• the aorta is the main and largest artery in the human body
  • it originates from the left ventricle and extends down to the abdomen, where it branches into the common iliac arteries and a small median sacral artery
  • it consists of these segments:
    • ascending aorta
      • coronary arteries originate in the aortic sinuses
    • aortic arch
      • the arch has 3 major branches: the brachiocephalic trunk, the left common carotid artery, and the subclavian artery
      • aortic arch ends, and the descending aorta begins approx. at the level of the Th4-5 intervertebral disc
    • descending aorta (divided by the diaphragm at the level of Th12 into the thoracic and abdominal parts)
      • major thoracic branches: intercostal and subcostal arteries, the superior and inferior left bronchial arteries, and variable branches to the esophagus, mediastinum, and pericardium
      • major abdominal branches:  lumbar and musculophrenic arteries, renal and middle suprarenal arteries, and visceral arteries (the celiac trunk, the superior mesenteric artery, and the inferior mesenteric artery)
  • in healthy adults, the aorta is usually less than 40 mm in diameter and gradually narrows downwards
    • the aorta enlarges with age at a rate of about 0.9 mm every ten years in men and 0.7 mm every ten years in women

Aortic conditions and diseases

  • aortic atherosclerosis
  • inflammatory disorders (e.g., Takayasu arteritis)
  • aortic aneurysms and pseudoaneurysms (abdominal, thoracic, thoracoabdominal)
  • acute aortic syndromes (AAS)
  • traumatic aortic injury
  • genetic syndromes (e.g., Marfan syndrome)
  • congenital defects (e.g., coarctation of the aorta)

Aortic arc atherosclerosis

  • aortic arch atherosclerosis is common in individuals aged over 60
  • there is an increased risk of thrombus formation, which may be the source (along with atheroma particles) of systemic or cerebral emboli
    • spontaneous embolism (previously classified as cryptogenic stroke); the floating thrombus poses the highest risk   Floating thrombus in the aortic arch (CTA)
    • during diagnostic procedures (e.g.,coronarography)
    • during cardiac surgery with extracorporeal circulation requiring cannulation of the aorta
  • the advent of transesophageal echocardiography (and later CTA/MRA) allowed the detection of atherosclerotic plaques within the aortic arch

Clinical presentation

  • involvement of each aortic segment is associated with specific consequences and complications

    • ascending aorta and arch: stroke, systemic embolization (distal arch)
    • abdominal aorta: aneurysm formation, abdominal angina, PAD, etc.)
  • atheromatous plaques in the aortic arch are associated with an increased risk of cerebrovascular embolic events  (→  complications during extracorporeal circulation)
    • especially plaques ≥ 4 mm are associated with an increased risk of recurrent stroke
    • extensive aortic arch atherosclerosis is also associated with an increased risk of “silent” white matter lesions  [Tugcu, 2016]
  • assessment of the aortic arch may help identify individuals who may benefit from aggressive treatment of vascular risk factors
  • stroke caused by aortic arch atherosclerosis is usually classified as large artery atherosclerosis (CISS, TOAST 1) or cardio-aortic embolism (SSS-TOAST 2)

Risk factors of atherosclerosis

Diagnostic evaluation

Clinical examination and laboratory tests

  • clinical examination
    • palpation and auscultation of the neck and abdomen to detect a noticeable pulsation or turbulent flow causing murmurs
    • blood pressure measurement on both arms
  • laboratory examination – screening for cardiovascular risk factors

Imaging methods

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Aortic arch atherosclerosis on CTA
Aortic arch plaques on CMR (Wehrum, 2017)
Atherosclerosis in the aortic arch


Vascular risk factors management

  • complex and aggressive management of vascular risk factors is indicated (patients with aortic atherosclerosis belong to the very high-risk group)

Antiplatelet therapy

  • stroke patients or asymptomatic patients with extensive aortic atherosclerosis should receive antiplatelet therapy unless anticoagulation is indicated for another reason (e.g., Afib) (AHA/ASA 2021 1/C-LD)
  • consider short-term anticoagulant treatment on a case-by-case basis in the presence of documented mobile thrombus


  • there are no data on the benefit of prophylactic aortic arch surgery or stenting to prevent stroke

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Aortic arch atherosclerosis