Cholesterol Embolism Clinical Presentation

Updated: Jul 21, 2023
  • Author: Lisa Kirkland, MD, FACP, FCCM, MSHA; Chief Editor: Vincent Lopez Rowe, MD, FACS  more...
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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
  • 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:

Other manifestations are as follows:



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.