$Background$

Inflammation drives atherosclerotic plaque rupture. Although inflammation can be measured using fluorine-18-labeled fluorodeoxyglucose positron emission tomography ([$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG PET), [$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG lacks cell specificity, and coronary imaging is unreliable because of myocardial spillover.

$Objectives$

Objectives This study tested the efficacy of gallium-68-labeled DOTATATE ($\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE), a somatostatin receptor subtype-2 (SST2)-binding PET tracer, for imaging atherosclerotic inflammation.

$Methods$

We confirmed $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE binding in macrophages and excised carotid plaques. $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE PET imaging was compared to [$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG PET imaging in 42 patients with atherosclerosis.

$Results$

Target $SSTR2$ gene expression occurred exclusively in “proinflammatory” M1 macrophages, specific $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE ligand binding to SST$\mathrm{<mrow\; data-mjx-texclass="ORD">2</mrow>}$ receptors occurred in CD68-positive macrophage-rich carotid plaque regions, and carotid $SSTR2$ mRNA was highly correlated with in vivo $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE PET signals (r = 0.89; 95% confidence interval [CI]: 0.28 to 0.99; p = 0.02). $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE mean of maximum tissue-to-blood ratios (mTBR) correctly identified culprit versus nonculprit arteries in patients with acute coronary syndrome (median difference: 0.69; interquartile range [IQR]: 0.22 to 1.15; p = 0.008) and transient ischemic attack/stroke (median difference: 0.13; IQR: 0.07 to 0.32; p = 0.003). $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE mTBR predicted high-risk coronary computed tomography features (receiver operating characteristics area under the curve [ROC AUC]: 0.86; 95% CI: 0.80 to 0.92; p < 0.0001), and correlated with Framingham risk score (r = 0.53; 95% CI: 0.32 to 0.69; p <0.0001) and [$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG uptake (r = 0.73; 95% CI: 0.64 to 0.81; p < 0.0001). [$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG mTBR differentiated culprit from nonculprit carotid lesions (median difference: 0.12; IQR: 0.0 to 0.23; p = 0.008) and high-risk from lower-risk coronary arteries (ROC AUC: 0.76; 95% CI: 0.62 to 0.91; p = 0.002); however, myocardial [$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG spillover rendered coronary [$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG scans uninterpretable in 27 patients (64%). Coronary $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE PET scans were readable in all patients.

$Conclusions$

We validated $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE PET as a novel marker of atherosclerotic inflammation and confirmed that $\mathrm{<mrow\; data-mjx-texclass="ORD">68</mrow>}$Ga-DOTATATE offers superior coronary imaging, excellent macrophage specificity, and better power to discriminate high-risk versus low-risk coronary lesions than [$\mathrm{<mrow\; data-mjx-texclass="ORD">18</mrow>}$F]FDG. (Vascular Inflammation Imaging Using Somatostatin Receptor Positron Emission Tomography [VISION]; NCT02021188)