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DOI: 10.1055/a-2536-9215
Aortic Atherosclerosis: An Updated Review of Current Guidelines and Management Approach—A Literature Review


Abstract
Aortic atheroma (AA) is defined by the development of atherosclerotic plaques within the aorta wall and is associated with unfavorable cardiovascular outcomes such as cryptogenic stroke, systemic embolism, and other major adverse cardiac events (MACE). The clinical significance of AA is discussed in this review along with its relationship to cardiovascular outcomes. The purpose of this review article is to present a thorough summary of the current state of knowledge on AA, including its pathogenesis, classifications and grading systems, clinical implications, methods for diagnosis and imaging, therapeutic modalities and treatments, and lastly pertinent complications. There are various methods of AA classification or grading, which entail scoring extent of disease via plaque thickness, severity of atherosclerosis, or by the presence of mobile components or ulcerations. The implications of AA as a systemic atherosclerotic process on the development of coronary artery disease and MACE include, but are not limited to, vascular diseases such as strokes or peripheral arterial disease. The diagnostic approaches include multiple invasive and noninvasive imaging modalities. The treatment strategies range from prevention to medical therapy to invasive surgical interventions. The present evaluation highlights the significance of sustained investigation and advancement in the domain of aortic atherosclerosis to augment precision in diagnosis and effectiveness of treatment.
Keywords
atherosclerosis - aortic plaque - cardiovascular disease - aortic calcification - intimal thickening - plaque rupture - transthoracic echocardiogram - imaging aortaPublication History
Article published online:
21 March 2025
© 2025. International College of Angiology. This article is published by Thieme.
Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
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References
- 1 Heidari H, Ran H, Spinka G. et al. Atherosclerotic plaque detected by transesophageal echocardiography is an independent predictor for all-cause mortality. Int J Cardiovasc Imaging 2020; 36 (08) 1437-1443
- 2 Takx RA, Partovi S, Ghoshhajra BB. Imaging of atherosclerosis. Int J Cardiovasc Imaging 2016; 32 (01) 5-12
- 3 Sharma U, Tak T. Aortic atheromas: current knowledge and controversies: a brief review of the literature. Echocardiography 2011; 28 (10) 1157-1163
- 4 Minelli S, Minelli P, Montinari MR. Reflections on atherosclerosis: lesson from the past and future research directions. J Multidiscip Healthc 2020; 13: 621-633
- 5 Thenappan T, Ali Raza J, Movahed A. Aortic atheromas: current concepts and controversies-a review of the literature. Echocardiography 2008; 25 (02) 198-207
- 6 Shin PS, Kim DS. Histochemical studies of fetal arteries of Koreans with special reference to atherogenesis in adults. Yonsei Med J 1963; 4: 37-42
- 7 Stary HC. Lipid and macrophage accumulations in arteries of children and the development of atherosclerosis. Am J Clin Nutr 2000; 72 (5, suppl): 1297S-1306S
- 8 McCloskey K, Vuillermin P, Ponsonby AL, Cheung M, Skilton MR, Burgner D. Aortic intima-media thickness measured by trans-abdominal ultrasound as an early life marker of subclinical atherosclerosis. Acta Paediatr 2014; 103 (02) 124-130
- 9 Teague HL, Ahlman MA, Alavi A. et al. Unraveling vascular inflammation: from immunology to imaging. J Am Coll Cardiol 2017; 70 (11) 1403-1412
- 10 Davignon J, Ganz P. Role of endothelial dysfunction in atherosclerosis. Circulation 2004; 109 (23, suppl 1): III27-III32
- 11 Pirillo A, Bonacina F, Norata GD, Catapano AL. The interplay of lipids, lipoproteins, and immunity in atherosclerosis. Curr Atheroscler Rep 2018; 20 (03) 12
- 12 Mullick AE, Soldau K, Kiosses WB, Bell III TA, Tobias PS, Curtiss LK. Increased endothelial expression of toll-like receptor 2 at sites of disturbed blood flow exacerbates early atherogenic events. J Exp Med 2008; 205 (02) 373-383
- 13 Newby AC. Metalloproteinase production from macrophages - a perfect storm leading to atherosclerotic plaque rupture and myocardial infarction. Exp Physiol 2016; 101 (11) 1327-1337
- 14 Stary HC, Chandler AB, Dinsmore RE. et al. 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 (05) 1355-1374
- 15 Libby P, Hansson GK. From focal lipid storage to systemic inflammation: JACC review topic of the week. J Am Coll Cardiol 2019; 74 (12) 1594-1607
- 16 Libby P, Hansson GK. Inflammation and immunity in diseases of the arterial tree: players and layers. Circ Res 2015; 116 (02) 307-311
- 17 Ketelhuth DFJ, Lutgens E, Bäck M. et al. Immunometabolism and atherosclerosis: perspectives and clinical significance: a position paper from the Working Group on Atherosclerosis and Vascular Biology of the European Society of Cardiology. Cardiovasc Res 2019; 115 (09) 1385-1392
- 18 Tabas I, García-Cardeña G, Owens GK. Recent insights into the cellular biology of atherosclerosis. J Cell Biol 2015; 209 (01) 13-22
- 19 Libby P, Buring JE, Badimon L. et al. Atherosclerosis. Nat Rev Dis Primers 2019; 5 (01) 56
- 20 Gimbrone Jr MA, García-Cardeña G. Endothelial cell dysfunction and the pathobiology of atherosclerosis. Circ Res 2016; 118 (04) 620-636
- 21 Libby P, Ridker PM, Hansson GK. Leducq Transatlantic Network on Atherothrombosis. Inflammation in atherosclerosis: from pathophysiology to practice. J Am Coll Cardiol 2009; 54 (23) 2129-2138
- 22 Ramji DP, Davies TS. Cytokines in atherosclerosis: key players in all stages of disease and promising therapeutic targets. Cytokine Growth Factor Rev 2015; 26 (06) 673-685
- 23 Trus E, Basta S, Gee K. Who's in charge here? Macrophage colony stimulating factor and granulocyte macrophage colony stimulating factor: competing factors in macrophage polarization. Cytokine 2020; 127: 154939
- 24 Basatemur GL, Jørgensen HF, Clarke MCH, Bennett MR, Mallat Z. Vascular smooth muscle cells in atherosclerosis. Nat Rev Cardiol 2019; 16 (12) 727-744
- 25 Libby P, Lichtman AH, Hansson GK. Immune effector mechanisms implicated in atherosclerosis: from mice to humans. Immunity 2013; 38 (06) 1092-1104
- 26 Oiseth S. et al. Atherosclerosis. Concise Medical Knowledge - Lecturio. Lecturio Medical, October 24, 2022 at: www.lecturio.com/concepts/atherosclerosis/
- 27 Amarenco P, Duyckaerts C, Tzourio C, Hénin D, Bousser MG, Hauw JJ. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992; 326 (04) 221-225
- 28 Davies MJ, Richardson PD, Woolf N, Katz DR, Mann J. Risk of thrombosis in human atherosclerotic plaques: role of extracellular lipid, macrophage, and smooth muscle cell content. Br Heart J 1993; 69 (05) 377-381
- 29 Kronzon I, Tunick PA. Aortic atherosclerotic disease and stroke. Circulation 2006; 114 (01) 63-75
- 30 Syed MBJ, Fletcher AJ, Forsythe RO. et al. Emerging techniques in atherosclerosis imaging. Br J Radiol 2019; 92 (1103): 20180309 images
- 31 Schoenhagen P, Ziada KM, Vince DG, Nissen SE, Tuzcu EM. Arterial remodeling and coronary artery disease: the concept of “dilated” versus “obstructive” coronary atherosclerosis. J Am Coll Cardiol 2001; 38 (02) 297-306
- 32 Sluimer JC, Kolodgie FD, Bijnens AP. et al. Thin-walled microvessels in human coronary atherosclerotic plaques show incomplete endothelial junctions relevance of compromised structural integrity for intraplaque microvascular leakage. J Am Coll Cardiol 2009; 53 (17) 1517-1527
- 33 Virmani R, Kolodgie FD, Burke AP. et al. Atherosclerotic plaque progression and vulnerability to rupture: angiogenesis as a source of intraplaque hemorrhage. Arterioscler Thromb Vasc Biol 2005; 25 (10) 2054-2061
- 34 Kolodgie FD, Gold HK, Burke AP. et al. Intraplaque hemorrhage and progression of coronary atheroma. N Engl J Med 2003; 349 (24) 2316-2325
- 35 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2022; 146 (24) e334-e482
- 36 Goldstein SA, Evangelista A, Abbara S. et al. Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of Cardiovascular Imaging: endorsed by the Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2015; 28 (02) 119-182
- 37 Montgomery DH, Ververis JJ, McGorisk G, Frohwein S, Martin RP, Taylor WR. Natural history of severe atheromatous disease of the thoracic aorta: a transesophageal echocardiographic study. J Am Coll Cardiol 1996; 27 (01) 95-101
- 38 Kurra V, Lieber ML, Sola S. et al. Extent of thoracic aortic atheroma burden and long-term mortality after cardiothoracic surgery: a computed tomography study. JACC Cardiovasc Imaging 2010; 3 (10) 1020-1029
- 39 Sagban AT, Grotemeyer D, Rehbein H. et al. [Occlusive aortic disease as coral reef aorta–experience in 80 cases]. Zentralbl Chir 2010; 135 (05) 438-444
- 40 Holfeld J, Gottardi R, Zimpfer D. et al. Treatment of symptomatic coral reef aorta by endovascular stent-graft placement. Ann Thorac Surg 2008; 85 (05) 1817-1819
- 41 Erbel R, Aboyans V, Boileau C. et al; ESC Committee for Practice Guidelines, The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J 2014; 35 (41) 2873-2926
- 42 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 (01) 144-150
- 43 Khoury Z, Gottlieb S, Stern S, Keren A. Frequency and distribution of atherosclerotic plaques in the thoracic aorta as determined by transesophageal echocardiography in patients with coronary artery disease. Am J Cardiol 1997; 79 (01) 23-27
- 44 Parthenakis F, Skalidis E, Simantirakis E, Kounali D, Vardas P, Nihoyannopoulos P. Absence of atherosclerotic lesions in the thoracic aorta indicates absence of significant coronary artery disease. Am J Cardiol 1996; 77 (12) 1118-1121
- 45 Otsuka K, Ishikawa H, Kono Y. et al. Aortic arch plaque morphology in patients with coronary artery disease undergoing coronary computed tomography angiography with wide-volume scan. Coron Artery Dis 2022; 33 (07) 531-539
- 46 Gu X, He Y, Li Z. et al. Relation between the incidence, location, and extent of thoracic aortic atherosclerosis detected by transesophageal echocardiography and the extent of coronary artery disease by angiography. Am J Cardiol 2011; 107 (02) 175-178
- 47 Arun K, Nambiar PN, Kannath SK. et al. Prevalence of aortic plaques in cryptogenic ischemic stroke: correlation to vascular risk factors and future events. Neurol India 2022; 70 (01) 182-187
- 48 Kim DY, Kim IS, Jung YH. et al. Impact of aortic atheroma and distensibility on diastolic function and prognosis in patients with ischemic stroke. Rev Cardiovasc Med 2022; 23 (01) 10
- 49 Osranek M, Pilip A, Patel PR, Molisse T, Tunick PA, Kronzon I. Amounts of aortic atherosclerosis in patients with aortic stenosis as determined by transesophageal echocardiography. Am J Cardiol 2009; 103 (05) 713-717
- 50 Fayad ZA, Fuster V. Clinical imaging of the high-risk or vulnerable atherosclerotic plaque. Circ Res 2001; 89 (04) 305-316
- 51 Schinkel AF, Kaspar M, Staub D. Contrast-enhanced ultrasound: clinical applications in patients with atherosclerosis. Int J Cardiovasc Imaging 2016; 32 (01) 35-48
- 52 Yao Y, Zhang P. Novel ultrasound techniques in the identification of vulnerable plaques-an updated review of the literature. Front Cardiovasc Med 2023; 10: 1069745
- 53 Cismaru G, Serban T, Tirpe A. Ultrasound methods in the evaluation of atherosclerosis: from pathophysiology to clinic. Biomedicines 2021; 9 (04) 418
- 54 Intra-vascular ultrasound (IVUS) study. SozoCardiology. August 6, 2021, www.sozocardiology.com/heart-treatments/intra-vascular-ultrasound-ivus-study/
- 55 Bolotin G, Domany Y, de Perini L. et al. Use of intraoperative epiaortic ultrasonography to delineate aortic atheroma. Chest 2005; 127 (01) 60-65
- 56 Rodrigues AC, Silva GS, Monaco CG. et al. Three-dimensional transesophageal echocardiographic evaluation of aortic plaque after cerebrovascular event. Rev Port Cardiol 2023; 42 (02) 149-155
- 57 Park KH, Lee HY, Lim C. et al. Clinical impact of computerised tomographic angiography performed for preoperative evaluation before coronary artery bypass grafting. Eur J Cardiothorac Surg 2010; 37 (06) 1346-1352
- 58 Asenbaum U, Nolz R, Puchner SB. et al. Coronary artery bypass grafting and perioperative stroke: imaging of atherosclerotic plaques in the ascending aorta with ungated high-pitch CT-angiography. Sci Rep 2020; 10 (01) 13909
- 59 Faber T, Rippy A, Hyslop WB, Hinderliter A, Sen S. Cardiovascular MRI in detection and measurement of aortic atheroma in stroke/TIA patients. J Neurol Disord 2013; 1 (04) 139
- 60 Gottsegen JM, Coplan NL. The atherosclerotic aortic arch: considerations in diagnostic imaging. Prev Cardiol 2008; 11 (03) 162-167
- 61 Akçakaya M, Basha TA, Chan RH, Manning WJ, Nezafat R. Accelerated isotropic sub-millimeter whole-heart coronary MRI: compressed sensing versus parallel imaging. Magn Reson Med 2014; 71 (02) 815-822
- 62 Ali ZA, Karimi Galougahi K, Mintz GS, Maehara A, Shlofmitz RA, Mattesini A. Intracoronary optical coherence tomography: state of the art and future directions. EuroIntervention 2021; 17 (02) e105-e123
- 63 Høilund-Carlsen PF, Piri R, Gerke O. et al. NaF-PET imaging of atherosclerosis burden. J Imaging 2023; 9 (02) 31
- 64 Fletcher AJ. et al. Thoracic aortic 18F-sodium fluoride activity and ischemic stroke. JACC Cardiovasc Imaging 2022; 15 (07) 1274-1288
- 65 Riambau V, Böckler D, Brunkwall J. et al; Esvs Guidelines Committee. Editor's choice - management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 53 (01) 4-52
- 66 Aortic Arch Disease. Vascular & Endovascular Surgery, UCSF. Accessed August 5, 2024 at: vascularsurgery.ucsf.edu/conditions–procedures/aortic-arch-disease.aspx#:∼:text=When%20aortic%20arch%20conditions%20become,inner%20lining%20of%20the%20arteries
- 67 Dini FL, Ballo P, Badano L. et al. Validation of an echo-Doppler decision model to predict left ventricular filling pressure in patients with heart failure independently of ejection fraction. Eur J Echocardiogr 2010; 11 (08) 703-710
- 68 Endothelial Dysfunction. Wikimedia Foundation, May 29, 2024, en.wikipedia.org/wiki/Endothelial_dysfunction
- 69 Abramowitz Y, Jilaihawi H, Chakravarty T, Mack MJ, Makkar RR. Porcelain aorta: a comprehensive review. Circulation 2015; 131 (09) 827-836