Cholesterol Crystal Embolism in a Patient with Spontaneous Ruptured Aortic Plaques Identified by Non-Obstructive General Angioscopy

Cholesterol crystal (CC) embolism is a disease in which CCs from atherosclerotic lesions embolize peripheral arteries, causing organ dysfunction. In this case, a patient with spontaneously ruptured aortic plaques (SRAPs) identified by non-obstructive general angioscopy (NOGA) may have developed a CC embolism. This is the first report of a CC embolism in a patient with SRAPs identified using NOGA, which further supports the previously speculated pathogenesis of CC embolism due to SRAPs.

Case series of mobile structures detected vividly by using superb microvascular imaging

Background

Superb microvascular imaging (SMI) is a new imaging technique that can reveal low-velocity blood flow without use of a contrast agent. SMI is based on an original algorithm and effectively removes tissue motion artifacts (clutter motion) from the background, thereby preserving visibility of low-velocity blood flow. SMI is expected to be useful for the evaluation of heart diseases, as well as blood vessels.

Case summary

Here, we report three cases in which a mobile structure in the heart or a blood vessel was detected easily by strong enhancement on SMI. In the heart, the entire mass was strongly enhanced by colour-SMI and had the appearance of 'a fire ball'. In the abdominal aorta and carotid artery, SMI captured a strongly enhanced echo image of a mass and revealed hyperechoic mobile plaque. It was hard to detect with the conventional echocardiography.

Discussion

It is important to detect mobile intravascular and intracardiac structures as they are risk factors of thrombosis. Echo images are often strongly affected by the skill of the examiner, the patient's body habitus, and the presence of intestinal gas; thus, it is often difficult to detect a small mass with conventional echocardiography. With the use of SMI, even small mobile structures can be displayed at high intensity in comparison with the surrounding blood flow. Therefore, the non-invasive SMI was useful for the detection of mobile intravascular and intracardiac structures. Our findings of the current report may lead to new developments in SMI for imaging in the cardiac region.

Predicting the presence of coronary artery disease by transesophageal echocardiography

Background

The accuracy of ultrasound signs as predictors for the presence of coronary artery disease (CAD) has been evaluated extensively in the 1990s and 2000s. Imaging quality has improved tremendously over the last decades.

Hypothesis

High-end ultrasound systems allow for accurate prediction of the presence or absence of CAD.

Methods

All patients who underwent a transesophageal echocardiography examination (TEE) between 2007 and 2016 and who had coronary angiography within 24 months before or after the TEE were retrospectively evaluated.

Results

A total of 242 patients fulfilled the inclusion criteria, 60% were male. Mean age was 70 years (SD ± 13 years). In multivariate regression analysis, plaque in the ascending aorta (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.18–5.32, p = 0.017), plaque in at least one of the thoracic aortic segments (OR 2.07, 95% CI 1.02–4.22, p = 0.045), and the presence of mitral annular calcification (MAC, OR 1.84, 95% CI 1.01–3.36, p = 0.046) were predictors of significant CAD. The isolated finding of aortic stenosis (AS) (OR 2.53, 95%CI 1.23–5.21, p = 0.012) was a significant predictor for the absence of normal coronary arteries.

Conclusion

With an negative predictive value (NPV) of 80%, the absence of MAC, AS, and aortic plaque makes the presence of significant CAD unlikely. If at least mild AS is present, normal coronary arteries are improbable.

Atherosclerotic plaque detected by transesophageal echocardiography is an independent predictor for all-cause mortality

Atherosclerotic lesions in the great arteries are frequent findings in the elderly. Numerous studies have shown their strong predictive value for cardiovascular disease, embolic events, and mortality. We sought to determine the risk of all-cause mortality depending on the localization of plaques in the thoracic aorta evaluated by transesophageal echocardiography (TEE). A total of 2,054 patients (median age 65 years, interquartile range 52–73; 58% men) who underwent a TEE examination between 01/2007 and 03/2015 were retrospectively analyzed. For each patient, the presence of atherosclerotic lesions in the ascending aorta, the aortic arch, and in the descending aorta, as well as cardiovascular risk factors and survival were documented. Median follow-up period was 48 months (interquartile range 38–58). Multivariate Cox regression analysis indicated plaque in the ascending aorta (HR of 1.36, 95% CI 1.01–1.83, P = 0.046), the aortic arch (HR of 1.78, 95% CI 1.29–2.45, P < 0.001), the descending aorta (HR of 2.01, 95% CI 1.54–2.77, P < 0.001), and plaque in any part of the thoracic aorta (HR of 1.84, 95% CI 1.42–2.4, P < 0.001), as independent predictors for all-cause mortality after adjusting for age, sex, arterial hypertension, hyperlipidemia, smoking, and diabetes. In this study, we could demonstrate that more than mild plaque at any site of the thoracic aorta predicts all-cause mortality. Assessment of atherosclerotic lesions in all segments of the thoracic aorta should be part of every routine TEE examination.

Impact of aortic plaque on progression rate and prognosis of aortic stenosis

BACKGROUNDS

Patients with aortic stenosis (AS) have a high prevalence of aortic plaque. However, no data exist regarding the clinical significance and prognostic value of aortic plaque in AS patients. This study examines the impact of aortic plaque on the rate of progression and clinical outcomes of AS.

METHODS

We retrospectively investigated 1812 transesophageal echocardiographic examinations between 2008 and 2015. We selected 100 consecutive patients (mean age; 75.1±7.4years) who showed maximal aortic jet velocity (AV-Vel) ≥2.0m/s by transthoracic echocardiography (TTE) and received follow-up TTE (mean follow-up duration 25±17months), and the mean progression rate of AV-Vel was calculated. Clinical and echocardiographic characteristics, including severity of aortic plaque, and cardiac events were examined.

RESULTS

At initial TTE, mean AV-Vel was 3.68±0.94m/s and mean aortic valve area 0.98±0.32cm². Mean progression rate of AV-Vel was 0.41m/s/year in 38 patients with severe aortic plaque, and -0.03m/s/year in the remaining 62 patients without severe aortic plaque. Severe aortic plaque (odds ratio[OR], 8.32) and hemodialysis (OR, 6.03) were independent predictors of rapid progression. The event-free survival rate at 3years was significantly lower in patients with severe aortic plaque than in those without (52% vs 82%, p=0.002). Severe aortic plaque (hazard ratio[HR], 2.89) and AV-Vel at initial TTE (HR, 3.28) were identified as independent predictors of cardiac events.

CONCLUSION

Severe aortic plaque was a predictor of rapid progression and poor prognosis in AS patients. Evaluation of aortic plaque provides additional information regarding surgical scheduling and follow-up.

Risk Factors of Aortic Plaque Progression Evaluated by Long-Term Follow-Up Data With Transesophageal Echocardiography

There are few longitudinal data regarding aortic plaque. This study aimed to examine chronological changes in aortic plaques with transesophageal echocardiography (TEE), and to clarify the risk factors of aortic plaque progression. Among 2,675 consecutive patients who underwent TEE, we retrospectively investigated 252 patients who underwent follow-up TEE with an interval >3 years. The thickness and morphology of aortic plaques were examined. Chronological changes in aortic plaques were investigated by comparing baseline and follow-up TEE. Clinical factors, laboratory data, and medications were evaluated. Among 252 study patients, the grade of aortic plaques was unchanged in 213 (group U), but progression was observed in 32 (group P) and regression in 7 patients (group R). Patients in group P were older; they had a higher prevalence of coronary artery disease, hypertension, smoking habit, and moderate or severe plaque at baseline TEE; more patients were using statins and no warfarin; and they had higher creatinine levels than those in group U. In multivariate analysis, moderate or severe plaques at baseline TEE were the strongest predictor of plaque progression. Among 50 patients who showed moderate or severe plaque at baseline TEE, smoking habit and no anticoagulation therapy were predictors of plaque progression. In conclusion, aortic plaques should be followed up using TEE in patients with moderate or severe plaque at baseline TEE.

Rosuvastatin prevents aortic arch plaque progression and improves prognosis in ischemic stroke patients

OBJECTIVES

Complicated aortic arch plaques (CAP) and their progression are important for recurrent ischemic stroke (IS) and its prognosis. We investigated the effects and clinical benefits of rosuvastatin therapy on this pathophysiology. The purpose of this study was to investigate whether rosuvastatin prevention of aortic arch plaque progression improved the prognosis of IS patients.

METHODS

Ninety-seven consecutive acute cerebral embolism patients were retrospectively surveyed. All had transesophageal echocardiography (TEE) to assess the presence or absence of CAP, defined as aortic wall thickness ≥4 mm or plaque ulceration. Patients received conventional antithrombotic therapy as clinically indicated. All patients with CAP were recommended to receive 5 mg rosuvastatin/day, administered by their attending physicians; not all physicians followed this recommendation. Six-month follow-up TEEs were performed in patients with CAP who received rosuvastatin. Major adverse cerebrovascular events (MACEs) comprised recurrent IS and death.

RESULTS

CAP was detected in 39 patients (40%), and MACEs in 15. Multivariate regression analysis showed that patients with CAP not taking rosuvastatin was an independent risk factor for MACEs (odds ratio = 18.044; 95% confidential interval = 2.089-155.846, p < 0.01). When patients were divided into three groups: those with CAP taking rosuvastatin, those with CAP not taking rosuvastatin, and those without CAP, Kaplan-Meier analysis demonstrated that patients with CAP not taking rosuvastatin had significantly more MACEs than those in the other two groups (long-rank test; χ² = 6.553, p < 0.05). Six-month TEE follow-ups in the 26 patients with CAP taking rosuvastatin showed significant improvement in CAP diameter with improved lipid profiles; 88% (23/26 patients) showed no morphological CAP progression; 15 of these showed CAP regression.

DISCUSSION

Rosuvastatin therapy prevented aortic arch plaque progression in IS patients with CAP, and may also have long-term clinical benefits.

Quantified Aortic Luminal Irregularity as a Predictor of Complications and Prognosis After Endovascular Aneurysm Repair

Atheromatous degeneration of the aorta is considered to be a risk factor for postoperative embolic complications after endovascular treatment, and is associated with a high incidence of vascular events in the long term. We devised a method to quantify the shagginess of the aorta using contrast-enhanced computed tomography (CT) images. This study examined the method's validity and prognostic usefulness in patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR). We retrospectively investigated 427 patients who underwent elective EVAR between 2007 and 2013. Preoperative contrast-enhanced CT images with a slice thickness of 1 mm were analyzed using a workstation, and the degree of aortic luminal irregularity from the level of the left subclavian artery ostium to that of the celiac artery ostium was quantified by computing a shagginess score. We compared the computed scores with subjective visual assessments of aortic shagginess. Subsequently, we evaluated the relationship between the computed scores and postoperative prognosis. The shagginess scores were significantly correlated with the visual assessments of the aortic lumen, which were performed by 5 experienced vascular surgeons (rho ranged from 0.564-0.654, all P < 0.001). Multiple logistic regression analysis demonstrated that the shagginess score was independently associated with the development of renal impairment within a month after EVAR (odds ratio, 2.78; 95% confidence interval [CI], 1.83-4.22, P < 0.001). The shagginess score was significantly higher in patients who suffered postoperative intestinal and peripheral ischemic complications, as compared with those who did not (P < 0.001). The mean postoperative follow-up period was 1207 ± 641 days. Cox proportional hazards regression showed that the shagginess score was a significant independent predictor of all-cause and cardiovascular mortality (hazard ratio [HR], 1.37; 95% CI, 1.09-1.72, P = 0.007, and HR, 1.51; 95% CI, 1.04-2.18, P = 0.030, respectively). The results suggest that the shagginess score provides a quantitative reflection of aortic luminal irregularity. It may serve as a useful predictive factor for postoperative renal function deterioration, embolic complications, and long-term mortality after elective EVAR.

Statins reduce extensive aortic atheromas in patients with abdominal aortic aneurysms

OBJECTIVE

Statins have been used widely to reduce dyslipidemia and recently have been reported to have pleiotropic effects such as plaque reduction and stabilization. This study retrospectively evaluated the regression of extensive thoracic atheromas ("shaggy aorta") in abdominal aortic aneurysm (AAA) patients who underwent contrast-enhanced computed tomography (CECT) before and after statin administration.

MATERIALS AND METHODS

CECT was used to examine thoracic aortas of 29 patients (statin group; n = 22, non-statin group; n = 7) with extensive atheromas from the ostium of the left subclavian artery to that of the more proximal renal artery. Extensive thoracic atheroma was defined by: (1) thickness >5 mm, (2) involved circumference of thoracic aorta >50%, and (3) length >30 mm. The areas of atheroma (cm(2)) were measured before and after administration of statins, and the atheroma reduction ratio (ARR) was evaluated.

RESULTS

The area of atheroma decreased after administration of statins, and the ARR was significant (P <0.01). The ARR increased with all cases in non-statin group. No complications associated with extensive atheroma were observed during the follow-up period.

CONCLUSION

This pilot study indicates statins can reduce extensive thoracic atheromas and lower lipid concentrations.

Effects of medical treatment on the prognosis and risk of embolic events in patients with severe aortic plaque

AIM

The optimal treatment strategy for patients with aortic atheroma is not well established because data regarding medical treatment for such patients are lacking, especially with respect to the Japanese population. The purpose of this study was to clarify the effects of medical treatment on the risk of embolic events and mortality in patients with severe aortic plaque.

METHODS

We retrospectively investigated 75 consecutive patients with severe aortic plaque detected on transesophageal echocardiography (TEE) between 1995 and 2005. The occurrence of embolic events and all-cause death in the period after TEE was assessed. The cumulative incidence of subsequent embolic events and death was evaluated in relation to specific medical treatments, including statins, antiplatelet drugs and warfarin.

RESULTS

Embolic events occurred in 27 patients (36%) and death occurred in 37 patients (49%) during follow-up (5.6±3.0 years). The patients who experienced embolic events had a significantly higher prevalence of previous embolic events, atrial fibrillation and hemodialysis than the patients who did not experience embolic events. Univariate and multivariate analyses showed that the use of statins and/or antiplatelet drugs was significantly associated with a low incidence of death but not with a low incidence of embolic events. On the other hand, warfarin exhibited neither beneficial nor harmful effects on the incidence of embolic events or death.

CONCLUSIONS

Statin and antiplatelet drugs have beneficial effects on the prognosis of patients with severe aortic plaque diagnosed on TEE.