atheroembolism; cholesterol embolism; aortic atheroembolism
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Etiology
- occurs in patients with severe atherosclerosis
- post arterial procedure
- spontaneously, i.e. large abdominal aortic aneurysm
- may also occur several weeks after starting warfarin therapy
Epidemiology
- most patients are > 60 years of age
Pathology
- embolization involves lodging of cholesterol crystals in small arterioles & capillary beds
- skin biopsy may show needle-shaped cholesterol crystals within dermal arteries (histology image)[6]
- inflammatory infiltrate
- intimal thickening
- perivascular fibrosis
- lipid-laden giant cells
- embolization occurs commonly to:
- embolization occurs less commonly to:
- central nervous system
- muscles
Clinical manifestations
- acute renal failure (ARF)
- after 24 hr (slower onset than ARF secondary to radiographic contrast media)
- severe hypertension may occur due to atheroembolism to the kidney
- poor prognosis for recovery of renal function
- livedo reticularis over the legs & thighs is common[2]
- purple toes (blue toe syndrome), digital gangrene
- visual changes, retinal changes, Hallenhorst plaque (pathognomonic)[2]
- cerebrovascular accident
- GI bleed
- abdominal pain, pancreatitis
- fatigue
- generalized myalgias
- low-grade fever may occur
Laboratory
- complete blood count (CBC)
- transient eosinophilia may be present
- leukocytosis may be noted
- renal function tests
- increased serum creatinine
- urinalysis: eosinophiluria may be present
- CH50 may be abnormal due to complement activation by cholesterol crystals
- complement C3 in serum may be low
- complement C4 in serum may be low
- erythrocyte sedimentation rate may be elevated
Diagnostic procedures
- biopsy of infarcted skin, nerve, kidney, or muscle
Differential diagnosis
Management
- no specific therapy
- aggressive control of cardiovascular risk factors
- control of hypertension
- correction of dyslipidemia
- glycemic control in diabetics
- smoking cessation[2]
- pharmaceutical agents
- acute (limited success)
- long-term
- LDL apheresis is investigational[2]
- surgical prophylaxis of further episodes
- repair of aneurysm
- removal of an ulcerated plaque
- digital necrosis & gangrene require amputation
More general terms
More specific terms
Additional terms
- blue toe syndrome
- cholesterol
- livedo reticularis; livedoid vasculopathy; mottled skin; cutis marmorata
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 535
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2021
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation. 2010 Aug 10;122(6):631-41 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20697039
- ↑ Saric M, Kronzon I. Cholesterol embolization syndrome. Curr Opin Cardiol. 2011 Nov;26(6):472-9. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21993354
- ↑ Quinones A, Saric M. The cholesterol emboli syndrome in atherosclerosis. Curr Atheroscler Rep. 2013 Apr;15(4):315. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23423524
- ↑ 6.0 6.1 6.2 Rashid RM, Barros BS (images) Hidden Heart Disease: 19 Dermatologic Clues You Should Know. Medscape. June 13, 2017. http://reference.medscape.com/slideshow/hidden-heart-disease-6004452