Emergent surgical removal of a free-floating calcified aortic arch plaque identified during TAVI resulted in favorable neurologic recovery with 0 adverse ischemic events in a 75-year-old male.
Case Report (n=1)
Emergent surgical removal of a free-floating calcified aortic arch plaque identified during TAVI can prevent catastrophic embolic events and result in favorable neurologic recovery.
Abstract Introduction Mobile aortic arch plaques are rare high-risk lesions, posing significant risk of stroke and systemic embolization. The risk increases with aortic manipulation like TAVI. Appearance on aortography may resemble aortic dissection, requiring prompt differentiation. Rapid recognition, advanced imaging, and coordinated surgical intervention are essential to prevent catastrophic neurologic or ischemic complications 1, 2. Case Presentation A 75-year-old male with severe aortic stenosis (AS), coronary artery disease (CAD), peripheral arterial disease (PAD), and left upper lobe adenocarcinoma treated with radiation under went attempted transcatheter aortic valve implantation (TAVI). Angiography identified a mobile linear structure in the aortic arch during wire advancement concerning for dissection versus free-floating plaque. The procedure was aborted, and he was transferred for cardiac surgery evaluation. CTA was negative for dissection, and revealed a large, calcified plaque at the aortic arch with potential obstruction of the innominate artery (Figure 1). Due to high embolic risk, he underwent emergent sternotomy with deep hypothermic circulatory arrest for excision of the free-floating plaque, bioprosthetic aortic valve replacement, and coronary artery bypass grafting. Plaque morphology was consistent with atheroma, which likely embolized during aortic manipulation. He developed severe hypoxemia requiring prolonged mechanical ventilation, likely the result of pre-existing lung disease. Otherwise, the postoperative course was largely unremarkable. He was successfully extubated on post-operative day four. Neurologic exam remained intact and he had no adverse ischemic events. Discussion Mobile aortic arch plaques are rare yet clinically significant sources of embolic stroke, seen in 1% of TEE studies and up to 4% of patients with embolic stroke. Large (≥4 mm), mobile, or calcified plaques have the highest embolic risk and independently predict recurrent stroke, myocardial infarction, and vascular death 1, 3. Atherosclerosis, PAD, and vascular manipulation, such as axillary access during TAVR, contribute to plaque instability. Aortic instrumentation may induce embolization. Differentiation of mobile plaques from dissection is essential, necessitating CT angiography and TEE for definitive diagnosis. 4, 5. Large plaques may require surgical removal, while smaller lesions are often managed with anti-platelet or anticoagulation therapy. Individualized planning and multidisciplinary collaboration are essential to prevent catastrophic embolic events in these high-risk patients 6. Conclusion This case illustrates a rare free-floating calcified aortic arch plaque identified during TAVI. Rapid imaging, multidisciplinary evaluation, and emergent surgical removal resulted in favorable neurologic recovery. Clinicians should remain vigilant for mobile plaques in high-risk patients undergoing structural heart procedures, as timely intervention is critical to prevent devastating embolic events. This abstract is funded by: None
Silverstein et al. (Fri,) conducted a case report in Severe aortic stenosis and free-floating calcified aortic arch plaque (n=1). Emergent surgical excision of plaque, bioprosthetic aortic valve replacement, and CABG was evaluated on Neurologic recovery and ischemic events. Emergent surgical removal of a free-floating calcified aortic arch plaque identified during TAVI resulted in favorable neurologic recovery with 0 adverse ischemic events in a 75-year-old male.