Cholesterol Embolism Clinical Presentation

  • Author: Lisa Kirkland, MD, FACP, CNSP, MSHA; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Aug 31, 2011
 

History

The diagnosis of cholesterol embolism must be considered in patients older than 50 years who have atherosclerotic disease presenting with multisystem dysfunction after undergoing an invasive vascular procedure or receiving an anticoagulant or thrombolytic agent within the past several months. All patients with the classic triad of livedo reticularis, acute renal failure, and eosinophilia should be evaluated for cholesterol embolism, including a funduscopic examination.

Clinicians should be aware that the syndrome may not manifest until chronic crystal embolization and inflammatory changes have occluded enough vessels to create detectable organ damage. Patients may have unexplained fever, weight loss, myalgias, or anorexia for weeks or months after a procedure before presenting with acute renal failure, hyperkalemia, GI bleeding, or stroke.

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Physical

  • Constitutional
    • Fever
    • Weight loss
    • Hypermetabolic state
  • Cardiovascular
    • Tachycardia
    • Uncontrolled or accelerating hypertension
    • Congestive heart failure
    • Myocardial infarction
    • Intact peripheral pulses with livedo reticularis and tissue ischemia: These findings suggest small-vessel occlusion, such as cholesterol embolization, in a patient at risk.
  • Neurologic
    • Hollenhorst plaques in retinal arteries
    • Hemispheric ischemic stroke
    • Paraplegia
    • Confusion
    • Delirium
  • Renal - Oliguria, acute renal failure
  • Dermatologic
  • Gangrene, nodules, purpura, cyanosis, ulcerations (in 35-90% of patients)
    • Livedo reticularis
    • Infarction of perineal area
    • Ischemic patches involving lower extremities more often than upper
    • Blue toe syndrome and splinter hemorrhages[2]
  • Gastrointestinal
    • Minor or major bleeding
    • Abdominal pain
    • Bowel infarction
    • Pancreatitis
    • Acalculous cholecystitis
  • Musculoskeletal - Myalgias
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Causes

Any risk factor for atherosclerotic disease is a risk factor for cholesterol embolism.

Preoperative risk factors for cholesterol embolism syndrome after coronary artery bypass surgery include being older than 60 years, hypertension, cerebrovascular disease, aortoiliac disease, and mitral annular calcification. Although the other factors are well known, the association between mitral annular calcification and aortic atherosclerosis was identified only recently.

Identifying patients at risk and making efforts to minimize aortic wall trauma help reduce the chance of cholesterol embolism. The risk for a patient developing cholesterol embolism may be reduced by using a brachial or axillary approach in patients known to have severely ulcerated aortic plaque, using soft flexible catheters, and avoiding high-pressure jets of contrast material.

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Contributor Information and Disclosures
Author

Lisa Kirkland, MD, FACP, CNSP, MSHA  Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard M Stillman†, MD, FACS  Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center

Richard M Stillman†, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Travis J Phifer, MD  Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport

Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

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Cholesterol crystal embolization from upstream coronary artery plaque after percutaneous transluminal coronary angioplasty.
Necrosis of the abdominal wall in a patient with cholesterol embolism syndrome who received anticoagulation.
 
 
 
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