Transcutaneous detection of aortic arch atheromas by suprasternal harmonic imaging
Ehud Schwammenthal, MD*, ,
Yvonne Schwammenthal, MD ,*,,
David Tanne, MD,,
Alexander Tenenbaum, MD*,,
Alex Garniek, MD ,,
Michael Motro, MD, FACC*,,
Babeth Rabinowitz, MD, FACC*,,
Michael Eldar, MD, FACC*, and
Micha S. Feinberg, MD*,
* Heart Institute and Cardiac Rehabilitation Institute, Tel Hashomer, Israel
Department of Neurology, Chaim Sheba Medical Center, Tel Hashomer, Israel
Department of Radiology, Chaim Sheba Medical Center, Tel Hashomer, Israel
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Figure 1 Long-axis view of the proximal thoracic aorta. (Left) Views of the ascending aorta with origin of the inominate artery (IA) obtained by anterior tilting of the transducer. (Right) Views of the distal arch and descending thoracic aorta (dAo) obtained by posterior tilting of the transducer. The origin of the left common carotid artery and the left subclavian artery are visualized in the same plane; the IA can be recognized, but its origin cannot be appropriately delineated in this plane.
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Figure 2 (Left) Large protruding aortic atheroma (arrows) vis-à-vis the origin of the left common carotid and subclavian artery detected by suprasternal harmonic imaging (HI) (zoomed frame, the overview image is shown as an inlay picture in the right upper corner). (Right) Same atheroma visualized by transesophageal echocardiography (TEE).
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Figure 3 (Left) Large protruding aortic atheroma at the minor curvature of the aortic arch (zoomed frame), with features compatible with ulceration (arrows). Long and continuous segments of the aortic wall appear as thick hypoechoic plaques (arrowheads). (Right) The same features can be identified by transesophageal echocardiography.
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Figure 4 Examination of the aortic arch by suprasternal harmonic imaging. (Top) Overview images of the proximal thoracic aorta (long axis). (Bottom) Zoomed image sections after adjusting gain facilitate detail recognition. (Left) Calcifications without protruding atheromas at the minor curvature of the aorta (three arrowheads pointing down) and at the origin of the inominate artery (two arrowheads pointing up). (Right) Large noncalcified atheroma (arrowheads) protruding into the proximal descending thoracic aorta vis-à-vis the origin of the left subclavian artery. Note that the hypoechoic ("soft") atheroma is clearly delineated only after zoom and gain adjustments.
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Figure 5 (Left) Visualization of the complete descending thoracic aorta in a long-axis view by suprasternal harmonic imaging (SHI). The posterior aortic wall is covered by aortic plaques over a segment of several centimeters. (Right) Transesophageal echocardiography (TEE) confirms the findings. Appropriate visualization of the latter half of the descending thoracic aorta was possible only in the minority of cases.
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Figure 6 (Left) Agreement between harmonic imaging (SHI) and transesophageal echocardiography (TEE) or dual helical computed tomography (DHCT) in the classification of aortic arch findings. (Right) Agreement between two observers in the classification of aortic arch findings using harmonic imaging. PAA = protruding atheroma of the aortic arch.
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Figure 7 Mobile thrombus superimposed on an atherosclerotic plaque of the aortic arch; the curved arrow indicates systolic motion of the thrombus). LCA = left common carotid artery; LSA = left subclavian artery.
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Figure 8 Dual helical computed tomography in a patients with a protruding atheroma of the aortic arch with a mobile thrombus, visualized by suprasternal harmonic imaging (Fig. 4), but not by transesophageal echocardiography. (Left) The dashed line demonstrates that the posterior view of the complex plaque from the esophagus (E) (arrow) is obstructed by the origin of the left bronchus (LB) from the trachea (T). The solid line depicts the view from the esophagus after maximum anterior rotation of the transducer before interference with the left bronchus. The angle of freedom limited by the left bronchus does not allow visualization of the aorta at all at the level of the complex plaque. (Right) The sagittal view shows that the complex plaque is readily accessible anteriorly from the suprasternal window.
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