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

BACKGROUND: Mobile atheromas of the aortic arch are associated with otherwi se unexplained strokes and transient ischemic attacks (TIA). They are assoc iated with increased perioperative strokes in patients undergoing coronary artery bypass surgery. Peripheral embolization is an additional risk. Trans esophageal echocardiography (TEE) accurately identifies mobile atheroma. An ticoagulant therapy may have therapeutic considerations In the management o f this condition. However, the risk of significant carotid artery disease a ssociated with mobile atheromas is unknown. METHODS: Between March 1994 and July 1998, 40 patients with mobile atheroma s by TEE and evidence of embolization were studied. Ail patients were captu red prospectively in a vascular registry and were retrospectively reviewed. Carotid artery disease was evaluated using carotid duplex imaging in an ac credited vascular laboratory. Ail patients with significant carotid disease , 70% or greater stenosis, underwent arteriography. Patients with significa nt carotid artery stenosis then underwent carotid endarterectomy. All patie nts with mobile atheromas were maintained on anticoagulation. RESULTS: Forty patients with mobile atheromas of the aortic arch were diagn osed with TEE. All 40 patients had evidence of embolization. Patient age ra nged from 57 to 73 years (mean 68.4). There were 22 men and 18 women. Twent y of 40 (50%) patients presented with symptoms of TIA. Eleven of 40 (28%) p atients presented with diffuse atheroembolization (lower extremity emboliza tion and renal insufficiency), Six of 40 (15%) patients presented with a co mpleted stroke. Three of 20 (7%) patients presented with acute extremity is chemia secondary to a peripheral embolus, Twenty-three of 40 (58%) of patie nts had significant carotid artery stenosis, 70% or greater stenosis. These 23 patients underwent both arteriography and carotid endarterectomy withou t complication. All patients were treated with anticoagulation and have rem ained anticoagulated. Clinical follow-up between 2 to 48 months (mean 18) h as demonstrated no further evidence of systemic embolization in these 40 pa tients. Repeat TEE was performed in 6 of 40 patients. These follow-up studi es no longer visualized mobile atheromas. CONCLUSIONS: Mobile atheromas are recognized sources for embolization. Rout ine carotid duplex imaging should be performed in patients found to have mo bile atheromas of the aortic arch. Carotid endarterectomy appears to be saf e in patients who have combined carotid artery stenosis and mobile atheroma s. Anticoagulation may have therapeutic considerations in the management of this condition. (C) 1999 by Excerpta Medica, Inc.