Distinct Cross-Vascular Association Patterns of Carotid Plaque Burden and Vulnerability Features with Coronary Atherosclerotic Burden in Patients Undergoing Carotid Revascularization

Background/Objectives: This study aimed to investigate the associations between preoperative carotid high-resolution magnetic resonance imaging (HR-MRI) plaque features and coronary atherosclerotic burden, and to compare the cross-vascular association patterns of plaque burden-related measures and individual vulnerable plaque features. Methods: This retrospective study included consecutive patients who underwent carotid revascularization and had both preoperative carotid HR-MRI and coronary computed tomography angiography (CTA) between April 2017 and December 2024. Carotid plaque characteristics included calcification, lipid-rich necrotic core (LRNC), intraplaque hemorrhage (IPH), loose matrix (LM), ulceration, maximum wall thickness (MWT), maximum wall area (MWA), and normalized wall index (NWI). Coronary atherosclerotic burden was characterized using coronary artery calcium score (CACS), maximum luminal stenosis, and the number of diseased coronary arteries; the number of coronary arteries with ≥50% stenosis was additionally recorded. Associations between carotid plaque characteristics and coronary atherosclerotic burden were evaluated using correlation analyses and multivariable logistic regression. Results: A total of 162 patients were included (mean age, 66.11 ± 7.54 years; 138 [85.2%] men). CACS ≥ 400 was present in 76 patients (46.9%), obstructive coronary disease (≥50% stenosis in at least one coronary artery) in 96 patients (59.3%), and involvement of ≥3 diseased coronary arteries in 128 patients (79.0%). Greater coronary atherosclerotic burden was consistently associated with higher carotid calcification volume and MWT and NWI (all p < 0.05). After adjustment for clinical risk factors and correction for multiple testing, calcification volume, MWT and NWI remained associated with CACS ≥ 400, obstructive coronary disease, and involvement of ≥3 diseased coronary arteries. In contrast, individual vulnerable plaque features, including LRNC, IPH, LM, and ulceration, showed weaker and less consistent associations. Conclusions: In patients undergoing carotid revascularization, preoperative carotid HR-MRI-derived plaque burden-related features showed more consistent associations with coronary atherosclerotic burden than individual vulnerable plaque features. These findings suggest that plaque burden-related and vulnerable plaque features may reflect different aspects of atherosclerosis, with plaque burden-related measures more closely reflecting cumulative systemic atherosclerotic involvement and vulnerable plaque features primarily characterizing local plaque composition and instability.