. 2022 Dec 2;136(23):1731–1758. doi: 10.1042/CS20210862

Table 1. Animal models of atherosclerosis: advantages and limitations.

Atherosclerosis model	Advantages	Limitations	Reference
Rabbit models
HCD	*Rabbits have CETP, thus a lipid profile that more closely resembles human	Lesions resemble fatty streaks Longer-term HFD leads to hepatotoxicity and inflammation Larger size of animal Higher costs of housing than mice *4–8 months to develop lesions	[31,195]
HCD plus mechanical injury	*Rapid development of lesions (2–4 weeks)	Balloon injury of the iliac artery requires high level surgical skills Procedure ∼45 min per animal	[32]
CRISPR/Cas9 generated LDLR deficiency	Severe hypercholesterolemia and atherosclerosis on regular chow Increased plasma TC, LDL-C, TG, reduced HDL *Aortic and coronary artery atherosclerosis detected	*CRISPR/Cas9 technology, zygote micro-injection and embryo transfer for generation	[196]
Mouse
C57Bl/6 plus HFD	*Lesions develop in ∼15–20 weeks in aortic sinus and proximal aorta	Primitive fatty streak lesions Restricted distribution of lesions mostly within sinus aorta	[197]
ApoE^−/− on regular chow	Elevated cholesterol levels of 400–600 mg/dl vs wild-type mice (75–110 mg/dl) Spontaneous lesions that are more advanced 12 weeks: fatty streaks 32 weeks: aortic plaque.	Plasma cholesterol carried by VLDL and chylomicrons particles, differs from humans (LDL) No plaque rupture or thrombosis	[198,199]
ApoE^−/− plus HFD	Elevated cholesterol of 1000 mg/dl Extensive accelerated atherosclerosis in aortic sinus, aortic branches and carotid artery *Large plaques by 14 weeks	Plasma cholesterol carried by VLDL and chylomicrons particles, differs from humans (LDL) No plaque rupture or thrombosis	[37,200]
Ldlr^−/− on regular chow or HFD	Elevated cholesterol of 200–300 mg/dl on chow diet, and ∼1000 mg/dl on an atherogenic diet Moderate atherosclerosis after 12 weeks of HFD Early lesion development in proximal aorta, and distal aorta when more advanced Better resembles human disease as cholesterol transported by LDL *Preferred model to study reverse cholesterol transport	Do not develop spontaneous lesions on regular diet No plaque rupture or thrombosis	[39,201]
ApoE^−/− x human apoB-100 Tg or Ldlr^−/− x human apoB-100 Tg	On ApoE^−/− background, increased TG content Similar serum cholesterol levels to ApoE^−/− mice but develop larger plaques *On Ldlr^−/− background: complex lesions, increased TC, TG, apo(a), reduced HDL on chow diet	*Additional crosses to these mice become difficult as homozygosity is required at 3 loci	[44,202]
ApoE^−/− x Ldlr^−/− dKO	Develop coronary artery disease and myocardial infarction Rapid plaque formation Fibroatheromas and fibroproliferative calcified and complicated lesions develop over time (16–80 weeks) Vasa vasorum can be studied in this model – develops extensive arterial and venous networks *Adventitial inflammation present		[203]
ApoE3-Leiden	*Reduced clearance of triglyceride-rich lipoproteins such as chylomicron- and VLDL-remnants	*No plaque rupture or thrombosis	[51]
ApoE3-Leiden.CETP	Cholesterol profile that more closely resembles human profile ‘Humanized’ plaque profile-5 stages observed	*No plaque rupture or thrombosis	[55]
PCSK9-AAV	Single injection and generated quickly compared with conventional crossbreeding No confounding effects from the lack of ApoE or LDLR *Can be used to study calcification and plaque regression	*Possible antiviral host immune response	[204,205]
Co-morbid mouse
ApoE^−/− Ob/ob (CAD and diabetes)	Leptin hormone deficient model – gives rise to spontaneous Type II diabetes on chow diet Clear advantage – does not require chemical induction of diabetes	Mice become obese Immunometabolic dysfunction *Increased infection susceptibility	[46,56]
ApoE^−/− Db/db (CAD and diabetes)	Point mutation in gene for leptin receptor Model of obesity, Type II diabetes and dyslipidemia *Mice more diabetic than ob/ob	Mice become obese Immunometabolic dysfunction *Increased susceptibility to infections	[206,207]
Ldlr^−/− ob/ob (CAD and diabetes)	*Obese, hyperglycemic, hypercholesterolemic and spontaneous lesions development on chow diet	* Mice become obese Immunometabolic dysfunction Increased susceptibility to infections	[208]
ApoE^−/−Gpx1^−/− dKO (atherosclerosis and oxidative stress)	Atheromas throughout aortic tree (arch to iliac bifurcation) on HFD for 24 weeks, most in abdominal aorta Can be made diabetic with streptozotocin (STZ): lesions in sinus and aortic tree Diabetic inflammatory changes observed after 5–10 weeks, preceding atherosclerosis Well defined plaque with necrotic core, infiltrating inflammatory cells	Model takes 20–24 weeks to develop No plaque rupture observed	[57,58,209]
Tanden stenosis ApoE^−/− (plaque rupture)	*Plaque rupture including thin fibrous cap, large necrotic core, intraplaque hemorrhage and plaque inflammation	*Requires microsurgery skills to suture carotid artery in two places	[59,61,62]
ApoE^−/− +HFD + AngII (4wks)	*Model of hypertension, oxidative stress, increased inflammation and plaque rupture	*Implanted mini-osmotic pumps required to infuse AngII	[62]
ApoE^−/−Fbn1^C1039G+/−	Model of spontaneous intra-plaque microvessels, hemorrhages, spontaneous plaque rupture, myocardial infarction and sudden death Coronary plaques	Sudden death on HFD Cerebral blood flow disturbed; head tilt, disorientation, motor disturbances (66% of cases)	[63,210]
ApoE^−/− and TAC	Coronary plaques, myocardial infarction on a chow diet moderate hypercholesterolemia *Plaque rupture	*Mice can die on exposure to physical stress (∼70%)	[64]
Rat models
HFD	Ease of blood collection, dissection of vessels Easier to house than pigs, rabbits *Larger biological samples than from mice	Less responsive to cholesterol than mice Physiologically different metabolism and microbiome vs humans	[211]
ApoE^−/− via TALEN technology	Plasma cholesterol increased 7.6-fold vs WT rats after 8-week HFD Mild aortic but severe coronary atherosclerosis *Myocardial cholesterol ester deposition	Do not develop spontaneous atherosclerosis, unlike ApoE^−/−* mice *Require HFD to induce plaque	[212]
Sprague Dawley ApoE^−/− via CRISPR/Cas9	Lesions in males are more advanced than females, analogous with human pathology Lesions develop in absence of HFD; model can be used to study lipid-independent effects Heavy plaque burden after 40 weeks HFD Severe atherosclerosis widely distributed including carotid arteries after 64 weeks of HFD	*Length of time to develop atherosclerosis	[68,213]
Ldlr^−/− + HFD	*HFD: severe hyperlipidemia, lipid deposit throughout aortic tree	*Females: more severe lesions, opposite to humans	[70]
Ldlr^−/− (ZFN technology)	*Plaques on HFD	No plaques on normal diet Develop obesity, may confound results	[70,71]
SD Ldlr^−/− via CRISPR/Cas9	Marked hyperlipidaemia, elevated cholesterol on normal chow with lesions of different stages Heavy plaques after 40 weeks on HFD	*Liver steatosis noted	[68]
Diabetic Zucker Fatty (ZDF)	Thoracic and abdominal lesions at 18 weeks of age Most severe in males		[74]
CETP Tg (on a Dahl, salt-sensitive hypertensive stain)	Develop lesions, on normal chow Coronary plaque *Myocardial infarctions noted		[214]
Tg[hCETP] SHRs	*Hypertension, insulin resistance	No increase in plasma LDL Do not develop atherosclerotic plaque	[77]
Zebrafish
HFD	Major advantages: small size, low maintenance costs, large offspring numbers Lipid metabolism comparable with humans CETP system functional Useful model for early progression analysis *HFD induces oxidized lipoproteins and hypercholesterolemia with early-stage lesions	Plasma lipid profiles differ between zebrafish and humans Small size limits certain measures: e.g. only small quantity of blood can be obtained from zebrafish ≥45 days old. *No advanced stage lesions are observed	[78]
Ldlr mutant by CRISPR/Cas9	Regular diet: moderate hypercholesterolemia High cholesterol feeding of larvae: lipids increased in blood vessels, exacerbated hypercholesterolemia and lesions	Limitations on size and sampling as noted above apply No advanced stage lesions are observed	[80]
apoc2 mutant via TALEN	Severe triglyceridemia Larvae on normal diet: lipid accumulation in macrophages similar to humans	Limitations on size and sampling as noted above apply No advanced stage lesions observed	[81]
lxr mutant via TALEN	LDL increase with HCD or HFD Severe hypercholesterolemia and hepatic steatosis *Lipid accumulation and fatty streaks	Limitations on size and sampling as noted above apply No advanced stage lesions are observed	[11]
Pigs
CRISPR/Cas9-mediated ApoE^−/− and Ldlr^−/− dKO	*Elevates serum LDL-C and TC levels	High costs, long time for model development, complex experimental procedures Lesions not reported	[87,88]
CRISPR/Cas9-mediated ApoE^−/− using SCNT technology	Moderate elevated serum cholesterol levels on chow diet HFHC diet for 3 months led to hypercholesterolemia (both LDL and HDL) *Spontaneous human-like atherosclerotic lesions in aorta and coronaries after 6 months of HFHC (fibrous plaque)	Time to develop lesions is long (6 months) Plaque rupture and thrombosis not studied	[87]
Non-human Primates
Cynomolgus monkeys fed a HFD for 9 months	Ultrasound: increase in plaque in carotid (CCA and BIF) Level of TC, TC/HDL, LDL correlated with amount of plaque and negatively correlated with HDL	High costs, long time needed for model development Variable responses by individuals	[91]

Abbreviations: AngII, angiotensin II; BIF, carotid bifurcation; CCA, common carotid artery; HCD, high cholesterol diet; HDL, high density lipoprotein; HFD, high fat diet; HFHC, high fat, high cholesterol diet; LDL-C, low density lipoprotein-cholesterol; NC, normal chow; TAC, transverse aortic constriction; TC, total cholesterol; TG, triglyceride; SCNT, single cell nuclear transfer; Tg, transgene; VLDL, very-low-density lipoprotein; n.i., no information; N/A, not applicable.