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)".)
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- 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