Rehman, Zia Ur

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eCommons@AKU Department of Surgery Department of Surgery 4-1-2022 Identifying the 'Vulnerable Plaque' in Asymptomatic Carotid Artery disease patients Zia Ur Rehman Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg  Part of the Cardiology Commons, Cardiovascular Diseases Commons, Emergency Medicine Commons, Pulmonology Commons, Radiology Commons, and the Surgery Commons LETTER TO THE EDITORJournal  of  the College of  Physicians and Surgeons Pakistan 2022,  Vol.  32(04):  552552Identifying the ‘VulnerablePlaque’ in AsymptomaticCarotid Artery DiseasePatientsSir,A number of randomised controlled trials (RCTs), conducted inthe 1990s showed benefit of carotid endarterectomy (CEA) andbest medical therapy (BMT) over BMT alone for patients withasymptomatic severe stenosis (70-99%) in preventing stroke.1-3Those RCTs were done before the routine use of statins andnewer antiplatelet medications. It is observed over the last twodecades that most patients remain stable on the current BMT,making  interventions  unnecessary  in  all  patients.  But  fewpatients do become symptomatic even on contemporary BMT.Identifying  and  offering  interventions  to  those  selectivepatients is more beneficial.3 These patients usually have ‘vulner-able plaques’, having active inflammation, high lipid content,neovascularity, thin capsule or intra-plaque haemorrhage.1Many investigations have proved useful  in  identifying theselesions. Ultrasound (US) gives fair idea about the character ofcarotid plaque.2 Soft plaques with high lipid content or intra--plaque haemorrhage are echolucent while fibrous tissues withcalcification are echogenic with mixed areas of brightness andvariations in texture.3 The plaque volume and area on ultra-sound also point to an unstable plaque and predict the risk ofrupture.  Contrast-enhanced ultrasound can visualise  plaqueneovascularisation.4  High-resolution  MRI  can  characteriseintra-plaque haemorrhage, lipid rich necrotic core, calcificationand  surface  disruption.5  High  agreement  between  the  MRIfindings and histological measures of ‘vulnerable plaque’ hasbeen  demonstrated.  Positron  emission  tomography  (PET)imaging utilising [18F] Fluodeoyglocose (FDG)  is effective indemonstrating inflammation in carotid plaques.Due to improved BMT and investigations technology, treatmentof  patients  with  high-grade  asymptomatic  carotid  arterydisease has shifted to ‘selective’ interventions, which is of para-mount clinical importance.CONFLICT OF INTEREST:The author declared no conflict of interest.AUTHOR’S CONTRIBUTION:ZUR: Study concept, literature review, first draft writing, criticalreview, final approval and responsibility of all aspects of work.  REFERENCESKassem M, Florea A, Mottaghy FM, van Oostenbrugge R,1.Kooi ME. Magnetic resonance imaging of carotid plaques:Current status and clinical perspectives. Ann Transl Med2020; 8(19):1266. doi: 10.21037/atm-2020-cass-16.Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW,2.Mayberg  MR,  et  al .  Analysis  of  pooled  data  fromrandomised  controlled  trials  of  endarterectomy  forsymptomatic  carotid  stenosis.  Lancet  2003;  361(9352):107-16. doi: 10.1016/s0140-6736(03)12228-3.Liem MI, Kennedy F, Bonati LH, van der Lugt A, Coolen BF,3.Nederveen AJ, et al.  Investigations of carotid stenosis toidentify  vulnerable atherosclerotic  plaque and determineindividual  stroke  risk.  Circ  J  2017;  81(9):1246-53.  doi:10.1253/circj.CJ-16-1284. Coli  S,  Magnoni  M,  Sangiorgi  G,  Marrocco-Trischitta MM,4.Melisurgo  G,  Mauriello  A,  et  al.  Contrast-enhancedultrasound  imaging  of  intraplaque  neovascularisation  incarotid  arteries:  Correlation  with  histology  and  plaqueechogenicity.  J  Am Coll  Cardiol  2008; 52(3):223-30. doi:10.1016/j.jacc.2008.02.082.Saam T, Cai JM, Cai YQ, An NY, Kampschulte A, Xu D, et al.5.Carotid  plaque  composition  differs  between  ethno-racialgroups: An MRI pilot  study comparing mainland Chineseand American Caucasian patients. Arterioscler Thromb VascBiol 2005; 25(3):611-6.  doi: 10.1161/01.ATV.0000155965.54679.79.  Zia  Ur  Rehman..................................................................................Section  of  Vascular  Surgery,  Department  of  Surgery,  The  AgaKhan  University  Hospital,  Karachi,  Pakistan..................................................................................Correspondence  to:  Dr.  Zia  Ur  Rehman,  Section  of  VascularSurgery,  Department  of  Surgery,  The  Aga  Khan  UniversityHospital,  Stadium  Road,  Karachi,  PakistanE-mail:  ziaur.rehman@aku.edu...................................................................Received: July 13, 2021;   Revised: October 03, 2021;Accepted:  October  11,  2021DOI:  https://doi.org/10.29271/jcpsp.2022.04.552••••••••••

Identifying the \u27Vulnerable Plaque\u27 in Asymptomatic Carotid Artery disease patients

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Identifying the \u27Vulnerable Plaque\u27 in Asymptomatic Carotid Artery disease patients

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