Published online before print July 26, 2004, doi: 10.1161/01.CIR.0000138103.91187.E3
(Circulation. 2004;110:756-762.)
© 2004 American Heart Association, Inc.
Original Articles |
Carotid Plaque Echolucency Increases the Risk of Stroke in Carotid Stenting
The Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) Study
From the Division of Vascular Surgery, Department of Surgical Sciences and Intensive Care (G.M.B., A.F., G.D., P.M.) and Section of Statistics, Department of Clinical Medicine, Prevention and Biotechnologies (S.G., M.G.V.), University of Milano-Bicocca, Milan, Italy; Bassini/S. Gerardo Teaching Hospital, Milan, Italy (G.M.B., A.F., G.D., P.M.); Arizona Heart Institute and Foundation, Phoenix (E.B.D.); Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus (A.N.N.); Department of Academic Vascular Surgery, Imperial College, London, UK (M.G.); Vascular Surgical Service, Klinikum Nurnberg Sud, Nurnberg, Germany (D.R.); and Wishaw General Hospital, Wishaw, Scotland (D.B.R.).
Correspondence Giorgio M. Biasi, MD, Professor of Vascular Surgery, Chief of the Department of Surgical Sciences and Intensive Care, University of Milan-Bicocca, Bassini/S. Gerardo Teaching Hospital, Via M. Gorki, 50, 20092 Cinisello Balsamo, Milan, Italy. E-mail giorgio.biasi{at}unimib.it
Received August 4, 2003; de novo received December 20, 2003; revision received March 1, 2004; accepted March 17, 2004.
Background— Carotid artery stenting (CAS) has recently emerged as a potential alternative to carotid endarterectomy. Cerebral embolization is the most devastating complication of CAS, and the echogenicity of carotid plaque has been indicated as one of the risk factors involved. This is the first study to analyze the role of a computer-assisted highly reproducible index of echogenicity, namely the gray-scale median (GSM), on the risk of stroke during CAS.
Methods and Results— The Imaging in Carotid Angioplasty and Risk of Stroke (ICAROS) registry included 418 cases of CAS collected from 11 international centers. An echographic evaluation of carotid plaque with GSM measurement was made preprocedurally. The onset of neurological deficits during the procedure and the postprocedural period was recorded. The overall rate of neurological complications was 3.6%: minor strokes, 2.2%, and major stroke, 1.4%. There were 11 of 155 strokes (7.1%) in patients with GSM 
25 and 4 of 263 (1.5%) in patients with GSM >25 (P=0.005). Patients with severe stenosis (
85%) had a higher rate of stroke (P=0.03). The effectiveness of brain protection devices was confirmed in those with GSM >25 (P=0.01) but not in those with GSM 25. Multivariate analysis revealed that GSM (OR, 7.11; P=0.002) and rate of stenosis (OR, 5.76; P=0.010) are independent predictors of stroke.
Conclusions— Carotid plaque echolucency, as measured by GSM 25, increases the risk of stroke in CAS. The inclusion of echolucency measured as GSM in the planning of any endovascular procedure of carotid lesions allows stratification of patients at different risks of complications in CAS.
Key Words: carotid arteries • plaque • stents • stroke • ultrasonics
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