1. Longitudinal necrotic shafts near TCFAs—A potential novel mechanism for plaque rupture to trigger ACS?

    Longitudinal necrotic shafts near TCFAs—A potential novel mechanism for plaque rupture to trigger ACS?

    It has been questioned for over 15 years why only less than 20% of TCFAs trigger ACS. We illustrate TCFA rupture into adjacent longitudinal necrotic shafts of massive amounts of thrombogenic material into the blood, leading to catastrophic clot formation. This is the potential mechanism for TCFAs triggering ACS. One case presented also illustrates the dangers of stent edges rupturing TCFAs.

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    On 10/16/14 mebrezin said:
    We have previously seen these shafts and at the very least, one other group has noted them. But this is the first association with pathologic consequences, particularly ACS.

    "The necrotic cores in culprit lesions have always been shown to occupy at least 10% of the plaque area in cross section. Necrotic core size is greater in the disrupted plaque compared with TCFA and occupies 34 ± 17% and 23 ± 17% of the plaque area, respectively. However, the length of the necrotic core is similar in ruptured and rupture-prone plaques, varying from 2 to 22 mm, with a mean of 9 and 8 mm. The pathologic observations dictate that instability is more closely associated with the circumferential extent of necrotic cores; at least three-fourths of the rupture-prone plaques involve >120° of vascular perimeter. Serial sections through the atherosclerotic lesions show the serpentine nature of necrotic cores, such that when it surfaces closer to the lumen it renders the plaques vulnerable to rupture." 1

    They did not connect these shafts with ACS or the thrombotic burden, but seemed to be more focused on rupture and cross sectional area.
    1. J. Narula and S. Achenbach, "Napkin-Ring Necrotic Cores: Defining Circumferential Extent of Necrotic Cores in Unstable Plaques," Jacc-Cardiovascular Imaging 2(12), 1436-1438 (2009).

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