S.C. Angiologia Medica - Messina Placca carotidea e ictus ischemico S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Prevalence of Stroke Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-146. S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina European Journal of Neurology 2006, 13: 581–598 S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina T. Willis (1621–1675) M. E. DeBakey (1908-2008) J. Wepfer (1620–1695) S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina 20 to 30% of strokes are caused by atherosclerotic carotid artery disease1 Carotid artery disease increases the risk for stroke: By plaque or clot breaking off from the carotid arteries and blocking a smaller artery in the brain By narrowing of the carotid arteries due to plaque build-up By a blood clot becoming wedged in a carotid artery narrowed by plaque Emboli Orgin (Source: www.sun.ac.za/neurology/lectures/stroke.htm) Emboli associated with stroke originates from the following sources: Heart Patients with atrial fibrillation, CHF, valvular disease, cardiomyopathy Aorta Atheroma of the aorta Carotid artery Plaque embolism from carotid artery atheroma Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for Asymptomatic Carotid Artery Stenosis. JAMA 1995;273:1421 S.C. Angiologia Medica - Messina 5

S.C. Angiologia Medica - Messina Stroke. 2010;41:1294-1297 S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Inzitari, D. et al. N Engl J Med 2000;342:1693-1700 S.C. Angiologia Medica - Messina

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S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina La placca carotidea “importante”………….è quella che darà dei sintomi cerebrali ma anche MACEs (Major Adverse Cardiovascular events) Come definirla ? a rischio (embolico o emodinamico) instabile in progressione vulnerabile S.C. Angiologia Medica - Messina

Placca carotidea a “rischio” o “instabile” (fino al 1992) Placca che determina una stenosi > 70 % (anche se di ecostruttura omogenea) Placca che determina una stenosi > 50%, disomogenea o con superficie microulcerata. Placca macro-ulcerata Placca emorragica Quindi, ricordando la definizione di placca cd a rischio, ne deriva che un esame semplice e non invasivo come l’ecocolor doppler dei TSA può fornire delle informazioni immediatamente fruibili e sostanziali nella gestione del paziente a rischio anche immediato. De Fabritiis, Scondotto et al, 1988 S.C. Angiologia Medica - Messina

Placca carotidea a “rischio” o “instabile” (2000) Superficie fortemente irregolare Capuccio fibroso sottile Presenza di core anecogeno ampio La percentuale di stenosi non è più rilevante J.Willet Cerebrovasc Dis. 10 suppl. 5, 2000 S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Stroke. 2006;37:2696-2701 S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina

Placca carotidea “instabile” (2006-2007) Flogosi (la placca recentemente sintomatica presenta i nfiltrazioni di macrofagi e linfociti T) Neovascolarizzazione (contiene microvasi immaturi) Fattori plasmatici dell’angiogenesi e della flogosi nei pazienti sintomatici Infezione (cellule correlate alla presenza di sostanze batteriche o virali) Connessione fra infezione e placca sintomatica S.C. Angiologia Medica - Messina

Placca carotidea “vulnerabile” (2012) “Susceptibility of a plaque to rupture thus causing a clinical cardiovascular event.” % stenosi > 70% pressione parietale/shear stress basso e incostante infiammazione/neovascolarizzazione cappuccio fibroso sottile fissurazione cappuccio fibroso denudazione endoteliale ampia presenza di lipidi S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Radiology 2009 251:2 583-9 S.C. Angiologia Medica - Messina

Carotid Endarterectomy SYMPTOMATIC PATIENTS p = .045 p < .001 p < .001 S.C. Angiologia Medica - Messina

Asymptomatic Stenosis CEA vs MEDICAL Asymptomatic Stenosis ns p <0.01 p <0.001 S.C. Angiologia Medica - Messina

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S.C. Angiologia Medica - Messina

Relationship Between Severity of Stenosis and Stroke Rate NASCET (2 year) ECST (3 years) ACAS (3 years) 60%-69% 428 13% 137 11% 131 6% 70%-79% 43 21% 170 9% 94 5% 80%-89% 33 27% 159 NS 90%-99% 24 35% 60 32% 80%-99% 57 31% 219 24% 88 3% S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina CMAJ • AUG. 31, 2004; 171 (5) Estimates of NNT with CEA to prevent 1 stroke in 2 years by age and degree of stenosis Patient group NNT Symptomatic ≥ 70% stenosis age < 75 yr 6 ≥ 70% stenosis age ≥ 75 yr 3 50%-69% stenosis 15 < 50% No benefit Asymptomatic > 60% stenosis 83 S.C. Angiologia Medica - Messina

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S.C. Angiologia Medica - Messina Stroke. 2010;41:e11-e17. S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina “I pazienti con una stenosi carotidea in progressione sono ad alto rischio per eventi maggiori alle coronarie ed alla circolazione periferica e cerebrale (MACE : IMA, Stroke, Amputazione, Morte)” “L’infiammazione al centro della disfunsione endoteliale e della crescita della placca” “Ripetuti controlli ECD dovrebbero essere eseguiti nei pazienti con placche e stenosi moderate alla ricerca di una malattia progressiva” S.C. Angiologia Medica - Messina

Number of Events in Patients With and Without CAS (during follow up) Stroke. 2007;38:1470-1475. Number of Events in Patients With and Without CAS (during follow up) Asynt CAS (n 221) No Asyntom (n 2463) Non vascular death 8% 3% Vascular death 15% 5% MI 13% 6% Ischemic Stroke 2% All first vascular events 20% 9% CEA 0% Endovascular interventation S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina From: Screening for Carotid Artery Stenosis: U.S.Preventive Services Task Force Recommendation Statement S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Comment: The perceived effectiveness and cost-effectiveness of carotid duplex ultrasound surveillance programs should be questioned. The study raises a significant question: Do carotid duplex surveillance programs primarily benefit physicians, vascular laboratories, or patients? The fact that 40% of the patients had only two duplex ultrasound scans performed during the surveillance period is a serious study limitation. Follow-up was, however, comparable to other studies in the literature and therefore the results likely can be generally applied to other practices. The personal and economic impact of stroke is huge, but this report still calls into serious question the use of limited health care resources to fund carotid duplex surveillance programs. Conclusion: Carotid duplex ultrasound surveillance programs are costly and inefficient. S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Despite these advances in understanding the pathophysiology of atherosclerotic plaque, the utility of morphological, pathological, and biochemical features in predicting the occurrence of TIA, stroke, or other symptomatic manifestations of ECVD has not been established clearly by prospective studies. S.C. Angiologia Medica - Messina

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S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Conceptually, the presence of a vulnerable plaque is, by definition, a probabilistic entity. It does not denote the occurrence of an event at present but rather a higher risk for such occurrence in the future relative to a non vulnerable or less vulnerable plaque. As such, before it is widely adopted by clinicians, plaque vulnerability (if validated) should be able to provide incremental predictive value on top of currently available methods of risk stratification, which may be less expensive and less invasive than the methods proposed to detect vulnerable plaques. S.C. Angiologia Medica - Messina

S.C. Angiologia Medica - Messina Moreover, the complex implications of such a probabilistic diagnosis are exemplified in the observation that not all plaques that rupture (the basis for the classic definition of the term) actually result in a clinical cardiovascular event. Some plaques would rupture and then become quiescent and heal without causing a myocardial infarction or stroke (so called silent plaque rupture). Conversely, not all acute cardiovascular events are the result of plaque rupture because non ruptured plaques have been implicated as culprit lesions nearly one third of the time in autopsy series. S.C. Angiologia Medica - Messina