Mobile Atheroma Research Articles

The enigma of fine mobile structures on the aortic surface in a patient undergoing transcatheter aortic valve replacement: a case report

Abstract Background The surface of the aorta generally does not show motion unless mobile atheroma, thrombi, vegetations, or intimal flaps are present. We previously described unusual mobile filamentous structures in the carotid artery. Here, we describe similar findings in the aorta and their possible cause. Case summary An 88-year-old female with progressive exertional dyspnoea and severe aortic stenosis had a successful transcatheter aortic valve replacement (TAVR). A filamentous structure was noted on the focused pre-operative 2D transoesophageal echocardiography in the proximal descending aorta and post-TAVR as long strand-like structures attached to the thickened intimal wall with a planar component on 3D imaging. These findings were not associated with symptoms or clinical sequelae on short- and long-term follow-up. Discussion The mobile structures that we describe are atypical for atheroma, thrombi, vegetations, and dissections in terms of their form and clinical presentation. 2D imaging showed that the filaments had focal thickening and emerged from the aortic surface. These findings suggest a relationship with the intima, perhaps from atherogenesis or injury with disruption or lifting of the intimal surface. No clinical sequelae were detected that may also relate to their position in the descending aorta and not the arch.

Modified Isolation Selective Cerebral Perfusion Technique for Intracardiac Disease with Mobile Atheroma.

Isolation selective cerebral perfusion (ISCP) technique is reportedly an effective method for preventing brain complications during the treatment of arch aneurysms. Here we present the case of a patient with intracardiac disease complicated by mobile atheroma in the proximal aorta. In this patient, not only the arterial cannulation of the ascending aorta might have posed a high risk of brain stroke but also the original ISCP technique could not be applied. We applied the ISCP technique for non-aortic disease without using circulatory arrest to prevent aortogenic brain embolism. The patients who underwent treatment using this technique were discharged without neurologic complications.

Increasing severity of aortic atherosclerosis in coronary artery bypass grafting patients evaluated by transesophageal echocardiography.

BackgroundAtherosclerotic disease in coronary artery bypass grafting (CABG) patients is a potential contributor to complications in the perioperative periods. This study was undertaken to better define how the frequency of aortic atheromatous disease among patients coming for CABG has evolved over the last decade.MethodsData from elective patients coming for CABG who underwent transesophageal echocardiography (TEE) examinations following induction of anesthesia were obtained for the years 2002 and 2009. Aortas were graded according to the method of Kronzon, with the following interpretations: normal = grade I, intimal thickening = 2, atheroma of less than 5 mm = 3, atheroma of > 5 mm = 4, and any mobile atheroma = 5. The data of 124 patients who underwent comprehensive exam of the aorta by one cardiac anesthesiologist were gathered and assigned into two groups based on the year TEE was done. Student’s t-test was used for statistical analysis. A P value < 0.05 was considered significant. The data were presented as mean ± SD.ResultsThere was significant difference between group 2002 (2.05 ± 1.28) and group 2009 (2.59 ± 1.11) in atheroma grade (P = 0.013).ConclusionsPatients coming for CABG in group 2009 exhibited significantly higher grades of aortic atheroma on TEE, compared to group 2002. Understanding the risk of atheroma in the elderly CABG population may help in altering surgical approaches to lessen the risk of catastrophic stroke. Potential options needing further study include the off-pump approach and modification of cross-clamp site and technique as well as other modalities.

Mobile atheromatous plaque of the aortic arch diagnosed by transthoracic echocardiography prior to coronary artery bypass surgery - which one would you choose : scepticism or wishful thinking?

A routine pre-operative chest X-ray of a patient admitted to our institution for an elective coronary artery bypass operation revealed a mildly dilated mediastinal silhouette, which led the cardiovascular surgery resident to schedule emergency transthoracic echocardiography (TTE), with a special note asking for detailed evaluation of the ascending aorta and aortic arch. TTE revealed a mobile atheroma at the aortic arch, which obliged the cardiac surgery team to modify their strategy to combined hemi-arcus aortae replacement and coronary artery bypass grafting (CABG). Although with transoesophageal echocardiography (TEE) a small portion of the ascending aorta may be obscured by the trachea, TEE provides higher resolution images than TTE. Therefore one can conclude that TEE is the imaging modality of choice for detecting aortic atheromatous plaques but in patients with low risk for stroke and aortic atheromas, a detailed TTE may be sufficient for the pre-operative assessment.

Femoral artery cannulation for thoracic aortic surgery: Safe under transesophageal echocardiographic control

Choice of cannulation site (femoral, axillary) for cardiopulmonary bypass for thoracic aortic surgery is controversial. We review a single-center consecutive experience with femoral cannulation in the era of transesophageal echocardiography (TEE). Femoral artery cannulation is our preference for both aneurysms and dissections. If intraoperative TEE (or preoperative computed tomography) shows mobile atheroma, we avoid femoral cannulation and use the right axillary artery. Charts were reviewed to detect any cannulation- or perfusion-related complications. Eight hundred eighty patients underwent cannulation for cardiopulmonary bypass for thoracic aortic surgery: 767 femoral (87%) and 113 other (13%, 87 aortic, 22 axillary, 4 innominate). Among the femoral cases, 673 (87.7%) were elective and 94 (12.2%) urgent or emergency. Hospital survival was 723 of 767 (94%): 654 of 673 (97%) for elective cases and 69 of 94 (73%) for urgent or emergency cases. Survivals were 549 of 572 (95%) for ascending and arch, 91 of 97 (93%) for descending, and 83 of 98 (84%) for thoracoabdominal. Stroke (fixed neurologic deficit) occurred in 14 of 767 cases (1.8%): 9 ascending or arch and 5 descending or thoracoabdominal. There were 5 paraplegias in the descending or thoracoabdominal group. There was 1 instance of intraoperative descending dissection (well tolerated), no arterial ruptures, and 6 instances (0.7%) of local femoral arterial narrowing requiring surgical correction (patch graft). One patient (0.1%) had postoperative ischemia of the cannulated limb, and 25 patients (3.2%) had local wound problems (infection 21, seroma 4) treated conservatively. This large experience in the TEE era strongly supports femoral cannulation for aortic surgery, with good survival, low stroke rate, minimal perfusion-related rupture or dissection, and minimal limb ischemia. If intraoperative TEE shows mobile atheroma, axillary cannulation is preferred.

Disappearing Flapping Plaque in the Internal Carotid Artery

Mobile atheromatous plaque at the origin of the internal carotid artery (ICA) is a rare finding at the carotid ultrasound examination. Acute thrombosis is unusually seen. Either may be secondary to plaque hemmorhage, plaque ulceration, carotid dissection, or proximal embolus. We report an 89-year-old male suffering from an acute neurologic event who on ultrasound had a flapping heterogeneous atheromatous plaque at the right ICA origin. This mobile atheromatous plaque is distinguished from acute thrombus by its echogenicity, narrow pedicle of attachment, and absence of underlying intima. Subsequent computed tomography angiography and repeat ultrasound within 24 hr demonstrated the disappearance of this plaque. Only three small intimal flaps remained. In the intervening period, the patient's symptoms significantly worsened. While conservative management of thrombus with intravenous thrombolysis has been shown in some settings to be appropriate, the diagnosis and management of mobile atheroma are unclear. This case suggests that differentiation between atheroma and thrombus may be valuable in determining management strategies.

Mobile Ascending Aortic Atheroma Diagnosed by Transesophageal Echocardiography as Source of Peripheral Vascular Embolism

Complex aortic atheromas are an important differential diagnosis to consider in evaluating sources of arterial embolization. Diagnosis of the embolic source is an essential first step, so treatment can then be initiated to prevent further reoccurrence. We report the case of a 36-year-old man, without significant medical history, who presented to the University of Illinois at Chicago with peripheral vascular embolism to the lower extremities. Computed tomography with contrast angiography and transthoracic echocardiography failed to reveal a source of the thromboembolism. A complex mobile atheroma was discovered in the ascending aorta during transesophageal echocardiography. The case presented is noteworthy when considering the following: the relative rarity of complex atheromas of the ascending aorta, the young age of the patient with no history of atherosclerotic disease, and the failure of computed tomography angiography to reveal the embolic source despite literature supporting high sensitivities for aortic plaque detection compared with transesophageal echocardiography.

Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons

Guidelines for the Performance of a Comprehensive Intraoperative Epiaortic Ultrasonographic Examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; Endorsed by the Society of Thoracic Surgeons

Metabolic relevance during isolation technique in total arch repair for patients at high risk with embolic stroke

In patients undergoing total arch replacement with protruding or mobile atheroma in the proximal aorta, we isolate cerebral circulation from systemic one by starting selective cerebral perfusion (SCP) before systemic arterial perfusion to prevent aortogenic embolic stroke. We disclose the safety of this isolation technique by measuring cerebral oxygenation and metabolism. Sixty-six patients underwent total arch replacement using SCP since 1998. The isolation technique was applied in sixteen patients. Jugular venous oxygen saturation (SjO(2)) was monitored in nine patients undergoing isolation technique (isolation-group) and in thirteen patients of the rest (conventional-group). Oxygen, glucose, and lactate extraction ratio (OER, GER, and LER) were measured at seven time points peri-operatively. The isolation-group had significantly longer SCP time (isolation: 185+/-52 min vs. conventional: 140+/-43 min, P<0.01). During cooling, SjO(2) was kept comparable between groups. OER was minimum at the end of cooling and comparable between groups (isolation: 3.8+/-7.7% vs. conventional: 11.7+/-13.8%, P=0.37). There were no significant differences in GER and LER between groups. There were neither in-hospital death nor stroke. Temporary neurological dysfunction was observed only in conventional-group (n=3, 23%, P=0.12). Isolation technique for total arch replacement could be performed safely and may provide acceptable results in patients at high risk for embolic stroke.

Risk Factors for Perioperative Stroke After Thoracic Endovascular Aortic Repair

Stroke has emerged as an important complication of thoracic endovascular aortic repair (TEVAR). Identifying risk factors for stroke is important to define the risks of this procedure. All neurologic complications were analyzed in a prospective database of patients in thoracic aortic stent graft trials from 1999 to 2006. Serial neurological examination was performed. Stroke was defined as any new onset focal neurologic deficit. The TEVAR was performed on 171 patients; 52 had lesions requiring coverage of the proximal descending thoracic aorta (extent A), 50 requiring coverage of the distal descending aorta (extent B), and 69 requiring coverage of the entire descending thoracic aorta (extent C). The incidence of stroke was 5.8%. Eighty-nine percent (8 of 9) of strokes occurred within 24 hours of operation. Stroke was associated with a 33% in-hospital mortality rate. Risk factors identified for stroke included prior stroke (odds ratio [OR] 9.4, confidence interval [CI] 2.3 to 38.1, p = 0.002) and extent A or C coverage (OR 5.5, CI 1.7-12.5, p = 0.001). The stroke rate in patients with both prior stroke and extent A or C coverage was 27.7%. Severe atheromatous disease involving the aortic arch by computed tomographic scan was strongly associated with perioperative stroke (OR = 14.8, CI 1.7 to 675.6, p = 0.0016). Transesophageal echocardiography demonstrated mobile atheroma in two patients with stroke. Stroke after TEVAR was associated with a high mortality. The TEVAR of the proximal descending aorta (extent A or C) in patients with a history of stroke had the highest perioperative stroke rate. These risk factors, together with high grade aortic atheroma of the aortic arch, predicted a high probability for cerebral embolization and can be used to identify patients at high risk for stroke as a consequence of TEVAR.

The “Sandblasting” Effect of Aortic Cannula on Arch Atheroma During Cardiopulmonary Bypass

A 69-yr-old woman presented with dyspnea on exertion was found to have moderate-to-severe mitral regurgitation with moderate left ventricular dysfunction (estimated ejection fraction was 30%) and was scheduled for elective mitral valve repair. The patient had undergone uneventful coronary artery bypass graft surgery 7 months earlier. Her medical history was otherwise significant for hypertension and diabetes. Intraoperative transesophageal echocardiography (TEE) confirmed moderate mitral regurgitation and showed diffuse atheromatous disease in the distal aortic arch with a maximal plaque height of 3 mm. Epiaortic scanning was not performed in this case. The mid-ascending aorta was cannulated under direct vision with a 17F Bio-Medicus® (Medtronic Inc, Minneapolis, MN) cannula. This is a straight, wirewound polyurethane cannula with a multiport tip and is usually chosen for femoral arterial cannulation. However, given the patient’s recent previous cardiac surgery and limited visibility of the ascending aorta, the surgeon (D.D.G.) opted for this particular cannula, which offers better flow with less aortic injury than a conventional 22F or 24F cannula. The improved flow characteristics come from the long segment of holes which put the cannula tip near the back wall. The location of aortic cannulation was not changed based on cannula type. After initiation of cardiopulmonary bypass (CPB), a new mobile atheroma was noted in the distal aortic arch, just distal to the tip of the aortic cannula (Fig. 1, see Video 1 available at www.anesthesia-analgesia.org). Although it is possible that this atheroma may have been missed by the pre-CPB routine TEE examination, the possibility of plaque disruption by CPB flow cannot be excluded. Both B-mode and color flow Doppler scans (see Video 2 available online) revealed that the jet stream of flow from the aortic cannula was directed toward the mobile atheroma. The surgical procedure was uneventful. Extracorporeal circulation was maintained at a nonpulsatile flow rate of 2–2.4 L · min−1· m−2. After discontinuation of CPB and removal of the aortic cannula, TEE examination of the aorta demonstrated the mobile atheroma at the same location, unchanged in character. Her postoperative recovery was unremarkable. There were no adverse postoperative neurological sequelae.Figure 1.: Mid-esophageal short axis view of the aorta at the junction of the distal arch and descending thoracic aorta. The cannula tip (A) is very close to the origin of the left subclavian artery that cannot be seen in this view. The subclavian artery would be best seen with the scan angle at 90° and slight rotation of the probe towards the right. The tip of the aortic cannula (A) can be seen directly opposing the atheroma (B). The corresponding Video (Video 1 available online) demonstrates the mobile atheroma.Adverse neurological outcomes have been correlated not only with atheroma in the ascending aorta, but also with those in the arch and descending aorta, and with carotid atherosclerosis (1). Aortic manipulation is usually implicated as being responsible for atheroma detachment and subsequent embolization. However, atheromata may also be detached by the “sandblasting” effect of high velocity aortic cannula flow during CPB that may be directed toward susceptible atheroma (2). Although type of cannula selected (curved versus straight; variable size) may not be associated with a higher incidence of cerebral emboli, location of cannulation (ascending aorta versus distal arch) may affect neurological outcome (3). The cannula selected in our case was 17 in. long and projected to a greater length into the aortic lumen than regularly used aortic cannulae, because it was seen by TEE in the distal arch. Effectively, cannulation in our case may be equivalent to distal aortic cannulation due to ultimate location of the cannula tip. Changes in aortic rotational flow have been documented during CPB and could explain the erosive effect of the high-velocity jet from aortic cannulae (4). In a recent report, Pybus described the potential mechanism for atheroma dislodgement due to rotational flow during CPB (5). Another possibility in the case we report is the development of an acute aortic dissection due to shear forces on an atheromatous aorta. We did not see an intimal tear during our case, making the diagnosis of aortic dissection highly unlikely. However, the plaque disruption that occurred during this surgery may have left the patient vulnerable to the future development of an aortic dissection from poorly controlled hypertension. Intraoperative TEE images during our case demonstrated how a susceptible atheroma may be at risk of detachment due to this sandblasting effect. Thus, surgical neuroprotective strategies aimed solely at identifying ascending aortic atheroma may not be sufficient. Fortunately, the patient did not have a postoperative stroke. Epiaortic scanning may be useful not only with selection of aortic cannulation site, but also adjustment of angulation of the distal tip of the aortic cannula. These echocardiographic images highlight the potential of the juxtaposition of aortic cannula and distal arch atheroma in the etiology of postoperative organ dysfunction.

Transthoracic Echocardiographic Diagnosis of Mobile Aortic Arch Atherothrombosis Associated with Stroke

Aortic arch atherosclerosis is associated with an increased risk of stroke or TIA. Up to now, transesophageal echocardiography has been the standard method for diagnosing protruding and/or mobile aortic arch atherosclerosis. We report a case where a mobile aortic arch atheroma was diagnosed using transthoracic echo in a patient with a recent stroke.

Aortic Arch Atheroma

Severe atheroma of the aortic arch has now been established as an important risk factor and mechanism for stroke and peripheral embolism. The odds ratio for stroke or peripheral embolism in patients with severe arch atheroma is greater than four, and for mobile atheroma it is greater than 12. The prevalence of severe arch atheroma among patients presenting with acute ischaemic stroke, at over 20%, is in the same order as that of atrial fibrillation and carotid atherosclerosis. In patients with ischaemic stroke for which no cause has been identified, it is reasonable to determine as to whether they have severe arch atheroma by performing a transoesophageal echocardiogram. Recurrent stroke is common in patients with aortic arch atheroma that are thicker than 4 mm or with mobile components, particularly in the elderly, cigarette smokers, and those with hypertension or diabetes. Patients found to have severe atheroma are at high risk of recurrent events (14.2% per year) and may, therefore, need an aggressive secondary prevention strategy. Currently, there is uncertainty as to what this should be, but either combination antiplatelet therapy (aspirin plus clopidogrel) or anticoagulation with warfarin (target INR 2.0-3.0) are commonly used. Which of these is most effective will be evident after the completion of the aortic arch related cerebral hazard trial.

Invited commentary

In recent years, axillary artery cannulation has gained considerable popularity as a site for arterial perfusion for thoracic aortic surgery, almost to the point of attaching a negative stigma to the use of the femoral artery for this purpose. There is no question that axillary artery cannulation offers significant advantages in specific circumstances, especially when the thoracoabdominal aorta is heavily diseased with mobile atheromatous lesions. In such circumstances, axillary cannulation can avoid the lifting of the aortic “tree bark” that can occur with retrograde femoral perfusion. This article by Lakew and colleagues serves an important role by reminding us that traditional femoral artery cannulation remains an excellent option for many patients. The authors have wisely restricted their analysis to a well-defined and specific group (ie, those patients undergoing surgery only for chronic aortic aneurysm, not dissection). This specificity permits meaningful results by defining a relatively uniform clinical setting for analysis. Also the number of patients is large and the two techniques (ie, femoral and direct aortic cannulation) are carried out simultaneously during the study period, an advantage compared with other comparative studies. The clinical and stroke results achieved in both groups in this study are superb. A weakness of this study is the potential for bias based on the surgeons’ perception of the aortic situation; thus one can safely conclude that femoral cannulation leads to good results in experienced hands. However, it is not safe to conclude that femoral and aortic cannulation are equivalent in all situations, as that would require a prospective, randomized investigation. Another weakness is that the authors did not report or incorporate findings from intraoperative transesophageal echocardiography in their evaluation of potential cannulation sites. In the present era, not using that information represents an anachronism. Another important concept demonstrated by this study is that simple deep hypothermic circulatory arrest with efficient arch surgery produces excellent clinical results with low cerebral complication rates. This point is important to keep in mind vis-à-vis the alternative techniques of retrograde or selective antegrade brain perfusion. The following additional technical observations deserve consideration in selecting cannulation sites for thoracic aortic surgery: •One must not use the femoral artery in cases in which there is intervening iliac or femoral occlusive disease, even moderate in severity. In such situations, forcing the entire pump output retrograde through even a moderate stenosis can precipitate retrograde aortic dissection.•One must avoid femoral cannulation if the intraoperative transesophageal echocardiography shows mobile atheroma in the intervening segment of the aorta.•Also, in cases in which femoral cannulation is initially used and at herosclerotic debris is found on opening and debriding the aorta, the cannula should be moved to the new graft to avoid propelling debris toward the brain.•In descending and thoracoabdominal aortic surgery, one can prevent emboli from reaching the brain by the simple convention of clamping the aorta before perfusion is started and terminating perfusion before the clamp is released. By doing so, wherever potential emboli may go, they are prevented from reaching the brain. Implementation of this measure halved our stroke rate for descending and thoracoabdominal aortic surgery [1Goldstein L.J. Davies R.R. Rizzo J.A. et al.Stroke in surgery of the thoracic aorta incidence, impact, etiology, and prevention.J Thorac Cardiovasc Surg. 2001; 122: 935-945Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar]. The article by Lakew and colleagues complements our recent article that demonstrates the safety and utility of femoral artery cannulation for acute type A aortic dissection [2Fusco D.S. Shaw R.K. Tranqulli M. Kopf G.S. Elefteriades J.A. Femoral cannulation is safe for type A dissection repair.Ann Thorac Surg. 2004; 78: 1285-1289Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar]. Thus, between these two articles, the good name of the former gold-standard, femoral cannulation, is to some extent restored to its prior status. Femoral cannulation remains quick, easy, and absent of severe mobile atheromas in the descending and abdominal aortas, it is quite safe for both chronic aneurysm and acute ascending aortic dissection. Femoral Versus Aortic Cannulation for Surgery of Chronic Ascending Aortic AneurysmThe Annals of Thoracic SurgeryVol. 80Issue 1PreviewFemoral artery cannulation and retrograde arterial perfusion have been postulated to increase the risk of cerebral embolism. In this study, the impact of the arterial cannulation site on the perioperative results after proximal aortic surgery is evaluated. Full-Text PDF

Splenic and mesenteric emboli in a patient with protruding aortic arch atheroma

Protruding atheromas in the thoracic aorta are an important cause of embolic disease. Transesophageal echocardiography (TEE) is the modality of choice for diagnosis of these lesions. We present a patient with splenic infarction in whom TEE revealed a large mobile atheroma in the aortic arch. A few hours following the disappearance of this mass from the aortic arch, the patient developed mesenteric artery embolism requiring subtotal small-bowel resection. We discuss the importance of the aortic arch as a source of peripheral emboli and the treatment modalities in these patients.

Isolation technique for stroke prevention in patients with a mobile atheroma

Mobile atheroma in the proximal aorta is a risk factor for brain complication after cardiovascular operation. We report a new technique of replacing the ascending and transverse aorta by establishing selective hypothermic antegrade cerebral perfusion. After cooling, cerebral vessels are clamped and systemic perfusion is started. This technique was applied in 5 patients. All patients woke up normally and recovered without neurologic complication.

Reduced neurological injury during CABG in patients with mobile aortic atheromas: a five-year follow-up study

Background. Mobile atheromas of the thoracic aorta have been identified as a major cause of stroke after coronary artery bypass grafting (CABG). This prospective study was undertaken to identify mobile atheromas and to determine the incidence of immediate postoperative embolic events after suitable surgical modifications. Late clinical events attributable to embolization were also studied. Methods. Between January 1993 and July 1997, 3,660 patients scheduled for CABG underwent intraoperative transesophageal echocardiography to identify aortic atheromatous disease. The disease was graded as follows: grade I, plaques extending less than 5 mm into the aortic lumen; grade II, plaques extending more than 5 mm into the aortic lumen; and grade III, plaques with a mobile element. Only patients with grade III atheromas were included in the study. Various surgical modifications were done depending on the location of the lesion, eg, aortic arch atherectomy, CABG combined with transmyocardial laser revascularization, off-pump CABG by median sternotomy, and minimally invasive direct coronary artery bypass. Measured outcomes were death, stroke, and other vascular events, both early (within 1 week) and late (1 to 5 years) after operation. Results. Of the 3,660 patients, 104 (2.84%) had mobile atheromas. The perioperative stroke rate was 0.96%, and the incidence of other vascular events was 1.92% at 1 week. There was no embolic event in the group of 88 patients who underwent off-pump CABG. Of the study group, 98.07% are in regular follow-up. At 5 years, 1 patient had had a nonfatal stroke, and 2 patients had died of causes unrelated to atheromatous disease. Conclusions. The stroke rate was very low in patients with mobile aortic atheromas who underwent CABG after modification in surgical technique, especially off-pump CABG. A follow-up of 5 years showed that patients with mobile atheromas have a very low incidence of spontaneous embolization.

Mobile atheroma of the aortic arch and the risk of carotid artery disease

Background: Mobile atheromas of the aortic arch are associated with otherwise unexplained strokes and transient ischemic attacks (TIA). They are associated with increased perioperative strokes in patients undergoing coronary artery bypass surgery. Peripheral embolization is an additional risk. Transesophageal echocardiography (TEE) accurately identifies mobile atheroma. Anticoagulant therapy may have therapeutic considerations in the management of this condition. However, the risk of significant carotid artery disease associated with mobile atheromas is unknown. Methods: Between March 1994 and July 1998, 40 patients with mobile atheromas by TEE and evidence of embolization were studied. All patients were captured prospectively in a vascular registry and were retrospectively reviewed. Carotid artery disease was evaluated using carotid duplex imaging in an accredited vascular laboratory. All patients with significant carotid disease, 70% or greater stenosis, underwent arteriography. Patients with significant carotid artery stenosis then underwent carotid endarterectomy. All patients with mobile atheromas were maintained on anticoagulation. Results: Forty patients with mobile atheromas of the aortic arch were diagnosed with TEE. All 40 patients had evidence of embolization. Patient age ranged from 57 to 73 years (mean 68.4). There were 22 men and 18 women. Twenty of 40 (50%) patients presented with symptoms of TIA. Eleven of 40 (28%) patients presented with diffuse atheroembolization (lower extremity embolization and renal insufficiency). Six of 40 (15%) patients presented with a completed stroke. Three of 20 (7%) patients presented with acute extremity ischemia secondary to a peripheral embolus. Twenty-three of 40 (58%) of patients had significant carotid artery stenosis, 70% or greater stenosis. These 23 patients underwent both arteriography and carotid endarterectomy without complication. All patients were treated with anticoagulation and have remained anticoagulated. Clinical follow-up between 2 to 48 months (mean 18) has demonstrated no further evidence of systemic embolization in these 40 patients. Repeat TEE was performed in 6 of 40 patients. These follow-up studies no longer visualized mobile atheromas. Conclusions: Mobile atheromas are recognized sources for embolization. Routine carotid duplex imaging should be performed in patients found to have mobile atheromas of the aortic arch. Carotid endarterectomy appears to be safe in patients who have combined carotid artery stenosis and mobile atheromas. Anticoagulation may have therapeutic considerations in the management of this condition.

Arterial inflow via an axillary artery graft for the severely atheromatous aorta

Background. Strategy for severe aortic atheromatous disease identified by intraoperative epiaortic ultrasound remains to be determined. We used axillary artery inflow through graft interposition in an attempt to avoid potential embolization. Methods. Between July 1995 and June 1997, axillary artery inflow was used in 29 patients. Procedures performed were coronary artery bypass in 21 patients (3 with combined carotid endarterectomy), aortic valve replacement in 2, valve replacement plus coronary artery bypass in 4, atrial septal defect repair in 1, and arch replacement in 1 patient. Fibrillatory arrest was used in 16 patients and circulatory arrest was used in 16 patients for excision of mobile atheroma or arch reconstruction. Antegrade cerebral perfusion through the axillary artery graft was carried out in 11 patients. Results. There were no brachial neurovascular complications. Two operative deaths occurred. Two patients had operative strokes and 2 more had postoperative stroke, all with resolution at late follow-up. There were no strokes in the subset of patients who had antegrade cerebral perfusion during circulatory arrest. Conclusions. The axillary artery is an excellent site for arterial inflow. Furthermore, antegrade cerebral perfusion is easily accomplished during periods of circulatory arrest. Finally, graft placement avoids potential local neurovascular complications.

Mobile Aortic Atheroma and Systemic Emboli: Efficacy of Anticoagulation and Influence of Plaque Morphology on Recurrent Stroke

Objectives. We sought to determine the influence of plaque morphology and warfarin anticoagulation on the risk of recurrent emboli in patients with mobile aortic atheroma.Background. An epidemiologic link between aortic atheroma and systemic emboli has been described both in pathologic and transesophageal studies. Likewise, a few studies have found an increased incidence of recurrent emboli in these patients. The therapeutic implications of these findings has not been studied.Methods. Thirty-one patients presenting with a systemic embolic event and found to have mobile aortic atheroma were studied. The height, width and area of both immobile and mobile portions of atheroma were quantitated. The dimensions of the mobile component was used to define three groups: small, intermediate and large mobile atheroma. The patients were followed up by means of telephone interview and clinical records, with emphasis on anticoagulant use and recurrent embolic or vascular events.Results. Patients not receiving warfarin had a higher incidence of vascular events (45% vs. 5%, p = 0.006). Stroke occurred in 27% of these patients and in none of those treated with warfarin. The annual incidence of stroke in patients not taking warfarin was 0.32. Myocardial infarction occurred in 18% of patients also in this group. Taken together, the risk of myocardial infarction or stroke was significantly increased in this group (p = 0.001). Forty-seven percent of patients with small, mobile atheroma did not receive warfarin. Recurrent stroke occurred in 38% of these patients, representing an annual incidence of 0.61. There were no strokes in patients with small, mobile atheroma treated with warfarin (p = 0.04). Likewise, none of the patients with intermediate or large mobile atheroma had a stroke during follow-up. Only three of these patients had not been taking warfarin.Conclusions. Patients presenting with systemic emboli and found to have mobile aortic atheroma on transesophageal echocardiography have a high incidence of recurrent vascular events. Warfarin is efficacious in preventing stroke in this population. The dimension of the mobile component of atheroma should not be used to determine the need for anticoagulation.