Skip to main content
SpringerLink
Log in

Cholesterol Emboli

  • Chapter
  • First Online:
Critical Limb Ischemia

  • 2422 Accesses

Abstract

Cholesterol emboli syndrome (CES) is a rare and often devastating multi-organ disease resulting in variable, nonspecific clinical findings that make diagnosis difficult, requiring a high index of suspicion. Cholesterol emboli originate from complex atheromatous plaque found in large caliber proximal arteries primarily in the aorto-iliac-femoral system. Plaque rupture results in distal embolization of plaque debris, including cholesterol crystals, that become lodged within smaller caliber arteries and arterioles resulting in mechanical obstruction and a provoked inflammatory response that leads to end-organ damage.

Multiple organs can be affected by cholesterol emboli including the brain, gastrointestinal tract, kidney, and skin that can manifest with a variety of clinical findings such as encephalopathy, gastrointestinal bleeding, renal failure, and “blue toes.” Plaque rupture can be spontaneous or result from aortic manipulation during catheterization-based procedures or vascular surgery. Treatment remains largely supportive and includes risk factor modification, statin therapy, general avoidance of anticoagulants and thrombolytic agents, and surgical or endovascular procedures to exclude sources of cholesterol emboli.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 139.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation. 2010;122(6):631–41.

    Article  PubMed  Google Scholar 

  2. Tunick PA, Kronzon I. Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol. 2000;35:545–54.

    Article  CAS  PubMed  Google Scholar 

  3. Fenger CE, Jacobsen JP, Dahlerup EA, Hornemann E, Collin T. Beretning af Obductionen over Albert Thorvaldsen (autopsy report of Albert Thorvaldsen). Ugeskr Laeger. 1844;10(14–15):215–8. In literature, this article is often referenced from Panum’s German translation as Obduktiosbericht (autopsy report).

    Google Scholar 

  4. Panum PL. Experimentelle Beiträge zur Lehre von der Embolie. Virchows Arch Pathol Anat Physiol. 1862;25:308–10.

    Article  Google Scholar 

  5. Flory CM. Arterial occlusions produced by emboli from eroded aortic atheromatous plaques. Am J Pathol. 1945;21(3):549–65.

    CAS  PubMed  PubMed Central  Google Scholar 

  6. Octavio Rios C. Applications of polarized light in the clinical laboratory; research on cholesterol crystals in bile & biliary calculi. Rev Sanid Mil Peru. 1956;29(85):71–7.

    CAS  PubMed  Google Scholar 

  7. Thurlbeck WM, Castleman B. Atheromatous emboli to the kidneys after aortic surgery. N Engl J Med. 1957;257(10):442–7.

    Article  CAS  PubMed  Google Scholar 

  8. Hollenhorst RW. Significance of bright plaques in the retinal arterioles. JAMA. 1961;178:23–9.

    Article  CAS  PubMed  Google Scholar 

  9. Karmody AM, et al. “Blue toe” syndrome. An indication for limb salvage surgery. Arch Surg. 1976;111(11):1263–8.

    Article  CAS  PubMed  Google Scholar 

  10. Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J. 1990;120(3):658–60.

    Article  CAS  PubMed  Google Scholar 

  11. Stary HC, et al. A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation. 1995;92(5):1355–74.

    Article  CAS  PubMed  Google Scholar 

  12. Katz SS, et al. Cholesterol turnover in lipid phases of human atherosclerotic plaque. J Lipid Res. 1982;23(5):733–7.

    CAS  PubMed  Google Scholar 

  13. Applebaum RM, Kronzon I. Evaluation and management of cholesterol embolization and the blue toe syndrome. Curr Opin Cardiol. 1996;11(5):533–42.

    Article  CAS  PubMed  Google Scholar 

  14. Tunick PA, et al. Diagnostic imaging of thoracic aortic atherosclerosis. AJR Am J Roentgenol. 2000;174(4):1119–25.

    Article  CAS  PubMed  Google Scholar 

  15. Tunick PA, Perez JL, Kronzon I. Protruding atheromas in the thoracic aorta and systemic embolization. Ann Intern Med. 1991;115(6):423–7.

    Article  CAS  PubMed  Google Scholar 

  16. Jones EF, et al. Proximal aortic atheroma. An independent risk factor for cerebral ischemia. Stroke. 1995;26(2):218–24.

    CAS  PubMed  Google Scholar 

  17. Amarenco P, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331(22):1474–9.

    Article  CAS  PubMed  Google Scholar 

  18. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. The French Study of Aortic Plaques in Stroke Group. N Engl J Med. 1996;334(19):1216–21.

    Google Scholar 

  19. Cohen A, et al. Aortic plaque morphology and vascular events: a follow-up study in patients with ischemic stroke. FAPS Investigators. French Study of Aortic Plaques in Stroke. Circulation. 1997;96(11):3838–41.

    Article  CAS  PubMed  Google Scholar 

  20. Coy KM, et al. Transesophageal echocardiographic detection of aortic atheromatosis may provide clues to occult renal dysfunction in the elderly. Am Heart J. 1992;123(6):1684–6.

    Article  CAS  PubMed  Google Scholar 

  21. Piazzese C, Tsang W, Sotaquira M, Kronzon I, Lang RM, Caiani EG. Semiautomated detection and quantification of aortic plaques from three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr. 2014;27(7):758–66.

    Article  PubMed  Google Scholar 

  22. Ko Y, et al. Significance of aortic atherosclerotic disease in possibly embolic stroke: 64-multidetector row computed tomography study. J Neurol. 2010;257(5):699–705.

    Article  PubMed  Google Scholar 

  23. Fayad ZA, et al. In vivo magnetic resonance evaluation of atherosclerotic plaques in the human thoracic aorta: a comparison with transesophageal echocardiography. Circulation. 2000;101(21):2503–9.

    Article  CAS  PubMed  Google Scholar 

  24. Harloff A, et al. 3D MRI provides improved visualization and detection of aortic arch plaques compared to transesophageal echocardiography. J Magn Reson Imaging. 2012;36(3):604–11.

    Article  PubMed  Google Scholar 

  25. Khatri IA, et al. Catheter-based aortography fails to identify aortic atherosclerotic lesions detected on transesophageal echocardiography. J Neuroimaging. 2005;15(3):261–5.

    Article  PubMed  Google Scholar 

  26. Shah PK. Molecular mechanisms of plaque instability. Curr Opin Lipidol. 2007;18(5):492–9.

    Article  CAS  PubMed  Google Scholar 

  27. Kealy WF. Atheroembolism. J Clin Pathol. 1978;31(10):984–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Cross SS. How common is cholesterol embolism? J Clin Pathol. 1991;44(10):859–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Tunick PA, et al. Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque. Am J Cardiol. 2002;90(12):1320–5.

    Article  PubMed  Google Scholar 

  30. Fukumoto Y, et al. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol. 2003;42(2):211–6.

    Article  PubMed  Google Scholar 

  31. Johnson LW, et al. Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques. Cathet Cardiovasc Diagn. 1994;31(3):165–72.

    Article  CAS  PubMed  Google Scholar 

  32. Saklayen MG, et al. Incidence of atheroembolic renal failure after coronary angiography. A prospective study. Angiology. 1997;48(7):609–13.

    Article  CAS  PubMed  Google Scholar 

  33. Kooiman J, et al. Risk of acute kidney injury after percutaneous coronary interventions using radial versus femoral vascular access: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Circ Cardiovasc Interv. 2014;7(2):190–8.

    Article  PubMed  Google Scholar 

  34. Webb JG, Wood DA. Current status of transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;60(6):483–92.

    Article  PubMed  Google Scholar 

  35. Blauth CI, et al. Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery. J Thorac Cardiovasc Surg. 1992;103(6):1104–11. discussion 1111–2.

    CAS  PubMed  Google Scholar 

  36. Ascione R, et al. Retinal and cerebral microembolization during coronary artery bypass surgery: a randomized, controlled trial. Circulation. 2005;112(25):3833–8.

    Article  PubMed  Google Scholar 

  37. Sila CA. Neurologic complications of vascular surgery. Neurol Clin. 1998;16(1):9–20.

    Article  CAS  PubMed  Google Scholar 

  38. Rapp JH, et al. Cerebral ischemia and infarction from atheroemboli <100 micron in Size. Stroke. 2003;34(8):1976–80.

    Article  PubMed  Google Scholar 

  39. Toya N, et al. Embolic complications after endovascular repair of abdominal aortic aneurysms. Surg Today. 2014;44(10):1893–9.

    Google Scholar 

  40. Blankenship JC, Butler M, Garbes A. Prospective assessment of cholesterol embolization in patients with acute myocardial infarction treated with thrombolytic vs conservative therapy. Chest. 1995;107(3):662–8.

    Article  CAS  PubMed  Google Scholar 

  41. Konstantinou DM, et al. Cholesterol embolization syndrome following thrombolysis during acute myocardial infarction. Herz. 2012;37(2):231–3.

    Article  CAS  PubMed  Google Scholar 

  42. Hyman BT, et al. Warfarin-related purple toes syndrome and cholesterol microembolization. Am J Med. 1987;82(6):1233–7.

    Article  CAS  PubMed  Google Scholar 

  43. Bruns FJ, Segel DP, Adler S. Control of cholesterol embolization by discontinuation of anticoagulant therapy. Am J Med Sci. 1978;275(1):105–8.

    Article  CAS  PubMed  Google Scholar 

  44. Shafi ST, et al. A case of dabigatran-associated acute renal failure. WMJ. 2013;112(4):173–5. quiz 176.

    PubMed  Google Scholar 

  45. Kim H, Zhen D, Lieske J, McBane R, Grande J, Sandhu G, Melduni R. Treatment of cholesterol embolization syndrome in the setting of an acute indication for anticoagulation therapy. J Med Case Rep. 2014;5:376–79.

    Google Scholar 

  46. Eliot RS, Kanjuh VI, Edwards JE. Atheromatous embolism. Circulation. 1964;30:611–8.

    Article  CAS  PubMed  Google Scholar 

  47. Gore I, McCombs HL, Lindquist RL. Observations on the fate of cholesterol emboli. J Atheroscler Res. 1964;4:527–35.

    Article  CAS  PubMed  Google Scholar 

  48. Soloway HB, Aronson SM. Atheromatous emboli to central nervous system. Report of 16 cases. Arch Neurol. 1964;11:657–67.

    Article  CAS  PubMed  Google Scholar 

  49. Ezzeddine MA, et al. Clinical characteristics of pathologically proved cholesterol emboli to the brain. Neurology. 2000;54(8):1681–3.

    Article  CAS  PubMed  Google Scholar 

  50. Spencer MP, et al. Detection of middle cerebral artery emboli during carotid endarterectomy using transcranial Doppler ultrasonography. Stroke. 1990;21(3):415–23.

    Article  CAS  PubMed  Google Scholar 

  51. Baker AJ, et al. Cerebral microemboli during coronary artery bypass using different cardioplegia techniques. Ann Thorac Surg. 1995;59(5):1187–91.

    Article  CAS  PubMed  Google Scholar 

  52. Ackerstaff RG, et al. The significance of microemboli detection by means of transcranial Doppler ultrasonography monitoring in carotid endarterectomy. J Vasc Surg. 1995;21(6):963–9.

    Article  CAS  PubMed  Google Scholar 

  53. Enevoldsen EM, et al. Cerebral infarct following carotid endarterectomy. Frequency, clinical and hemodynamic significance evaluated by MRI and TCD. Acta Neurol Scand. 1999;100(2):106–10.

    Article  CAS  PubMed  Google Scholar 

  54. Scolari F, et al. Cholesterol crystal embolism: a recognizable cause of renal disease. Am J Kidney Dis. 2000;36(6):1089–109.

    Article  CAS  PubMed  Google Scholar 

  55. Haas M, et al. Etiologies and outcome of acute renal insufficiency in older adults: a renal biopsy study of 259 cases. Am J Kidney Dis. 2000;35(3):433–47.

    Article  CAS  PubMed  Google Scholar 

  56. Fine MJ, Kapoor W, Falanga V. Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology. 1987;38(10):769–84.

    Article  CAS  PubMed  Google Scholar 

  57. Lye WC, Cheah JS, Sinniah R. Renal cholesterol embolic disease. Case report and review of the literature. Am J Nephrol. 1993;13(6):489–93.

    Article  CAS  PubMed  Google Scholar 

  58. Scolari F, et al. The challenge of diagnosing atheroembolic renal disease: clinical features and prognostic factors. Circulation. 2007;116(3):298–304.

    Article  PubMed  Google Scholar 

  59. Rushovich AM. Perforation of the jejunum: a complication of atheromatous embolization. Am J Gastroenterol. 1983;78(2):77–82.

    CAS  PubMed  Google Scholar 

  60. Moolenaar W, Lamers CB. Cholesterol crystal embolization and the digestive system. Scand J Gastroenterol Suppl. 1991;188:69–72.

    Article  CAS  PubMed  Google Scholar 

  61. Francis J, Kapoor WN. Intestinal pseudopolyps and gastrointestinal hemorrhage due to cholesterol crystal embolization. Am J Med. 1988;85(2):269–71.

    Article  CAS  PubMed  Google Scholar 

  62. Probstein JG, Joshi RA, Blumenthal HT. Atheromatous embolization; an etiology of acute pancreatitis. AMA Arch Surg. 1957;75(4):566–71. discussion 571–2.

    Article  CAS  PubMed  Google Scholar 

  63. Donohue KG, Saap L, Falanga V. Cholesterol crystal embolization: an atherosclerotic disease with frequent and varied cutaneous manifestations. J Eur Acad Dermatol Venereol. 2003;17(5):504–11.

    Article  CAS  PubMed  Google Scholar 

  64. Falanga V, Fine MJ, Kapoor WN. The cutaneous manifestations of cholesterol crystal embolization. Arch Dermatol. 1986;122(10):1194–8.

    Article  CAS  PubMed  Google Scholar 

  65. O’Keeffe ST, et al. Blue toe syndrome. Causes and management. Arch Intern Med. 1992;152(11):2197–202.

    Article  PubMed  Google Scholar 

  66. Kasinath BS, Lewis EJ. Eosinophilia as a clue to the diagnosis of atheroembolic renal disease. Arch Intern Med. 1987;147(8):1384–5.

    Article  CAS  PubMed  Google Scholar 

  67. Cecioni I, et al. Eosinophilia in cholesterol atheroembolic disease. J Allergy Clin Immunol. 2007;120(6):1470–1. author reply 1471.

    Article  CAS  PubMed  Google Scholar 

  68. Jucgla A, et al. Cholesterol embolism: still an unrecognized entity with a high mortality rate. J Am Acad Dermatol. 2006;55(5):786–93.

    Article  PubMed  Google Scholar 

  69. Tunick PA, Kronzon I. Embolism from the aorta: atheroemboli and thromboemboli. Curr Treat Options Cardiovasc Med. 2001;3(3):181–6.

    Article  PubMed  Google Scholar 

  70. Ueno Y, et al. Rationale and design of the EPISTEME trial: efficacy of post-stroke intensive rosuvastatin treatment for aortogenic embolic stroke. Cardiovasc Drugs Ther. 2014;28(1):79–85.

    Article  CAS  PubMed  Google Scholar 

  71. Smith Jr SC, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113(19):2363–72.

    Article  PubMed  Google Scholar 

  72. Yusuf S, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342(3):145–53.

    Article  CAS  PubMed  Google Scholar 

  73. Belenfant X, Meyrier A, Jacquot C. Supportive treatment improves survival in multivisceral cholesterol crystal embolism. Am J Kidney Dis. 1999;33(5):840–50.

    Article  CAS  PubMed  Google Scholar 

  74. Masuda J, et al. Use of corticosteroids in the treatment of cholesterol crystal embolism after cardiac catheterization: a report of four Japanese cases. Intern Med. 2013;52(9):993–8.

    Article  CAS  PubMed  Google Scholar 

  75. Nakayama M, et al. The effect of low-dose corticosteroids on short- and long-term renal outcome in patients with cholesterol crystal embolism. Ren Fail. 2011;33(3):298–306.

    Article  CAS  PubMed  Google Scholar 

  76. Keen RR, et al. Surgical management of atheroembolization. J Vasc Surg. 1995;21(5):773–80. discussion 780–1.

    Article  CAS  PubMed  Google Scholar 

  77. Shames ML, et al. Treatment of embolizing arterial lesions with endoluminally placed stent grafts. Ann Vasc Surg. 2002;16(5):608–12.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Echocardiography Lab, Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, 560 First Avenue, Tisch 11 East, New York, NY, 10016, USA

    Muhamed Saric MD, PhD

  2. Department of Cardiology, New York University Langone Medical Center, New York, NY, USA

    Rose Tompkins

Authors
  1. Muhamed Saric MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rose Tompkins
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Loyola University Medical Center, Maywood, Illinois, USA

    Robert S. Dieter

  2. Northwestern Medicine Central DuPage Hospital, Glen Ellyn, Illinois, USA

    Raymond A. Dieter, Jr

  3. The University of Tennessee Medical Center, Knoxville, Tennessee, USA

    Raymond A. Dieter, III

  4. West Virginia University, Charleston, West Virginia, USA

    Aravinda Nanjundappa

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Saric, M., Tompkins, R. (2017). Cholesterol Emboli. In: Dieter, R., Dieter, Jr, R., Dieter, III, R., Nanjundappa, A. (eds) Critical Limb Ischemia. Springer, Cham. https://doi.org/10.1007/978-3-319-31991-9_27

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-31991-9_27

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-31989-6

  • Online ISBN: 978-3-319-31991-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation