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Aortic Atheroma –

Significance, Prognosis
and Treatment.

Cardiology
Meeting
Significance

 Aortic atheroma can be a source


of otherwise unexplained embolic
events (eg stroke, TIA, peripheral
emboli).
 Retrospective and some
prospective studies have been
published to determine
prevalence, natural history and
therapy.
 Aortic atheroma also poses a risk
for manipulation of the aorta
during catheterisation, balloon
pump placement and cardiac
surgery.
Detection of Atheroma

 Transoesophageal
echocardiography is the
investigation of choice.
– Histologic correlations of aortic
segments with TOE findings in 62
aortic segments.
 Vaduganathan et al, JACC 30(2): 357-63, 1997 Aug.

 Association: aortic and carotid


atheroma.
– Mobile atheroma on TOE was
associated with greater than 70%
carotid stenosis in 23 of 40 patients
(58%). Suggest carotid duplex.
 Arko F et al, Am J Surgery 178(3): 206-8, 1999 Sep.

 Risk factors for aortic atheroma.


– Similar to coronary artery disease.
 Tribouilloy C et al, Am J Cardiol 82:1552-5, 1998 Dec.
Grading of Atheroma

 Grade I – normal intima.


 Grade II –increased intimal echo
density without thickening.
 Grade IIIA – increased intimal
echo density with single plaque ≤
3mm.
 Grade IIIB – multiple plaques ≤
3mm.
 Grade IV - ≥1 plaque > 3mm.
 Grade V – mobile or ulcerated
plaques.
Prevalence

 7% incidence of complex intra-


aortic plaque in 556 patients
undergoing TOE for various
indications. Of these, one third
had pendunculated mobile
atheroma.
– Karalis D et al, JACC 17:73-78, 1991.
 122 patients having TOE because
of unexplained embolisation –
27% had protruding atheroma
(Grade V).
– Tunick, Perez, Kronzon, Ann Int Med 115:423-7, 1991.
Risk of Embolisation (1)

 Prospective review of 183 patients


with the diagnosis of aortic arch
atheroma on TOE.
– 136 patients had raised plaques
<5mm.
– 47 patients had complex plaques
≥5mm.
– Follow-up 16±7 months
– Vascular events in 15 patients (8.2%)
– Incidence of event: 4.1 per 100
person-yrs with raised plaque.
– Incidence of event: 13.7 per 100
person-yrs with complex plaque.
– Kaplan – Meier Curves.
 Mitusch et al, Stroke 28:36-9, 1997.
 Germany
Risk of Embolisation (2)

 Spontaneous Echo Contrast


(SEC) in combination with
complex atherosclerosis had the
highest risk of embolism in a 105
patient retrospective study.
– Finkelhor RS et al, AM Heart J,
137(6):1088-93, 1999 Jan.
 Plaques with a mobile component
have a high embolic risk
compared to fixed plaque.
– Tenenbaum A et al, Cardiology,
89(4):246-51, 1998 May.
– 73% vs 12% - Karalis et al, JACC
17:73-78, 1991.
Embolisation during
Invasive Procedures

 Review of patients who were


referred for TOE following an
invasive aortic procedure.
– Femoral catheterisation.
– Intra-aortic balloon pump placement.
– Mobile vs. Non-mobile plaque.
 Karalis et al, JACC 19:280A, 1992.
 Open Heart Surgery with CPB
– Intraoperative TOE in 130 pts >65 yrs
– 18% had atheroma protruding into
arch.
– Incidence of stroke was significantly
higher in pts with protruding
atheromas (15%) than in those
without (2%).
– Surgical technique was modified with
improved outcomes.
Treatment (1)

 Warfarin
– In the 1960s and 70s there was
concern that warfarin could worsen
the clinical picture by causing plaque
haemorrhage and increased
cholesterol embolism.
– Arko et al studied 14 patients with
Grade V atheroma and history of
embolism. All were anticoagulated.
Over 6 to 30 months, there were no
further emboli.
 Arko et al Am J Surg 174:737-740, 1997.
– SPAF III trial compared standard
warfarin to low-dose warfarin +
aspirin in AF. Subgroup with aortic
plaque. Better outcomes with
standard warfarin.
 Blackshear et al Am J Cardiol 83:453-5, 1999
Feb
Treatment (2)

 Antiplatelet Agents
– Ferrari et al followed patients after a
diagnosis of aortic atheroma was
made on TOE.
 Treatment was left up to the treating
doctor.
 Patients on warfarin had fewer embolic
events and lower mortality than those on
antiplatelet agents.
 Statins
– Pitsavos et al performed TOEs on 16
patients with newly diagnosed familial
hypercholesterolaemia treated with
pravastatin (baseline and 2 yrs later).
Plaque was graded. Grade was
stable in 7, progressed in 3 and
regressed in 6 patients.
 Pitsavos et al Am J Cardiol 82(12): 1484-
8 1998 Dec.
Treatment (3)

 Thrombolysis of mobile plaque


– Case reports only.
 Aortic endarterectomy
– 12 patients
– Complications:
 1 dissection causing intraoperative death
 1 postoperative stroke
 1 sudden death at 8 months
 1 embolus to toes at 3 months

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