Introduction
One critical complication of cardiac surgery is cerebrovascular accidents (CVAs).
Ascending aorta atherosclerosis poses a significant risk of embolisation to distal
vessels and to cerebral arteries. Epi-aortic ultrasonography (EUS) is thought to offer
a safe, high-quality accurate visualisation of the diseased aorta to guide the surgeon
on the best surgical approach to the planned procedure and potentially improve neurological
outcomes post-cardiac surgery.
Method
The authors conducted a comprehensive search of PubMed, Scopus and Embase. Studies
that reported on epi-aortic ultrasound use in cardiac surgery were included. Major
exclusion criteria were: (1) abstracts, conference presentations, editorials, literature
reviews; (2) case series with <5 participants; (3) epi-aortic ultrasound in trauma
or other surgeries.
Results
A total of 59 studies and 48,255 patients were included in this review. Out of the
studies that reported patient co-morbidities prior to cardiac surgery, 31.6% had diabetes,
59.5% had hyperlipidaemia and 66.1% had a diagnosis of hypertension. Of those that
reported significant ascending aorta atherosclerosis found on EUS, this ranged from
8.3% of patients to 95.2% with a mean percentage of 37.8%. Hospital mortality ranged
from 7% to 13%; four studies reported zero deaths. Long-term mortality and stroke
rate varied significantly with hospital duration.
Conclusion
Current data have shown EUS to have superiority over manual palpation and transoesophageal
echocardiography in the prevention of CVAs following cardiac surgery. Yet, EUS has
not been implemented as a routine standard of care. Extensive adoption of EUS in clinical
practice is warranted to aid large, randomised trials before making prospective conclusions
on the efficacy of this screening method.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Heart, Lung and CirculationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Avoiding stroke during cardiac surgery.Semin. Cardiothorac Vasc Anesth. 2010; 14: 95-101
- Adverse neurologic events: risks of intracardiac versus extracardiac surgery.J Cardiothorac Vasc Anesth. 1996; 10: 31-37
- Stroke prevention in cardiac surgery.Interact Cardiovasc Thorac Surg. 2012; 15: 155-157
- Brain protection in cardiac surgery.Anesthesiol Clin. 2008; 26: 521
- Adverse cerebral outcomes after coronary bypass surgery. Multicenter study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators.N Engl J Med. 1996; 335: 1857-1864
- Imaging techniques for diagnosis of thoracic aortic atherosclerosis.Int J Vasc Med. 2016; 4726094
- The atherosclerotic aortic arch: considerations in diagnostic imaging.Prev Cardiol. 2008; 11: 162-167
- Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasonographic examination: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists; endorsed by the Society of Thoracic Surgeons.J Am Soc Echocardiogr. 2007; 20: 1227-1235
- Meta-analysis of the diagnostic accuracy of transesophageal echocardiography for assessment of atherosclerosis in the ascending aorta in patients undergoing cardiac surgery.Acta Anaesthesiol Scand. 2008; 52: 1179-1187
Ozatik MA, Vural KM, Sener E, Tasdemir O. Epiaortic ultrasound: aortic screening in coronary revascularization. 1999;7:168–172. https://doi.org/10.1177/021849239900700302
- Does epiaortic ultrasound screening reduce perioperative stroke in patients undergoing coronary surgery? A topical review.J Clin Neurosci. 2018; 50: 30-34
- The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ. 2021; : 372
- Aortic atheroma is related to number of particulates captured by intra-aortic filtration in CABG.Eur J Cardiothorac Surg. 2002; 22: 539-544
- Preoperative computed tomography or intraoperative epiaortic ultrasound for the diagnosis of atherosclerosis of the ascending aorta?.Heart Surg Forum. 2004; 7: 142-146
- A policy to reduce stroke in patients with extensive atherosclerosis of the ascending aorta undergoing coronary surgery.Interact Cardiovasc Thorac Surg. 2004; 3: 28-32
- Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment of atherosclerosis of the thoracic aorta.J Am Coll Cardiol. 1996; 28: 942-947
- PAS-Port® clampless proximal anastomotic device for coronary bypass surgery in porcelain aorta.Eur J Cardiothorac Surg. 2011; 39: 49-52
- Cerebral emboli generation during off-pump coronary artery bypass grafting with a clampless device versus partial clamping of the ascending aorta.Innovations (Phila). 2010; 5: 7-11
- Early results and problems with St. Jude Medical Symmetry bypass system in Japan.Asian Cardiovasc Thorac Ann. 2004; 12: 236-238
- The ascending aorta: how much does transesophageal echocardiography see?.Anesth Analg. 1994; 78: 240-244
- Management of the severely atherosclerotic aorta during cardiac operations.J Card Surg. 1994; 9: 490-494
- Epiaortic ultrasound-guided true lumen cannulation of ascending aorta in acute aortic dissection type A.J Med Assoc Thail. 2021; 104: 604-609
- The use of intraoperative epiaortic ultrasonography in monitoring patients over 75 years old treated with aortic valve replacement. Kardiochirurgia i torakochirurgia Pol.(Polish J cardio-thoracic Surg.). 2017; 14: 10-15
- Coronary artery bypass grafting for patients with an atherosclerotic ascending aorta.Jpn J Thorac Cardiovasc Surg. 2001; 49: 195-200
- Reduced neuropsychological dysfunction using epiaortic echocardiography and the exclusive Y graft.Ann Thorac Surg. 2000; 69: 1431-1438
- The use of the SonoSite ultrasound device for intraoperative evaluation of the aorta.J Cardiothorac Vasc Anesth. 2004; 18: 715-718
- Resolving the blind spot of transoesophageal echocardiography: a new diagnostic device for visualizing the ascending aorta in cardiac surgery.Br J Anaesth. 2007; 98: 434-441
- Ascending aortic atheroma assessed intraoperatively by epiaortic and transesophageal echocardiography.Ann Thorac Surg. 2000; 70: 25-30
- Increased incidence of proximal aortic atherosclerotic disease in patients with internal carotid occlusion.Heart Surg Forum. 2002; 6: 55-59
- Postoperative stroke after off-pump versus on-pump coronary artery bypass surgery.J Thorac Cardiovasc Surg. 2007; 133: 169-173
- Impact of ascending aortic wall thickness and atherosclerosis on the intermediate survival after coronary artery bypass surgery.Eur J Cardiothorac Surg. 2012; 41: e94-e99
- Epiaortic ultrasound to prevent stroke in coronary artery bypass grafting.Ann Thorac Surg. 2020; 109: 294-301
- Do particulate emboli from the ascending aorta in coronary bypass grafting correlate with aortic wall thickness?.Interact Cardiovasc Thorac Surg. 2006; 5: 716-720
- Trends in aortic clamp use during coronary artery bypass surgery: effect of aortic clamping strategies on neurologic outcomes.J Thorac Cardiovasc Surg. 2014; 147: 652-657
- Atherosclerosis of the ascending aorta is a predictor of renal dysfunction after cardiac operations.J Thorac Cardiovasc Surg. 1999; 117: 111-116
- Postoperative cognitive dysfunction and aortic atheroma.Ann Thorac Surg. 2010; 89: 1091-1097
- Cerebral ischemic disorders and cerebral oxygen balance during cardiopulmonary bypass surgery: preoperative evaluation using magnetic resonance imaging and angiography.Anesth Analg. 1997; 84: 5-11
- Aortic atherosclerosis and postoperative neurological dysfunction in elderly coronary surgical patients.Ann Thorac Surg. 2003; 75: 1912-1918
- Operative strategies to reduce cerebral embolic events during on- and off-pump coronary artery bypass surgery: a stratified, prospective randomized trial.J Thorac Cardiovasc Surg. 2017; 154: 1278-1285.e1
- Modification of surgical technique for ascending aortic atherosclerosis: impact on stroke reduction in coronary artery bypass grafting.J Thorac Cardiovasc Surg. 2003; 126: 391-400
- Risk factors for early or delayed stroke after cardiac surgery.Circulation. 1999; 100: 642-647
- Enhanced intra-operative grading of ascending aorta atheroma by epiaortic ultrasound vs echocardiography.Int J Cardiol. 2008; 128: 218-223
- Synchronized epiaortic two-dimensional and color Doppler echocardiographic guidance enables routine ascending aortic cannulation in type A acute aortic dissection.J Thorac Cardiovasc Surg. 2011; 141: 354-360
- Impact of aortic atherosclerosis burden on outcomes of surgical aortic valve replacement.Ann Thorac Surg. 2020; 109: 465-471
- Postoperative neurological complications and risk factors for pre-existing silent brain infarction in elderly patients undergoing coronary artery bypass grafting.J Anesth. 2012; 26: 405-411
- Added value of modified transoesophageal echocardiography in the diagnosis of atherosclerosis of the distal ascending aorta in cardiac surgery patients.Eur Heart J - Cardiovasc Imaging. 2014; 15: 623-630
- Intraoperative epiaortic scanning for preventing early stroke after off-pump coronary artery bypass.Br J Anaesth. 2013; 111: 374-381
- Initial clinical experience with the Heartstring.Jpn J Thorac Cardiovasc Surg. 2006; 54: 424-428
- Effects of a proximal seal system on neurologic outcomes of off-pump coronary artery bypass grafting.Int Heart J. 2019; 60: 593-600
- Transesophageal echocardiography can be used to screen for ascending aortic atherosclerosis.Anesth Analg. 1995; 81: 225-228
- Intraoperative epiaortic ultrasound scanning guides operative strategies and identifies patients at high risk during coronary artery bypass grafting.Innovations (Phila). 2009; 4: 99-105
- Echocardiographic and pathological evaluation of atherosclerosis in the ascending aorta during coronary artery bypass grafting.Anesth Analg. 2000; 90: 1262-1268
- Does intensive management of cerebral hemodynamics and atheromatous aorta reduce stroke after coronary artery surgery?.Ann Thorac Surg. 2008; 85: 513-519
- Intraoperative epiaortic ultrasound during cardiac surgery.J Card Surg. 1996; 11: 49-55
- Risk factors for stroke following coronary artery bypass operations.J Card Surg. 2005; 20: 52-57
- The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients.Ann Thorac Surg. 2008; 85: 548-553
- Factors associated with presence of ascending aortic atherosclerosis in CABG patients.Ann Thorac Surg. 2004; 78: 2028-2032
- The influence of ascending aortic atherosclerosis on the long-term survival after CABG.Eur J Cardio-Thoracic Surg. 2005; 28: 558-562
- Epiaortic ultrasound for assessment of intraluminal atheroma; insights from the REGROUP trial.J Cardiothorac Vasc Anesth. 2020; 34: 726-732
- Assessment of ascending aorta using epiaortic ultrasonography during off-pump coronary artery bypass grafting.Ann Thorac Surg. 2002; 74: 2097-2100
- An intraoperative assessment of the ascending aorta: a comparison of digital palpation, transesophageal echocardiography, and epiaortic ultrasonography.J Cardiothorac. Vasc Anesth. 2007; 21: 805-809
- Safety and efficacy of central cannulation through ascending aorta for type A aortic dissection.Interact Cardiovasc Thorac Surg. 2010; 11: 34-37
- The intraoperative assessment of ascending aortic atheroma: epiaortic imaging is superior to both transesophageal echocardiography and direct palpation.J Cardiothorac Vasc Anesth. 1997; 11: 704-707
- Intraoperative transit-time flow measurement and high-frequency ultrasound assessment in coronary artery bypass grafting.J Thorac Cardiovasc Surg. 2020; 159: 1283-1292.e2
- Extracorporeal circulation before and after ultrasonographic evaluation of the ascending aorta.Ann Thorac Surg. 1999; 67: 478-483
- Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta.J Am Coll Cardiol. 2001; 38: 131-135
- Surgical management of the atherosclerotic ascending aorta: is endoaortic balloon occlusion safe?.Ann Thorac Surg. 2006; 82: 1709-1714
- The impact of epiaortic ultrasonographic scanning on the risk of perioperative stroke.Eur J Cardiothorac Surg. 2006; 29: 720-728
- Continuous-flow cell saver reduces cognitive decline in elderly patients after coronary bypass surgery.Circulation. 2007; 116: 1888-1895
- Epiaortic scanning modifies planned intraoperative surgical management but not cerebral embolic load during coronary artery bypass surgery.Anesth Analg. 2008; 106: 1611-1618
- Intimal aortic atherosclerosis in cardiac surgery: surgical strategies to prevent embolic stroke.Eur J Cardiothorac Surg. 2021; 60: 1259-1267
- Does routine use of aortic ultrasonography decrease the stroke rate in coronary artery bypass surgery?.J Vasc Surg. 1995; 21: 98-109
- Coronary artery bypass grafting with and without manipulation of the ascending aorta: a network meta-analysis.J Am Coll Cardiol. 2017; 69: 924-936
- Surgery for type A aortic dissection in patients with cerebral malperfusion: results from the International Registry of Acute Aortic Dissection.J Thorac Cardiovasc Surg. 2020; https://doi.org/10.1016/j.jtcvs.2019.11.003
- Atherosclerotic disease of the proximal aorta and the risk of vascular events in a population-based cohort: the Aortic Plaques and Risk of Ischemic Stroke (APRIS) study.Stroke. 2009; 40: 2313-2318
- Failure to rescue: variation in mortality after cardiac surgery.Interact Cardiovasc Thorac Surg. 2021; 33: 848-856
- Comprehensive stroke care and outcomes: time for a paradigm shift.Stroke. 2021; 52: 385-393
- Impact of postoperative complications after cardiac surgery on long-term survival.J Card Surg. 2021; 36: 2045-2052
- Systematic review of factors influencing length of stay in ICU after adult cardiac surgery.BMC Health Serv Res. 2016; 16: 318
Article info
Publication history
Published online: March 02, 2023
Accepted:
January 29,
2023
Received in revised form:
January 25,
2023
Received:
November 6,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
