Cholesterol Embolism Workup

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

Laboratory Studies

  • CBC count
    • 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 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 produce increases in cardiac enzymes, amylase, and hepatobiliary enzymes.
  • Inflammatory mediators
    • Nonspecific findings include hypocomplementemia, positive rheumatoid factor, antinuclear antibodies, and elevated C-reactive proteins (CRPs) and sedimentation rates.
    • One study demonstrated a CRP level of >1.0 mg/Dl was an independent predictor of cholesterol emboli in patients with coronary artery disease. (odds ratio, 4.64).
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Imaging Studies

  • Angiography
    • 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
    • Transesophageal echocardiography (TEE) is gaining acceptance as an imaging tool for detecting atheromatous lesions in the ascending and thoracic aorta.
    • 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.
  • Dual helical CT
    • Thin sections viewed on nonenhanced dual helical CT may be useful for rapid and noninvasive detection of protruding aortic atheroma.
    • This test can help visualize areas 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 imagery: Little data exist regarding MRI and atheromatous plaque, but a reasonable expectation is that sensitivity is good.
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Procedures

  • Tissue biopsy
    • Demonstration of cholesterol crystals in occluded arterioles is the only definitive test for cholesterol embolism.
    • Skin, renal, muscle, or GI tract biopsy may reveal crystal ghosts inside vessels.
    • Often, multiple samples may be necessary to demonstrate the crystals.
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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 by fibrinoid necrosis, as depicted in 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.

See the image below.

Necrosis of the abdominal wall in a patient with cNecrosis of the abdominal wall in a patient with cholesterol embolism syndrome who received anticoagulation.
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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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