Accentuated remodeling on the upstream side of atherosclerotic lesions

Although it has been postulated that atherosclerotic stenotic lesions cannot remodel in response to altered flow, evidence to support or refute this hypothesis has been elusive. In vitro models have shown that accelerated endothelial shear stress occurs on the upstream side of stenoses, while turbulent lower shear stress is seen on the downstream side. We therefore compared vascular remodeling at paired sites 2 mm upstream and 2 mm downstream of the site of minimal lumen area in 25 atherosclerotic lesions in 23 patients using intravascular ultrasound. Remodeling was compared by 2 methods: normalized vessel area (vessel arealesion/vessel areareference) and remodeling index (change in vessel area/change in plaque area from reference). Normalized vessel area was significantly greater upstream than downstream (1.21 ± 0.06 vs 1.12 ± 0.09; p <0.05), despite similar plaque burden (8.84 ± 0.81 vs 8.42 ± 0.85 mm2) resulting in larger lumen area (8.15 ± 1.02 vs 6.10 ± 0.88 mm2; p <0.05). Remodeling index was also significantly higher upstream than downstream (0.67 ± 0.20 vs 0.12 ± 0.24, respectively, p <0.05). Accentuation of remodeling on the upstream side was significantly correlated (r = 0.54, p = 0.01) with the mean degree of shear acceleration expected by stenosis severity. Impaired remodeling on the downstream side may partly explain stenosis propagation down a vessel.