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 preceding 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 (embolization) 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:

Fever
Weight loss
Hypermetabolic state

Cardiovascular manifestations include the following:

Tachycardia
Uncontrolled or accelerating hypertension
Congestive heart failure (CHF)
Myocardial infarction (MI)
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:

Hollenhorst plaques in retinal arteries
Hemispheric ischemic stroke
Paraplegia
Confusion
Delirium

Renal manifestations include the following:

Dermatologic manifestations include the following:

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 extremities
Blue toe syndrome and splinter hemorrhages ^[8]

GI manifestations include the following:

Minor or major bleeding
Abdominal pain
Bowel infarction
Pancreatitis
Acalculous cholecystitis

Other manifestations are as follows:

Musculoskeletal - Myalgias
Endocrine - Adrenal insufficiency
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.

Differential Diagnoses

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Media Gallery

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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Cholesterol Embolism Clinical Presentation

History

Physical Examination

Complications

References

Tables

Contributor Information and Disclosures

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