History
The diagnosis of cholesterol embolism must be considered in patients older than 50 years who have atherosclerotic disease and who present 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 undergo evaluation for cholesterol embolism, including a fundoscopic examination.
Clinicians should be aware that cholesterol embolism syndrome (CES) may not manifest until chronic crystal embolization and inflammatory changes have occluded vessels sufficiently 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, gastrointestinal (GI) bleeding, or stroke.
Physical Examination
Constitutional manifestations of cholesterol embolism include the following:
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Fever
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Weight loss
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Hypermetabolic state
Cardiovascular manifestations include the following:
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Tachycardia
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Uncontrolled or accelerating hypertension
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Congestive heart failure (CHF)
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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 manifestations include the following:
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Hollenhorst plaques in retinal arteries
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Hemispheric ischemic stroke
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Paraplegia
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Confusion
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Delirium
Renal manifestations include the following:
Dermatologic manifestations include the following:
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Gangrene, nodules, purpura, cyanosis, ulcerations (in 35-90% of patients)
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Livedo reticularis
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Infarction of perineal area
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Ischemic patches involving lower extremities more often than upper
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Blue toe syndrome and splinter hemorrhages [6]
GI manifestations include the following:
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Minor or major bleeding
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Abdominal pain
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Bowel infarction
Other manifestations are as follows:
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Musculoskeletal - Myalgias
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Endocrine - Adrenal insufficiency
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Pulmonary - Acute respiratory distress syndrome (ARDS)
Complications
Cholesterol embolism can directly affect all organs except the lungs, resulting in complications that range from mild dysfunction to complete organ failure. Supportive care of organ dysfunction may be necessary and may include hemodialysis, bowel resection, cholecystectomy, and pancreatitis management.
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Cholesterol crystal embolization from upstream coronary artery plaque after percutaneous transluminal coronary angioplasty.
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Necrosis of the abdominal wall in a patient with cholesterol embolism syndrome who received anticoagulation.
