Abstract
Atherosclerosis is a key pathological process that causes a plethora of pathologies, including coronary artery disease, peripheral artery disease, and ischemic stroke. The silent progression of the atherosclerotic disease prompts for new surveillance tools that can visualize, characterize, and provide a risk evaluation of the atherosclerotic plaque. Conventional ultrasound methods—bright (B)-mode US plus Doppler mode—provide a rapid, cost-efficient way to visualize an established plaque and give a rapid risk stratification of the patient through the Gray–Weale standardization—echolucent plaques with ≥50% stenosis have a significantly greater risk of ipsilateral stroke. Although rather disputed, the measurement of carotid intima-media thickness (C-IMT) may prove useful in identifying subclinical atherosclerosis. In addition, contrast-enhanced ultrasonography (CEUS) allows for a better image resolution and the visualization and quantification of plaque neovascularization, which has been correlated with future cardiovascular events. Newly emerging elastography techniques such as strain elastography and shear-wave elastography add a new dimension to this evaluation—the biomechanics of the arterial wall, which is altered in atherosclerosis. The invasive counterpart, intravascular ultrasound (IVUS), enables an individualized assessment of the anti-atherosclerotic therapies, as well as a direct risk assessment of these lesions through virtual histology IVUS.
Highlights
Atherosclerosis is a key multifactorial, systemic pathophysiological process that causes a plethora of pathologies such as coronary heart disease, peripheral arterial disease and ischemic stroke [1]
The current paper presents a critical, evidence-based review of the current US methods that can detect and characterize atherosclerosis, starting from the classic noninvasive bright (B)-mode US, contrast-enhanced ultrasound imaging (CEUS), elastography techniques, to the invasive spectrum—intravascular ultrasound (IVUS), transesophageal echocardiography, and epiaortic ultrasound
The practical importance of detecting atherosclerotic aortic plaques by transesophageal ultrasound is mainly validated in four clinical scenarios: (1) in patients with cryptogenic stroke, as an extensive assessment to detect the cause of cerebral embolism; (2) in patients who will be subjects of cardiac surgery and when manipulation of the ascending aorta is expected [141]; (3) in patients undergoing invasive cardiac procedures [142] when the aorta is the route to the left ventricle for guidewires or catheters: left accessory pathway ablation or left ventricle (LV) tachycardia, coronary angiography, ventriculography, or percutaneous implantation of the aortic valve [143], and (4) in patients with atrial fibrillation in whom the detection of atherosclerotic plaques brings an additional point to the CHA2 DS2 -VASc score [144,145], confirming the indication of long-term anticoagulation
Summary
Atherosclerosis is a key multifactorial, systemic pathophysiological process that causes a plethora of pathologies such as coronary heart disease, peripheral arterial disease and ischemic stroke [1]. One of the reasons for this wide distribution is the multitude and the heterogeneity of the risk factors that lead to atherosclerosis—hypertension, diabetes mellitus, and cigarette smoking among others [3], along with the typical silent progression of the atherosclerotic disease to advanced stages Considering this silent progression, estimative risk stratification is essential in the current clinical practice through a direct assessment of the atherosclerotic plaque and determination of its vulnerability or indirectly, through statistically confirmed risk scores. One of the studies that highlighted the potential of ultrasound (US) methods in the direct evaluation of atherosclerosis is the 2015 prospective BioImage study [5] The authors concluded that imaging biomarkers that directly quantify atherosclerosis, including 3D-US, may be used as complementary methods to conventional risk factors, highlighting the importance of US techniques in the atherosclerotic plaque evaluation. Our critical approach will keep in line the US differences between stable atherosclerotic plaques and vulnerable plaques, as the pathological risk for these entities is significantly different
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