Cholesterol Embolization Syndrome

Atheroembolism, also known as cholesterol crystal embolism or cholesterol embolism, refers to arterio-arterial embolism of cholesterol crystals or small pieces of atheromatous material originating from an atherosclerotic plaque usually from the aorta but occasionally from other arteries. Cholesterol crystal embolism results in partial or total occlusion of small arteries, leading to tissue or organ ischemia. 

Risk factors for developing cholesterol crystal embolism are largely those associated with developing general atherosclerotic diseases such as smoking, hypercholesterolemia, hypertension, obesity, and diabetes.

Characteristic findings include livedo reticularis, gangrene of the digits (blue toe syndrome), and transient vision loss (a golden or brightly refractile cholesterol body within a retinal artery [Hollenhorst plaque] is pathognomonic). Patients often present with stroke or AKI following recent cardiac or aortic surgery or other intravascular procedures (catheterization). It must be differentiated from Contrast-induced nephropathy.

Diagnosis of Cholesterol Embolization Syndrome

• Laboratory findings
  • Elevated serum creatinine, eosinophilia, hypocomplementemia
  • Urinalysis — typically benign with few cells or casts. may have eosinophiluria
• Skin or renal biopsy
  • Biconvex, needle-shaped clefts within occluded vessels
  • Perivascular inflammation with eosinophils

Treatment of Cholesterol Embolization Syndrome

• Usually supportive treatment
  • Anticoagulation is not suggested unless another indication exists (most of the occlusion is atheroembolic debris, not thrombus).
  • Control BP
  • Amputation or surgical resection is only needed in extreme cases.
  • Asymptomatic aortic atheroma should be aggressively treated with antiplatelet agents and statins to reduce the risk of future cardiovascular events.
    

The prognosis in patients with cholesterol crystal embolism correlates with the degree of underlying atherosclerosis and is overall poor.

References

1. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.106.680991