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Ultrasound screen in carotid stenting. (Predictive of Plaque Stability).

SCOTTSDALE, ARIZ -- Echographic studies of carotid plaque can be used to distinguish high-risk patients who are poor candidates for carotid stenting as well as those who have unstable plaques and might benefit from devices designed to capture plaque debris released during the intervention.

Results from the 2-year international Imaging in Carotid Angioplasties and Risk of Stroke (ICAROS) study showed that patients with a gray-scale median (GSM) value of less than 25 on ultrasound were at a markedly higher risk for complications during stenting than were patients with higher GSM readings, Dr. Giorgio M. Biasi said at an international congress on endovascular interventions sponsored by the Arizona Heart Institute.

Study coordinators proposed that carotid stenting should be contraindicated in such patients, and that brain protection devices should be used when a patient's preprocedure GSM is between 25 and 50. Dr. Biasi, the lead investigator, explained that the GSM is a standardized marker of plaque consistency. GSM is derived from ultrasound images that are graded by degree of echolucency.

The most echolucent component-blood--is assigned a value of zero, while adventitia is assigned a GSM value of 185195. The components are averaged to characterize overall plaque consistency.

Training in imaging and calculating GSM was conducted by researchers from 16 sites worldwide, including the Arizona Heart Institute in Phoenix and Montefiore Medical Center in New York City, prior to enrollment of 496 patients for the ICAROS trial.

Carotid stenting was then performed. Adequate images and follow-up were obtained in 418 patients; 54% underwent the procedure for restenosis and 46% for primary lesions. Brain protection devices were used in about half of the cases.

The total complication rate was 6.6% (28 patients), reported Dr. Biasi, professor of vascular surgery and chief of surgical sciences and intensive care at the University of Milan-Bicocca (Italy). Transient ischemic attacks were reported in 3.1%; 3.5% had minor or major strokes.

"It is interesting to note that 71% of the complications occurred with a GSM less than 25," he said. Patients with a GSM between 25 and 50 accounted for 21% of complications; 8% occurred in patients with a GSM greater than 50.

The findings led Dr. Biasi and his assodates to suggest that the procedure be avoided in patients with a GSM less than 25 and only done using cerebral protection in those with a GSM of 25-50. Brain protection devices should be "optional" in carotid stenting candidates with a GSM greater than 50, he said.

GSM is another parameter, in addition to the rate of stenosis and neurologic symptoms, that can help to determine which patients are good candidates for carotid stenting and which should receive cerebral protection, Dr. Biasi said.

"Reliable, quantifiable, easily accessible information on the plaque also is of importance medicolegally," he added.

Yet 30% of complications reported during the study occurred with a brain protection device in place. "Even though several publications have reported much lower neurologic complication rates during protected carotid stenting, debris-capturing devices cannot be considered the panacea for all embolic events," Dr. Biasi said.
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Author:Bates, Betsy
Publication:Internal Medicine News
Date:May 15, 2002
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