Ann Thorac Surg 1995;60:457-458
© 1995 The Society of Thoracic Surgeons
Case Reports
Excision of Focal Aortic Arch Atheroma Using Deep Hypothermic Circulatory Arrest
Scott J. Swanson, MD,
Lawrence H. Cohn, MD
Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
Accepted for publication February 10, 1995.
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Abstract
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A 68-year-old woman who had a stroke was found by transesophageal echocardiography to have two focal areas of pedunculated atherosclerosis in the arch of her aorta. Using echocardiographic imaging for guidance in aortic cannulation placement and deep hypothermic circulatory arrest, we removed the localized atheromata from the otherwise relatively normal aorta. She had an uneventful recovery. With the more frequent identification of discrete areas of aortic atherosclerosis as a result of transesophageal echocardiography, this procedure may become the standard by which to treat this problem.
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Introduction
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Stroke is one of the leading causes of morbidity and mortality in this country. Not uncommonly the source of the embolism remains indeterminate. The usual workup includes evaluation of the heart and extracranial cerebral vessels. If these areas are found to be normal and there is not another more unusual cause for the stroke, a patient typically is anticoagulated and followed up closely [1]. Recently, with the advent and evolution of transesophageal echocardiography (TEE), isolated areas of the aorta, particularly in the region of the arch, have been identified that contain pedunculated atherosclerotic lesions [2]. We describe a method using deep hypothermic circulatory arrest and intraoperative echocardiography to guide arterial cannulation placement for excision of such focal areas of protruding atheroma and therefore decrease the likelihood of further stroke.
A 68-year-old woman, with a long smoking history and claudication, presented to a local hospital with expressive aphagia and decreased sensation over the right side of her face. A head computed tomographic scan revealed a left frontal lobe infarct. Carotid noninvasive studies demonstrated less than 20% obstruction to flow bilaterally. A transthoracic echocardiogram showed no valvular pathology or abnormalities within any of the cardiac chambers. A TEE was performed, which showed a rather large focal protruding lesion within the aorta at the level of the proximal arch (Fig 1
) and another smaller lesion in the more distal arch. The aorta was otherwise normal, without evidence of diffuse atherosclerosis, aneurysmal dilatation, or dissection. The patient's symptoms completely resolved over 5 days. She was anticoagulated with warfarin and referred to us for consultation. Given her complete absence of anginal symptoms, a normal electrocardiogram, and a known risk in this setting of invasive aortic procedures [3], a coronary angiogram was not obtained.
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Fig 1. . Transesophageal echocardiogram, longitudinal view. Arrowhead demonstrates a large protruding mass beginning in the proximal aortic arch (the first of the two lesions removed). Appearance of near-obliteration is partially artifactual. (Ao = aorta; LA = left atrium; RA = right atrium.)
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The patient was taken to the operating room. She was placed on cardiopulmonary bypass using a right atrial venous cannula and a carefully placed aortic cannula in her descending aorta just beyond the arch. To visual inspection and palpation the entire aorta appeared normal, which is typical in this setting [4]. Placement of the arterial cannula was based on information from TEE as well as hand-held (by the surgeon) epiaortic echocardiographic images. The patient then was cooled to 15°C and her circulation was arrested. Circulatory arrest obviated the need for aortic clamping and therefore disruption of the pedunculated intraluminal masses. The aortic incision was begun just proximal to the arch. In the region of the innominate and left common carotid arteries a discrete, soft, friable lesion, approximately 2.5 cm in diameter, was noted protruding well into the lumen. Another similar, though smaller (2.0 cm in diameter) mass was seen in the distal arch proximal to the cannulation site. These were excised using an endarterectomy technique. The aortic cannula was repositioned in the ascending aorta, and the aorta was carefully irrigated and evacuated of air then closed with a running monofilament suture. The patient was warmed and weaned from bypass. She had an uneventful recovery and was discharged from the hospital on postoperative day 6 receiving an aspirin a day. Over mid-term follow-up (12 months), she has had no further neurologic events. Pathologic examination revealed complex atherosclerotic plaque and thrombus.
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Comment
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With the continued improvement in imaging technology, localized areas of aortic atherosclerosis will be detected as the only source for prior stroke [3] and therefore raise the question of how best to treat this finding. Nonoperative therapy using anticoagulation has only been effective anecdotally in other instances of aortic embolization [1]. Extrapolating from the experience of others where intraoperative strategies to debride areas of protruding aortic atheromas led to a decrease in perioperative stroke [5, 6], a case can be made for primary surgical intervention when intraluminal abnormalities within the aorta are thought to be responsible for stroke. This has been done in selected cases when there has been evidence for repeated peripheral emboli and a mass in the arch by echocardiography [7, 8].
Surgical treatment for an abnormal aorta consists mainly of replacement insofar as the disease process is generally a diffuse one [9]. Others have reported modification of operative strategy, when significant aortic lesions were encountered intraoperatively by TEE, to include arch debridement [5, 6] and aortic arch exploration in the setting of multiple peripheral emboli [7, 8]. This report underscores the importance of careful evaluation of the aortic arch as a source for unexplained stroke and describes a successful treatment strategy. Emphasis on initial arterial cannulation placement with guidance from TEE and epiaortic echocardiography as well as a ``no-touch'' technique using hypothermic circulatory arrest is noteworthy.
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Footnotes
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Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.
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References
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- Bansal RC, Pauls GL, Shankel SW. Blue digit syndrome: transesophageal echocardiographic identification of thoracic aortic plaque-related thrombi and successful outcome with warfarin. J Am Soc Echocardiogr 1993;6:319–23.[Medline]
- Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of a patient with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J 1990;120:658–60.[Medline]
- Karalis DG, Chandrasekaran K, Victor MF, Ross JJ, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 1991;17:73–8.[Abstract]
- Blanchard DC, Kimura BJ, Dittrich HC, Demaria AN. Transesophageal echocardiography of the aorta. JAMA 1994;272:546–51.[Abstract/Free Full Text]
- Katz ES, Tunick PA, Rusinck H, Ribakove G, Spencer RC, Kronzon I. Protruding atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol 1992;20:70–7.[Abstract]
- Ribakove GH, Katz ES, Galloway AC, et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 1992;53:758–63.[Abstract]
- Tunick PA, Culliford AT, Lamparello PJ, Kronzon I. Atheromatosis of the aortic arch as an occult source of multiple systemic emboli. Ann Intern Med 1991;114:391–2.
- Tunick PA, Lackner H, Katz ES, Culliford AT, Giangola G, Kronzon I. Multiple emboli from a large aortic arch thrombus in a patient with thrombotic diathesis. Am Heart J 1992;124:239–41.[Medline]
- Cohn LH. Thoracic aortic aneurysms and aortic dissection. In: Sabiston DC, Spencer FC, eds. Surgery of the chest. Philadelphia: Saunders, 1990:1182--209.
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Abstract
Introduction
