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

Presented at the 27th Annual Meeting of the Society for Clinical Vascular Surgery, Lake Buena Vista, Florida, March 24–28, 1999.
https://doi.org/10.1016/S0002-9610(99)00115-4Get rights and content

Abstract

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.

Section snippets

Methods

Between March 1994 and July 1998, 40 patients with mobile atheromas by transesophageal echocardiography were studied to determine the incidence of significant carotid artery disease (70% or greater stenosis). All patients were captured prospectively in a vascular registry and were retrospectively reviewed. Patients with mobile atheromas and evidence of embolization were identified and both inpatient and outpatient records analyzed in detail. Specifically studied were age, gender, site of

Results

Forty patients with mobile atheromas of the thoracic aorta were diagnosed with transesophageal echocardiography. All 40 patients had evidence of embolization (Table). Patient age ranged from 57 to 73 years (mean 68.4). There were 22 men and 18 women in the study. 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

Comments

The efficacy of carotid endarterectomy for asymptomatic carotid stenosis has found that surgery reduces the subsequent incidence of ipsilateral neurologic events. However, there was no effect on the overall incidence of stroke and death because nearly a quarter of neurologic events in patients treated with carotid stenosis developed on the side contralateral to that of the carotid lesion.12 Therefore, a number of the neurologic events in these patients could have developed as a result of an

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