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Cholesterol Embolism Workup

  • Author: Lisa Kirkland, MD, FACP, FCCM, MSHA; Chief Editor: Vincent Lopez Rowe, MD  more...
Updated: Aug 10, 2015

Laboratory Studies

Laboratory studies to be considered in the workup for cholesterol embolism include the following:

  • Complete blood count (CBC) - Leukocytosis with left shift is nonspecific; eosinophilia strongly suggests atheroembolization and is present in as many as 80% of patients with cholesterol embolism syndrome
  • Chemistry - Elevated blood urea nitrogen (BUN) and creatinine levels are present in virtually all cases of cholesterol embolism syndrome
  • Urinalysis - Microscopic hematuria, proteinuria, and hyaline casts are common; pyuria actually may be eosinophiluria, a major clue for the diagnosis of cholesterol embolism syndrome
  • Tissue-specific laboratory tests - Muscle injury causes an elevated creatine kinase (CK) level; myocardial, pancreatic, and hepatobiliary involvement produces increases in cardiac enzymes, amylase, and hepatobiliary enzymes
  • Inflammatory mediators - Nonspecific findings include hypocomplementemia, positive rheumatoid factor, antinuclear antibodies, and elevated C-reactive protein [5] (CRP) and sedimentation rates; one study found a CRP level higher than 1.0 mg/dL to be an independent predictor of cholesterol emboli in patients with coronary artery disease

Imaging Studies


Contrast angiography of involved organs may be performed to rule out more treatable causes of tissue ischemia, such as polyarteritis nodosa. Angiography may induce atheroembolism.


Transesophageal echocardiography (TEE) is gaining acceptance as an imaging tool for detecting atheromatous lesions in the ascending and thoracic aorta.[6, 7, 8, 9] Protruding mobile atheromatous masses have been associated with a higher incidence of stroke or cholesterol embolism in patients who undergo cardiac bypass or patients who receive anticoagulants. TEE may eventually be performed in all patients undergoing bypass before aortic cannulation. It also may be performed in all patients with ischemic stroke with an unclear etiology.

Computed tomography

Thin sections viewed on nonenhanced dual helical (spiral) computed tomography (CT) may be useful for rapid and noninvasive detection of protruding aortic atheroma.[10] This test can help visualize areas that are poorly imaged on TEE, such as the distal ascending aorta and arch. One study suggests 87% sensitivity, 82% specificity, and 84% overall accuracy.

Magnetic resonance imaging

Data on magnetic resonance imaging (MRI) and atheromatous plaque are relatively sparse, but a reasonable expectation is that MRI should exhibit good sensitivity in this setting.



Demonstration of cholesterol crystals in occluded arterioles is the only definitive test for cholesterol embolism. Skin,[11] renal, muscle, or gastrointestinal tract biopsy may reveal crystal ghosts inside vessels. Often, multiple samples may be necessary to demonstrate the crystals.


Histologic Findings

The actual cholesterol crystals are dissolved during fixation, leaving intra-arterial biconvex ghosts. Often, the crystals are missed because the depth of the tissue sample is inadequate. If these ghosts are absent, the diagnosis still may be inferred from the presence of fibrinoid necrosis (see the image below) and a foreign-body reaction in tissues commonly involved by atheromatous emboli in a patient with consistent clinical findings. Exuberant adventitial fibrosis contributes to vessel lumen occlusion.

Necrosis of the abdominal wall in a patient with c Necrosis of the abdominal wall in a patient with cholesterol embolism syndrome who received anticoagulation.
Contributor Information and Disclosures

Lisa Kirkland, MD, FACP, FCCM, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; Vice Chair, Department of Critical Care, ANW Intensivists, Abbott Northwestern Hospital

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Travis J Phifer, MD 

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

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