title: Surgical treatment of nonaneurysmal aortic arch lesions in patients with systemic embolization.
abstract: OBJECTIVE
  Atherosclerotic lesions of the aortic arch are potential sources of arterial embolism. Here we investigate whether surgery, with the necessary circulatory supports, can be proposed as a good option for treatment of this problem. Study of these lesions on a national scale in France has made possible the assessment for future indications of techniques and results of the surgical management of aortic arch lesions, which retrospectively proved to be embolic.
  
  
  METHODS
  Thirty-eight patients, (19 men and 19 women) underwent surgery between 1976 and 1996 in 17 French cardiovascular surgical centers. The average age at the time of surgery was 49 +/- 12 years (range, 31 to 82 years). Atherosclerotic lesions were detected with transesophagial echocardiography (n = 19), angiography of the aortic arch (n = 16), computed tomography (n = 9), and magnetic resonance imaging (n = 10). Surgery consisted of thrombectomy and endarterectomy (n = 22), aortic resection and graft replacement (n = 10), and patch aortoplasty (n = 5; one thrombus disappeared spontaneously before surgery was performed).
  
  
  RESULTS
  The average postoperative period was 30 months (range, 3 to 82 months). Contact was lost with four patients after a follow-up period of 12 months. On pathologic specimens obtained at surgery, an atherosclerotic plaque was found in 73% of the cases (n = 28). In 15% of the cases, the aorta appeared normal (n = 6) and four other types of lesion were identified: angiosarcoma (n = 1), ectasia at the insertion of the remains of the ductus arteriosus (n = 1), rupture of tunica intima (n = 1), and a fibroblastic plaque (n = 1). A thrombus was identified in 26 cases, attached to the arterial wall in 18 cases. When transesophagial echocardiographic results showed mobile lesions (n = 22), histopathologic examination of specimens allowed the detection of a thrombus in 18 cases and an atherosclerotic plaque with a mobile projection in four cases. The postoperative mortality rate was 2.6%. The morbidity rate (28.9%; n = 11) was related to neurologic complications (n = 6), vascular complications (n = 4), and infection (n = 1). Four cases (12%) were reoperated.
  
  
  CONCLUSIONS
  Nonaneurysmal aortic arch lesions are a frequent and still underestimated source of stroke and peripheral embolization. Surgery with circulatory support can be recommended in good operative candidates with recurrent critical events despite medical management and with high embolic potential (young patients with no calcified plaques).
authors.affiliation: Department of Vascular Surgery, Guillaume et René Laënnec Hospital, Boulevard J Monod St Herblain, 44093 Nantes cédex 1, France.
authors.forename: Yann
authors.initials: Y
authors.lastname: Gouëffic
authors.forename: Philippe
authors.initials: P
authors.lastname: Chaillou
authors.forename: J Christophe
authors.initials: JC
authors.lastname: Pillet
authors.forename: Daniel
authors.initials: D
authors.lastname: Duveau
authors.forename: Philippe
authors.initials: P
authors.lastname: Patra
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001015:Aortic Arch Syndromes / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D004617:Embolism / Q000150:complications* / Q000401:mortality / Q000601:surgery*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014656:Vascular Surgical Procedures / Q000009:adverse effects*