The Cholesterol Emboli Syndrome in Atherosclerosis

  • Adriana Quinones
  • Muhamed Saric
Coronary Heart Disease (JA Farmer, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Coronary Heart Disease


Cholesterol emboli syndrome is a relatively rare, but potentially devastating, manifestation of atherosclerotic disease. Cholesterol emboli syndrome is characterized by waves of arterio-arterial embolization of cholesterol crystals and atheroma debris from atherosclerotic plaques in the aorta or its large branches to small or medium caliber arteries (100–200 μm in diameter) that frequently occur after invasive arterial procedures. End-organ damage is due to mechanical occlusion and inflammatory response in the destination arteries. Clinical manifestations may include renal failure, blue toe syndrome, global neurologic deficits and a variety of gastrointestinal, ocular and constitutional signs and symptoms. There is no specific therapy for cholesterol emboli syndrome. Supportive measures include modifications of risk factors, use of statins and antiplatelet agents, avoidance of anticoagulation and thrombolytic agents, and utilization of surgical and endovascular techniques to exclude sources of cholesterol emboli.


Atherosclerosis Atheroma Cholesterol emboli Plaque 



No potential conflicts of interest relevant to this article were reported.


Papers of particular interest, published recently, have been highlighted as: •Of importance •• Of major importance

  1. 1.
    • Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation. 2010;122(6):631–41. This paper provides extensive review of historical developments and present day management of cholesterol embolization syndrome. Google Scholar
  2. 2.
    Saric M, Kronzon I. Aortic atherosclerosis and embolic events. Curr Cardiol Rep. 2012;14(3):342–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Tunick PA, Kronzon I. Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol. 2000;35(3):545–54.PubMedCrossRefGoogle Scholar
  4. 4.
    • Saric M, Kronzon I. Embolism from aortic plaque: atheroembolism (cholesterol crystal embolism). In: Basow DS, editor. UpTo- Date. Waltham: UpToDate; 2011. This article provides comprehensive review of medical and surgical therapies in patients with cholesterol emboli syndrome. Google Scholar
  5. 5.
    •• Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011 Nov 29;58(23):2432–46. This extensive guidelines paper provides thorough and up-to-date recommendations regarding general management of atherosclerosis. Google Scholar
  6. 6.
    Saric M, Kronzon I. Cholesterol embolization syndrome. Curr Opin Cardiol. 2011;26(6):472–9.PubMedCrossRefGoogle Scholar
  7. 7.
    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
  8. 8.
    Panum PL. Experimentelle Beiträge zur Lehre von der Embolie. Virchows Arch Pathol Anat Physiol. 1862;25:308–10.CrossRefGoogle Scholar
  9. 9.
    Flory CM. Arterial occlusions produced by emboli from eroded atheromatous plaques. Am J Pathol. 1945;21:549–65.PubMedGoogle Scholar
  10. 10.
    Octavio RC. 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 [Article in Spanish].Google Scholar
  11. 11.
    Hollenhorst RW. Significance of bright plaques in the retinal arterioles. JAMA. 1961;178:23–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Karmody AM, Powers SR, Monaco VJ, Leather RP. ‘Blue toe’ syndrome: an indication for limb salvage surgery. Arch Surg. 1976;111:1263–8.PubMedCrossRefGoogle Scholar
  13. 13.
    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;120:658–60.PubMedCrossRefGoogle Scholar
  14. 14.
    Stary HC, Chandler AB, Dinsmore RE, Fuster V, Glagov S, Insull Jr W, Rosenfeld ME, Schwartz CJ, Wagner WD, Wissler RW. 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.PubMedCrossRefGoogle Scholar
  15. 15.
    Katz SS, Small DM, Smith FR, Dell RB, Goodman DS. Cholesterol turnover in lipid phases of human atherosclerotic plaque. J Lipid Res. 1982;23:733–7.PubMedGoogle Scholar
  16. 16.
    Applebaum RM, Kronzon I. Evaluation and management of cholesterol embolization and the blue toe syndrome. Curr Opin Cardiol. 1996;11:533–42.PubMedCrossRefGoogle Scholar
  17. 17.
    •• Pepi M, Evangelista A, Nihoyannopoulos P, Flachskampf FA, Athanassopoulos G, Colonna P, Habib G, Ringelstein EB, Sicari R, Zamorano JL, Sitges M, Caso P. European Association of Echocardiography. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr. 2010;11(6):461–76. These are the latest guidelines for the use of echocardiography to detect cardiac and aortic sources of emboli. Google Scholar
  18. 18.
    Tunick PA, Krinsky GA, Lee VS, Kronzon I. Diagnostic imaging of thoracic aortic atherosclerosis. AJR Am J Roentgenol. 2000;174:1119–25.PubMedCrossRefGoogle Scholar
  19. 19.
    Jones EF, Kalman JM, Calafiore P, Tonkin AM, Donnan GA. Proximal aortic atheroma: an independent risk factor for cerebral ischemia. Stroke. 1995;26:218–24.PubMedGoogle Scholar
  20. 20.
    Amarenco P, Cohen A, Tzourio C, Bertrand B, Hommel M, Besson G, Chauvel C, Touboul PJ, Bousser MG. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331:1474–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Koppang JR, Nanda NC, Coghlan C, Sanyal R. Histologically confirmed cholesterol atheroemboli with identification of the source by transesophageal echocardiography. Echocardiography. 1992;9:379–83.CrossRefGoogle Scholar
  22. 22.
    Coy KM, Maurer G, Goodman D, Siegel RJ. Transesophageal echocardiographic detection of aortic atheromatosis may provide clues to occult renal dysfunction in the elderly. Am Heart J. 1992;123:1684–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Ko Y, Park JH, Yang MH, Ko SB, Choi SI, Chun EJ, Han MK, Bae HJ. Significance of aortic atherosclerotic disease in possibly embolic stroke: 64-multidetector row computed tomography study. J Neurol. 2010;257(5):699–705.PubMedCrossRefGoogle Scholar
  24. 24.
    Zahuranec DB, Mueller GC, Bach DS, Stojanovska J, Brown DL, Lisabeth LD, Patel S, Hughes RM, Attili AK, Armstrong WF, Morgenstern LB. Pilot study of cardiac magnetic resonance imaging for detection of embolic source after ischemic stroke. J Stroke Cerebrovasc Dis. 2012;21(8):794–800.PubMedCrossRefGoogle Scholar
  25. 25.
    Khatri IA, Mian N, Alkawi A, Janjua N, Kirmani JF, Saric M, Levine JC, Qureshi AI. Catheter-based aortography fails to identify aortic atherosclerotic lesions detected on transesophageal echocardiography. J Neuroimaging. 2005;15(3):261–5.PubMedGoogle Scholar
  26. 26.
    Soufi M, Sattler AM, Maisch B, Schaefer JR. Molecular mechanisms involved in atherosclerosis. Herz. 2002;27(7):637–48.PubMedCrossRefGoogle Scholar
  27. 27.
    Kealy WF. Atheroembolism. J Clin Pathol. 1978;31:984–89.PubMedCrossRefGoogle Scholar
  28. 28.
    Cross SS. How common is cholesterol embolism? J Clin Pathol. 1991;44:859–61.PubMedCrossRefGoogle Scholar
  29. 29.
    Keeley EC, Grines CL. Scraping of aortic debris by coronary guiding catheters: a prospective evaluation of 1,000 cases. J Am Coll Cardiol. 1998;32:1861–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A. Cholesterol Embolism Study (CHEST) Investigators. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol. 2003;42:211–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Saklayen MG, Gupta S, Suryaprasad A, Azmeh W. Incidence of atheroembolic renal failure after coronary angiography: a prospective study. Angiology. 1997;48:609–13.PubMedCrossRefGoogle Scholar
  32. 32.
    Johnson LW, Esente P, Giambartolomei A, Grant WD, Loin M, Reger MJ, Shaw C, Walford GD. Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques. Cathet Cardiovasc Diagn. 1994;31:165–72.PubMedCrossRefGoogle Scholar
  33. 33.
    Blauth CI, Cosgrove DM, Webb BW, Ratliff NB, Boylan M, Piedmonte MR, Lytle BW, Loop FD. Atheroembolism from the ascending aorta: an emerging problem in cardiac surgery. J Thorac Cardiovasc Surg. 1992;103:1104–11. discussion 1111–1112.PubMedGoogle Scholar
  34. 34.
    Ascione R, Ghosh A, Reeves BC, Arnold J, Potts M, Shah A, Angelini GD. Retinal and cerebral microembolization during coronary artery bypass surgery: a randomized, controlled trial. Circulation. 2005;112:3833–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Sila CA. Neurologic complications of vascular surgery. Neurol Clin. 1998;16:9–20.PubMedCrossRefGoogle Scholar
  36. 36.
    Rapp JH, Pan XM, Yu B, Swanson RA, Higashida RT, Simpson P, Saloner D. Cerebral ischemia and infarction from atheroemboli, 100 microm in size. Stroke. 2003;34:1976–80.PubMedCrossRefGoogle Scholar
  37. 37.
    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;107:662–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Konstantinou DM, Chatzizisis YS, Farmakis G, Styliadis I, Giannoglou GD. Cholesterol embolization syndrome following thrombolysis during acute myocardial infarction. Herz. 2012;37(2):231–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Eliot RS, Kanjuh VI, Edwards JE. Atheromatous embolism. Circulation. 1964;30:611–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Gore I, McCoombs HL, Lindquist RL. Observation on the fate of cholesterol emboli. J Atheroscler Res. 1964;4:531–47.CrossRefGoogle Scholar
  41. 41.
    Soloway HB, Aronson SM. Atheromatous emboli to central nervous system. Arch Neurol. 1964;11:657–67.PubMedCrossRefGoogle Scholar
  42. 42.
    Aaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. J Neurosurg. 1982;57:769–74.PubMedCrossRefGoogle Scholar
  43. 43.
    Ezzeddine MA, Primavera JM, Rosand J, Hedley-Whyte ET, Rordorf G. Clinical characteristics of pathologically proved cholesterol emboli to the brain. Neurology. 2000;54:1681–3.PubMedCrossRefGoogle Scholar
  44. 44.
    Fine MJ, Kapoor W, Falanga V. Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology. 1987;38:769–84.PubMedCrossRefGoogle Scholar
  45. 45.
    Lye WC, Cheah JS, Sinniah R. Renal cholesterol embolic disease: case report and review of the literature. Am J Nephrol. 1993;13:489–93.PubMedCrossRefGoogle Scholar
  46. 46.
    Scolari F, Ravani P, Gaggi R, Santostefano M, Rollino C, Stabellini N, Colla L, Viola BF, Maiorca P, Venturelli C, Bonardelli S, Faggiano P, Barrett BJ. The challenge of diagnosing atheroembolic renal disease: clinical features and prognostic factors. Circulation. 2007;116:298–304.PubMedCrossRefGoogle Scholar
  47. 47.
    Moolenaar W, Lamers CBHW. Cholesterol crystal embolization and the digestive system. Scand J Gastroenterol. 1991;26 suppl 188:69–72.CrossRefGoogle Scholar
  48. 48.
    Francis J, Kapoor W. Intestinal pseudopolyps and gastrointestinal hemorrhage due to cholesterol crystal embolization. Am J Med. 1988;85:269–71.PubMedCrossRefGoogle Scholar
  49. 49.
    Moolenaar W, Kreuning J, Eulderink F, Lamers CBHW. Ischemic colitis and acalculous necrotizing cholecystitis as rare manifestations of cholesterol emboli in the same patient. Am J Gastroenterol. 1989;84:1421–2.PubMedGoogle Scholar
  50. 50.
    Probstein JG, Joshi RA, Blurnenthal HT. Atheromatous embolism: an etiology of acute pancreatitis. Arch Surg. 1957;75:566–72.CrossRefGoogle Scholar
  51. 51.
    Donohue KG, Saap L, Falanga V. Cholesterol crystal embolization: an atherosclerotic disease with frequent and varied cutaneous manifestations. J Eur Acad Dermatol Venereol. 2003;17:504–11.PubMedCrossRefGoogle Scholar
  52. 52.
    Falanga V, Fine MJ, Kapoor WN. The cutaneous manifestations of cholesterol crystal embolization. Arch Dermatol. 1986;122:1194–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Matsuzaki M, Ono S, Tomochika Y, Michishige H, Tanaka N, Okuda F, Kusukawa R. Advances in transesophageal echocardiography for the evaluation of atherosclerotic lesions in thoracic aorta–the effects of hypertension, hypercholesterolemia, and aging on atherosclerotic lesions. Jpn Circ J. 1992;56(6):592–602.PubMedCrossRefGoogle Scholar
  54. 54.
    Cutaneous Manifestations of Cholesterol Embolism. eMedicine Web site. Accessed December 20, 2012.
  55. 55.
    Kasinath BS, Lewis EJ. Eosinophilia as a clue to the diagnosis of atheroembolic renal disease. Arch Intern Med. 1987;147:1384–5.PubMedCrossRefGoogle Scholar
  56. 56.
    Jucgla A, Moreso F, Muniesa C, Moreno A, Vidaller A. Cholesterol embolism: still an unrecognized entity with a high mortality rate. J Am Acad Dermatol. 2006;55:786–93.PubMedCrossRefGoogle Scholar
  57. 57.
    Kronzon I, Tunick PA. Aortic atherosclerotic disease and stroke. Circulation. 2006;114:63–75.PubMedCrossRefGoogle Scholar
  58. 58.
    Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. the Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin- converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med. 2000;342:145–53.PubMedCrossRefGoogle Scholar
  59. 59.
    Keen RR, McCarthy WJ, Shireman PK, et al. Surgical management of theroembolization. J Vasc Surg. 1995;21:773.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Leon H. Charney Division of CardiologyNew York University Langone Medical CenterNew YorkUSA

Personalised recommendations