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J Thorac Cardiovasc Surg 1999;118:1114-1115
© 1999 Mosby, Inc.
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From the Department of Cardiovascular Surgery, Robert-Bosch-Hospital,a the Dr Margarete Fischer-Bosch Institute of Clinical Pharmacology,b Stuttgart, and the Department of Internal Medicine II (Cardiology), General Hospital,c Ludwigsburg, Germany.
Address for reprints: Matthias Schwab, MD, Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Robert-Bosch-Krankenhaus, Auerbachstrasse 112, D- 70376 Stuttgart, Germany (E-mail: matthias.schwab{at}ikp-stuttgart.de ).
Atherosclerotic lesions of the aorta, particularly in the region of the arch, are potential sources of cerebral and systemic embolization.
1 Herein we describe 2 patients in whom successful surgical treatment was performed in deep hypothermic circulatory arrest by excision of the aortic arch atheroma and synthetic graft replacement.
Clinical summaries
PATIENT 1
A 39-year-old woman with pre-existing rheumatoid arthritis was admitted because of sudden-onset aphasia and a left brachiofacial hemiparesis. Long-term smoking and arterial hypertension were identified as cardiovascular risk factors. A hemostatic disorder could be excluded. According to the underlying disease of rheumatoid arthritis, elevated acute phase reactants (eg, C-reactive protein) and presence of rheumatoid factors (eg, immunoglobulin M rheumatoid factor) were found. Cranial computed tomography of the head at admission revealed three 1.2-cm large ischemic areas in the right basal layer, ganglion, and multiple small ischemic areas in the temporoparietal medullary layer. Further investigations, such as lumbar puncture and electrocardiography, showed no pathologic findings. The Doppler ultrasound examination of the internal carotid arteries and the vertebral arteries revealed an 80% and 60% stenosis of the left and the right vertebral arteries, respectively. Transesophageal echocardiography (TEE) showed an atherosclerotic plaque with superimposed mobile thrombotic components on the concavity of the posterior segment of the aortic arch (Fig 1). No further abnormalities of the aorta or of the cardiac chambers were found. At operation, the patient was placed on cardiopulmonary bypass with the use of arterial cannulation of the ascending aorta, which was free of atherosclerotic plaques according to information from the TEE. After the patient’s body was cooled to a core temperature of 18°C, her circulation was arrested for 38 minutes. The aortic arch was incised from the innominate artery and extended to the small curvature of the aortic arch. Opposite the left common carotid artery, a focal atherosclerotic lesion (6 x 4 cm in diameter) was noted, which extended to the ligamentum Botalli with protruding atheroma components. The entire atheroma was excised. Reconstruction of the small curvature up to the descending aorta was performed with an impregnated Dacron patch (Fig 2). The postoperative course was uneventful. Histologic examination confirmed an atherosclerotic process with ulcerations. After discharge, a temporary anticoagulation was discontinued. Over a mid-term follow-up of 8 months, the patient has had no further neurologic events.
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Discussion.
Atherosclerotic plaques of the aortic arch have been considered to be a rare cause of thromboembolic events and recurrent ischemic stroke. 1 The prevalence of insertion of thrombi on the wall opposite the ostia of the aortic arch, also seen in our cases, is striking.
Optimal treatment strategies for atherosclerotic aortic plaques remain unclear. In some cases, anticoagulation with warfarin was considered to prevent thrombotic formations and, consequently, cerebral embolism. 2 However, recurrent embolic events may occur despite anticoagulant therapy in patients who do not undergo surgical treatment of atheromas. 3 On the other hand, in the literature, surgical treatment of symptomatic atherosclerotic lesions of the aortic arch was attempted in only a few cases. For example, Swanson and Cohn 4 described an endarterectomy technique in deep hypothermic circulatory arrest as a safe procedure in a patient with 2 focal atheromas in the aortic arch. Laperche and colleagues 3 recommended that, despite its own risk, surgical removal of atherosclerotic plaques with thrombotic components does not appear to be associated with the high risk of surgical removal of aortic debris.
In accordance with our surgical procedure, Belden and colleagues 5 reported a successful aortectomy with synthetic graft replacement of the aortic arch in a patient with multiple cerebral embolism that had been caused by a broad-based, mobile, protruding atheroma in the transverse aortic arch.
In patients with atherosclerotic plaques of the aortic arch, (partial) aortectomy in deep hypothermic arrest therefore seems to be a safe approach and should be considered as the method of choice. To our knowledge, all described cases, including our patients, had an uneventful postoperative recovery and no further neurologic events.
For etiologic diagnosis of arterial embolism, several studies emphasize TEE as a reliable method to detect cardiac thrombi, patent foramen ovale (associated with paradoxic embolism), atrial septal aneurysm, or localized areas of aortic atherosclerosis. 1,3 In our 2 patients, TEE permitted the precise localization of the atherosclerotic plaques and mobile thrombotic appositions.
References
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