© 1999 by European Society of Cardiology
Copyright © 1999, European Society of Cardiology
Angioscopic complex lesions are predominantly compensatory enlarged: an angioscopy and intracoronary ultrasound study
aDepartment of Cardiology, Heart Lung Institute, University Hospital Utrecht, Utrecht, Netherlands
bInteruniversity Cardiology Institute of the Netherlands, Utrecht, Netherlands
cHeart Center Rotterdam, Erasmus University Rotterdam, Rotterdam, Netherlands
* Corresponding author. Tel.: +31-30-250-7155; fax: +31-30-252-2693; e-mail: exp.card@hli.azu.nl
Received 4 June 1998; accepted 24 September 1998
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Abstract |
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 Top Abstract 1 Introduction2 Methods3 Results4 DiscussionReferences |
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Objectives: Atherosclerotic remodeling of the coronary artery may lead to compensatory enlargement or to shrinkage. Post-mortem data suggest a relation between compensatory enlargement and histopathological markers of plaque vulnerability. In patients that required a coronary intervention, we investigated retrospectively the relation between the angioscopic appearance and the remodeling mode of the culprit lesion. Methods: In 34 patients, coronary angioscopy and intracoronary ultrasound (ICUS) imaging was performed across the culprit lesion before the intervention. Only single de novo lesions were included. With angioscopy, lesions with a smooth surface without thrombus were classified as smooth, whereas lesions with an irregular surface with or without thrombus were classified as complex. With ICUS, remodeling of the culprit lesions was determined by the relative cross-sectional vessel area (lesion vessel area/reference vessel area)x100%. Lesions were divided into three groups: compensatory enlargement (relative vessel area
105%), no-remodeling (relative vessel area between 95 and 105%) and shrinkage (relative vessel area 
95%). Results: In 22 patients good images were obtained with both imaging modalities. More complex lesions were compensatory enlarged compared to shrunken lesions, whereas more smooth lesions were shrunken compared to compensatory enlarged lesions, 8/9 versus 2/7 and 5/7 versus 1/9, respectively (p=0.035). Conclusions: In patients selected for coronary intervention, angioscopic complex atherosclerotic lesions were found predominantly in compensatory enlarged arterial segments, whereas smooth lesions were found predominantly in shrunken arterial segments.
KEYWORDS Remodeling; Atherosclerosis; Coronary artery; Human; Angioscopy; Intravascular ultrasound
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1 Introduction |
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TopAbstract1 Introduction2 Methods3 Results4 DiscussionReferences |
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During the atherosclerotic process the coronary artery may locally be subjected to different modes of remodeling: compensatory enlargement [1, 2], non remodeling [3]and shrinkage [3–6]. Compensatory enlargement of the artery in response to plaque formation will preserve luminal area. In contrast, arterial shrinkage will accelerate luminal narrowing by plaque formation. Of clinical interest is a postulated relation between coronary atherosclerotic plaque and vessel size, i.e. mode of atherosclerotic remodeling, and plaque vulnerability. Recently, we reported in a post-mortem study [7]that significantly more histopathological markers for plaque vulnerability were present in compensatory enlarged lesions with large plaques compared to shrinkage lesions with small plaques.
From previous coronary angioscopy studies it is known that culprit lesions in patients with unstable angina have a complex/ulcerated appearance with a predominantly yellow color, ragged edges and thrombi, whereas culprit lesions in patients with stable angina have a smooth surface with a predominant white color and no thrombi [8–11].
In this retrospective study, we investigated whether the angioscopic appearance of the primary culprit lesion was related to the mode of atherosclerotic remodeling (enlargement or shrinkage) in patients that required percutaneous coronary intervention. We hypothesized that angioscopic complex lesions are compensatory enlarged.
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2 Methods |
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TopAbstract1 Introduction2 Methods3 Results4 DiscussionReferences |
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Between January 1993 and September 1994, an angioscopy and intracoronary ultrasound (ICUS) procedure of a de novo culprit lesion before a scheduled percutaneous coronary intervention was performed in 34 patients. Only patients with an angiographic focal lesion in the proximal or mid native coronary artery segment suitable for coronary angioscopy were selected. A focal lesion was defined as an angiographic lumen narrowing of at least 60% compared to its normal looking adjacent reference segments and a length of less than 20 mm by eye-balling. The culprit lesion was determined by angiography, thallium scintigraphy, stress echocardiography or by electrocardiographic changes during angina pectoris. All patients had angina pectoris class 2–4, classified according to the New York Heart Association criteria. Patients were divided in two groups. Patients with stable angina pectoris were classified as the Stable Group and patients with unstable angina pectoris or patients with post myocardial infarction angina after a recent myocardial infarction (within 3 months) were classified as the Unstable Group. In all cases the coronary intervention (balloon angioplasty or atherectomy) was done electively. Some time delay in intracoronary imaging in the six patients with unstable angina (range 5–21 days, mean 11 days) and the six patients after a recent myocardial infarction (range 7–120 days, mean 66 days) was present. All patients were treated with aspirin 100–250 mg daily and received 10 000 U of heparin intravenously at the beginning of the procedure. Intracoronary nitroglycerin was injected before an ICUS procedure was performed.
Informed consent was obtained of all patients and the investigation conformed with the principles outlined in the Declaration of Helsinki [12].
2.1 Coronary angioscopy and intravascular ultrasound imaging
Angioscopy was performed with the ImageCath system (Baxter Healthcare Corporation, Irvine, CA), which includes an angioscope catheter, an irrigation system, a light source and a video system. The 4.5 French ImageCath coronary angioscope catheter is an integrated design consisting of a flexible catheter jacket with a distensible occlusion cuff at the distal end and a mono-railed fiberoptic imaging bundle that can extend to 5 cm into the blood-free field for viewing. Under the guidance of fluoroscopy the angioscope was advanced a few centimeter proximal to the lesion. After irrigation with warmed saline and low pressure inflation of the occlusive cuff, the fiberoptic bundle was advanced over a 0.014 inch guide-wire across the lesion. The lesion was inspected in multiple sessions by moving the angioscope back and forth across the lesion while having a clear view.
The ICUS procedures were performed with the Cardiovascular Imaging System (CVIS Inc., Sunnyvale, CA) coupled to a 4.3 or 2.9 French 30 MHz coronary imaging catheter. Intravascular ultrasound images were obtained by a slow manual pull-back maneuver across the lesion and its adjacent segments. Simultaneously with fluoroscopy, the intravascular ultrasound or angioscopy images and voices of the physicians were recorded on high resolution S-VHS video tapes for off-line analysis. For correlation between the fluoroscopy and intravascular ultrasound images or angioscopy, a time code was added to each signal by two synchronized video frame counters, or both video signals were on-line mixed into one signal and recorded.
2.2 Qualitative angioscopy analysis
Angioscopy images were analyzed off-line independently by two observers (PCS, PPTdJ). Both observers were unaware of the ICUS findings and the medical history of the patient. In case of disagreement, consensus was reached by further joint reading. Images were analyzed according to the Ermenonville classification [13]. The angioscopic evaluation of the culprit lesion consisted of an assessment of the angioscopic views of the culprit lesion (central vision view, vessel wall with complete lumen view, vessel wall with incomplete lumen view, vessel wall view), the shape of narrowing (round/elliptical, slit-like, complex shaped), vessel surface description (smooth, irregular, mobile flaps, non-mobile dissections), plaque color (white, gray, yellow, brown, red, pink) and presence of thrombus (red, white, mixed, lining or protruding). A lesion was classified as smooth, if the lesion surface had predominantly a white color and did not show any irregularities and thrombi. A lesion was defined as complex if its surface was patchy colored and irregular with jagged edges and/or flaps with or without thrombus.
2.3 Quantitative intravascular ultrasound analysis
The ICUS images were analyzed off-line with a digital analyzer as described previously [14]by an independent observer (GP) who was unaware of the angioscopy findings and the medical history of the patient. The site with the most severe lumen obliteration on the ICUS images of the culprit lesion and one reference site in the proximal and one site in the distal adjacent segments were selected. The reference sites had no major side branches in between and had a normal angiographic appearance and the least amount of plaque on ICUS.
In the three selected cross sections, the lumen area (mm2) and the area circumscribed by the external elastic lamina (vessel area, mm2) were traced. The external elastic lamina was defined as the outer border of the echolucent zone, which represents the interface between media and adventitia [15]. The media+atherosclerotic plaque area was defined as plaque area (mm2) and calculated by subtracting the lumen area from the vessel area. To compare the vessel area at the lesion with its reference area, we defined the reference vessel area as (vessel area proximal+vessel area distal)/2. When proximally or distally a side-branch was present adjacent to the lesion, only the vessel area distally (n=1) or proximally (n=3) of the lesion was taken as a reference, respectively. Atherosclerotic remodeling was calculated as relative vessel area: (lesion vessel area/reference vessel area)x100%. The lesions were divided in three groups based on the percentage relative vessel area: shrinkage (relative vessel area 95%), no remodeling (relative vessel area between 95% and 105%), compensatory enlargement (relative vessel area 105%) [16].
2.4 Statistics
All values are presented as mean±standard deviation (SD). Comparison of data was performed by using a two tailed student t-test for continuous variables and a two tailed Fisher Exact test for comparison of dichotomous and categorical variables. A Fisher Exact test with Monte Carlo simulation was performed for the comparison of stable and unstable angina group versus the three atherosclerotic remodeling modes. A p-value of less than 0.05 was considered statistically significant.
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3 Results |
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TopAbstract1 Introduction2 Methods3 Results4 DiscussionReferences |
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Adequate angioscopy and ICUS visualization across the culprit lesion and its adjacent reference segments was obtained in 22 of the 34 patients (65%). In three patients the ICUS catheter did not pass the lesion, while in another patient no adequate images could be obtained because of extensive calcification. Eight patients were excluded by the independent angioscopy observers because the angioscopy images of the culprit lesion did not show a circumferential view (central vision view or vessel wall with complete lumen view) across the culprit lesion. Final analysis was performed on 22 patients (17 male; age 60±9 years). Patient characteristics are listed in Table 1.
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With ICUS, compensatory enlargement, no remodeling or shrinkage of the culprit lesion was present in nine, six and seven patients, respectively.
The relation between the angioscopic appearance and mode of remodeling by ICUS of the culprit lesion is listed in Table 2. A trend in the distribution of the three atherosclerotic remodeling modes among the angioscopic smooth and complex lesions was noted (p=0.054). Significantly more complex lesions were compensatory enlarged compared to shrunken lesions, whereas significantly more smooth lesions were shrunken compared to compensatory enlarged lesions, respectively 8/9 versus 2/7 and 5/7 versus 1/9, (p=0.035). The relative vessel area in complex lesions was 114±33% versus 91±17% in smooth lesions (p=0.061). The plaque area in complex lesions was 15.6±5.2 versus 12.3±2.5 mm2 in non-complex lesions, (p=0.065, see Fig. 1).
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) at the proximal reference (prox), stenosis and distal reference (dist) sites in both patient groups. A trend towards a greater plaque area in complex lesions compared to smooth lesions is noted, 15.6±5.2 versus 12.3±2.5 mm2 (p=0.065).The relation between the angioscopic appearance of the culprit lesion (Figs. 2–5
) and the type of angina is listed in Table 3. Culprit lesions in patients with stable angina were more often smooth, whereas complex lesions were mainly present in patients with unstable coronary syndromes (6/10 versus 10/12, p=0.074). None of the ten lesion in the patients with stable angina showed thrombus, whereas five of the twelve lesions in the patients with acute coronary syndromes showed red thrombus.
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The relation between the mode of remodeling of the culprit lesion (Figs. 6 and 7
) and type of angina is listed in Table 4. A trend in the distribution of the three atherosclerotic remodeling modes among the stable and unstable angina group was noted (p=0.126). Compensatory enlarged culprit lesions were mainly present in the patients with unstable coronary syndromes compared to the patients with stable angina, whereas the lesions were more often shrunken in the patients with stable angina compared to the patients with unstable coronary syndromes, respectively 7/8 versus 2/6 and 4/6 versus 1/8 (p=0.091).
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The majority of the culprit lesions had a yellow or yellow–white appearance with angioscopy (16/22 (73%), Table 5). A trend of more yellow and less homogeneously white color of compensatory enlarged culprit lesions compared to shrunken culprit lesions was noted, 8/9 versus 4/7 respectively (p=0.142).
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4 Discussion |
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TopAbstract1 Introduction2 Methods3 Results4 DiscussionReferences |
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The principal finding of this study was that angioscopic complex lesions with or without thrombi were predominantly found in compensatory enlarged coronary segments, whereas smooth lesions were predominantly found in shrunken segments. Previously other investigators have reported that a relation may exist between unstable angina and the presence of atheroma with an irregular surface and thrombi at the culprit lesion site [8–17]. Our findings may support these earlier observations since a trend towards more complex lesions was observed in patients with acute coronary syndromes presenting with acute coronary syndromes. The ICUS findings corroborate preliminary studies that reported a significant relation between compensatory enlarged culprit lesions and acute coronary syndromes [18, 19].
The majority of compensatory enlarged lesions had a yellow color (8/9 lesions). Lesions of yellow color are considered to represent either degenerated fibrous plaque (fibrous plaque with patchy necrosis) or atheromatous plaque, which consists of a large lipid pool with a thin fibrous cap. White lesions, in contrast, are considered to represent fibrous plaque primarily consisting of connective tissue without necrosis [20].
In the present study, compensatory enlarged lesions showed a trend towards greater plaque areas than shrunken lesions. Previous histopathological studies by Kragel and coworkers [21, 22]revealed a linear increase of atheromatous core and inflammatory infiltrates and a linear decrease of cellular fibrous tissue with increasing cross sectional area narrowing in coronary artery lesions of patients who died with unstable angina. In addition, we recently observed that, in the femoral artery, large plaques in large vessel segments have more pathohistological markers for plaque vulnerability than small plaques [7]. The latter post mortem studies imply that large plaques are likely to have more vulnerability properties than small plaques. The present in vivo study may support these aforementioned post-mortem observations, since compensatorily enlarged segments tended to have a more complex surface image on angioscopy and showed a trend towards greater plaque areas than shrunken lesions as visualized with ICUS.
4.1 Limitations of the study
First, this is a cross-sectional study in a limited number of patients. We can therefore only suggest the existence of a relation between the mode of remodeling, the angioscopic appearance and clinical syndromes. Second, only patients that required a coronary intervention and who were studied by both ICUS and angioscopy were included retrospectively. As a result, the number of patients in this study is limited. The exclusion of 12/34 patients owing to incomplete or inadequate ICUS and/or angioscopy images might somehow have introduced a selection bias. Third, arterial remodeling may have affected reference segments with less than 50% plaque [1, 23, 24]. Fourth, the mean delay of 66 days between a recent myocardial infarction in six patients and the intracoronary imaging implies that the culprit lesion could have changed in angioscopic appearance. A recent angioscopy study, however, suggest that healing of the infarct related lesion requires more than 1 month [25].
In conclusion, in patients that required coronary intervention, culprit lesions with angioscopic complex appearance were predominantly compensatory enlarged, whereas smooth lesions were more often shrunken.
Time for primary review 42 days.
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Notes |
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1 PCS was supported by the Dutch Heart Foundation, grant NHS 94-115.
2 GP is a fellow of the Catharijne Foundation, Utrecht, The Netherlands.
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