Embolism from aortic plaque: Thromboembolism
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- Section Editors
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Jose Biller, MD, FACP, FAAN, FAHA
Jose Biller, MD, FACP, FAAN, FAHA
- Section Editor — Stroke
- Professor of Neurology and Neurological Surgery
- Chairman Department of Neurology
- Loyola University Chicago
- Stritch School of Medicine
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
Aortic atherosclerotic plaques are a manifestation of systemic atherosclerosis (image 1 and movie 1). They are associated with risk factors for atherosclerotic disease, and are more common in patients with coronary artery disease and in older individuals [1-5]. In addition, aortic atherosclerotic plaques are an important cause of systemic embolization [6-9]. Embolic events in the setting of aortic atherosclerosis can occur spontaneously or they can be induced by mechanical interventions including guidewire/catheter manipulation during cardiac catheterization, intraaortic balloon pulsations, and vessel clamping/manipulations during cardiac and vascular surgery [10,11]. The risk of embolism in patients with aortic atherosclerosis is markedly increased for plaques that are mobile and/or protruding, particularly if >4 mm in thickness.
The clinical features, prevention, and treatment of thromboembolism from aortic plaques will be reviewed here, with a focus on stroke, which is the most common clinical manifestation. Atheroembolism is discussed separately. (See "Embolism from atherosclerotic plaque: Atheroembolism (cholesterol crystal embolism)".)
THROMBOEMBOLISM VERSUS ATHEROEMBOLISM
Thromboembolism from aortic plaques is common, whereas cholesterol crystal embolization is fairly rare. Although there is some overlap, these disorders have characteristic distinguishing features:
●Thromboembolism may occur when an atherosclerotic plaque from large or medium arteries becomes unstable, and superimposed thrombi embolize. The thromboemboli tend to be single, and tend to lodge in small or medium arteries, resulting most often in stroke or transient ischemic attack [6-9,12]. Limb ischemia (upper or lower extremity), renal infarction, intestinal ischemia, or ischemia of other organs can also occur [9,13].
●The term atheroembolism is used synonymously with cholesterol crystal embolism, cholesterol embolism or micro-atheroembolism. These terms refer to arterio-arterial embolism of fragments of atheromatous material originating from an atherosclerotic plaque of the aorta or occasionally other arteries. The result of such embolization is tissue and organ damage produced by multiple small artery occlusions (eg, "blue toe" syndrome, retinal ischemia, renal failure, livedo reticularis, and intestinal infarction). (See "Embolism from atherosclerotic plaque: Atheroembolism (cholesterol crystal embolism)".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Fazio GP, Redberg RF, Winslow T, Schiller NB. Transesophageal echocardiographically detected atherosclerotic aortic plaque is a marker for coronary artery disease. J Am Coll Cardiol 1993; 21:144.
- Matsuzaki M, Ono S, Tomochika Y, et al. Advances in transesophageal echocardiography for the evaluation of atherosclerotic lesions in thoracic aorta--the effects of hypertension, hypercholesterolemia, and aging on atherosclerotic lesions. Jpn Circ J 1992; 56:592.
- Agmon Y, Khandheria BK, Meissner I, et al. Independent association of high blood pressure and aortic atherosclerosis: A population-based study. Circulation 2000; 102:2087.
- Jaffer FA, O'Donnell CJ, Larson MG, et al. Age and sex distribution of subclinical aortic atherosclerosis: a magnetic resonance imaging examination of the Framingham Heart Study. Arterioscler Thromb Vasc Biol 2002; 22:849.
- Agmon Y, Khandheria BK, Meissner I, et al. C-reactive protein and atherosclerosis of the thoracic aorta: a population-based transesophageal echocardiographic study. Arch Intern Med 2004; 164:1781.
- Tunick PA, Kronzon I. Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol 2000; 35:545.
- Amarenco P, Duyckaerts C, Tzourio C, et al. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992; 326:221.
- Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994; 331:1474.
- French Study of Aortic Plaques in Stroke Group, Amarenco P, Cohen A, et al. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996; 334:1216.
- Karalis DG, Quinn V, Victor MF, et al. Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta. Am Heart J 1996; 131:1149.
- Katz ES, Tunick PA, Rusinek H, et al. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol 1992; 20:70.
- Jones EF, Kalman JM, Calafiore P, et al. Proximal aortic atheroma. An independent risk factor for cerebral ischemia. Stroke 1995; 26:218.
- Tunick PA, Rosenzweig BP, Katz ES, et al. High risk for vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol 1994; 23:1085.
- Davies MJ, Richardson PD, Woolf N, et al. Risk of thrombosis in human atherosclerotic plaques: role of extracellular lipid, macrophage, and smooth muscle cell content. Br Heart J 1993; 69:377.
- Cohen A, Tzourio C, Bertrand B, et al. Aortic plaque morphology and vascular events: a follow-up study in patients with ischemic stroke. FAPS Investigators. French Study of Aortic Plaques in Stroke. Circulation 1997; 96:3838.
- Tunick PA, Nayar AC, Goodkin GM, et al. Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque. Am J Cardiol 2002; 90:1320.
- Tunick PA, Perez JL, Kronzon I. Protruding atheromas in the thoracic aorta and systemic embolization. Ann Intern Med 1991; 115:423.
- Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Ann Intern Med 1998; 128:639.
- Zabalgoitia M, Halperin JL, Pearce LA, et al. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators. J Am Coll Cardiol 1998; 31:1622.
- Mitusch R, Doherty C, Wucherpfennig H, et al. Vascular events during follow-up in patients with aortic arch atherosclerosis. Stroke 1997; 28:36.
- Meissner I, Khandheria BK, Sheps SG, et al. Atherosclerosis of the aorta: risk factor, risk marker, or innocent bystander? A prospective population-based transesophageal echocardiography study. J Am Coll Cardiol 2004; 44:1018.
- Karalis DG, Chandrasekaran K, Victor MF, et al. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 1991; 17:73.
- Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the aortic arch without aortic debris. A transesophageal echocardiographic finding associated with unexplained arterial embolism. The Filiale Echocardiographie de la Société Française de Cardiologie. Circulation 1997; 96:288.
- Tunick PA, Culliford AT, Lamparello PJ, Kronzon I. Atheromatosis of the aortic arch as an occult source of multiple systemic emboli. Ann Intern Med 1991; 114:391.
- Tunick PA, Lackner H, Katz ES, et al. Multiple emboli from a large aortic arch thrombus in a patient with thrombotic diathesis. Am Heart J 1992; 124:239.
- Vaduganathan P, Ewton A, Nagueh SF, et al. Pathologic correlates of aortic plaques, thrombi and mobile "aortic debris" imaged in vivo with transesophageal echocardiography. J Am Coll Cardiol 1997; 30:357.
- Khatibzadeh M, Mitusch R, Stierle U, et al. Aortic atherosclerotic plaques as a source of systemic embolism. J Am Coll Cardiol 1996; 27:664.
- Dressler FA, Craig WR, Castello R, Labovitz AJ. Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol 1998; 31:134.
- Hausmann D, Gulba D, Bargheer K, et al. Successful thrombolysis of an aortic-arch thrombus in a patient after mesenteric embolism. N Engl J Med 1992; 327:500.
- Freedberg RS, Tunick PA, Culliford AT, et al. Disappearance of a large intraaortic mass in a patient with prior systemic embolization. Am Heart J 1993; 125:1445.
- Keeley EC, Grines CL. Scraping of aortic debris by coronary guiding catheters: a prospective evaluation of 1,000 cases. J Am Coll Cardiol 1998; 32:1861.
- Baim DS, Wahr D, George B, et al. Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts. Circulation 2002; 105:1285.
- Henriques JP, Zijlstra F, Ottervanger JP, et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J 2002; 23:1112.
- Stern A, Tunick PA, Culliford AT, et al. Protruding aortic arch atheromas: risk of stroke during heart surgery with and without aortic arch endarterectomy. Am Heart J 1999; 138:746.
- van Dijk D, Keizer AM, Diephuis JC, et al. Neurocognitive dysfunction after coronary artery bypass surgery: a systematic review. J Thorac Cardiovasc Surg 2000; 120:632.
- Weinberger J, Azhar S, Danisi F, et al. A new noninvasive technique for imaging atherosclerotic plaque in the aortic arch of stroke patients by transcutaneous real-time B-mode ultrasonography: an initial report. Stroke 1998; 29:673.
- Oyama N, Gona P, Salton CJ, et al. Differential impact of age, sex, and hypertension on aortic atherosclerosis: the Framingham Heart Study. Arterioscler Thromb Vasc Biol 2008; 28:155.
- Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996; 348:633.
- Ferrari E, Vidal R, Chevallier T, Baudouy M. Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral anticoagulants. J Am Coll Cardiol 1999; 33:1317.
- Amarenco P, Davis S, Jones EF, et al. Clopidogrel plus aspirin versus warfarin in patients with stroke and aortic arch plaques. Stroke 2014; 45:1248.
- Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004; 364:331.
- Bhatt DL, Fox KA, Hacke W, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006; 354:1706.
- SPS3 Investigators, Benavente OR, Hart RG, et al. Effects of clopidogrel added to aspirin in patients with recent lacunar stroke. N Engl J Med 2012; 367:817.
- Lima JA, Desai MY, Steen H, et al. Statin-induced cholesterol lowering and plaque regression after 6 months of magnetic resonance imaging-monitored therapy. Circulation 2004; 110:2336.
- Yonemura A, Momiyama Y, Fayad ZA, et al. Effect of lipid-lowering therapy with atorvastatin on atherosclerotic aortic plaques detected by noninvasive magnetic resonance imaging. J Am Coll Cardiol 2005; 45:733.
- Pitsavos CE, Aggeli KI, Barbetseas JD, et al. Effects of pravastatin on thoracic aortic atherosclerosis in patients with heterozygous familial hypercholesterolemia. Am J Cardiol 1998; 82:1484.
- Corti R, Fuster V, Fayad ZA, et al. Effects of aggressive versus conventional lipid-lowering therapy by simvastatin on human atherosclerotic lesions: a prospective, randomized, double-blind trial with high-resolution magnetic resonance imaging. J Am Coll Cardiol 2005; 46:106.
- Herrera CJ, Frazin LJ, Dau PC, et al. Atherosclerotic plaque evolution in the descending thoracic aorta in familial hypercholesterolemic patients. A transesophageal echo study. Arterioscler Thromb 1994; 14:1723.
- Kawahara T, Nishikawa M, Kawahara C, et al. Atorvastatin, etidronate, or both in patients at high risk for atherosclerotic aortic plaques: a randomized, controlled trial. Circulation 2013; 127:2327.
- Corti R, Fayad ZA, Fuster V, et al. Effects of lipid-lowering by simvastatin on human atherosclerotic lesions: a longitudinal study by high-resolution, noninvasive magnetic resonance imaging. Circulation 2001; 104:249.
- Lansberg MG, O'Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S.
- Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e669S.
- Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
- Wareing TH, Davila-Roman VG, Daily BB, et al. Strategy for the reduction of stroke incidence in cardiac surgical patients. Ann Thorac Surg 1993; 55:1400.
- Jeyabalan G, Wallace JR, Chaer RA, et al. Endovascular strategies for treatment of embolizing thoracoabdominal aortic lesions. J Vasc Surg 2014; 59:1256.
- Dougherty MJ, Calligaro KD. Endovascular treatment of embolization of aortic plaque with covered stents. J Vasc Surg 2002; 36:727.
- Carroccio A, Olin JW, Ellozy SH, et al. The role of aortic stent grafting in the treatment of atheromatous embolization syndrome: results after a mean of 15 months follow-up. J Vasc Surg 2004; 40:424.
- Donas KP, Schönefeld T, Schwindt A, et al. Successful percutaneous endovascular treatment of symptomatic infrarenal aortic stenosis caused by soft-plaque with the Endurant stent-graft. J Cardiovasc Surg (Torino) 2011; 52:89.
- Tsuji Y, Tanaka Y, Kitagawa A, et al. Endovascular stent-graft repair for penetrating atherosclerotic ulcer in the infrarenal abdominal aorta. J Vasc Surg 2003; 38:383.
- Wolf PS, Burman HE, Starnes BW. Endovascular treatment of massive thoracic aortic thrombus and associated ruptured atheroma. Ann Vasc Surg 2010; 24:416.e9.
- THROMBOEMBOLISM VERSUS ATHEROEMBOLISM
- COMPLEX AORTIC PLAQUE
- Association with embolization
- Risk factors for embolization
- - Plaque thickness
- - Plaque ulceration and mobility
- - Plaque location
- - Cardiovascular procedures
- CLINICAL MANIFESTATIONS
- Other imaging techniques
- Medical therapy
- - Antithrombotic therapy
- - Lipid-lowering therapy
- - Recommendations
- - Endovascular surgery
- SUMMARY AND RECOMMENDATIONS