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Stent Placement versus Percutaneous Transluminal Angioplasty of Human Carotid Arteries in Cadavers in Situ: Distal Embolization and Findings at Intravascular US, MR Imaging, and Histopathologic Analysis¹

¹ From the Departments of Clinical Radiology (H.I.M., H.T.R., R.L.V., P.V.), Surgery (M.H.), and Pathology (V.M.K.), Kuopio University Hospital, Puijonlaaksontie 2, SF-70210 Kuopio, Finland, and the Department of Pathology and Forensic Medicine, University of Kuopio, Finland (V.M.K.). Received June 5, 1998; revision requested July 31; final revision received November 2; accepted February 9, 1999. Address reprint requests to H.I.M. (e-mail: hannu.manninen@kuh.fi ).

View larger version (54K): [in a new window]   Figure l. (a) X-ray angiogram at lateral projection shows a complex stenotic lesion at the bulbar segment of the internal carotid artery. Corresponding sagittal T1-weighted MR image (400/14) (boxed insert) demonstrates a fully patent, smooth arterial lumen after stent placement and complementary balloon dilation, but the stent does not entirely cover the proximal edge of the plaque. The white arrow denotes the end of the stent. The open arrow and black arrow denote the levels at which the corresponding (b, c) axial intravascular US scans and (d, e) axial MR images were obtained. (b) Axial intravascular US scan obtained at the level of the open arrow in a before treatment (left) shows an eccentric, hypoechoic lesion (solid arrow) consistent with a "soft" plaque. The intravascular US scan obtained after stent placement (right) shows an excellent result. The extension of the plaque (open arrows) is satisfactorily seen through the stent mesh. (c) Intravascular US scan obtained at the level denoted by the black arrow in a before treatment (left) reveals a tight stenosis with a deep calcification (arrows). The intravascular US scan obtained after stent placement (right) reveals good contact between the stent and the arterial wall, but the calcification (arrows) hinders visualization of the deeper part of the plaque. (d) Axial T1- (400/14)(left), intermediate- (2,500/17) (middle), and T2-weighted (TR/TE 2,500/102) (right) MR images obtained at the level of the open arrow in a show the full extension of the plaque (arrows) in the stent-treated artery. (e) T1- (400/14) (left), intermediate- (2,500/17) (middle), and T2-weighted (2,500/102) (right) MR images obtained at the level denoted by the black arrow in a show the calcification (arrow) and plaque behind the stent.

View larger version (139K): [in a new window]   Figure 2. Photomicrograph of two embolic intimal strips (arrows) filtered from the effluent obtained during stent placement in the lesion in Figure 1. (Papanicolaou stain; original magnification, x2.)

View larger version (150K): [in a new window]   Figure 3. Axial intravascular US scan at the bulbar segment of the internal carotid artery shows a partly loosened intimal flap (open arrow) floating in the lumen beside the eccentric plaque (closed arrows) after PTA.

View larger version (130K): [in a new window]   Figure 4a. (a) X-ray angiogram of the extracranial carotid artery obtained at the lateral projection before intervention and corresponding sagittal T1-weighted (400/14) MR image (boxed insert) obtained after stent placement. The long arrows indicate the ends of the stent that covers the whole length of the lesion. The short arrow denotes the level at which the corresponding axial MR images in b were obtained. (b) On the axial T1-weighted image (400/14) (left), the deep calcification (solid arrow) of the internal carotid bulb (at the level of the short arrow in a) is clearly depicted. However, the calcification is hardly recognized on the intermediate- (2,500/17) (middle) and T2-weighted (2,500/102) (right) images. A slight artifact due to the stent (open arrow) is seen on the T1-weighted image, but the stent has no signal intensity on the intermediate- and T2-weighted images.

View larger version (62K): [in a new window]   Figure 4b. (a) X-ray angiogram of the extracranial carotid artery obtained at the lateral projection before intervention and corresponding sagittal T1-weighted (400/14) MR image (boxed insert) obtained after stent placement. The long arrows indicate the ends of the stent that covers the whole length of the lesion. The short arrow denotes the level at which the corresponding axial MR images in b were obtained. (b) On the axial T1-weighted image (400/14) (left), the deep calcification (solid arrow) of the internal carotid bulb (at the level of the short arrow in a) is clearly depicted. However, the calcification is hardly recognized on the intermediate- (2,500/17) (middle) and T2-weighted (2,500/102) (right) images. A slight artifact due to the stent (open arrow) is seen on the T1-weighted image, but the stent has no signal intensity on the intermediate- and T2-weighted images.

View larger version (149K): [in a new window]   Figure 5. Axial intravascular US scan shows poor contact between the stent (open arrow) and the calcified arterial wall (solid arrow) despite balloon dilation inside the stent.

View larger version (88K): [in a new window]   Figure 6a. (a) Axial intravascular US scan of the internal carotid artery bulb obtained before balloon PTA (left) demonstrates an eccentric lesion with a deep calcification (solid arrow). The intravascular US scan obtained after angioplasty (right) reveals major dissections (open arrows) originating from the shoulder regions of the plaque and extending deep behind the plaque. (b) Histopathologic specimen confirms separation of the fibrotic plaque (arrow) from the medial layer. (Masson trichrome stain; original magnification, x2.) (c) On the axial T1- (400/14) (left), intermediate- (2,500/17) (middle), and T2-weighted (2,500/102) (right) MR images, the crescent outline of the dissection (arrowhead) can be discerned, but the deep calcification (arrow), delineated as a definite hypointense lesion on the T2- and intermediate-weighted images, is hardly discernable on the T1-weighted image.

View larger version (148K): [in a new window]   Figure 6b. (a) Axial intravascular US scan of the internal carotid artery bulb obtained before balloon PTA (left) demonstrates an eccentric lesion with a deep calcification (solid arrow). The intravascular US scan obtained after angioplasty (right) reveals major dissections (open arrows) originating from the shoulder regions of the plaque and extending deep behind the plaque. (b) Histopathologic specimen confirms separation of the fibrotic plaque (arrow) from the medial layer. (Masson trichrome stain; original magnification, x2.) (c) On the axial T1- (400/14) (left), intermediate- (2,500/17) (middle), and T2-weighted (2,500/102) (right) MR images, the crescent outline of the dissection (arrowhead) can be discerned, but the deep calcification (arrow), delineated as a definite hypointense lesion on the T2- and intermediate-weighted images, is hardly discernable on the T1-weighted image.

View larger version (54K): [in a new window]   Figure 6c. (a) Axial intravascular US scan of the internal carotid artery bulb obtained before balloon PTA (left) demonstrates an eccentric lesion with a deep calcification (solid arrow). The intravascular US scan obtained after angioplasty (right) reveals major dissections (open arrows) originating from the shoulder regions of the plaque and extending deep behind the plaque. (b) Histopathologic specimen confirms separation of the fibrotic plaque (arrow) from the medial layer. (Masson trichrome stain; original magnification, x2.) (c) On the axial T1- (400/14) (left), intermediate- (2,500/17) (middle), and T2-weighted (2,500/102) (right) MR images, the crescent outline of the dissection (arrowhead) can be discerned, but the deep calcification (arrow), delineated as a definite hypointense lesion on the T2- and intermediate-weighted images, is hardly discernable on the T1-weighted image.