Current Cardiology Reports

, Volume 14, Issue 3, pp 342–349 | Cite as

Aortic Atherosclerosis and Embolic Events

  • Muhamed Saric
  • Itzhak Kronzon
Echocardiography (RM Lang, Section Editor)


Aortic plaques are a manifestation of the general process of atherosclerosis in which there is a progressive accumulation of cholesterol and other lipids in the intimal-medial layer of the aorta with secondary inflammation, repetitive fibrous tissue deposition, and eventually luminal surface erosions and appearance of often mobile thrombi protruding into the lumen of the aorta. Aortic plaques may give rise to two types of emboli: thromboemboli and atheroemboli (cholesterol crystal emboli). Thromboemboli are relatively large, tend to occlude medium to large arteries, and cause strokes, transient ischemic attacks, and renal infarcts and other forms of peripheral thromboembolism. Cholesterol crystal emboli are relatively minute, tend to occlude small arteries and arterioles, and may cause the blue toe syndrome, new or worsening renal insufficiency, gut ischemia, etc. Transesophageal echocardiography remains the gold standard for visualization of aortic plaques in the thoracic aorta. There are no proven therapies for aortic embolism per se; general atherosclerosis management strategies are recommended.


Atherosclerosis Aorta Thromboembolism Atheroma Plaque Atheroembolism Cholesterol embolization syndrome Transesophageal echocardiography 3D echocardiography Computed tomography Magnetic resonance imaging Stroke Transient ischemic attack 



Conflicts of interest: M. Saric: none; I. Kronzon: has received honoraria from Philips Healthcare.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Haller, Albrecht von. Observatio XXXXVII: materia ossium morbosorum. In: Opuscula pathologica. Lausanne: Bousquet; 1755. p. 124–8.Google Scholar
  2. 2.
    Lobstein JGCFM. Traités d’anatomie pathologique. Paris: Chez F. G. Levrault; 1833. p. 550–3.Google Scholar
  3. 3.
    Marchand JF. Über arteriosklerose (athero-sklerose). Verh Kongresses Innere Medizin. 1904;21:23–59.Google Scholar
  4. 4.
    Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III). JAMA. 2001;285:2486–249.Google Scholar
  5. 5.
    Selzman CH, Miller SA, Harken AH. Therapeutic implications of inflammation in atherosclerotic cardiovascular disease. Ann Thorac Surg. 2001;71(6):2066–74.PubMedCrossRefGoogle Scholar
  6. 6.
    Danesh J, Lewington S, Thompson SG, et al. Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis. JAMA. 2005;294(14):1799–809.PubMedCrossRefGoogle Scholar
  7. 7.
    Stary HC, Chandler AB, Dinsmore RE, Fuster V, Glagov S, Insull Jr W, Rosenfeld ME, Schwartz CJ, Wagner WD, Wissler RW. A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation. 1995;92(5):1355–74.PubMedGoogle Scholar
  8. 8.
    •• Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, Eagle KA, Hermann LK, Isselbacher EM, Kazerooni EA, Kouchoukos NT, Lytle BW, Milewicz DM, Reich DL, Sen S, Shinn JA, Svensson LG, Williams DM; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010 Apr 6;55(14):e27–129. This paper provides an extensive review of aortic atherosclerosis and the latest guidelines for its management. PubMedCrossRefGoogle Scholar
  9. 9.
    Golledge J, Norman PE. Atherosclerosis and abdominal aortic aneurysm: cause, response, or common risk factors? Arterioscler Thromb Vasc Biol. 2010;30(6):1075–7.PubMedCrossRefGoogle Scholar
  10. 10.
    • Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation. 2010;122:631–41. This article provides an exhaustive review of cholesterol embolization syndrome, which together with thromboembolism, is the major manifestation of aortic atherosclerosis. PubMedCrossRefGoogle Scholar
  11. 11.
    Tunick PA, Kronzon I. Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol. 2000;35:545–54.PubMedCrossRefGoogle Scholar
  12. 12.
    Fenger CE, Jacobsen JP, Dahlerup EA, Hornemann E, Collin T. Beretning af Obductionen over Albert Thorvaldsen (autopsy report of Albert Thorvaldsen). Ugeskr Laeger. 1844;X(14–15):215–8.Google Scholar
  13. 13.
    Panum PL. Experimentelle Beiträge zur Lehre von der Embolie. Virchows Arch Pathol Anat Physiol. 1862;25:308–10.CrossRefGoogle Scholar
  14. 14.
    Tunick PA, Katz ES, Freedberg RS, Rosezweig BP, Perez JL, Kronzon I. High risk vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol. 1994;23:1085–90.PubMedCrossRefGoogle Scholar
  15. 15.
    Stern A, Tunick PA, Culliford AT, Lachmann J, Baumann FG, Kanchuger M, Marschall K, Shah A, Grossi E, Kronzon I. Protruding aortic arch atheromas: risk of stroke during heart surgery with and without aortic arch endarterectomy. Am Heart J. 1999;138:746–52.PubMedCrossRefGoogle Scholar
  16. 16.
    Rodés-Cabau J, Dumont E, Boone RH, Larose E, Bagur R, Gurvitch R, Bédard F, Doyle D, De Larochellière R, Jayasuria C, Villeneuve J, Marrero A, Côté M, Pibarot P, Webb JG. Cerebral embolism following transcatheter aortic valve implantation: comparison of transfemoral and transapical approaches. J Am Coll Cardiol. 2011;57(1):18–28.PubMedCrossRefGoogle Scholar
  17. 17.
    Szeto WY, Augoustides JG, Desai ND, Moeller P, McGarvey ML, Walsh E, Bannan A, Herrmann HC, Bavaria JE. Cerebral embolic exposure during transfemoral and transapical transcatheter aortic valve replacement. J Card Surg. 2011;26(4):348–54.PubMedCrossRefGoogle Scholar
  18. 18.
    Saric M, Kronzon I. Cholesterol embolization syndrome. Curr Opin Cardiol. 2011;26:472–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Rana BS, Monaghan MJ, Ring L, Shapiro LS, Nihoyannopoulos P. The pivotal role of echocardiography in cardiac sources of embolism. Eur J Echocardiogr. 2011;12(10):i25–31.PubMedCrossRefGoogle Scholar
  20. 20.
    •• Pepi M, Evangelista A, Nihoyannopoulos P, Flachskampf FA, Athanassopoulos G, Colonna P, Habib G, Ringelstein EB, Sicari R, Zamorano JL, Sitges M, Caso P; European Association of Echocardiography. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr. 2010 Jul;11(6):461–76. These are the latest guidelines for the use of echocardiography for the detection of cardiac and aortic sources of emboli. PubMedCrossRefGoogle Scholar
  21. 21.
    Davila-Roman VG, Phillips KJ, Daily BB, Davila RM, Kouchoukos NT, Barzilai B. Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment of atherosclerosis of the thoracic aorta. J Am Coll Cardiol. 1996;28:942–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Amarenco P, Cohen A, Tzourio C, Bertrand B, Hommel M, Besson G, Chauvel C, Touboul PJ, Bousser MG. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331(22):1474–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Sharma U, Tak T. Aortic atheromas: current knowledge and controversies: a brief review of the literature. Echocardiogr. 2011;28(10):1157–63.CrossRefGoogle Scholar
  24. 24.
    Ko Y, Park JH, Yang MH, Ko SB, Choi SI, Chun EJ, Han MK, Bae HJ. Significance of aortic atherosclerotic disease in possibly embolic stroke: 64-multidetector row computed tomography study. J Neurol. 2010;257(5):699–705.PubMedCrossRefGoogle Scholar
  25. 25.
    Zahuranec DB, Mueller GC, Bach DS, Stojanovska J, Brown DL, Lisabeth LD, Patel S, Hughes RM, Attili AK, Armstrong WF, Morgenstern LB. Pilot study of cardiac magnetic resonance imaging for detection of embolic source after ischemic stroke. J Stroke Cerebrovasc Dis. 2011 Jun 1. [Epub ahead of print].Google Scholar
  26. 26.
    Barazangi N, Wintermark M, Lease K, Rao R, Smith W, Josephson SA. Comparison of computed tomography angiography and transesophageal echocardiography for evaluating aortic arch disease. J Stroke Cerebrovasc Dis. 2011;20(5):436–42.PubMedCrossRefGoogle Scholar
  27. 27.
    Khatri IA, Mian N, Al-Kawi A, Janjua N, Kirmani JF, Saric M, Levine JC, Qureshi AI. Arch aortogram fails to identify aortic atherosclerotic lesions detected on transesophageal echocardiogram. J Neuroimaging. 2005;15:1–5.Google Scholar
  28. 28.
    Dunphy MP, Freiman A, Larson SM, Strauss HW. Association of vascular 18F-FDG uptake with vascular calcification. J Nucl Med. 2005;46(8):1278–84.PubMedGoogle Scholar
  29. 29.
    Harloff A, Simon J, Brendecke S, Assefa D, Helbing T, Frydrychowicz A, Weber J, Olschewski M, Strecker C, Hennig J, Weiller C, Markl M. Complex plaques in the proximal descending aorta: an underestimated embolic source of stroke. Stroke. 2010;41(6):1145–50.PubMedCrossRefGoogle Scholar
  30. 30.
    Saric M, Kronzon I. Embolism from aortic plaque: atheroembolism (cholesterol crystal embolism). In: Basow DS, editor. UpToDate. Waltham: UpToDate; 2011.Google Scholar
  31. 31.
    Tunick PA, Nayar AC, Goodkin GM, Mirchandani S, Francescone S, Rosenzweig BP, Freedberg RS, Katz ES, Applebaum RM, Kronzon I. Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque. Am J Cardiol. 2002;90:1320–5.PubMedCrossRefGoogle Scholar
  32. 32.
    American Heart Association website: accessed February 25, 2012.
  33. 33.
    Adams Jr HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh 3rd EE. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35–41.PubMedCrossRefGoogle Scholar
  34. 34.
    Estol CJ. Dr C. Miller Fisher and the history of carotid artery disease. Stroke. 1996;27(3):559–66.PubMedCrossRefGoogle Scholar
  35. 35.
    Chiari H. Ueber Verhalten des Teilungswinkels der Carotis Communis bei der Endarteritis Chronica Deformans. Verh Dtsch Ges Pathol. 1905;9:326.Google Scholar
  36. 36.
    Kronzon I, Tunick PA. Transesophageal echocardiography as a tool in the evaluation of patients with embolic disorders. Prog Cardiovasc Dis. 1993;36:39–60.PubMedCrossRefGoogle Scholar
  37. 37.
    Sacco RL, Ellenberg JH, Mohr JP, Tatemichi TK, Hier DB, Price TR, Wolf PA. Infarcts of undermined cause: the NINCDS stroke data bank. Ann Neurol. 1989;25:382–90.PubMedCrossRefGoogle Scholar
  38. 38.
    Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new finding seen by transesophageal echocardiography. AM Heart J. 1990;120:658–60.PubMedCrossRefGoogle Scholar
  39. 39.
    Kronzon I, Tunick PA. Atheromatous disease of the thoracic aorta: pathologic and clinical implications. Ann Intern Med. 1997;126:629–37.PubMedGoogle Scholar
  40. 40.
    Vaduganathan P, Ewton A, Nagueh SF, Weilbaecher DG, Safi HJ, Zoghbi WA. Pathologic correlates of aortic plaques, thrombi and mobile “aortic debris” imaged in vivo with transesophageal echocardiography. J Am Coll Cardiol. 1997;30(2):357–63.PubMedCrossRefGoogle Scholar
  41. 41.
    Ezzeddine MA, Primavera JM, Rosand J, Hedley-Whyte ET, Rordorf G. Clinical characteristics of pathologically proved cholesterol emboli to the brain. Neurology. 2000;54:1681–3.PubMedGoogle Scholar
  42. 42.
    Hollenhorst RW. Significance of bright plaques in the retinal arterioles. JAMA. 1961;178:23–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Bunt TJ. The clinical significance of the asymptomatic Hollenhorst plaque. J Vasc Surg. 1986;4(6):559–62.PubMedGoogle Scholar
  44. 44.
    Scolari F, Ravani P, Gaggi R, Santostefano M, Rollino C, Stabellini N, Colla L, Viola BF, Maiorca P, Venturelli C, Bonardelli S, Faggiano P, Barrett BJ. The challenge of diagnosing atheroembolic renal disease: clinical features and prognostic factors. Circulation. 2007;116:298–304.PubMedCrossRefGoogle Scholar
  45. 45.
    Moolenaar W, Lamers CBHW. Cholesterol crystal embolization and the digestive system. Scand J Gastroenterol. 1991;26 suppl 188:69–72.CrossRefGoogle Scholar
  46. 46.
    Falanga V, Fine MJ, Kapoor WN. The cutaneous manifestations of cholesterol crystal embolization. Arch Dermatol. 1986;122:1194–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Karmody AM, Powers SR, Monaco VJ, Leather RP. ‘Blue toe’ syndrome: an indication for limb salvage surgery. Arch Surg. 1976;111:1263–8.PubMedCrossRefGoogle Scholar
  48. 48.
  49. 49.
    Wolf PS, Burman HE, Starnes BW. Endovascular treatment of massive thoracic aortic thrombus and associated ruptured atheroma. Ann Vasc Surg. 2010;24(3):416.e9–416.e12.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Leon H. Charney Division of CardiologyNew York University Langone Medical CenterNew YorkUSA
  2. 2.Department of Cardiovascular MedicineLenox Hill HospitalNew YorkUSA
  3. 3.Noninvasive Cardiology LaboratoryNew York University Langone Medical CenterNew YorkUSA
  4. 4.Lenox Hill Interventional Cardiac and Vascular ServicesNew YorkUSA

Personalised recommendations