % 1.5 % 70-84 % stenosis 3.3 % 0.0 % 85-99% stenosis 12.7 % 2.6 % Asymptomatic 6.1 % 0.6 % Symptomatic 9.8 % 3.3 % Circulation 2004;110:756
  39. 39. US ICAROS Carotid plaques Stroke Rate post Carotid Stenting Logistic Multivariate Model Condition Odds Ratio P GSM < 25 7.11 .002 Stenosis > 85% 5.76 .010 Symptoms 2.92 .061 Brain CT 2.54 .099 Circulation 2004;110:756
  40. 40. US plaque characterization Carotid plaques • Grayscale: blood-adventitia: 0-190 • Red: hemorrhage: 0-4 • Yellow: lipid: 8-26 • Green: muscle: 41-76 • Green: fibrous tissue: 112-196 • Blue: calcium: 211-255 J Vasc Surg 2002; 35:1210
  41. 41. US plaque characterization Carotid plaques • Sergio’s dogmas • Worst part of the plaque • Plaque outside the stent • Medical practice What happens to the plaque being treated with drugs/preventive behavior ?
  42. 42. US plaque characterization Carotid plaques
  43. 43. US plaque characterization Carotid plaques • Plaque characterization: GSM = 78
  44. 44. US plaque characterization Carotid plaques • Plaque characterization: GSM = 25
  45. 45. US plaque characterization Carotid plaques
  46. 46. US plaque characterization Carotid plaques • Conclusion • Indicative of stenting complications/results • Follow-up of medical treatment • Worst part of the plaque
  47. 47. IMAGO 2010 Massaio k 3 de Setembro Atlas Curso de ultrassom em Natal
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