Aortic Arch Atheroma Research Articles

Prevalence and Characteristics of Known versus Newly Detected Atrial Fibrillation in Ischemic Stroke: A Population-Based Study

Background: Atrial fibrillation (AF) is frequently diagnosed during the acute stage of ischemic stroke (IS), and it may reflect undiagnosed AF before stroke, thus representing a missed opportunity for stroke prevention. This population-based study aimed to assess the prevalence of known AF (KAF) and AF diagnosed early after IS (AFDAS) and to compare clinical and brain/arterial imaging characteristics between patients. Methods: Among patients with acute IS recorded in the population-based Dijon Stroke Registry, France (2013–2020), we identified those with KAF or AFDAS. AFDAS was considered when AF was diagnosed during the initial work-up based on electrocardiograms, in-hospital continuous electrocardiographic and/or Holter monitoring. Clinical and imaging characteristics on brain CT scan or angio-CT scan when available including old parenchymal lesions, arterial territory of the index IS, and aortic arch, cervical and intracranial arteries atheroma were compared between groups (KAF vs. AFDAS). Regression logistic models were used to assess factors associated with AFDAS (compared to KAF). Results: Among 1,756 IS patients, 550 (31.3%) had AF (mean age: 83.6 ± 10.3 years old, 60.5% women), of whom 367 (66.7%) presented with KAF and 183 (33.3%) had AFDAS. In multivariable model, hypertension (OR = 0.37; 95% CI: 0.21–0.64, p p = 0.002), previous stroke (OR = 0.42; 95% CI: 0.26–0.67, p p p = 0.012). Conclusions: Our findings indicate a more advanced stage of the atrial cardiomyopathy in KAF as compared with AFDAS patients and may thus contribute to the fact that in these latter patients AF had not been diagnosed prior to stroke. This group of patients undeniably represents a missed opportunity for stroke prevention.

The Role of Transcranial Doppler in Patients with Cryptogenic Stroke

Identifying the stroke mechanism is crucial for secondary prevention of ischemic stroke. However, approximately 20% to 30% of patients with ischemic stroke do not display a discernible cause after standard diagnostic evaluation and are classified as having cryptogenic stroke. Most cryptogenic strokes are believed to be of embolic origin, referred to as embolic stroke of undetermined source. Several potential causes, including occult atrial fibrillation, aortic arch atheroma, non-stenotic atherosclerosis, coagulopathy, and patent foramen ovale (PFO), are significant contributors to cryptogenic stroke. Among these, PFO-associated strokes often manifest as small cortical lesions in the posterior circulation and are associated with fewer traditional risk factors. Ischemic stroke is considered a high risk if there is a large PFO with significant shunting or the presence of an atrial septal aneurysm. Although transesophageal echocardiography is regarded as the gold standard for diagnosing PFO, its invasiveness, high cost, and challenges in certain stroke patients necessitate alternative approaches. Recently, transcranial Doppler (TCD) has emerged as a valuable screening tool for detecting high-risk PFOs, as supported by recent research. Accurate determination of the culprit PFO responsible for ischemic stroke remains crucial for guiding appropriate treatment decisions. This article provides a comprehensive review of the different modalities used to diagnose PFO, strategies for assessing the risk of PFO causing paradoxical embolism, and the role of TCD in patients with cryptogenic stroke caused by other etiologies.

Aortic arch atheroma and stroke recurrence in mild stroke patients: ADS post-hoc analysis

BackgroundAortic arch atheroma is one of the embolic sources in patients with ischemic stroke. Although transesophageal echocardiogram (TEE) is the golden standard to evaluate the aortic arch atheroma, it is invasive and may be limited to patients with suspected embolism. Present post-hoc analysis evaluated the acute dual study data on mild stroke patients who had aortic arch atheroma proven by TEE and evaluate whether combined cilostazol and aspirin therapy might reduce the rate of stroke recurrence comparing aspirin therapy. MethodsAortic arch atheroma was defined as aortic arch plaque with a maximal intima-medial thickness of ≥4.0 mm. Stroke recurrence included new diffusion-weighted image (DWI) lesions within 14 days. ResultAmong 316 (227 [72%] men; median, 66 [interquartile, 60–76] years old) patients, TEE found that 93 patients (29%) had the aortic arch atheroma, and 223 (71%) did not had it. The aortic arch atheroma group was older (P = 0.001) and accompanied with diabetes mellitus (P = 0.003), dyslipidemia (P = 0.046), smoking (P = 0.034), and had previous ischemic stroke history (P = 0.042) and multiple infarcts (P = 0.024) on admission. During hospitalization, new DWI lesion was frequently observed in the aortic arch atheroma group compared to the group without it (14.1% vs. 6.8%, P = 0.049). The rates of new DWI lesion were not different between dual antiplatelet therapy group and aspirin group (14.9% vs. 13.3%, P = 1.000). ConclusionAortic arch atheroma was the representative of systematic arteriosclerosis associated with new DWI lesion in short-term. Combined antiplatelet therapy using cilostazol did not prevent new DWI appearance comparing aspirin therapy in this cohort.

Аortic arch atheroma as a source of arterio-arterial embolism and ischemic stroke

Introduction. Currently, despite the introduction of modern diagnostic algorithms in 20-40 % of patients with ischemic stroke, it is not possible to establish its cause. Potential causes of acute cerebral ischemia in patients with cryptogenic ischemic stroke include paroxysmal atrial fibrillation, patent foramen ovale, atrial cardiomyopathy, carotid network, aortic arch atheroma, and cancer-associated thrombophilia.Target: to systematize data on methods for diagnosing and preventing aortic arch atheroma.Material and methods. The literature search was carried out in electronic search systems Scopus, eLibrary, PubMed using the key words: ischemic stroke, cryptogenic stroke, aortic arch atheroma, pathogenesis of ischemic stroke.Results. At present, despite such a detailed study of therapeutic strategies for the prevention of recurrent thrombotic events in patients with aortic arch atheroma, none of the drugs has proven its advantage. Although the NAVIGATE ESUS and RESPECT ESUS trials did not show the superiority of oral anticoagulants over antiplatelet agents in preventing recurrent ischemic strokes in patients with cryptogenic stroke, it was found that cryptogenic ischemic stroke is heterogeneous, which requires a differentiated approach to secondary prevention.Conclusion. Аortic atheroma can be the cause of embolic syndrome and cryptogenic stroke. The main methods for diagnosing aortic atheroma are transesophageal echocardiography and computed tomographic angiography. The therapeutic strategy for the treatment of aortic atheroma is lipid-lowering, antithrombotic therapy in combination with blockers of the renin-angiotensin-aldosterone system.

Spontaneous Echo Contrast in the Left Atrium and Aortic-Arch Atheroma, Detected by Transesophageal Echocardiography, Was Negatively Correlated with Cognitive Function.

The relationship between transesophageal echocardiography findings and cognitive function. This study aimed to establish an association between transesophageal echocardiography findings and cognitive function in stroke survivors. A single-center study was conducted between April 1, 2017 and March 31, 2022. All subjects that were included had a past history of ischemic stroke and were admitted after >21 days from onset. The participants underwent cognitive function tests including a Mini-Mental State Examination, Revised Hasegawa Dementia Scale, Frontal Assessment Battery, and transesophageal echocardiography. The results of 126 participants were analyzed. The cognitive function of participants with a spontaneous echo contrast (+) in the left atrium including appendage or of those with an aorta-arch plaque with a maximum thickness ≥4 mm significantly worse while neither the patent foramen ovale nor the branch extending plaque influenced cognitive function (The median cognitive scores of the spontaneous echo contrast (-) versus (+) were 26 versus 22, p < 0.01**, 26 versus 21, p < 0.001***, and 14 versus 11, p < 0.01**. Those of the aortic-arch plaque max thickness (<4 mm) versus (≥4 mm) were 26 versus 25, p < 0.05*, 27 versus 24, p < 0.05*, and 15 versus 13, p < 0.05*). Our findings show that spontaneous echo contrast in the left atrium and aortic-arch atheroma detected by transesophageal echocardiography, were negatively associated with cognitive function.

A call to improve the diagnosis and treatment of cardiogenic stroke: there is still a long way to go

Cardiogenic stroke, manifested as a clinical syndrome in which emboli from the heart and aortic arch pass through the circulation and cause cerebral artery embolism and corresponding brain dysfunction, accounts for 20% to 30% of all ischemic strokes. Regarding the etiological classification, the boundary between cardiogenic stroke and cryptogenic stroke, especially embolic stroke of undetermined source (ESUS), as well as aortic arch atheromas categorization remain uncertain. Concerning the diagnosis, the criteria need to be formulated and unified, and thus the author proposes new diagnostic criteria. With regard to the treatment, anticoagulation therapy should be started or restarted several days to several weeks after the onset of stroke (e.g., atrial fibrillation-related), and treatment during acute phase and for prevention of stroke recurrence should be initiated after multi-disciplinary consultation.

Coexisting of aortic arch atheroma and atrial fibrillation for short-term recurrence and poor functional outcome in acute stroke.

Multiple embolic sources are sometimes observed simultaneously in patients with embolic stroke. The present study investigated the effects of coexisting aortic arch atheroma ≥ 4mm thick and atrial fibrillation (AF) on short-term stroke recurrence and functional outcome. Transesophageal echocardiography (TEE) was performed in consecutive embolic stroke patients, and 395 patients were classified into 4 groups according to the presence of aortic arch atheroma ≥ 4mm thick and AF: AF - /ARCH - group, AF + /ARCH - group, AF - /ARCH + group, and AF + /ARCH + group. In accordance with these 4 groups, we evaluated stroke recurrence and all-cause death for 3months after stroke onset, and also evaluated the 3-month functional outcome using the modified Rankin scale (mRS). Among the 128 AF patients, 39.1% also had aortic arch atheroma ≥ 4mm thick. Of the 395 enrolled cases, the AF + /ARCH + group showed the highest frequencies of stroke recurrence and all-cause death during 3months after onset. On multivariate analysis, stroke recurrence or all-cause death during 3months after onset was relatively more frequent in the AF + /ARCH + group than in the AF + /ARCH - group (OR, 2.34; 95% CI, 0.82-6.69; p = 0.11), but that was not statistically significant, and poor functional outcome (mRS score 3-6) at 3months was significantly more frequent in the AF + /ARCH + group than in the AF + /ARCH - group (OR, 2.59; 95% CI, 1.08-6.24; p = 0.0339). Aortic arch atheroma concomitant with AF is not rare and appears associated with increased risks of stroke recurrence and poor functional outcome.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography.

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

Aortic Sources of Embolism.

Aortic arch atheroma is a frequent finding in ischemic stroke patients. Its role as a source of cerebral emboli or a marker of atherosclerosis is unclear. Transesophageal echography is considered the gold standard for its detection, whereas computed tomography angiography is a good alternative; magnetic resonance and positron emission tomography could be proposed to better analyze plaque vulnerability. Despite the interest in this condition, the optimal antithrombotic treatment remains uncertain, while intensive lipid-lowering therapy should be recommended. This review aims to offer guidance on patients with aortic arch atheroma, about its causal role in stroke, diagnosis, and treatment based on current available evidence.

Impact of early transesophageal echocardiography on therapeutic management of patients with acute embolic strokes of undetermined source (ESUS)

Up to one-fourth of ischemic strokes remain cryptogenic after standard evaluation. The ESUS concept for embolic strokes of undetermined source was defined in 2014, the patients being supposed to benefit from anticoagulation, but the studies are negative as of this date. Transthoracic and transesophageal (TEE) echocardiography are the main diagnostic tools for cardiac and aortic sources of embolism, the second being superior. However, its therapeutic impact is not fully determined, since it is not recommended in ESUS. We aimed to assess prospectively, in consecutive ESUS patients admitted to our stoke unit, the rate of treatment change induced by transesophageal echocardiography (TEE), and to identify predictive factors for such modifications. Acute ESUS patients were prospectively included to undergo TEE within seven days. Demographic, laboratory, MRI and echocardiographic data were recorded. The primary endpoint was the rate of TEE induced therapeutic modification. Between October 2016 and May 2018, 154 ESUS patients entered the analyses. TEE changed the treatment in 22 patients (14.3%): anticoagulation in 7, cardiac surgery in 2, dual antiplatelet therapy for complex aortic arch atheroma in 10, antibiotics in 2 and atrial septal defect closure in 1. Patients with TEE induced treatment modification were significantly older (68.9 vs. 59.0 years, P < 0.001), and had more vascular risk factors: diabetes mellitus (36.4% vs. 15.9%, P = 0.036), hypertension (68.2% vs. 43.9%, P = 0.035), hypercholesterolemia (72.7% vs. 28.8%, P < 0.001) and more CRP (63.6% vs. 33.3%, P = 0.007), hs Troponin I (50.0% vs. 22.7%, P = 0.007) and NT-pro-BNP (31.8% vs. 9.8%, P = 0.011) elevation. There was a trend to more multiple infarcts on DWI MRI in treatment change group (50.0% vs. 31.8%, P = 0.097). TEE lead to a treatment modification in 14% of cases. Selected ESUS patients may benefit from TEE.

Transesophageal echocardiography for aortic arch atheromas in patients with cryptogenic stroke/transient ischemic attack – An underutilized entity

Introduction: Large aortic arch atheromas (≥4 mm) and complex and mobile aortic atheromas have been associated with ischemic brain stroke in various previous studies. Transesophageal echocardiography (TEE) is the imaging modality of choice, however, is an underutilized investigation in routine clinical practice. We sought out to find the prevalence and severity of aortic arch atheromas in patients with cryptogenic stroke/transient ischemic attack (TIA) at a tertiary care center. Patients and Methods: One hundred and eighty-eight consecutive stroke patients were screened for stroke risk factors. Sixty-one patients were found to have stroke without obvious cause (cryptogenic), 52 patients underwent TEE, four patients were further excluded after evidence of potential cardioembolic source in TEE, and finally, data of 48 patients with cryptogenic stroke were analyzed. Results: We found that one-third of the patients (n = 16, 33.3%) had aortic atheromas and half of them (n = 8, 16.4%) had atheromas ≥4 mm. Diabetes, dyslipidemia, and smoking status were individually associated with a higher prevalence of aortic plaques in our study (P = 0.03). The frequency of aortic plaques was significantly higher in patients with ischemic brain infarction than in TIA (P = 0.01). Large atheromas (≥4 mm) were significantly associated with more severe clinical illness as assessed by the National Institute of Health Stroke Scale, longer hospital stay, and death (P Conclusions: In the present observational study at a tertiary care center, we found that the relevant aortic atheromas in patients with cryptogenic stroke are fairly common and are associated with adverse clinical events. The diagnosis of aortic atheromas should be sought actively by TEE in patients with cryptogenic stroke or in patients with recurrent embolic events and multiple risk factors. Antiplatelet agents and statins are the mainstay of therapy. Anticoagulation is reasonable in selected high-risk patients. Future randomized trials of direct oral anticoagulants compared to antiplatelet therapy in patients with complex aortic atheromas are anticipated to guide the clinicians.

Etiology of Cryptogenic Stroke

Ischemic stroke is a heterogeneous syndrome with a plurality of potential etiological factors. The routine diagnosis does not always allow the cause of acute cerebrovascular accident to be found, in such cases we talk about cryptogenic ischemic stroke, which incidence is 20-40%. The category of patients with cryptogenic stroke was first characterized and assigned to a separate group in the database of the National Institute of Neurological Diseases and Stroke in the USA, and later in the TOAST study. The diagnosis of cryptogenic stroke is usually based on the exclusion of well-known causes of acute cerebrovascular accidents, such as atherosclerosis, cardiac arrhythmias, arterial hypertension. Due to the considerable variability of concepts for cryptogenic stroke, the term ESUS (Embolic Stroke of Undetermined Source) appeared in 2014 and formulated criteria which accurately characterized these patients: non-lacunar cerebral infarction by CT and/or MRI, no atherosclerotic lesion stenosing a stroke-associated artery of more than 50%, no sources of high-risk cardioembolism, no other causes of stroke such as dissection of the artery supplying the area of infarction in the brain, migraine, arteritis. Among the potential causes and sources of cerebral embolism in patients with cryptogenic stroke are heart, veins of lower extremities and pelvis, nonstenosing atherosclerosis of brachiocephalic artery, atheroma of aortic arch, paradoxical embolism non-atherosclerotic vasculopathy, monogenic diseases, hypercoagulable states, and others. We should note that there is a lot of studies on the possible causes of cryptogenic stroke in the available literature, but no common approach to classification of etiologic factors and examination algorythms were developed. The high incidence of cryptogenic stroke, the significant heterogeneity of its etiopathogenetic mechanisms and the need for differentiated approaches to the secondary prevention of this type of acute cerebrovascular accident determine the relevance of further studies in this field.

P2469The yield of transoesophageal echocardiography in embolic stroke of unknown source

Abstract Purpose Transthoracic echocardiography (TTE) and transoesophageal (TOE) are the main diagnostic tools for the detection of potential cardiac and aortic sources of embolism (PCSE). TOE is superior to TTE. However, its therapeutic impact is questioned. TOE is no longer recommended in ESUS (embolic stroke of unknown source), which is thought to be caused by undiagnosed atrial fibrillation (AF). Recent studies however report an about 10% change in therapeutic management due to TOE. We aimed to assess prospectively, in patients admitted to our stoke unit and diagnosed ESUS, the rate of treatment change induced by TOE. Methods Patients diagnosed with acute (≤7 days) ESUS were included to undergo TOE. ON TTE, PCSE, left ventricular ejection fraction (LVEF, %), left atrial area (LA-A, cm2), indexed left atrial volume (LAV, ml/m2) were recorded. On TOE, PCSE, left atrial appendage area (LAA-A, cm2), left atrial appendage emptying velocity (LAA-EV, cm/s) were recorded. PCSE on TTE and TOE were classified according to EAE guidelines. Results Between October 2016 and May 2018, 1322 TTEs were performed in patients admitted to our newly labelled stroke unit. ESUS was diagnosed in 152 patients, who underwent TOE. Mean delay (95% CI) between stroke onset and TTE was 2.2 days (1.9–2.5). Mean (95% CI) age was 61 years (58–63). 56/152 were female (37%). On TTE, mean (95% CI) LVEF was 62% (61–64), mean LA-A was 19 cm2 (19–20) and mean LA-V was 32 ml/m2 (31–34) ml/m2. In 38 patients, a major PCSE was identified by TTE. In 4 cases, there were 2 potential major PCSE and in one case 3. In 79 patients, at least one minor PCSE was identified by TTE, among which 35 PFO. On TEE, mean (95% CI) LAA-A and LAA-EV were: 5.2 cm2 (4.9–5.5) % and 76 cm/s (72–80) cm/s. In 50 patients, a major PCSE was identified by TOE. Eleven patients had 2 major PCSE. In 115 patients, at least one minor PCSE was identified by TOE, among which 34 PFO. According to EAE guidelines, a treatment change induced by TOE occurred in 12 patients. Anticoagulation in 5 patients (aortic arch thrombus in 2, thrombus of the proximal descending aorta in 1, LAA thrombus in 1, and thrombotic non-infectious vegetations in 2). Surgery in one patient (LAA fibroelastoma), antibiotics in two patients with infectious endocarditis, One patient had aortic fibroelastoma not seen on TTE. Finally, two patients with mobile aortic arch debris had dual antiplatelet therapy (DAT). In two other patients, TOE showed a mitral fibroelastoma and a mobile aortic arch thrombus, but these abnormalities were already seen on TTE, hence not taken into account. When considering the eight patients who had, at neurologist's discretion, the instauration of DAT for complex aortic arch atheroma, 12+8 patients had therapeutic modifications induced by TOE (13%). Conclusion Major PCSE on TOE lead to a treatment change in 12/152 patients (8%) according to EAE guidelines, and 13% when complex aortic arch atheroma was considered.

Effectiveness of embolic protection filter devices in stroke prevention during endovascular aortic arch repair in significant aortic atheroma patients.

The objective of this study was to evaluate the effectiveness of embolic protection filter device in stroke prevention during hybrid endovascular arch repair in patients with significant aortic atheroma. Twenty-two patients (20 men, mean age 79.0 years, mean logistic EuroSCORE 23.9%) with aortic arch/proximal descending aortic diseases and significant aortic atheroma (atheroma grade ≥ II) who were deemed unfit for conventional open surgery underwent endovascular aortic arch repair with protection of the supra-arch vessels using a balloon catheter and filter devices. The effectiveness in preventing stroke was evaluated by a postoperative neurological examination protocol, which was followed by neuroimaging with computed tomography/DW-magnetic resonance imaging (MRI) study in cases with neurological deficits. The atheroma grades of the aortic arch were II, III and IV in 36%, 14% and 50% of the patients, respectively. In total, 37 filter devices were placed in the supra-aortic vessels (5 brachiocephalic arteries, 23 carotid arteries, 5 subclavian arteries and 4 vertebral arteries). Technical success was achieved in all patients, and 30-day mortality was 4.5% (1/22 cases). Two (9.1%) cases showed neurological symptomatic stroke postoperatively. With DW-MRI examination, a major new region was detected in the filter-protected left carotid artery in one case and in the balloon-protected left vertebral artery in another case. In high-risk patients with significant aortic arch atheroma, hybrid endovascular aortic arch repair with embolic protection using a filter device showed satisfactory early results. Filter protection could be an attractive adjunct manoeuvre for preventing critical stroke during endovascular arch repair.

Etiologies of simultaneous cerebral infarcts in multiple arterial territories: A simple literature-based pooled analysis.

Acute multiple infarcts in multiple cerebral circulations are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories. We conducted a systematic review of the literature using PubMed, Scopus, Embase, Clinicaltrial.gov, WHO International Clinical Trials Registry Platform (ICTRP), and Cochrane library. Studies reporting multiple acute strokes in more than one arterial territory based on diffusion-weighted imaging (DWI) findings were reviewed and included. Studies were excluded if they had limited inclusion criteria, performed limited subgroup analysis, did not use diffusion weighted imaging (DWI), and were not published in English. Out of 15056 stroke patients from 21 studies included in this study, 1914 (13%) patients had acute multiple infarcts in multiple cerebral circulations. One hundred and ninety-nine patients were excluded as their workup and diagnosis were not reported. Out of 1715 patients, 472 (27.6%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories [37.2%, 95% confidence interval (CI): 36-40%] followed by large artery atherosclerosis including aortic arch atheroma (25.7%, 95% CI: 21-25%). Hematological disorders were found to be the cause of cerebral infarcts in 36 (2.1%, 95% CI: 2-4%) patients. Other etiologies for stroke in multiple arterial territories were small vessel pathologies and intracranial small vessel atherosclerosis (1.8%), inflammatory disorders such as vasculitis and infection (0.2%), and iatrogenic causes (0.1%). Acute multiple infarcts in multiple cerebral circulations occur among 13% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.

Externalized transapical guidewire technique for complex aortic disease: a single-centre experience.

The through-and-through guidewire technique has been utilized for safe advancement of a high-profile stent graft delivery system through the tortuous aorta. A brachial-to-femoral configuration is most commonly established, but a few alternatives have been described. This study aimed to report our experience with the externalized transapical guidewire (ETAG) technique in patients who underwent thoracic endovascular aortic repair (TEVAR) and to explore its utility, feasibility and safety. Patients who underwent TEVAR between April 2015 and March 2017 were retrospectively reviewed, and 5 patients who underwent the procedure with the ETAG technique were found eligible for the study. Indications for the ETAG technique were the following challenging aortic anatomical configurations: (i) severely angulated aorta in 3; (ii) proximity of the proximal landing zone to the aortic valve in 2; (iii) a limited proximal landing zone in 1; and (iv) complex atheroma predominantly on the greater curvature of the aorta in 3 patients. TEVAR was completed in all cases. The ETAG technique was utilized in all patients. The delivery system tip was navigated along the lesser curvature of the aortic arch as it was advanced. During deployment, conformability was increased by pushing both ends of the wire. Tip retrieval was also enhanced in 3 patients. Patients with complex aortic atheroma had no embolic complications. All patients survived TEVAR, but 1 patient with an aorto-oesophageal fistula did not survive the second-stage oesophagectomy. Postoperative complications included delayed cardiac tamponade requiring drainage in 2 patients. The ETAG technique was useful in overcoming several anatomical challenges encountered during TEVAR. Contact of the delivery system with the greater curvature of the aortic arch could be avoided with this technique, potentially reducing embolization risk related to the complex aortic arch atheroma.

PAR2 (Protease-Activated Receptor 2) Deficiency Attenuates Atherosclerosis in Mice.

PAR2 (protease-activated receptor 2)-dependent signaling results in augmented inflammation and has been implicated in the pathogenesis of several autoimmune conditions. The objective of this study was to determine the effect of PAR2 deficiency on the development of atherosclerosis. PAR2 mRNA and protein expression is increased in human carotid artery and mouse aortic arch atheroma versus control carotid and aortic arch arteries, respectively. To determine the effect of PAR2 deficiency on atherosclerosis, male and female low-density lipoprotein receptor-deficient (Ldlr-/-) mice (8-12 weeks old) that were Par2+/+ or Par2-/- were fed a fat- and cholesterol-enriched diet for 12 or 24 weeks. PAR2 deficiency attenuated atherosclerosis in the aortic sinus and aortic root after 12 and 24 weeks. PAR2 deficiency did not alter total plasma cholesterol concentrations or lipoprotein distributions. Bone marrow transplantation showed that PAR2 on nonhematopoietic cells contributed to atherosclerosis. PAR2 deficiency significantly attenuated levels of the chemokines Ccl2 and Cxcl1 in the circulation and macrophage content in atherosclerotic lesions. Mechanistic studies using isolated primary vascular smooth muscle cells showed that PAR2 deficiency is associated with reduced Ccl2 and Cxcl1 mRNA expression and protein release into the supernatant resulting in less monocyte migration. Our results indicate that PAR2 deficiency is associated with attenuation of atherosclerosis and may reduce lesion progression by blunting Ccl2- and Cxcl1-induced monocyte infiltration.

Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Correction to: 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Abstract WP211: Mechanism of Simultaneous Cerebral Infarcts in Multiple Arterial Territories: A Literature-Based Pooled Analysis

Introduction: Acute multiple cerebral infarcts in multiple arterial territories are thought to suggest the presence of cardioembolic sources. However, several studies have shown other etiologies for simultaneous cerebral infarcts in multiple arterial territories. Methods: We conducted a systematic review of the literature through PubMed, Scopus, Embase, Clinicaltrial.gov, ICTRP and Cochrane library. Studies containing multiple acute strokes in more than one arterial territory based on diffusion weighted imaging (DWI) findings were screened. Articles were excluded if they had limited inclusion criteria, performed limited subgroup analysis, or did not use DWI. Results: Out of 16551 stroke patients from 25 studies included in this study, 1967 (12%) patients had simultaneous acute cerebral infarcts in multiple arterial territories. 199 patients were excluded as their workup and diagnosis were not reported. Out of 1768 patients, 491 (28%) patients had an undetermined etiology. Cardioembolism was the most common cause of stroke in multiple arterial territories (38%, 95%CI: 36-40%) followed by large artery atherosclerosis including aortic arch atheroma (23%, 95%CI: 21-25%). Hematological disorders were found to be the cause of cerebral infarcts in 52 (3%, 95%CI: 2-4%) patients. Out of 143 patients who were reported to have simultaneous brain infarcts in bilateral hemispheres or anterior and posterior circulations, 78 (54%, 95%CI: 46-62%) were found to have cardiacembolism. Other etiologies for stroke in multiple arterial territories were intracranial atherosclerosis, vasculitis and other inflammatory diseases, infection, and iatrogenic causes. Conclusion: Simultaneous cerebral infarcts in multiple arterial territories occur among 12% of stroke patients. Although cardioembolism is the most common cause, there are several other etiologies that require a different workup and secondary prevention strategy.

Cardioembolic Stroke: Mechanisms and Therapeutics

AbstractCardioembolic stroke accounts for nearly 30% of all known stroke mechanisms. This percentage may be underestimated, however, when considering the large proportion of cryptogenic strokes that likely have a covert cardiac source. Although it is well known that cardioembolic stroke can occur in the setting of atrial fibrillation, other mechanisms such as a systolic heart failure, patent foramen ovale, valvular dysfunction, and aortic arch atheroma are commonly encountered in daily practice. The authors provide an overview on the epidemiology, pathogenesis, diagnostic evaluation, and secondary prevention treatment strategies for cardioembolic stroke.