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PubMed1991

Angioscopic evaluation of intravascular morphology after coronary endarterectomy.

Coronary endarterectomy in diffuse coronary disease is attended by an increased incidence of perioperative myocardial infarction and vein graft occlusion, which have been partially attributed to the presence of occlusive or thrombogenic intraluminal flaps in the main vessel or its smaller branches. To define the nature and incidence of these features we studied 15 endarterectomized right coronary arteries in 15 patients (12 men, 3 women; age, 55 +/- 7 years [mean +/- standard deviation]) undergoing a coronary operation for multivessel disease. After endarterectomy and distal graft anastomosis, angioscopy was performed using a 1.8-mm Olympus angioscope during graft perfusion with crystalloid solution. The endarterectomy cores were 66 +/- 30 mm in length with 11 major bifurcations and two trifurcations providing 30 major endpoints. At 22 of 30 major endpoints the distal end of the core was smooth and tapered. There were 17 minor side-branch endpoints. Angioscopy revealed the presence of wispish intraluminal fronds and medial bruising in all (100%) arteries. Twenty-nine of the 30 intraluminal endpoints could be visualized. Major intraluminal flaps were seen at the eight nontapered endpoints and six of the 21 smooth tapered endpoints that were visualized. Fifteen minor side branches could be identified angioscopically: a flap was seen at only one side-branch origin. The average examination time was 3.2 +/- 1.1 minutes (7.7% +/- 2.7% of cross-clamp time), and examination required 200 to 250 mL of perfusate. This technique enables immediate and accurate postinterventional assessment of intravascular morphology with minimal prolongation of ischemic time and has shown that small side branches are not compromised by endarterectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Artery Bypass↗
PubMed1991

Angioscopic coronary macromorphology in patients with acute coronary disorders.

To investigate the pathogenesis of acute coronary disorders and to clarify what type of plaque precedes these disorders, percutaneous transluminal coronary angioscopy, by means of a new angioscope, was carried out during catheterisation in 100 consecutive patients anatomically suitable for such investigations. The quality of the angioscopic image was good enough for analysis in 84 patients (14 with acute myocardial infarction [within 8 h of onset], 16 with recent myocardial infarction [3 days-2 months since onset], 24 with old myocardial infarctions, 10 with unstable angina, and 20 with stable angina). Thrombi were observed in most patients with acute coronary disorders (all 14 with acute myocardial infarction, 9 of 10 with unstable angina). Occlusive thrombi were more common in patients with acute myocardial infarction than in those with unstable angina (11 [79%] vs 1 [10%]; p less than 0.001), whereas mural (non-occlusive) thrombi were more common in the unstable angina than in the acute myocardial infarction group (8 [80%] vs 3 [21%]; p less than 0.001). Xanthomatous ulcerated plaques or ragged irregular surfaces were seen in patients with acute coronary disorders and in those with recent myocardial infarction. Xanthomatous plaques were more common in patients with acute coronary disorders (50%) than in those with stable angina (15%) or old myocardial infarction (8%). By contrast white and smooth plaques were seen in cases of stable angina and old myocardial infarction. Angioscopy could display the intracoronary lumen more precisely than could coronary arteriography. This angioscopic study suggested that, although a thrombus overlying a rupture in the lining of the plaque was common in both unstable angina and acute myocardial infarction, the character of the thrombus may differ between these disorders, and lipid-rich xanthomatous plaque may precede rupture.

Acute Disease↗
PubMed1995

Experience with a new valvulotome for lower-extremity revascularization procedures by the in situ method.

Between November 1990 and November 1992, 50 consecutive cases requiring lower-extremity revascularization by the in situ method were compared with regard to use of two different valve cutters, the Hall valvulotome and the Insitucat. There were no amputations in patients with patent grafts, nor were any infections or false aneurysms noted during the course of this study. In the Insitucat group (n = 25), primary patency was achieved in 19 cases. Five of the six graft failures underwent additional procedures of which three remained patent, adding to the secondary patency rate (22 of 25). The greatest problem with regard to maintaining primary graft patency was that of missed or retained valves, but the incidence of this problem decreased during the course of this study as experience was gained with the catheter in conjunction with angioscopy. Experience with the Insitucat valvulotome has demonstrated its efficacy, though enhanced by monitoring the results with angioscopy. The development and discovery of focal stenotic areas and retained valves by surveillance sonography have resulted in enhanced (assisted) primary graft patency rates. The incidence of these problems appears to be comparable with that occurring with other means of producing valvular incompetence for an in situ reconstruction where valvulotomes of similar design are employed. This was confirmed by comparative analysis with another group of 25 in situ vein bypasses performed during the same time period but during the Hall valvulotome.

Aged↗
PubMed1997

Percutaneous coronary angioscopic comparison of thrombus formation during percutaneous coronary angioplasty with ionic and nonionic low osmolality contrast media in unstable angina.

Patients with unstable coronary syndromes are more likely to have a lesion containing thrombus and have a higher procedural complication and restenosis rate. The aim of this study was to evaluate the effect of an ionic (ioxaglate) and a nonionic (iohexol) low osmolality contrast media on thrombus generation using percutaneous intracoronary angioscopy in patients with unstable angina undergoing percutaneous transluminal coronary angioplasty (PTCA). Thirty patients with unstable angina pectoris randomized to either ioxaglate or iohexol (15 patients in each group), underwent percutaneous intracoronary angioscopy before and after PTCA and 15 minutes after PTCA. Angioscopically visible thrombus was defined using the Ermenonville classification and the lesion divided into 3 zones-proximal, mid, and distal. Angiographic filling defects were seen in 3 patients before PTCA, and in 10 after PTCA. Angioscopically visible thrombus was seen in 10 patients before PTCA in the ioxaglate group and 8 in the iohexol group. After PTCA 5 patients (33.3%) in the ioxaglate and 11 (73.6%) in the iohexol group developed new thrombus, p = 0.028. Total thrombi before PTCA were 16 versus 13, after PTCA 25 versus 27, and at 15 minutes after PTCA 23 versus 25, ioxaglate versus iohexol respectively, p = NS. There was no correlation between type or extent of intimal dissection and angioscopically visible new thrombus formation. Angiography underestimated the incidence of intracoronary thrombus before and after PTCA. Nonionic low osmolality contrast medium was associated with significantly more patients developing angioscopically visible new thrombus. This has clinical implications in the choice of contrast medium used in PTCA, particularly in the setting of unstable angina.

Aged↗
PubMedDate not supplied

Intravascular ultrasound estimation of arterial stenosis.

The evaluation of the degree of reduction in the cross-sectional area of an artery has important pathophysiologic and therapeutic implications. Currently, no technique can easily provide this information. In this in vitro study we evaluated the potential of a new imaging technique, intravascular high frequency ultrasound angioscopy, in the estimation of percentage of cross-sectional area stenosis of an artery. To do this, we compared intravascular high frequency ultrasound to previously-validated external high frequency ultrasound and to anatomic estimation of arterial stenosis. Using a prototype intraluminal imaging catheter with a 20 MHz ultrasound transducer at its tip, we imaged 20 arterial segments of various size (15 to 90 mm2 lumen area by anatomy) in the control state and after experimental stenosis. These arterial segments were also imaged by external high frequency ultrasound. Lumen areas were measured from calibrated ultrasound images in the control state and after stenosis, and percentage of cross-sectional area stenosis was calculated. These data were compared to the percentage of area stenosis derived from calibrated anatomic photographs of the arteries taken in the control state and after stenosis. Both intravascular ultrasound angioscopy and external high frequency ultrasound yielded high-resolution, two-dimensional, circumferential images of the arteries. Alterations in vessel area and shape were apparent after creation of stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Arteries↗
PubMed1989

The mechanism of angioplasty--endoscopic and morphometric investigations in an experimental model.

The effect of angioplasty using two different sizes of balloon catheter were examined by angiography and angioscopy before and after dilatation. A significant increase in the outer and inner diameters was seen accompanied by a decrease in the cross sectional area of the stenoses as well as the thickness of the vascular wall. Angioscopy revealed typical longitudinal tears of the plaque edges which are pressed during flow against the vessel wall. Turbidity of saline could be seen after dilatation indicating possible rupture of the atheromatous plaque. These findings are discussed in the light of the mechanisms of angioplasty and the possible reasons for the good early and long-term results.

Angioplasty, Balloon↗
PubMed1997

Adjunctive Therapy with an Antithrombotic Drug Can Prevent Reocclusion and Induce Residual Thrombus Reduction After Percutaneous Transcatheter Angioplasty of the Thrombotic Lesions.

Acute reocclusion after successful angioplasty is a severe complication. The preventive effects of heparin, the synthetic antithrombin, argtroban, and the defibrinogenating agent batroxobin on reocclusion after balloon angioplasty of thrombotic occlusions were evaluated in canine iliac arteries. After the 2-hour-old thrombus was evaluated by angiography and angioscopy, percutaneous transcatheter angioplasty (PTA) was performed on the thrombotic stenosis. We used one of the three agents, heparin (100 U/kg), the antithrombin argatroban (0.3 mg/kg), or the defibrinogenating agent batroxobin (0.3 U/kg). Then angioscopy and angiography were performed before, just after, and 2 hours after PTA. After PTA, angiography revealed a marked reduction in percent stenosis in all groups (from 88 +/- 8% to 24 +/- 4% in the heparin group, from 79 +/- 7% to 26 + 11% in the argatroban group and from 89 +/- 12% to 32 +/- 7% in the batroxobin group). At 2 hours after PTA, angiography demonstrated a greater reduction in percent stenosis with argatroban (from 26 +/- 11% to 9 +/- 3%) and batroxobin (from 32 +/- 7% to 10 +/- 8%), and maintenance of percent stenosis reduced by PTA with heparin (from 24 +/- 5% to 28 +/- 9%) when compared with the significant reversal of percent obstruction in the control side. Angioscopic visualization also demonstrated a similar trend. These results show that these antithrombotic drugs have a preventive effect on reocclusion after balloon angioplasty for thrombotic obstruction.

Journal Article↗
PubMed2004

Significance of angioscopic morphology for the estimation of macrophage infiltration and vascular physiology.

OBJECTIVE: The aim of the present study was to determine whether direct visual morphology can predict vascular physiology, macrophage infiltration and plaque architecture of atherosclerotic lesions. METHODS: Twenty male New Zealand white rabbits weighing 2.5-2.8 kg (mean, 2.7 +/- 0.2 kg) were used. We fed rabbits a 1% cholesterol diet after creating an injury in the middle abdominal aorta using a 2 Fr Fogarty balloon catheter. After 8 weeks, the morphology of plaque lesions was evaluated by angioscopy, and was classified as protruding or lining. Vascular endothelial function (VEF) was evaluated using a Doppler guidewire, and was expressed as ratio of basal to peak velocity (cm/s) in 30 s occlusion using a balloon catheter. Macrophages obtained from abdominal sections were stained with monoclonal antibody against rabbit macrophages (RAM-11). Density of total macrophage cell infiltration was quantified as absolute area of RAM-11 staining. RESULTS: Macrophage density and intima/media (I/M) ratio were significantly higher in the protruding group than in the lining group: macrophage density, 40 +/- 10 vs. 5 +/- 10%, p < 0.01; I/M ratio, 1.2 +/- 1.4 vs. 0.2 +/- 4, p < 0.05. Vascular flow reserve (VFR) was lower in the protruding group than in the lining group (1.8 +/- 0.7 vs. 2.2 +/- 0.5, p < 0.05). There was significant negative correlation between VEF and macrophage cell density (r = -0.593, p < 0.01), whereas there was no significant correlation between VEF and I/M ratio (r = -0.332, p = 0.330). CONCLUSION: The present findings suggest that protruding lesions revealed by angioscopy are rich in macrophages and have a higher I/M ratio and lower VFR.

Angioplasty, Balloon↗
PubMed1998

Provision of training in carotid surgery does not compromise patient safety.

BACKGROUND: Vascular surgeons perceive that carotid endarterectomy carries a higher risk of stroke if performed by a surgical trainee. Accordingly, some trainees consider that they receive a less than adequate training in carotid surgery before taking up a consultant position. The aim of this study was to establish whether the stroke rate was adversely affected if carotid endarterectomy was performed by a surgical trainee under consultant supervision. METHODS: This was a prospective study of 151 consecutive patients undergoing carotid endarterectomy between 1 January and 31 December 1996 using a standardized technique including intraoperative and postoperative transcranial Doppler monitoring and completion angioscopy. RESULTS: The overall mortality and/or disabling stroke rate was 0.7 per cent (one of 151 patients), whereas the mortality and/or any stroke rate was 1.3 per cent (two of 151). Surgical trainees performed 82 of 151 carotid endarterectomies, with a mortality rate of 1 per cent and a mortality and/or any stroke rate of 2 per cent. There was no significant difference in the incidence of retained thrombus or intimal flaps between trainees and consultants as detected by angioscopy. CONCLUSION: Vascular surgical trainees can receive a comprehensive training in carotid artery surgery without incurring an unacceptable increase in operative risk.

Aged↗
PubMed2004

Vascular anastomosing by gluing--an experimental study.

BACKGROUND: Performing anastomoses by stitching is very time-consuming. We therefore looked for an alternative technique and used a relatively new surgical adhesive. METHODS: Ten anastomoses between the aorta and a prosthesis were performed on five pigs (Deutsche Landrasse) using surgical glue (BioGlue). The proximal anastomoses between the abdominal aorta and the prostheses were performed end-to-side just below the renal arteries, the distal anastomoses in an end-to-end fashion just above the iliac bifurcation. The aorta between the anastomoses was ligated and resected. The animals were sacrificed between one week and up to four months after operation and anastomoses were analysed by angiography, CT angiography, angioscopy, and histology. RESULTS: Angiography and CT angiography revealed that all anastomoses were patent. No aneurysms were found at the site of anastomoses. No haematomas were detected. Angioscopy revealed well-healed connections between the original aorta and the prosthesis. CONCLUSIONS: We could demonstrate that anastomoses between the aorta and a prosthesis can be performed safely using a surgical adhesive. Further investigations of these anastomoses, especially over the long term, using calcified aortas, are necessary.

Adhesives↗
PubMed1988

Removal of focal atheromatous lesions by angioscopically guided high-speed rotary atherectomy. Preliminary experimental observations.

A new high-speed rotary atherectomy device, inserted over a guide wire and directed with an angioscope, offers the potential of restoring patency of outflow vessels by "boring out" the atheromatous lesion of the orifices of runoff vessels. The device was tested on 68 cadaver arteries with atheromatous lesions involving the superficial femoral, popliteal, and tibial arteries. This was performed with either free segments or in situ with the device placed through a popliteal arteriotomy. The gross results of rotary atherectomy were assessed by angioscopy, angiography, or both. The luminal surfaces were studied with scanning electron microscopy and transverse sections of vessels were studied with light microscopy. The pulverized atheroma, in colloidal suspension, was analyzed for particle size by Coulter counter. The effect of a colloidal suspension of atheromatous particles on distal capillary circulation was measured in animal experiments. Obstructive lesions were successfully removed in 36 of 37 stenotic arteries (97%) and 18 of 31 completely occluded arteries (58%), an overall efficacy of 54 of 68 (79%). In successfully atherectomized arteries, angioscopy and angiography demonstrated a widely patent, smooth, polished surface. Light microscopy demonstrated removal of the diseased intima with maintenance of the outer media and adventitia. The pulverized atheroma particles were generally smaller than red blood cells and injection of the colloidal atheroma into canine femoral arteries failed to produce local tissue injury. We conclude that in the human cadaver this atherectomy device effectively enlarges and recanalizes obstructed superficial femoral, popliteal, and tibial arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiography↗
PubMed1988

Angioscopic thromboembolectomy: preliminary observations with a recent technique.

Video angioscopy was employed in 12 patients to monitor thrombectomy or embolectomy within prosthetic bypass grafts (n = 4), saphenous vein grafts (n = 2), and native femoropopliteal arteries (n = 6). A flexible, 2.8 mm diameter angioscope was introduced into the vessel for confirmation and accurate localization of the diagnosed embolus. A Fogarty embolectomy balloon catheter was passed alongside the angioscope and balloon inflation was visually calibrated to the exact vessel lumen. Thromboembolic debris was then retrieved under direct visualization. Intraoperative angiograms were obtained in all cases and results were compared with the finding at angioscopy. After conventional thrombectomy, angioscopic inspection revealed residual thrombus within the lumen or adherent to the wall in 10 of 12 cases. Residual debris was also identified in tributary vessels in two cases, and the embolectomy catheter was successfully guided into these channels by the tip of the scope. Limb salvage was achieved in all but one patient, with early follow-up of up to 18 months. As a result of this experience we conclude that angioscopic thromboembolectomy has several advantages over the traditional blind technique: (1) accurate detection and localization of thrombus or embolus; (2) monitoring and control of the degree of balloon inflation, thereby preventing vessel wall damage caused by overinflation; (3) detection and retrieval of residual clot after blind embolectomy; (4) manipulation of the balloon catheter to selected vessels; (5) decreased requirement for repeated arteriograms; (6) increased speed, convenience, and accuracy when compared with intraoperative angiography; and (7) avoidance of surgical exposure of the distal popliteal and tibial vessels.

Adult↗
PubMed2006

Angioscopic differences in neointimal coverage and in persistence of thrombus between sirolimus-eluting stents and bare metal stents after a 6-month implantation.

AIMS: The neointimal coverage and intracoronary thrombi within stented segments at 6 months after implantation between sirolimus-eluting stents (SESs) and bare metal stents (BMSs) were compared by direct visualization using angioscopy. METHODS AND RESULTS: Forty-six patients (36 stable angina and 10 acute coronary syndrome) were treated with 33 SESs and 33 BMSs. Immediately after and 6 months after stenting, each of the stented segments, edge body, and overlapping segment were observed by angioscopy and the grade of neointimal coverage over the stents was classified as 0: absent neointima, 1: visible struts through thin neointima, or 2: invisible struts. The existence of thrombi was also evaluated. The average grade of the neointimal coverage at 6 months follow-up was lower in the SES than that in the BMS (edge: 1.4+/-0.7 vs. 1.9+/-0.2, body: 1.0+/-0.5 vs. 1.8+/-0.5, overlapping segment: 0.6+/-0.7 vs. 1.8+/-0.5; P<0.0001, P<0.0001, P=0.0069, respectively). The frequency of persistence of thrombus was significantly higher in the SESs than that in the BMSs (86 vs. 29%, respectively; P=0.031). CONCLUSION: The present study suggested a delayed neointimal stent coverage and slower thrombus disappearance process in the SESs in comparison to the BMSs.

Aged↗
PubMed1991

A prospective evaluation of arterial intimal injuries in an experimental model.

The management of arterial intimal defects remains controversial because of uncertainty concerning their natural history. We developed an experimental canine model to prospectively evaluate posterior wall intimal flaps in the superficial femoral artery. Arterial intimal flaps were constructed in 20 anesthetized dogs (40 arteries) and evaluated by arteriography, and angioscopy, and intravascular ultrasound. Postoperative patency rates at 1 (n = 20) and 3 weeks (n = 20) were compared with a control group of ten animals (n = 20, arteriotomy without intimal flap). Acute thromboses occurred in five experimental arteries with thromboses of eight additional experimental arteries at followup. Control patency was 100%, while experimental group patencies were 75% (p less than 0.05) at 1 week and 60% (p less than 0.009) at 3 weeks. All thrombosed arteries had intimal flaps with greater than 75% luminal stenosis. We conclude that intimal injuries cause arterial thromboses acutely and during subsequent followup. Intimal flaps with stenosis greater than 75% as determined arteriographically are at greatest risk for thrombosis. Angioscopy and intravascular ultrasound characterize arterial intimal defects and may delineate injuries requiring surgical or endovascular repair.

Angiography↗
PubMed1995

Future challenges to coronary angioplasty: perspectives on intracoronary imaging and physiology.

Several intravascular techniques have been developed with the purpose of achieving optimal guidance for treatment during coronary angioplasty (PTCA). Although the coronary angiographic technique is well established, there are still some inherent limitations. Due to intimal rupture, tears, dissection and thrombus following PTCA treatment, angiography does not allow exact delineation of the true borders of the vessel. Coronary angioscopy is currently the most sensitive method to detect coronary thrombus and can also be used to classify atheromatous plaques. Furthermore, coronary dissection can be detected with more accuracy than with angiography. One limitation associated with angioscopy is the need to occlude the vessel during imaging, which may create myocardial ischaemia. Furthermore, there is presently no method for quantifying angioscopic findings. Intravascular ultrasound produces a cross-sectional image of the vessel, which permits analysis of the layers of the vascular wall. Characterization and classification of various types of plaque can be made because thrombus, lipid, fibrous tissue and calcium have different ultrasonic echogenicity. Flow velocity measurement with the Doppler technique is an interesting approach to the physiological assessment of coronary stenoses. Coronary flow reserve can be estimated with this method and monitoring of the flow signal following angioplasty will aid in the diagnosis of flow-limiting complications. The trans-stenotic pressure gradient is a valuable measure of the haemodynamic importance of a coronary lesion. Trans-stenotic gradients during maximal hyperaemia obtained with a miniaturized pressure transducer yield reliable information regarding the severity of the stenosis, and the pressure values may be used to calculate the relative coronary flow reserve. In conclusion, all of these intracoronary diagnostic techniques will to some extent play a role in the future of coronary angioplasty. Safety, cost and complexity are some of the factors which will determine the growth potential of each method.

Angioplasty, Balloon, Coronary↗
PubMed1991

Dissolution of peripheral arterial thrombi by ultrasound.

BACKGROUND: We have previously shown that continuous-wave ultrasound can rapidly dissolve human thrombi in vitro, with 99% of all residual particles measuring less than 10 microns in diameter. To assess the effects of pulsed-wave ultrasound energy on whole blood clots, 1) in vitro studies were preformed to assess precisely the rates of clot disruption and to quantify particulate size, and 2) in vivo studies were performed to assess the efficacy and safety of catheter-delivered ultrasound for intra-arterial thrombus dissolution. METHODS AND RESULTS: In vitro, we studied 50 samples of human whole blood clots and using an 89-cm-long wire probe, applied pulse-wave energies from 8 to 23 W. The corresponding peak-to-peak tip displacement range was 63.5 - 102 microns. We studied arterial thrombosis in vivo in 21 canine superficial femoral arteries. To produce an acute thrombosis, 200 units of thrombin followed by 2 ml of 72-hour-old autologous clot were injected into a 5-7-cm segment of femoral artery and left to coagulate for 2 hours. Ultrasound energy was intermittently applied at a frequency of 20 kHz with a prototype ultrasound wire ensheathed in a catheter and directed to clots by fluoroscopy. In nine cases, angioscopic guidance was used to put the probe into direct contact with the intra-arterial thromboses. In vitro clot dissolution times were inversely related to the ultrasound power output (r = 0.95). All in vivo canine thromboses were disrupted in 4 minutes or less. All successful recanalizations were confirmed by angiography and in nine cases by angioscopy as well. Angioscopy demonstrated that probe activation caused rapid clot disruption. Histological studies of the vessels showed no evidence of thermal or cavitation injury, occlusive distal embolization, or perforation. CONCLUSIONS: Our findings in this experimental canine model suggest that ultrasound clot dissolution has the potential to be an effective and safe alternative to current treatment modalities for peripheral arterial thrombosis.

Animals↗
PubMed2003

Relative value of normalized sonographic in vitro analysis of arteriosclerotic plaques of internal carotid artery.

BACKGROUND AND PURPOSE: A close correlation between B-mode sonography and the histopathology and surface structure of plaque is rarely seen in vivo with high-grade stenoses of the extracranial carotid artery. The goal of this study was to determine whether normalized gray scale analysis and surface analysis of the plaque are capable of characterizing the attributes correctly. METHODS: Optimized B-mode images of 107 carotid endarterectomy specimens were captured, and the gray scale median (GSM) was calculated. The specimens were classified histologically into 3 groups: (1) calcium-rich hard plaques, (2) lipid-rich soft plaques, and (3) combined plaques. The surfaces of the plaques were classified as smooth or rough on the basis of standardized reference samples. The endoluminal surface was digitally documented in vitro by videoendoscopy and again classified into the same categories. All stages of the investigation were performed by 2 observers at 2 different times. RESULTS: Evaluation of the GSM showed close interobserver and intraobserver correlation (P<0.01, R>0.8). However, there was only 46% agreement between the GSM and the histopathological findings. In both in vitro angioscopy (kappa=0.936, P<0.001) and sonographic evaluation (kappa=0.842, P<0.001), there was a high correlation between the observers with regard to the evaluable specimens. In 73%, agreement was observed between the sonographic image and angioscopy. CONCLUSIONS: Normalized gray scale analysis and evaluation of the plaque surface in an in vitro study make possible observer-independent evaluation. The composition of the plaque cannot be visualized with sufficient accuracy by sonographic GSM analysis. This also applies to the correlation between sonography and actual surface composition of the plaque.

Aged↗