Recognition of the importance of embolization in atherosclerotic vascular disease.

It is uncommon in medicine for emerging data to completely transform a field, particularly in such a common disease state as atherosclerotic vascular disease. New evidence from multiple fronts has underscored the frequency and prognostic importance of atherosclerotic embolization in the microvasculature. Until recently, we have had limited access to diagnose microvascular obstruction in living patients. With the availability of imaging technology that includes magnetic resonance, myocardial contrast echocardiography, and transcerebral or transcranial Doppler (TCD), microvascular obstruction has been documented in a far greater proportion of patients than ever conceived. The linkage between microvascular obstruction and unfavorable long-term clinical prognosis has been established in many series. Furthermore, therapeutics shown to reduce microvascular obstruction have improved clinical outcomes. The purpose of this article is to present the case for a disturbingly and unexpectedly high rate of arterial embolization in certain atherosclerotic conditions and to review the promise of newer therapeutics or devices to reduce the risk or ameliorate the sequelae of embolization.