대한영상의학회지 (Journal of the Korean Society of Radiology)

  • 제78권6호
  • /
  • Pages.380-388
  • /
  • 2018
  • /
  • 1738-2637(pISSN)
  • /
  • 2288-2928(eISSN)
대한영상의학회 (The Korean Society of Radiology)
권호 표지
DOI QR코드

DOI QR Code

불안정성 죽상반을 가지는 환자에 대한 색전 보호 기구를 통한 경동맥 스텐트의 안정성

The Safety of Protected Carotid Artery Stenting in Patients with Unstable Plaque on Carotid High-Resolution MR Imaging

  • 정재영 (전북대학교 의학전문대학원 전북대학교병원 영상의학과) ;
  • 곽효성 (전북대학교 의학전문대학원 전북대학교병원 영상의학과) ;
  • 황승배 (전북대학교 의학전문대학원 전북대학교병원 영상의학과) ;
  • 정경호 (전북대학교 의학전문대학원 전북대학교병원 영상의학과)
  • Jeong, Jae Yeong (Department of Radiology, Chonbuk National University Medical School and Hospital) ;
  • Kwak, Hyo Sung (Department of Radiology, Chonbuk National University Medical School and Hospital) ;
  • Hwang, Seung Bae (Department of Radiology, Chonbuk National University Medical School and Hospital) ;
  • Chung, Gyung Ho (Department of Radiology, Chonbuk National University Medical School and Hospital)
  • 투고 : 2017.08.02
  • 심사 : 2018.02.20
  • 발행 : 2018.06.01
⟨ 이전 논문 다음 논문 ⟩

초록

목적: 경동맥 MRI에서 불안정성 죽상반을 동반한 심한 경동맥협착증 환자에서 색전 보호 기구를 통한 경동맥 스텐트의 안정성을 평가하고자 하였다. 대상과 방법: 심한 경동맥 협착증을 가지는 102명의 환자를 대상으로 전향적 연구를 진행하였다. 이러한 환자들은 시술전 경동맥 MRI와 시술 후 diffusion-weighted imaging (이하 DWI)를 시행하였다. 시술 후 30일 이내의 동측의 허혈 발생과 일차적 결과를 평가하였다. 결과: 시행한 경동맥 죽상반 MRI 상에서 50명(49.0%)의 환자가 경화반 내측 출혈(intraplaue hemorrhage), 84명(82.4%)의 환자가 얇은 혹은 균열된 섬유피막(thin/ruptured fibrous caps)을 보였으며 43명(42.2%)의 환자에서 궤양(ulcer)이 동반되었다. 시술 30일 내에 뇌졸중, 심근경색, 사망 등의 발생률은 3.9%였다. 시술 후에 DWI에서 새롭게 발생한 허혈성 병변은 증상이 없는 환자군(9/56, 16.1%)보다 증상이 있는 환자군(17/46, 37.0%)에서 보다 빈번하게 관찰되었다(p = 0.03). 그러나 불안정성 죽상반의 종류에 따른 시술 후 일차적 결과는 통계학적으로 차이가 없었다. 결론: 경동맥 MRI에서 불안정성 죽상반의 종류와 상관없이 색전 보호 기구를 통한 경동맥 스텐트 시술은 안전하다. 또한, 시술 전 증상이 있는 환자군에서 시술 후 동측의 허혈 발생이 빈번하게 일어나므로 더욱 세심한 치료가 필요하다.

Purpose: The aim of this study was to determine the safety of the carotid artery stenting (CAS) procedure, using an embolic protection device which is based on the presence of unstable plaques on carotid MR imaging in patients who presented with severe carotid artery stenosis. Materials and Methods: This prospective study assessed 102 consecutive patients who had been noted with severe carotid stenosis. These patients underwent a preprocedural carotid MR imaging, and a periprocedural diffusion-weighted imaging (DWI) after the CAS. The unstable plaque on the carotid MR imaging was defined as characterized as intraplaque hemorrhage (IPH), thin/ruptured fibrous caps, or ulcers. We analyzed the incidence of the noted periprocedural ipsilateral ischemic events on the DWI, and noted the primary outcomes within 30 days of the CAS. Results: In the study, it is noted that 50 patients (49.0%) had IPH, 84 patients (82.4%) had thin/ruptured fibrous caps, and 43 patients (42.2%) had ulcers as seen on the carotid plaque MR imaging. The IPH was more common in the symptomatic group than in the asymptomatic group (58.7% vs. 41.1%, p = 0.12). Overall, the DWI was positive after CAS in 25.5% of cases. Additionally, the combined rate of 30-day stroke, myocardial infarction, or death was recorded at 3.9%. The new periprocedural ischemic lesions on the DWI were characteristically more frequently observed in the symptomatic group (17/46, 37.0%) than in the asymptomatic group (9/56, 16.1%) (p = 0.03). There was no significant difference in the primary outcome of the CAS, based on the type of unstable plaque of IPH, thin/ruptured fibrous caps, or ulcers. Conclusion: The protected CAS appears to be safe, regardless of the noted unstable plaque findings as seen on the carotid MR imaging. In this case, because of the higher risk of periprocedural ipsilateral ischemic events, it is therefore recommended that the symptomatic patients should receive more careful treatment during the CAS placement going forward.

키워드

과제정보

연구 과제 주관 기관 : Chonbuk National University Hospital

참고문헌

  1. Virmani R, Burke AP, Kolodgie FD, Farb A. Vulnerable plaque: the pathology of unstable coronary lesions. J Interv Cardiol 2002;15:439-446 https://doi.org/10.1111/j.1540-8183.2002.tb01087.x
  2. Fuster V, Stein B, Ambrose JA, Badimon L, Badimon JJ, Chesebro JH. Atherosclerotic plaque rupture and thrombosis. evolving concepts. Circulation 1990;82(3 Suppl):II47-59
  3. Cai J, Hatsukami TS, Ferguson MS, Kerwin WS, Saam T, Chu B, et al. In vivo quantitative measurement of intact fibrous cap and lipid-rich necrotic core size in atherosclerotic carotid plaque: comparison of high-resolution, contrast-enhanced magnetic resonance imaging and histology. Circulation 2005;112:3437-3444 https://doi.org/10.1161/CIRCULATIONAHA.104.528174
  4. Takaya N, Cai J, Ferguson MS, Yarnykh VL, Chu B, Saam T, et al. Intra- and interreader reproducibility of magnetic resonance imaging for quantifying the lipid-rich necrotic core is improved with gadolinium contrast enhancement. J Magn Reson Imaging 2006;24:203-210 https://doi.org/10.1002/jmri.20599
  5. Cai JM, Hatsukami TS, Ferguson MS, Small R, Polissar NL, Yuan C. Classification of human carotid atherosclerotic lesions with in vivo multicontrast magnetic resonance imaging. Circulation 2002;106:1368-1373 https://doi.org/10.1161/01.CIR.0000028591.44554.F9
  6. Clarke SE, Hammond RR, Mitchell JR, Rutt BK. Quantitative assessment of carotid plaque composition using multicontrast MRI and registered histology. Magn Reson Med 2003;50:1199-1208 https://doi.org/10.1002/mrm.10618
  7. Saam T, Cai JM, Cai YQ, An NY, Kampschulte A, Xu D, et al. Carotid plaque composition differs between ethno-racial groups: an MRI pilot study comparing mainland Chinese and American Caucasian patients. Arterioscler Thromb Vasc Biol 2005;25:611-616 https://doi.org/10.1161/01.ATV.0000155965.54679.79
  8. Cappendijk VC, Cleutjens KB, Kessels AG, Heeneman S, Schurink GW, Welten RJ, et al. Assessment of human atherosclerotic carotid plaque components with multisequence MR imaging: initial experience. Radiology 2005;234:487-492 https://doi.org/10.1148/radiol.2342032101
  9. Takaya N, Yuan C, Chu B, Saam T, Underhill H, Cai J, et al. Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events: a prospective assessment with MRI--initial results. Stroke 2006;37:818-823 https://doi.org/10.1161/01.STR.0000204638.91099.91
  10. Singh N, Moody AR, Gladstone DJ, Leung G, Ravikumar R, Zhan J, et al. Moderate carotid artery stenosis: MR imaging-depicted intraplaque hemorrhage predicts risk of cerebrovascular ischemic events in asymptomatic men. Radiology 2009;252:502-508 https://doi.org/10.1148/radiol.2522080792
  11. Altaf N, Daniels L, Morgan PS, Auer D, MacSweeney ST, Moody AR, et al. Detection of intraplaque hemorrhage by magnetic resonance imaging in symptomatic patients with mild to moderate carotid stenosis predicts recurrent neurological events. J Vasc Surg 2008;47:337-342 https://doi.org/10.1016/j.jvs.2007.09.064
  12. Rothwell PM, Gibson R, Warlow CP. Interrelation between plaque surface morphology and degree of stenosis on carotid angiograms and the risk of ischemic stroke in patients with symptomatic carotid stenosis. on behalf of the European Carotid Surgery Trialists' Collaborative Group. Stroke 2000;31:615-621 https://doi.org/10.1161/01.STR.31.3.615
  13. Eliasziw M, Streifler JY, Fox AJ, Hachinski VC, Ferguson GG, Barnett HJ. Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial. Stroke 1994;25:304-308 https://doi.org/10.1161/01.STR.25.2.304
  14. Bonati LH, Dobson J, Featherstone RL, Ederle J, van der Worp HB, de Borst GJ, et al. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet 2015;385:529-538 https://doi.org/10.1016/S0140-6736(14)61184-3
  15. Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med 2010;363:11-23 https://doi.org/10.1056/NEJMoa0912321
  16. Grimm JC, Arhuidese I, Beaulieu RJ, Qazi U, Perler BA, Freischlag JA, et al. Surgeon's 30-day outcomes supporting the carotid revascularization endarterectomy versus stenting trial. JAMA Surg 2014;149:1314-1318 https://doi.org/10.1001/jamasurg.2014.1762
  17. Mantese VA, Timaran CH, Chiu D, Begg RJ, Brott TG; CREST Investigators. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST): stenting versus carotid endarterectomy for carotid disease. Stroke 2010;41(10 Suppl):S31-S34 https://doi.org/10.1161/STROKEAHA.110.595330
  18. Yoshimura S, Yamada K, Kawasaki M, Asano T, Kanematsu M, Takamatsu M, et al. High-intensity signal on time-of-flight magnetic resonance angiography indicates carotid plaques at high risk for cerebral embolism during stenting. Stroke 2011;42:3132-3137 https://doi.org/10.1161/STROKEAHA.111.615708
  19. Yoon W, Kim SK, Park MS, Chae HJ, Kang HK. Safety of protected carotid artery stenting in patients with severe carotid artery stenosis and carotid intraplaque hemorrhage. AJNR Am J Neuroradiol 2012;33:1027-1031 https://doi.org/10.3174/ajnr.A2911
  20. Chung GH, Jeong JY, Kwak HS, Hwang SB. Associations between cerebral embolism and carotid intraplaque hemorrhage during protected carotid artery stenting. AJNR Am J Neuroradiol 2016;37:686-691 https://doi.org/10.3174/ajnr.A4576
  21. Yoshimura S, Yamada K, Kawasaki M, Asano T, Kanematsu M, Miyai M, et al. Selection of carotid artery stenting or endarterectomy based on magnetic resonance plaque imaging reduced periprocedural adverse events. J Stroke Cerebrovasc Dis 2013;22:1082-1087 https://doi.org/10.1016/j.jstrokecerebrovasdis.2012.07.018
  22. Sun J, Balu N, Hippe DS, Xue Y, Dong L, Zhao X, et al. Subclinical carotid atherosclerosis: short-term natural history of lipid-rich necrotic core--a multicenter study with MR imaging. Radiology 2013;268:61-68 https://doi.org/10.1148/radiol.13121702
  23. Sun J, Underhill HR, Hippe DS, Xue Y, Yuan C, Hatsukami TS. Sustained acceleration in carotid atherosclerotic plaque progression with intraplaque hemorrhage: a long-term time course study. JACC Cardiovasc Imaging 2012;5:798-804 https://doi.org/10.1016/j.jcmg.2012.03.014
  24. Lee KJ, Kwak HS, Chung GH, Hwang SB, Song JS. Assessment of carotid diffusion-weighted imaging for detection of lipid-rich necrotic core in symptomatic carotid atheroma. J Korean Soc Radiol 2016;74:160-168 https://doi.org/10.3348/jksr.2016.74.3.160
  25. Zhao XQ, Dong L, Hatsukami T, Phan BA, Chu B, Moore A, et al. MR imaging of carotid plaque composition during lipidlowering therapy a prospective assessment of effect and time course. JACC Cardiovasc Imaging 2011;4:977-986 https://doi.org/10.1016/j.jcmg.2011.06.013
  26. Saam T, Hetterich H, Hoffmann V, Yuan C, Dichgans M, Poppert H, et al. Meta-analysis and systematic review of the predictive value of carotid plaque hemorrhage on cerebrovascular events by magnetic resonance imaging. J Am Coll Cardiol 2013;62:1081-1091 https://doi.org/10.1016/j.jacc.2013.06.015
  27. Chiam PTL, Roubin GS, Iyer SS, Green RM, Soffer DE, Brennan C, et al. Carotid artery stenting in elderly patients: importance of case selection. Catheter Cardiovasc Interv 2008;72:318-324 https://doi.org/10.1002/ccd.21620
  28. Bijuklic K, Wandler A, Varnakov Y, Tuebler T, Schofer J. Risk factors for cerebral embolization after carotid artery stenting with embolic protection: a diffusion-weighted magnetic resonance imaging study in 837 consecutive patients. Circ Cardiovasc Interv 2013;6:311-316 https://doi.org/10.1161/CIRCINTERVENTIONS.112.000093
  29. Schnaudigel S, Groschel K, Pilgram SM, Kastrup A. New brain lesions after carotid stenting versus carotid endarterectomy: a systematic review of the literature. Stroke 2008;39:1911-1919 https://doi.org/10.1161/STROKEAHA.107.500603
  30. Yang M, Yu Y, Walsh WR, Yang JL, Baker L, Lennox AF, et al. A microscopic and biomarker evaluation of embolic filter debris collected during carotid artery stenting. J Endovasc Ther 2016;23:275-284 https://doi.org/10.1177/1526602816628284