Aortic Arch Type Research Articles

P-004 Radiation Dose Analysis of Large and Giant Internal Carotid Artery Aneurysm Treatment with the Pipeline Embolization Device versus Traditional Coiling Techniques

BackgroundFlow diversion is an effective and increasingly accepted method for endovascular treatment of cerebral aneurysms. Additionally, the public has heightened concerns regarding radiation exposure from medical procedures. This study analyzes...

Interrupted aortic arch with retrograde subclavian perfusion

Type B interrupted aortic arch results in the left subclavian artery being perfused by a patent ductus arteriosus and antegrade flow is usually seen in the left subclavian artery. We describe a case of retrograde perfusion of the left subclavian artery through the circle of Willis in the presence of interrupted aortic arch type B and a restrictive patent ductus arteriosus. This is similar to subclavian steal syndrome when the perfusion pressure from the cerebral circuit is greater than that from the left subclavian artery. Early recognition of this phenomenon may alter management by indicating restriction at ductal level. This case highlights the need for a comprehensive review of both ventricular systolic function and ductal haemodynamics when retrograde flow is seen in the subclavian artery.

Radiation dose analysis of large and giant internal carotid artery aneurysm treatment with the pipeline embolization device versus traditional coiling techniques

BackgroundFlow diversion is an effective and increasingly accepted method for endovascular treatment of cerebral aneurysms. Additionally, the public has heightened concerns regarding radiation exposure from medical procedures. This study analyzes...

Tetralogy of Fallot with coarctation of the aorta: a newly recognised developmental and anatomic syndrome

Tetralogy of Fallot and coarctation of the aorta is an exceptional association. We report here four cases of infants referred for tetralogy of Fallot with or without pulmonary atresia associated with aortic coarctation from 1974 to 2013. All had a right aortic arch, and the coarctation was abnormally situated between the right common carotid and the right subclavian arteries. In all, two infants had an abnormal left subclavian artery and one child had DiGeorge syndrome. All underwent staged surgical repair of the left and right-sided obstructions. A review of the literature shows two types of coarctation in this context. In left aortic arch, coarctation is situated distal to the left subclavian artery. In right aortic arch, coarctation is distal to the right common carotid artery, mirror-image of interrupted left aortic arch type B, associated with anomalies of the branches of the aorta, and should be considered a complex anomaly of aortic arches in the setting of an outflow tract defect due to abnormal migration of cardiac neural crest cells. Screening for this unusual association is critical in the initial assessment of all patients with tetralogy of Fallot.

Abstract W P23: Predictors of Time From Groin Puncture to Base Catheter Placement

Background and Purpose: Time to reperfusion is recognized as an important predictor of good outcome in endovascular stroke therapy. A significant but unstudied factor in delay to reperfusion is prolonged time from groin puncture to base catheter placement (P2C). The purpose of this study was to assess the factors that influence time from P2C in the cohort of patients in whom procedural steps were collected prospectively. Methods: A prospective analysis of patients who had intra-arterial therapy for acute stroke from August of 2012 to August of 2013 was performed. Following characteristics were collected: baseline clinical demographics, aortic arch types, time from P2C, procedural and clinical outcomes. Results: Data from a total of 143 patients were collected prospectively {median age 69 years; median baseline NIH Stroke Scale 16; occlusion sites: MCA-M1 71%; MCA-M2 13%, ICA-T 6%, basilar artery 10%, tandem occlusion 26%}. Patients were further divided based on their arch type (type 1: 48%, type 2: 33%, type 3: 13%). Majority of the patients were treated with newer mechanical embolectomy devices (manual aspiration +/- stent-retriever 96%). Recanalization rate (TICI 2b or 3) was 90%. The median procedural times were as follow (minutes): time from P2C: 20, time from baseline catheter to reperfusion: 36, median total procedural times: 85. The rate of favorable functional outcomes at 90 days (mRS 0-2) was 45%. Patients with favorable outcomes had shorter P2C (31 min vs. 19 min p=0.02). In a multivariate analysis the predictors of longer P2C were age (OR 1.04, P=0.05, 95% CI 1.00-1.08), vertebrobasilar location (OR 5.4, P=0.027, 95% CI 1.21-24.1), smoking (OR 3.7, P=0.02, 95% 1.2-11.1), and with trend toward significance for hypertension (OR 3.03, P=0.062, 95% 0.94-0.97). Discussion: Shorter P2C is associated with higher rate of favorable outcomes. Independent risk factors associated longer time are age, vertebrobasilar occlusions, active smoking and history of hypertension. Alternative arterial access may be considered in patients who are likely to have longer P2C.

Absent right superior vena cava with persistent left superior vena cava and normal atrial arrangement

Background: This study aims to investigate the role of echocardiography in the detection of venous anomalies of large thoracic veins in patients with large coronary sinus. Methods: Between January 2010 and March 2012, six patients (3 boys, 3 girls; mean age 4.1; range 3 days - 9 years) were diagnosed with an absent right superior vena cava (RSVC) accompanied by persistent left superior vena cava (PLSVC) in our clinic. The diagnosis of the absent RSVC was established by echocardiography and angiography. Results: Diagnosis of the absent RSVC was confirmed by echocardiography in four patients. The diagnosis was based on cardiac catheterization and angiography in two patients. Additional cardiac anomalies included peripheral pulmonary stenosis, patent ductus arteriosus, tetralogy of Fallot, atrial septal defect, ventricular septal defect and interrupted aortic arch type B. One patient had Trisomy 9p syndrome, while another one was the baby of a diabetic mother. Three patients were followed clinically, while other three patients were operated. Conclusion: Absent RSVC should be thoroughly investigated in cases with a large coronary sinus along with increased coronary sinus flow and PLSVC, as evidenced by echocardiography.

Early ischemic brain lesions after carotid angioplasty and stenting on diffusion-weighted magnetic resonance imaging study

Summary Aim: The aim of the paper is to evaluate the appearance of the new early ischemic lesions in the brain after carotid angioplasty and stenting on diffusion-weighted magnetic resonance imaging, and their relationship with clinical and procedural factors. Methods: Carotid artery stenting (CAS) procedures performed by a single interventional cardiologist in years November 2006 to January 2013 were evaluated retrospectively. In total, 227 procedures for 211 patients (mean age 69.8 ± 8.5 years) were performed, from which 171 (75.3%) for male and 56 (24.7%) for female patients. Seventy-two (34.1%) patients had symptomatic stenosis of carotid artery. The following protection systems to avoid the distal microembolism were used during the CAS: (1) Filters: FilterWire EZ (Boston Scientific Corporation); Emboshield NAV (Abbott Vascular); SpideRX (EV3); Defender (Medtronic); FiberNet Filter (Invatec-Medtronic); (2) Occlusion MoMa Baloon System (Invatec-Medtronic). Acute ischemic damages of the brain before and after CAS procedure were diagnosed using magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) sequences. Sixty-five (30.8%) patients underwent MRI test. Exact and asymptomatic χ2 criteria were applied for testing the hypothesis of inter-dependency of the symptoms. Results: Forty-six (70.8%) patients had new ischemic foci in the brain on MRI DWI after CAS procedures. Among those patients, focal damage of the brain was diagnosed in 36 (78.3%) cases; linear damage of the brain - in 9 (19.6%) patients; ipsilateral damage of the brain - in 37 (80.4%) patients; bilateral damage of the brain - in 16 (34.8%) patients, 38 (82.6%) patients were diagnosed with forebrain damage; 4 (8.7%) patients were diagnosed with damage of brainstem; 5 (10.9%) patients were diagnosed with cerebellum damage. Clinical symptoms of brain damage were diagnosed only for 2 (4.3%) patients. Focal damage of the brain was significantly less frequent only for aortic arch type 1, if compared with aortic arch type 2 and 3: 64.3%, 93.3% and 100.0%, respectively (p < 0.05). Focal damage of the brain occurred least in patients (28.6%) with Emboshield NAV protection type, if compared to other types of protection (71.4-100.0%). Linear >10mmbrain damage was less frequent when using FilterWire EZ, Emboshield NAV and SpideRX protection type. Ipsilateral ischemic brain damage also occurred less frequent when using Emboshield NAV protection type; bilateral damage occurred less frequent when using FilterWire EZ, Emboshield NAV and SpideRX protection type. Ischemic forebrain damage was also diagnosed less often in patients for whom protection type FilterWire EZ and Emboshield NAV was applied. Conclusions: Most frequent findings by MRI after CAS procedures were focal, ipsilateral and forebrain damage (about 80%), but less than 5% patients had clinical symptoms. In the case of aorta arch type 1 focal ischemic damage of the brain was significantly less frequent, then in aortic arch type 2 and 3. The localization and extent of brain damage was associated with the type of protection systems that have been used.

The Diverse Clinical Features of Chromosome 22q11.2 Deletion Syndrome (DiGeorge Syndrome)

A 2-year-old boy with chromosome 22q11.2 deletion syndrome was referred for recurrent sinopulmonary infections. He was diagnosed shortly after birth by a fluorescence in situ hybridization test that was performed due to interrupted aortic arch type B. He had no hypocalcemia, and his recovery from cardiac repair was uneventful. He had difficulty feeding and gained weight slowly, but, otherwise, there were no concerns during his first year of life. At 15 months of age, he began to develop significant otitis media and bronchitis. He was hospitalized once for pneumonia at 18 months of age and has never been off antibiotics for more than 1 week since then. He has not had any previous immunologic evaluation. Recurrent sinopulmonary infections in a child with chromosome 22q11.2 deletion syndrome can have the same etiologies as in any other child. Atopy, anatomic issues, cystic fibrosis, and new environmental exposures could be considered in this setting. Early childhood can be problematic for patients with chromosome 22q11.2 deletion syndrome due to unfavorable drainage of the middle ear and sinuses. Atopy occurs at a higher frequency in 22q11.2 deletion syndrome, and these children also have a higher rate of gastroesophageal reflux and aspiration than the general population. As would be appropriate for any child who presents with recurrent infections at 2 years of age, an immunologic evaluation should be performed. In this review, we will highlight recent findings and new data on the management of children and adults with chromosome 22q11.2 deletion syndrome.

Inflammatory Mediators and Cerebral Embolism in Carotid Stenting: New Markers of Risk

To investigate serological predictors of risk for cerebral embolism after carotid artery stenting (CAS). Twenty consecutive symptomatic and asymptomatic patients (13 men; mean age 74 years) with carotid artery stenosis undergoing standardized filter-protected CAS (Wallstent) were preoperatively evaluated to identify unstable plaque (duplex ultrasound), complicated aortic plaque (transesophageal echocardiography), and inflammatory status [high-sensitivity C-reactive protein (hs-CRP) and serum amyloid-A protein (SAA) serum levels]. Aortic arch type, carotid tortuosity, and complexity of the procedure were considered. Cerebral embolism was evaluated by comparing the number, volume, and side (ipsilateral and non-ipsilateral) of preoperative and postoperative cerebral lesions detected on diffusion-weighted resonance magnetic imaging (DW-MRI) and through light and scanning electron microscopy analysis of cerebral protection filters obtained from CAS. All CAS procedures were completed with no complications. All patients had a negative preoperative DW-MRI, but at least 1 asymptomatic cerebral lesion appeared on DW-MRI after the procedure in 18 (90%) patients. Female gender was associated with a higher number of cerebral lesions (18.2±10.9 vs. 8.3±8.8 for men, p=0.03). Carotid plaque morphology, supra-aortic vessel anatomy, and procedure complexity did not correlate with number or volume of new cerebral lesions. Complicated aortic plaque was associated with a higher volume of non-ipsilateral cerebral lesions than uncomplicated plaque (235.0±259.3 vs. 63.6±63.2 mm(3), respectively; p=0.02). Hs-CRP ≥5 mg/L and SAA ≥10 mg/L were significantly associated with a higher number of new cerebral lesions [16.2±10.7 vs. 4.3±3.4 for hs-CRP <5 mg/L (p=0.02) and 14.8±10.3 vs. 2.8±3.4 for SAA <10 mg/L (p=0.006), respectively]. Hs-CRP ≥5 mg/L and SAA ≥10 mg/L also correlated with greater surface involvement by embolic materials in the protection filters at microscopic analysis [37.0% (5.1%) vs. 26.9% (2.5%) for hs-CRP <5 mg/L, p=0.004; 35.9% (13.5%) vs. 22.2% (6.9%) for SAA <10 mg/L, p=0.02]. In addition to female gender and the presence of complicated aortic plaque, inflammatory status can be a predictor of cerebral embolism in CAS.

TCT-510 Bovine arch vs aortic arch type III. The importance of the type of complex aortic arch in carotid stenting.

TCT-510 Bovine arch vs aortic arch type III. The importance of the type of complex aortic arch in carotid stenting.

TCT-732 Predictors of Aortic Arch Type: Implications in Patients with Severe Aortic Stenosis Being Evaluated for Transcatheter Aortic Valve Replacement

TCT-732 Predictors of Aortic Arch Type: Implications in Patients with Severe Aortic Stenosis Being Evaluated for Transcatheter Aortic Valve Replacement

Risk factors for ipsi- and contralateral cerebral ischemic lesions after carotid artery stenting with embolic protection

Objective: We aimed to identify factors predictive for new ipsi- and contralateral cerebral ischemic lesions during embolic protected carotid artery stenting (CAS). Background: Carotid endarterectomy and CAS appear to have similar overall perioperative stroke rates, which, however, may differ in specific patient subgroups. Knowledge of the risk factors for cerebral embolic events during CAS may impact treatment decisions for the individual patient, but have not been extensively studied. Aim of the study: To evaluate the risk factors for cerebral embolization after carotid artery stenting with embolic protection. Methods: Out of 837 consecutive patients undergoing CAS with cerebral embolic protection pre- and post-procedural diffusion weighted magnetic resonance imaging (DW-MRI) was performed for evaluation of new cerebral ischemic lesions in 728 patients (86.9%). Multivariate logistic regression analyses were performed to identify factors predictive for embolic events. Results: New ischemic lesions were found in 32.8% of the patients. Age, hypertension, lesion length, lesion excentricity, and aortic arch type III were significantly associated with new ischemic lesions, calcified lesions were negatively associated. In 25% of patients with embolic events lesions were also found in the contralateral hemisphere. Predictive factors for contralateral lesions were age, > 50% stenosis of the contralateral internal carotid artery, and an aortic arch type II, with a trend for aortic arch type III. Conclusions: Age, hypertension, lesion morphology, and aortic arch type were predictive for procedural related cerebral embolic events during embolic protected CAS. Age, significant contralateral carotid stenosis and complex aortic arch type were predictive for contralateral ischemic events. These findings may help to find the optimal treatment decision for the individual patient with carotid artery stenosis.

Aortic arch augmentation using a pulmonary artery autograft patch and a reversed left subclavian artery flap for an interrupted aortic arch type B complex

Adequate arch augmentation for interrupted aortic arch repair is quite important to avoid post-operative recoarctation and bronchial compression. We describe here two successful cases of aortic arch reconstruction using autologous materials such as a pulmonary artery patch and a reversed left subclavian artery flap in infants with an interrupted aortic arch type B complex.

Risk Factors for Cerebral Embolization After Carotid Artery Stenting With Embolic Protection

Meta-analyses of randomized trials have shown an increased risk of periprocedural stroke after carotid artery stenting (CAS) compared with carotid endarterectomy, which may differ in specific patient subgroups. Knowledge of risk factors for cerebral embolic lesions during CAS may impact treatment decisions for the individual patient, but these factors have not been extensively studied. We aimed to identify factors predictive for cerebral ischemic lesions during embolic protected CAS. Preprocedural and postprocedural diffusion-weighted magnetic resonance imaging was performed for evaluation of new cerebral ischemic lesions in 728 (86.9%) of 837 consecutive patients undergoing CAS with cerebral embolic protection. Multivariable logistic regression analyses were performed to identify factors predictive for embolic lesions. New ischemic lesions were found in 32.8% of patients. Age, hypertension, lesion length, lesion eccentricity, and aortic arch type III were significantly associated with new ischemic lesions; calcified lesions were negatively associated. In 25% of these patients embolic lesions were also found in the contralateral hemisphere. Predictive factors for contralateral lesions were age, >50% stenosis of the contralateral internal carotid artery, and an aortic arch type II, with a trend for aortic arch type III. Age, hypertension, lesion morphology, and aortic arch type were predictive for procedural-related cerebral embolic lesions during embolic protected CAS. Age, significant contralateral carotid stenosis, and complex aortic arch type were predictive for bilateral ischemic lesions. The clinical implications of ischemic lesions are not yet fully understood.

22q11.2 Deletions in Patients with Conotruncal Defects: Data from 1,610 Consecutive Cases

The 22q11.2 deletion syndrome is characterized by multiple congenital anomalies including conotruncal cardiac defects. Identifying the patient with a 22q11.2 deletion (22q11del) can be challenging because many extracardiac features become apparent later in life. We sought to better define the cardiac phenotype associated with a 22q11del to help direct genetic testing. 1,610 patients with conotruncal defects were sequentially tested for a 22q11del. The counts and frequencies of primary lesions and cardiac features were tabulated for those with and those without a 22q11del. Logistic regression models investigated cardiac features that predicted deletion status in tetralogy of Fallot (TOF). Deletion frequency varied by primary anatomic phenotype. Regardless of the cardiac diagnosis, a concurrent aortic arch anomaly (AAA) was strongly associated with deletion status [odds ratio (OR), 5.07; 95 % confidence interval (CI), 3.66-7.04]. In the TOF subset, the strongest predictor of deletion status was an AAA (OR, 3.14; 95 % CI 1.87-5.27; p < 0.001), followed by pulmonary valve atresia (OR, 2.03; 95 % CI 1.02-4.02; p = 0.04). Among those with double-outlet right ventricle and transposition of the great arteries, only those with an AAA had a 22q11del. However, 5 % of the patients with an isolated conoventricular ventricular septal defect and normal aortic arch anatomy had a 22q11del, whereas no one with an interrupted aortic arch type A had a 22q11del. A subset of patients with conotruncal defects are at risk for a 22q11del. A concurrent AAA increases the risk regardless of the intracardiac anatomy. These findings help to direct genetic screening for the 22q11.2 deletion syndrome in the cardiac patient.

277: Conotruncal defects: is the ventricular septal defect always the same?

Conotruncal defects (CTD) are a group of cardiac malformations hetero-geneous from an anatomic standpoint but with a common embryologic origin: an abnormal rotation of the outflow tract. The outlet septum is therefore malaligned or absent, resulting in a ventricular septal defect (VSD). To analyze the anatomy of the VSD in hearts with CTD. We reviewed 200 heart specimens with CTD from the anatomic collection of the French Center of Reference for Complex Congenital Heart Defects: 70 Tetralogy of Fallot (TOF), 53 TOF with pulmonary atresia (TOF-PA), 54 common arterial trunk (CAT), and 23 interrupted aortic arch type B (IAA-B). Special attention was paid to the rims of the VSD viewed from the right ventricular side, the relationships between tricuspid and aortic valves, and the anatomy of the outlet septum. The VSD was located between the 2 limbs of the septal band (conoventricular) in all hearts. There was a fibrous continuity between tricuspid and aortic valves in 0% of IAA-B, 66% of TOF, 37% of TOF-PA, 1% of CAT (p<0.005). When present, this continuity always involved the anterior tricuspid leaflet. The outlet septum was demonstrable in 81% of IAA-B, 96% of TOF, 39% of TOF-PA, 0% of CAT (p<0.0001). All CTD share the same VSD, located between the two limbs of the septal band. However, there are some differences regarding the inferior rim of the VSD. The continuity of the aortic valve with the anterior, and not the septal, tricuspid leaflet indicates that this continuity may be a consequence of the malposition of the ventriculo-infundibular fold, along with its outlet septal component, rather than a perimembranous extension of the VSD. Finally, these differences suggest an anatomic continuum from IAA-B to CAT rather than distinct physiological phenotypes, related to various degrees of abnormal rotation of the outflow tract, excessive in IAA-B, incomplete in TOF, TOF-PA and CAT.

Anatomical variations in branching pattern of arcus aorta: 64-slice CTA appearance

To review the 64-slice CTA (computed tomography angiography) appearance of anatomical variations in branching pattern of the arcus aorta, and to determine their prevalence in 1001 cases. 1001 cases that underwent carotid CTA (performed by a 64-slice scanner) were included in the study. Seven types of aortic arch were found. In 853 cases (853/1001, 85.2%) classical branching pattern of arcus aorta (three branches; TB, LCC, LS) was observed. Variations were present in 147 cases (147/1001, 14.7%). One case (1/1001, 0.1%) had right aortic arch. The most frequent variation was origination of LCC from TB (arch with 2 branches, TB with LCC and LS) which was observed in 78 cases (78/1001, 7.8%). Origination of LV directly from the aortic arch (four branches; TB, LCC, LV, LS or TB, LCC, LS, LV) was observed in 51 cases (51/1001, 5.1%). In two cases (2/1001, 0.2%) truncus bicaroticus (3 branches; RS, common trunk for carotids, LS) was present. In seven cases (7/1001, 0.7%) aortic arch had four branches in the order of RCC, RS, LCC and LS. In one case (1/1001, 0.1%) left truncus brachiocephalicus (three branches; RS, RCC, LTB) was present. Seven cases (7/1001, 0.7%) had aberrant RS (RCC, LCC, LS, RS). Variations in branching pattern of arcus aorta are not rare and being aware of them before surgical and interventional procedures of this region is important. CTA can depict the anatomical features of the aortic arch and is valuable as a road map.

Maternal transmission of interstitial 8p23.1 deletion detected during prenatal diagnosis

We report on the first prenatally diagnosed interstitial 8p23.1 maternally inherited deletion. At 20 weeks of gestation (WG) the fetus was diagnosed with a complete atrioventricular canal. In infancy, the mother underwent a two-step cardiac surgery for an interrupted aortic arch type A associated to an inlet ventricular septal defect (VSD). A straddling of the tricuspid valve type B was confirmed during surgery. The outcome showed no cardiac failure or conduction anomalies. However, she presented with moderate intellectual disability. Classical and molecular cytogenetic studies on amniotic and maternal lymphocytes cells showed a nearly identical interstitial deletion of the 8p23.1 region encompassing the GATA4 gene locus (Mother: nt 6,913,337-12,580,828, fetus: nt 7,074,449-12,580,828) with no modification of the telomeric region. The relevance of our report is not only the maternal syndromic interstitial 8p23.1 deletion, but also maternal transmission which has never been reported before. The maternal and fetal phenotypes were not identical, however, even though they had the same cellular and molecular background: an alteration of the epithelial mesenchymal transition of the atrioventricular valvulo-septal complex where GATA4 plays a positive role in the regulation. We reviewed all cases of interstitial 8p23.1 deletions diagnosed either prenatally or postnatally.

Tbx1 Genetically Interacts With the Transforming Growth Factor-β/Bone Morphogenetic Protein Inhibitor Smad7 During Great Vessel Remodeling

Growth and remodeling of the pharyngeal arch arteries are vital for the development of a mature great vessel system. Dysmorphogenesis of the fourth arch arteries can result in interruption of the aortic arch type B, typically found in DiGeorge syndrome. Tbx1 haploinsufficient embryos, which model DiGeorge syndrome, display fourth arch artery defects during formation of the vessels. Recovery from such defects is a documented yet unexplained phenotype in Tbx1 haploinsufficiency. To understand the nature of fourth arch artery growth recovery in Tbx1 haploinsufficiency and its underlying genetic control. We categorized vessel phenotypes of Tbx1 heterozygotes as hypoplastic or aplastic at the conclusion of pharyngeal artery formation and compared these against the frequency of vessel defects scored at the end of great vessel development. The frequency of hypoplastic vessels decreased during embryogenesis, whereas no reduction of vessel aplasia was seen, implying recovery is attributable to remodeling of hypoplastic vessels. We showed that Smad7, an inhibitory Smad within the transforming growth factor-β pathway, is regulated by Tbx1, is required for arch artery remodeling, and genetically interacts with Tbx1 in this process. Tbx1 and Tbx1;Smad7 haploinsufficiency affected several remodeling processes; however, concurrent haploinsufficiency particularly impacted on the earliest stage of vascular smooth muscle cell vessel coverage and subsequent fibronectin deposition. Conditional reconstitution of Smad7 with a Tbx1Cre driver indicated that the interaction between the 2 genes is cell autonomous. Tbx1 acts upstream of Smad7 controlling vascular smooth muscle and extracellular matrix investment of the fourth arch artery.

RR21. Inflammatory Mediators and Cerebral Embolism in Carotid Stenting: New Markers of Risk

Cerebral embolism is a feared complication of carotid artery stenting (CAS) and might be associated with specific morphological patterns, however serological predictors of risk have been scarcely investigated. Consecutive patients with carotid artery stenosis undergoing filter-protected CAS were preoperatively evaluated to identify unstable plaque at duplex ultrasound, complicated aortic plaque at trans-esophageal echocardiography and inflammatory status with high sensitivity C-reactive proteins (hs-CRP) and serum amyloid-A protein (SSA) serum levels. Aortic arch type, carotid tortuosity, and complexity of the procedure were considered. Cerebral embolism was evaluated by comparing number, volume and side of preoperative and postoperative cerebral lesions at diffusion weight resonance magnetic imaging (DW-RMI) and through light and scanning electron microscopy analysis of cerebral protection filters obtained from CAS. Twenty consecutive patients were submitted to CAS with no complications. At least 1 asymptomatic cerebral lesion on DW-MRI was present in 18 (90%) patients. Female gender was associated with a higher number of cerebral lesions (18.2±10.9 vs. 8.3±8.8 P = .03). Plaque morphology, supraaortic vessels anatomy and procedure complexity did not correlate with number or volume of new cerebral lesions at DW-RMI. The presence of complicated aortic plaque was associated with higher volume of contralateral cerebral lesions (2350±2593 vs. 636±632 mm3 P = .02). Hs-CRP >5mg/l and SAA >10 mg/l were significantly associated with a higher number of cerebral lesions (16.2 ± 10.7 vs. 4.3±3.4 P = .02, and 14.8 ± 10.3 vs. 2.8 ± 3.4 P = .006, respectively). Hs-CRP>5 and SAA>10 mg/l also correlated with greater surface involvement by embolic materials in the protection filters at microscopic analysis (37.0 ± 5.7 vs. 26.9 ± 2.5 P = .004). Inflammatory status is associated with higher embolic risk during CAS independent from morphological and technical aspects of the procedure.