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.