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IMAGO 2010Massaio 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-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.
Pubmed.orgIMT
0
500
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3500
4000
4500
5000
1 yr 2yrs 3 yrs 5yrs 10 yrs total
Stents
IMT
Pubmed.orgIMT
0
200
400
600
800
1000
1200
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1600
IMT
Medical applicationsIMT
Medical applicationsIMT
• Screening• Treatment monitoring• Scare tactics
Technical hintsIMT
Technical hintsIMT
Technical hintsIMT
Technical hintsIMT
Technical hintsIMT
Trchnical hintsIMT
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
CommentsIMT
• 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 ?
Outline
Carotid plaques
• US historical perspectiveVelocity measurementsImaging: percent stenosis
• US plaque characterizationMethodPresent resultsSergio’s dogmas
US velocities
Carotid plaques
• Duplex Doppler US
US velocities
Carotid plaques
• 1980’s
PSV > 125 cm/s
X-ray arteriography luminography
US high sensitivityUS high PPV
University of Washington
US velocities
Carotid plaques
• 1980’s
EDV > 140 cm/s
Carotid EndarterectomyUS high PPVUS poor sensitivity
University of Washington
US velocities
Carotid plaques
• 1980’s
EDV > 100 cm/s
Carotid EndarterectomyUS high PPVUS high sensitivity
everybody else
US velocity ???
Carotid plaques
• Measurement error/variabilityPSV = 125 = 100-150 cm/s
EDV = 100 = 80-120 cm/s
Salles-Cunha et al DAHOS
US velocity ???
Carotid plaques
• Affected by gainangle of insonationinstrument design
US velocity ???
Carotid plaques
• Kinks, tortuosities• Long plaques• Contralateral occlusion• Critical stenosis: low velocity
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 stenosisXR NASCET > 70%
• US < 50% diameter stenosisXR < 50%
• US 50-70% diameter stenosisDo what you want to do
Salles-Cunha et al JVC
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 endarterectomyLess than 10% of vascular laboratory patients
• Medical treatment• Preventive medicine• Stenting
US plaque characterization
Carotid plaques
• Methods • Present results
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
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
US plaque characterization
Carotid plaques
• Symptomatic plaques are more hypoechoic than
asymptomatic plaques
J Vasc Surg 2000; 31:39
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
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
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
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
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 ?
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 medical
treatment
• Worst part of the plaque
IMAGO 2010Massaio k 3 de Setembro
AtlasCurso de ultrassom em Natal
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