RPS 215 - Advancing the boundaries of vascular ultrasound

Author Block: J. Yiwen, J. Wang, M. Chen, Y. Yang; Shanghai/CN
Purpose: Objective: To investigate the independent predictive value of plaque characteristics based on conventional ultrasound and contrast-enhanced ultrasound (CEUS)—specifically a composite model integrating intraplaque punctate calcification and contrast enhancement—for new-onset cerebral infarction in patients with CP-RADS category 2 carotid plaques, and to develop and validate a nomogram prediction model incorporating clinical and imaging features.
Methods or Background: Methods: This retrospective study included 744 patients with CP-RADS category 2 carotid plaques who underwent carotid ultrasound and CEUS. Following follow-up, 404 patients were randomized 7:3 into training (n=283) and validation (n=121) sets. Independent predictors of new-onset cerebral infarction were identified through univariate and multivariate logistic regression, and used to develop a nomogram. Model performance was assessed by ROC analysis, AUC, sensitivity, and specificity.
Results or Findings: The plaque characteristics (the composite model of intraplaque punctate calcification and contrast enhancemen) is an independent predictor of new-onset cerebral infarction in CP-RADS Category 2 carotid plaques. Our nomogram demonstrates accurate and stable prediction, offering a reliable tool for early risk stratification and individualized intervention.
Conclusion: Conclusion: Plaque characteristics (the composite model of intraplaque punctate calcification and contrast enhancement) serve as an independent predictor of new-onset cerebral infarction in patients with CP-RADS Category 2 carotid plaques. The nomogram model developed in this study exhibits good predictive accuracy and stability, providing an intuitive and reliable quantitative tool for early identification of high-risk populations and implementation of individualized interventions.
Limitations: This single-center retrospective study has inherent limitations. The single-institution sample limits generalizability, and the retrospective design may introduce systematic bias. To minimize bias, we exclusively enrolled patients with recent cerebral infarction (within 6 months) to clearly define cerebrovascular events. Future multi-center studies with extended follow-up are needed to validate the model's predictive performance and clinical utility.
Funding for this study: No
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study strictly adheres to the ethical principles of the Declaration of Helsinki (2013 revision) and has been approved by the Ethics Committee of Shanghai Tongren Hospital

Author Block: A. Borlea, D. I. Stoian, S. MIHUTA, A. BENA, C. Paul; Timisoara/RO
Purpose: PURPOSE. To investigate the relationship between serum trimethylamine N-oxide (TMAO), a gut-derived metabolite, and carotid intima–media thickness (CIMT) as an ultrasound marker of subclinical atherosclerosis in children with obesity.
Methods or Background: METHODS. We enrolled 70 children aged 4–18 years: 50 obese (BMI >95th percentile, waist circumference >90th percentile) and 20 normal-weight controls. Clinical evaluation included BMI, waist-to-height ratio, Tanner stage, and signs of insulin resistance. Serum TMAO was measured by liquid chromatography–mass spectrometry, alongside fasting glucose, insulin, lipid profile, transaminases, creatinine, uric acid, and vitamin D. CIMT was assessed bilaterally with high-resolution ultrasound. Arterial stiffness parameters (pulse wave velocity [PWV], augmentation index, and central and peripheral blood pressures) were recorded for comparison.
Results or Findings: RESULTS. Obese children had significantly higher TMAO levels (median 289.5 vs 218.7 µg/L, p=0.02) and CIMT (0.56 ± 0.07 vs 0.49 ± 0.05 mm, p<0.001) compared to controls. Serum TMAO correlated positively with CIMT (ρ=0.41, p<0.001), PWV (ρ=0.36, p=0.004), and systolic blood pressure (ρ=0.33, p=0.007). In multivariable regression, TMAO remained an independent predictor of CIMT (β=0.37, p<0.001), even after adjusting for BMI, waist measures, age, and puberty stage. Children with insulin resistance had higher CIMT and PWV than their non-insulin-resistant peers, but TMAO levels did not differ significantly between subgroups. Logistic regression showed that higher TMAO was associated with increased odds of acanthosis nigricans (p=0.03).
Conclusion: CONCLUSION. Serum TMAO is elevated in pediatric obesity and independently predicts carotid intima–media thickness, reinforcing the role of ultrasound as the key imaging modality to detect early vascular injury in this population.
Limitations: Limitations: cross-sectional design; limited control sample; absence of dietary/microbiome profiling
Funding for this study: No funding
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The Ethics Committee for Scientific Research of the “Pius Brinzeu” Emergency County Hospital has approved the study (No. 349/15.11.2022)

Author Block: C. Chen, H. Yunqian, J. Xu, M. Chen; Shanghai/CN
Purpose: This study aimed to evaluate the efficacy of ultrasound-based Carotid Plaque Reporting and Data System (CP-RADS) in stroke risk stratification and to explore the incremental value of contrast-enhanced ultrasound derived intraplaque neovascularization features in refining this classification system.
Methods or Background: A analysis was conducted on cohort of 148 patients with carotid plaques who underwent routine ultrasound and CEUS between May and December 2019. CP-RADS grades (1–4) were independently assigned by radiologists based on ultrasound features. Interobserver and intraobserver reliability were assessed. Patients were followed up for 24 months to record ipsilateral ischemic stroke. Cox regression analyzed associations between CEUS characteristics, plaque grades, and stroke.
Results or Findings: 33 (21.86%) experienced ipsilateral ischemic stroke. The interobserver and intraobserver reliability for CP-RADS grading was well (ICC>0.8). The stroke group exhibited significantly older (P=0.036) and higher prevalence of prior stroke history (P=0.044). Surface microbubble perfusion was more frequent in stroke patients (66.66% vs 41.73%, P<0.05), while no significant difference was observed in neovascularization density. CP-RADS grades showed no intergroup differences, with 60.6% of strokes occurring in CP-RADS 3/4 patients. Surface microbubble perfusion independently predicted stroke risk in CP-RADS 3/4 patients (adjusted HR=4.938, 95CI:1.258-19.381, P=0.022).
Conclusion: Incorporating CEUS-derived microbubble perfusion features enhances accuracy for high-risk plaques (CP-RADS 3/4). This approach provides a cost-effective, simple, and widely applicable tool for optimizing clinical stroke prevention strategies.
Limitations: Several limitations are noted. First, limited sample size (n=151) and relatively short median follow-up (24 months), ongoing cohort studies with expanded patient data are underway. Second, inherent ultrasound limitations in characterizing plaque components (e.g., lipid core, calcification) and observer dependency in imaging feature interpretation may contribute to Carotid Plaque RADS misclassification.
Funding for this study: This research was supported by Shanghai Tongren Hospital, with project numbers TRYJ2022LC09, tx2023xk18, and TK2017r04
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: We obtained verbal informed consent from all participants. This study was approved by the Ethics Committee of Shanghai Tongren Hospital hospital.

Author Block: C. Chen, J. Xu, H. Yunqian, M. Chen; Shanghai/CN
Purpose: To evaluate the viscoelastic characteristics of carotid artery walls in plaque-free populations under different cardiovascular risk levels by carotid wall viscoelasticity imaging, analyze the correlation between carotid viscoelastic parameters and the degree of cardiovascular risk. Assessing the ability of these parameters to identify high-risk individuals, providing a basis for early detection of high-risk populations for cardiovascular diseases.
Methods or Background: A total of 518 patients undergoing carotid viscoelasticity imaging between April 2023 and June 2024 were consecutively enrolled. Clinical data were collected, and participants were stratified into low-risk (<6%), intermediate-risk (6–20%), and high-risk (>20%) groups based on the Framingham Risk Score. The correlation between carotid wall viscoelastic parameters and cardiovascular risk levels was analyzed, and ROC curves were used to evaluate the discriminative ability of different viscoelastic parameters for identifying high-risk populations.
Results or Findings: The low-risk, intermediate-risk, and high-risk groups comprised 229, 222, and 67 participants, respectively. Correlation analysis revealed linear positive associations between all carotid viscoelastic parameters and increasing cardiovascular risk levels. Among all parameters, C-Emin and C-Vmean demonstrated the highest specificity (0.746) and sensitivity (0.801), respectively, for identifying high-risk individuals.
Conclusion: This study indicates that carotid viscoelastic parameters are positively correlated with elevated cardiovascular risk levels. Elastic parameters and viscous parameters play distinct roles in distinguishing high-risk populations, with C-Vmean providing superior sensitivity. These findings suggest that viscous parameters effectively differentiate cardiovascular risk strata, offering critical insights for early identification of plaque-free individuals at high cardiovascular risk.
Limitations: Current equipment does not support electrocardiogram-integrated viscoelastic imaging, preventing the acquisition of systolic and diastolic viscoelastic parameters.So participants were instructed to maintain breath-holding and stable positioning during examinations, performed exclusively by senior radiologists with extensive viscoelastic imaging expertise. Patients unable to maintain stability were excluded
Funding for this study: This research was supported by Shanghai Tongren Hospital, with project numbers TRYJ2022LC09, tx2023xk18, and TK2017r04
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the ethics committee of our institution.

Author Block: H. Jin, H. Yunqian, Q. Chen, Y. Yang, M. Chen; Shanghai/CN
Purpose: To determine whether ultrasound-derived viscoelastic properties of carotid plaques can identify individuals with mild (<50 %) carotid stenosis who are at heightened risk of an ischemic cerebrovascular event.
Methods or Background: Consecutive patients with mild carotid stenosis examined between April 2023 and June 2024 were enrolled. Ninety-seven had sustained an ischemic cerebrovascular event within the preceding 6 months; 592 had remained event-free. Gray-scale and viscoelastic ultrasound were used to quantify plaque elasticity and viscosity. Logistic regression was employed to assess the association between viscoelastic parameters and incident events while adjusting for clinical covariates. ROC analysis evaluated the predictive performance of these parameters.
Results or Findings: Plaques in the event group exhibited significantly lower mean elastic modulus (P-Emean) and mean viscous modulus (P-Vmean) than those in the asymptomatic group. Both P-Emean and P-Vmean emerged as independent predictors of events. Combined viscoelastic models yielded excellent discrimination, with the elastic-component model achieving an AUC of 0.871.
Conclusion: In patients with mild carotid stenosis, plaque biomechanics are closely linked to cerebrovascular events. Ultrasound assessment of plaque viscoelasticity can improve risk stratification and lays the groundwork for precision management of this population.
Limitations: Histological validation of the viscoelastic parameters was not performed.
Funding for this study: This research was supported by Shanghai Tongren Hospital, with project numbers TRYJ2022LC09, tx2023xk18, and TK2017r04
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the ethics committee of our hospital.

Author Block: M. Kader, L. Zhang, H. Yunqian, M. Chen, Y. Yang, Q. Chen; Shanghai/CN
Purpose: This study aimed to investigate the ultrasonic characteristics of plaques in patients with mild carotid stenosis (stenosis <50%) complicated with embolic stroke of unknown cause (ESUS), in order to provide new ideas and basis for the etiological diagnosis and individualized treatment of ESUS.
Methods or Background: This retrospective study analyzed carotid plaque characteristics in 106 stroke patients admitted from May to December 2019 and divided into three groups: Embolic Stroke of Undetermined Source (ESUS, n=23), Extracranial Large Artery Atherosclerosis (LAA, n=28), and a non-stroke control group (n=55), using ultrasound and contrast-enhanced ultrasound. The echo intensity, surface morphology and perfusion pattern of carotid plaques and other related ultrasound parameters were compared between different groups. The binary logistic regression model, ROC curve and multivariate analysis were used to evaluate the diagnostic efficacy of ultrasound parameters and clinical factors.
Results or Findings: Both LAA and ESUS groups exhibited significantly higher frequencies of microbubble perfusion and "inside-to-outside" perfusion patterns compared to controls. Key plaque features including hypoechoic areas, irregular morphology, and incomplete fibrous cap showed significant intergroup differences (P < 0.05). The combination of plaque thickness <3.4 mm and absence of "inside-to-outside" perfusion pattern achieved an AUC of 0.802 for ESUS diagnosis with 80.4% accuracy.
Conclusion: These findings suggest that integrated assessment of plaque thickness and CEUS perfusion patterns enhances stroke subtype differentiation and prognostic risk assessment, providing valuable guidance for individualized diagnosis and treatment strategies.
Limitations: The single-center design with small sample size (n=106) affects generalizability, ultrasound assessments carry inherent subjectivity, comprehensive evaluation of embolic sources requires additional imaging modalities, and insufficient follow-up duration prevents long-term outcome assessment.
Funding for this study: Not applicable
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:

Author Block: M. Czeczelewski, A. Drelich-Zbroja, M. A. Kuczyńska; Lublin/PL
Purpose: Patients following endovascular aneurysm repair (EVAR) require long-term imaging surveillance to detect late complications such as endoleaks. CTA remains the gold standard for follow-up but exposes patients to ionizing radiation and iodinated contrast agents. Microvascular ultrasound (MVUS) is a novel, contrast-free technique capable of visualizing slow microvascular flow. This study aimed to compare the diagnostic accuracy of MVUS with CEUS and CTA in detecting endoleaks after EVAR.
Methods or Background: A prospective cross-sectional study was conducted in 73 consecutive patients (60 males, 13 females) who underwent EVAR. Within one week post-procedure, each participant underwent ultrasound assessment including both MVUS and CEUS. CEUS was performed after intravenous administration of 1.6 mL of SonoVue (Bracco, Italy). Within one month, all patients underwent triple-phase CTA, which served as the reference standard. Endoleaks were classified according to the Mayo Clinic classification.
Results or Findings: Among the 73 patients, the stent graft types included Zenith Flex (19; 26%), Zenith t-Branch (27; 37%), Gore Excluder (17; 23%), and Medtronic Endurant II (10; 14%). Ultrasound prior to discharge revealed 42 endoleaks, including 33 detected by both MVUS and CEUS, and 9 detected only by MVUS. One month later, CTA confirmed 28 of the 33 endoleaks initially detected by CEUS and MVUS, while 3 had resolved and 3 patients were lost to follow-up. Of the 9 endoleaks detected only by MVUS, one was confirmed by CTA. These MVUS-only endoleaks were characterized by fine, linear flow signals perpendicular to the transducer.
Conclusion: MVUS demonstrates high sensitivity for detecting endoleaks following EVAR.
Limitations: This single-center study had a limited sample size and short follow-up duration. CTA was performed up to one month after ultrasound, which limits its reliability as a reference standard.
Funding for this study: ESR Research Seed Grants 2024
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Medical University of Lublin Bioethics committee
KE-0254/57/03/2024

Author Block: D. J. Petrovic; Belgrade/RS
Purpose: The objective of the survey was to establish the correlation between carotid intima-media thickness (CIMT) and type 2 diabetes mellitus (T2DM), as well as to assess the hemodynamic parameters and their relationship to T2DM.
Methods or Background: 186 participants between the ages of 42 and 84 with proven T2DM (112 men and 74 women; mean age ± SD, 63.13 ± 6.96) were retrospectively examined (prospective design or retrospective analysis of a prospective data set) by the carotid ultrasound Doppler examination measuring carotid morpho-functional features. Subjects were followed for 26 months from the inclusion in the study (regular control examinations and phone contact). Data were recorded on new cases of mortality (CV mortality) and adverse CV events (myocardial infarction - MI, cardiac insufficiency, surgical revascularization - coronary or stroke, etc.).
Results or Findings: In this study, the value of CIMT varies between 0.56 and 1.41mm (mean CIMT=1.05 ± 0.12mm) while functional results were (RI=0.81 ± 7; PI =1.16±0.185; PSV=132.5 ± 16.65; EDV=28.33 ± 9.04; carotid artery diameter = 6.5 ± 0.92mm). After 26 months of time frame follow-up, 24 vascular events were noted (MI, TIA, stroke, and coronary angioplasty).
Conclusion: The evaluation of morphological (CIMT) and functional (RI, PSV, EDV) parameters is a reliable indicator and barometer for assessing the degree of diabetic vascular remodeling during atherosclerosis progression.
Limitations: Relatively limited sample size, retrospective nature.
Funding for this study: No fundings
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: