Which choice best localizes the salient abnormality?
Anterior mediastinum.Left ventricular wall.Aorta.Pulmonary arteries.Pleura.
An aortic atheroma is a thrombus. It is thought that aortic atheromas most commonly occur as a progression of atherosclerotic disease where intimal damage has occurred either acutely from trauma or much more commonly from atherosclerotic progression. Atheromas can occur anywhere within the aorta or vasculature. They can be either freely mobile or fixed in position. Patients can present asymptomatically or with symptoms of distal embolic events. Ascending aortic atheromas are a significant risk factor for stroke. Therefore particular attention should be given to ascending aortic atheromas because of their potential to cause cerebral vascular events.
The best well described classification for aortic arch atheromas is the Montgomery system. I- Normal or mild thickening of the intima. II- Extensive intimal thickening. III- Atheroma <5mm. IV- Atheroma >5mm, and V- Mobile lesion.
CT is described as being excellent in defining intimal wall irregularity and the size of atheromas. CT is however poor at distinguishing fixed from freely mobile clot, which can dramatically alter management. Even small atheromas that are freely mobile are often treated surgically due to the potential high risk of distal embolic events. Some literature describes trans esophageal echo as being superior to CT in defining whether clots are fixed or mobile. Cardiac gated CT's can be helpful in eliminating pulsation artifact and differentiating atheromas from dissection flaps.
Treatment varies by location of the atheroma, patient status, and institution. Our patient was treated at a large cardiovascular center and on TEE was shown to have a class V freely mobile ascending aortic atheroma. He was treated surgically on cardiac bypass and underwent open resection and placement of a focal aortic arch graft at the site of the intimal injury. Other treatment options include systemic anticoagulation, and endovascular therapy. Non-surgical treatment is often reserved for non-mobile small atheromas. Optimal treatment is not well defined in the literature.
Radiologic overview of the diagnosis: