Extracellular vesicles as orchestrators of arterial and venous thrombosis: A unified mechanistic model

Extracellular vesicles (EVs) function as the central mechanobiological orchestrators connecting vascular inflammation and hemostasis. In this review, we propose a unified mechanistic model wherein EV thrombogenicity is governed by convergent catalytic switches: phosphatidylserine (PS) externalization, which scaffolds tenase and prothrombinase assembly, and the structural "decryption" of Tissue Factor (TF) via membrane reorganization and thiol-disulfide exchange. While these molecular drivers are universal, their pathological manifestations diverge strictly by hemodynamic context. In the high-shear arterial environment, EVs act as stress transducers; platelet-EVs leverage von Willebrand factor-GPIb interactions to drive acute occlusion. Conversely, under venous stasis, an immunothrombotic axis dominates; here, hypoxic endothelial- and leukocyte-EVs shuttle mitochondrial DAMPs to potentiate Neutrophil Extracellular Trap (NET) formation, scaffolding the fibrin-rich "red thrombus." Despite this mechanistic clarity, clinical translation is impeded by methodological constraints, particularly the confounding interference of lipoproteins (e.g., chylomicrons) in functional assays. Ultimately, harnessing EVs as "liquid biopsy" biomarkers or therapeutic vectors requires a paradigm shift from particle enumeration to functional phenotyping, alongside rigorous safety engineering to resolve the inherent thrombogenic paradox of EV-based interventions.