Maximum Principal Stress at the Superficial Calcification-Tissue Interface in Carotid Plaque Predicts Long-Term Adverse Events After Carotid Artery Stenting: A Case-Control Study (version1)

To investigate whether the number of superficial calcification clusters in target carotid plaque influences the prognosis of patients undergoing carotid artery stenting (CAS) by altering intraplaque stress distribution. Patients receiving CAS and occurring major adverse cardiovascular events (MACEs) more than 30 days after discharge during follow-up were screened from the carotid stenosis database. These were matched 1:2 with controls based on age, sex, BMI, symptom status, alcohol abuse, smoking history, and > 3 superficial calcification clusters in the target plaque. Finite element analysis simulated intraplaque stress distribution during balloon inflation and revealed significantly elevated intraplaque maximum principal stress in patients with numerous superficial calcification clusters. Subsequent analysis of all 42 patients in the case-control study using Conditional logistic regression demonstrated that maximum principal stress at the superficial calcification-tissue interface (PSSCT) > 110 kPa was significantly associated with MACEs [P = 0.0429; odds ratio (OR) = 5.31; 95% confidence interval (CI): 1.05–26.8]. Finally, analysis of maximum PSSCT in target plaques containing varying numbers of superficial calcification clusters revealed that plaques with more superficial calcification clusters exhibited an increased probability of developing elevated maximum PSSCT. Therefore, elevated maximum PSSCT is significantly associated with MACEs in patients receiving CAS, representing a likely mediating pathway through which the number of superficial calcification cluster influences long-term prognosis after CAS.