The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke

Objective: To test the hypothesis that the size of a juxtaluminal black (hypoechoic) area (JBA) in ultrasound images of asymptomatic carotid artery plaques predicts future ipsilateral ischemic stroke. Methods: A JBA was defined as an area of pixels with a grayscale value <25 adjacent to the lumen without a visible echogenic cap after image normalization. The size of a JBA was measured in the carotid plaque images of 1121 patients with asymptomatic carotid stenosis 50% to 99% in relation to the bulb (Asymptomatic Carotid Stenosis and Risk of Stroke study); the patients were followed for up to 8 years. Results: The JBA had a linear association with future stroke rate. The area under the receiver-operating characteristic curve was 0.816. Using Kaplan-Meier curves, the mean annual stroke rate was 0.4% in 706 patients with a JBA <4 mm 2, 1.4% in 171 patients with a JBA 4 to 8 mm2, 3.2% in 46 patients with a JBA 8 to 10 mm2, and 5% in 198 patients with a JBA >10 mm2 (P <.001). In a Cox model with ipsilateral ischemic events (amaurosis fugax, transient ischemic attack [TIA], or stroke) as the dependent variable, the JBA (<4 mm2, 4-8 mm2, >8 mm2) was still significant after adjusting for other plaque features known to be associated with increased risk, including stenosis, grayscale median, presence of discrete white areas without acoustic shadowing indicating neovascularization, plaque area, and history of contralateral TIA or stroke. Plaque area and grayscale median were not significant. Using the significant variables (stenosis, discrete white areas without acoustic shadowing, JBA, and history of contralateral TIA or stroke), this model predicted the annual risk of stroke for each patient (range, 0.1%-10.0%). The average annual stroke risk was <1% in 734 patients, 1% to 1.9% in 94 patients, 2% to 3.9% in 134 patients, 4% to 5.9% in 125 patients, and 6% to 10% in 34 patients. Conclusions: The size of a JBA is linearly related to the risk of stroke and can be used in risk stratification models. These findings need to be confirmed in future prospective studies or in the medical arm of randomized controlled studies in the presence of optimal medical therapy. In the meantime, the JBA may be used to select asymptomatic patients at high stroke risk for carotid endarterectomy and spare patients at low risk from an unnecessary operation

Definizione dei percorsi diagnostico-terapeutici nelle arteriopatie ostruttive croniche periferiche

Definizione dei percorsi diagnostico-terapeutici nelle arteriopatie ostruttive croniche periferiche

Antiplatelet Therapy and Other Interventions after Revascularisation Procedures in Patients with Peripheral Arterial Disease: a Meta-analysis

AbstractObjectives to evaluate the efficacy of conservative adjuvant therapy after revascularisation procedures in patients with peripheral arterial disease. Design meta-analysis. Materials English-language studies published from 1976 to 1997. Methods reports on conservative therapies in patients with peripheral arterial disease after percutaneous transluminal angioplasty, endarterectomy, thromboendarterectomy or bypass grafting were eligible. Uncontrolled or retrospective studies, double reports or trials without clinical outcomes were excluded. Included studies were graded as level 1 (randomised and double- or assessor-blind), level 2 (open randomised), or level 3 (non-randomised comparative). (Loss of) patency, amputation, vascular events and mortality were the outcomes considered. When feasible, end-of-treatment results, either continuous or binary, were combined with appropriate statistical methods. Results thirty-two studies were included. Compared to non-active control, aspirin with dipyridamole improved (loss of) patency (odds ratio (OR) 0.69, 95% confidence interval (CI), 0.53 to 0.90) and mortality (OR 0.80, 95% CI, 0.57 to 1.14); ticlopidine improved (loss of) patency (OR 0.53, 95% CI, 0.33 to 0.85) and amputation (OR 0.29, 95% CI, 0.08 to 1.01). Data on the effectiveness of vitamin-K inhibitors were not conclusive. Conclusions patients with peripheral arterial disease improve their outcome by receiving aspirin with dipyridamole or ticlopidine after a revascularisation procedure