mobility of a component of the plaque. (See 'Complex aortic plaque' above.) All patients with aortic atherosclerosis with or without a history of otherwise unexplained stroke or peripheral embolism should be treated for secondary prevention of cardiovascular disease. These therapies include antiplatelet therapy (eg, aspirin or clopidogrel), lipid-lowering therapy (eg, statin), blood pressure control, smoking cessation, and, in patients with diabetes, glycemic control. The benefit of antithrombotic therapy for aortic arch plaque with or without stroke is uncertain. (See 'Treatment' above and "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".) For patients with stroke and complex aortic plaque ( 4 mm thick and/or atheroma with a mobile component), or patients without stroke but atheroma with a mobile component, dual antiplatelet therapy plus high-intensity statin therapy is warranted. The optimal approach for patients without stroke and simple plaque (<4 mm without a mobile component) or diffuse atheromatous plaques ("shaggy" aorta) is controversial because the data are limited. Aspirin or clopidogrel (monotherapy) plus high-intensity statin is likely adequate. https://www.uptodate.com/contents/thromboembolism-from-aortic-plaque/print 12/23 7/5/23, 11:50 AM Thromboembolism from aortic plaque - UpToDate Although the optimal low density lipoprotein cholesterol target or statin dose intensity is unknown for this population, we believe that using targets similar to those recommended for the secondary prevention of coronary artery disease is appropriate. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk" and "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease".) Prophylactic surgery for the management of atherosclerotic plaque has been performed, but there is no evidence of benefit. Among patients undergoing cardiac surgery or aortic surgery at risk for aortic atherosclerosis, intraoperative ultrasound may be beneficial to help to guide sites of aortic manipulation or clamping. For secondary prevention, endovascular stent-grafting may be feasible in patients who have had an embolic event. (See 'Surgery' above.) ACKNOWLEDGMENT The UpToDate editorial staff acknowledges Emile R Mohler, III, MD (deceased), who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. 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. 2. Matsuzaki M, Ono S, Tomochika Y, et al. 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Topic 8197 Version 28.0 https://www.uptodate.com/contents/thromboembolism-from-aortic-plaque/print 18/23 7/5/23, 11:50 AM Thromboembolism from aortic plaque - UpToDate GRAPHICS Thoracic aortic plaque Three transesophageal echocardiograms of the thoracic aorta: left: normal; middle: moderate (3 mm) plaque; and right: severe (7 mm) plaque. Reproduced with permission from: Tunick, PA, Kronzon, I. Atheroembolism. In: Vascular Medicine. A Companion to Braunwald's Heart Disease, 1st edition, Dzau, VJ, Creager, M, Loscalzo, J, et al (Eds), WB Saunders 2005. Copyright 2005 Elsevier. Graphic 72777 Version 2.0 https://www.uptodate.com/contents/thromboembolism-from-aortic-plaque/print 19/23 7/5/23, 11:50 AM Thromboembolism from aortic plaque - UpToDate Aortic source for distal embolism The patient presented with embolic occlusion of the right common femoral artery presumably from the aorta. In the CT image, the aorta is ectatic with irregular intraluminal thrombus. The selected bone windows help to differentiate the contrast bolus from the calcium in the aortic wall. While the aorta in this segment measures 3.4 cm, the more proximal infrarenal aorta was normal in size at 2.8 cm. CT: computed tomography. Graphic 118891 Version 1.0 https://www.uptodate.com/contents/thromboembolism-from-aortic-plaque/print 20/23 7/5/23, 11:50 AM Thromboembolism from aortic plaque - UpToDate Increasing risk of stroke with aortic plaque thickness Relation between stroke and plaque thickness and location. There is a rising likelihood of stroke with increasing plaque thickness in the ascending aorta (AA) or aortic arch. Plaque in the descending aorta is generally not associated with stroke in the absence of severe aortic regurgitation . Data from Amarenco, P, Cohen, A, Tzourio, C, et al, N Engl J Med 1994; 331:1474. Graphic 61664 Version 1.0 https://www.uptodate.com/contents/thromboembolism-from-aortic-plaque/print 21/23 7/5/23, 11:50 AM Thromboembolism from aortic plaque - UpToDate Femoral artery emboli on CT scan A transverse CT scan through the pelvis (A) shows nonocclusive thrombus in the left superficial femoral and deep femoral arteries (circle). (B) is a magnified view of (A) and shows nonocclusive thrombus in the SFA (arrowhead) and in the DFA (arrow). (C) is a magnified sagittal reformat of the CT scan and shows the thrombus straddling the bifurcation (dashed arrow) and extending into the SFA (arrowhead) and DFA (arrow). CT: computed tomography; SFA: superficial femoral artery; DFA: deep femoral artery. Graphic 98593 Version 2.0 https://www.uptodate.com/contents/thromboembolism-from-aortic-plaque/print 22/23 7/5/23, 11:50 AM Thromboembolism from aortic plaque - UpToDate Contributor Disclosures Benjamin J Pearce, MD, FACS No relevant financial relationship(s) with ineligible companies to disclose. Jos Biller, MD, FACP, FAAN, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Joseph L Mills, Sr, MD No relevant financial relationship(s) with ineligible companies to disclose. John F Eidt, MD Grant/Research/Clinical Trial Support: Syntactx [Clinical events, data/safety monitoring for medical device trials]. All of the relevant financial relationships listed have been mitigated. Warren J Manning, MD Equity Ownership/Stock Options: Pfizer [Anticoagulants]. All of the relevant financial relationships listed have been mitigated. Kathryn A Collins, MD, PhD, FACS No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/thromboembolism-from-aortic-plaque/print 23/23