Cholesterol Emboli Syndrome

Background

This is a syndrome that presents with signs and symptoms related to the end organ it affects.

OUTLINE

Epidemiology

Histopathological Features and Variants

Prognosis and Treatment

Commonly Used Terms

Internet Links

EPIDEMIOLOGY CHARACTERIZATION

INCIDENCE

How common is cholesterol embolism?

Cross SS.

Department of Pathology, University of Sheffield Medical School
J Clin Pathol 1991 Oct;44(10):859-61 Abstract quote
Histological sections of spleen and both kidneys from 372 necropsies were examined for the presence of cholesterol emboli. These were identified in nine (2.4%) cases and the clinical histories of these cases were reviewed.

All the subjects with cholesterol emboli were older than 60 years and eight out of nine were male. Lesions of differing ages were found in individual cases, suggesting that the process of embolism was recurrent. Two of the cases had undergone arteriography procedures in the month before death and, if these were excluded, then the incidence of "spontaneous" cholesterol embolism was 1.9%. This incidence is much lower than that of previously published studies and may be due to a lower incidence of cholesterol embolism in Britain compared with North America or a decrease in incidence over the past two decades.

In three of the subjects with cholesterol embolism the cause of death could be related to systemic atherosclerosis, but in the other six cases there was no apparent correlation between the finding of cholesterol embolism and the cause of death. The clinical relevance of the histological finding of cholesterol embolism can only be assessed in conjunction with clinical information.

AGE RANGE-MEDIAN

SEX (M:F)

GEOGRAPHY

HISTOLOGICAL TYPES CHARACTERIZATION

GENERAL

VARIANTS

BRAIN

Cerebral protection during carotid artery stenting: collection and histopathologic analysis of embolized debris.

Angelini A, Reimers B, Della Barbera M, Sacca S, Pasquetto G, Cernetti C, Valente M, Pascotto P, Thiene G.

Department of Pathology, University of Padua Medical School, Italy.
Stroke 2002 Feb;33(2):456-61 Abstract quote
BACKGROUND AND PURPOSE: Histopathologic analysis was performed to better understand quantity, particle size, and composition of embolized debris collected in protection filters during carotid artery stent implantation.

METHODS: Elective carotid stent implantation with the use of a distal filter protection was attempted in 38 consecutive lesions (36 patients) of the internal carotid artery presenting >70% diameter stenosis (mean, 82.1+/-11.1%). Mean age of the patients was 70.7+/-7.7 years; 75% were men, and 50% of patients had previous neurological symptoms.

RESULTS: In 37 lesions (97.4%) it was possible to position the filter device, and in all lesions a stent was successfully implanted. The only complication occurring in the hospital and during the 30-day follow-up was 1 death due to acute myocardial infarction. Neurological sequelae did not occur. Histomorphometric analysis was performed on the filters. Presence of debris was detected in 83.7% of filters. The mean surface area of the polyurethane membrane filter covered with material was 53.2+/-19.8%. Particle size ranged from 1.08 to 5043.5 microm (mean, 289.5+/-512 microm) in the major axis and 0.7 to 1175.3 microm (mean, 119.7+/-186.7 microm) in the minor axis. Collected debris consisted predominantly of thrombotic material, foam cells, and cholesterol clefts.

CONCLUSIONS: By the use of distal protection filters during carotid artery stenting, it was possible to collect particulate debris potentially leading to distal vessel occlusion in a high percentage of cases. Qualitative analysis of embolized material showed debris dislocated during the percutaneous intervention from atheromatous plaques.

EYE

Echocardiographic findings of patients with retinal ischemia or embolism.

Mouradian M, Wijman CA, Tomasian D, Davidoff R, Koleini B, Babikian VL.

Department of Neurology, Boston University School of Medicine, Boston, MA, USA.
J Neuroimaging 2002 Jul;12(3):219-23 Abstract quote
BACKGROUND AND PURPOSE: A potential source of emboli is not detected in more than 50% of patients with retinal arterial occlusive events. Echocardiographic studies are not always included in the diagnostic workup of these patients. The authors studied the diagnostic yield of transthoracic (TTE) and/or transesophageal (TEE) echocardiography in identifying potential sources of emboli in patients with retinal ischemia or embolism.

METHODS: In a prospective study, 73 consecutive patients with clinically diagnosed retinal ischemia or embolism received a standardized diagnostic workup including retinal photography, echocardiography, and imaging studies of the internal carotid arteries. TTE was performed in 83.6% of patients, TEE was performed in 5.5% of patients, and both TTE and TEE were performed in 11.0% of patients. Ophthalmological diagnoses consisted of amaurosis fugax (n = 28), asymptomatic cholesterol embolism to the retina (n = 34), and branch or central retinal artery occlusion (n = 11).

RESULTS: Echocardiography identified a potential cardiac or proximal aortic source for embolism in 16 of 73 (21.9%) patients, including 8 who also had either atrial fibrillation or internal carotid artery stenosis of more than 50% on the side of interest. Thus, 8 of 73 (11.0%) patients had lesions detected only by echocardiography. The most commonly identified lesions were proximal aortic plaque of more than 4 mm thickness (n = 7, 9.6%) and left ventricular ejection fraction of less than 30% (n = 6, 8.2%). TEE was particularly helpful in identifying prominent aortic plaques.

CONCLUSION: Echocardiography frequently identifies lesions of the heart or aortic arch that can act as potential sources for retinal ischemia or embolism. Further studies are needed to evaluate the prognostic and therapeutic relevance of these findings.

GASTROINTESTINAL TRACT

Ischemic colitis and acalculous necrotizing cholecystitis as rare manifestations of cholesterol emboli in the same patient.

Moolenaar W, Kreuning J, Eulderink F, Lamers CB.

Department of Gastroenterology, University Hospital, Leiden, The Netherlands.

Am J Gastroenterol 1989 Nov;84(11):1421-2 Abstract quote
A case is reported of a patient with ischemic colitis and acalculous necrotizing cholecystitis, rare manifestations of cholesterol emboli in one patient. Cholesterol emboli are often encountered at autopsy, suggesting that such abnormalities frequently are missed during life time, as happened initially in our patient.

We conclude that multisystemic disease in elderly patients can be due to cholesterol emboli. The sooner the diagnosis is made, the more beneficial prophylactical measures will be.

SKIN

Perplexing papules and plaques.

Tran T, Morgan J, Morgan MB.

Suncoast Hospital Dermatology Residency.
Am J Dermatopathol 2002 Aug;24(4):374-6 Abstract quote
Dermatologic diseases are capable of presenting in a variety of clinical and pathologic guises. We present the clinicopathologic features of an unusual case misinterpreted initially as a dermal hypersensitivity reaction that was later deemed to be the cholesterol emboli syndrome.

Salient histologic features of this case were the presence of numerous dermal eosinophils and the diagnostic finding of an intravascular cholesterol embolus. The presence of dermal eosinophilia should prompt a search for cholesterol emboli in the appropriate context.

PROGNOSIS AND TREATMENT CHARACTERIZATION

PROGNOSTIC FACTORS

TREATMENT

STEROIDS

Treatment of atheroembolization with corticosteroids.

Mann SJ, Sos TA.

New York Presbyterian Hospital--Weill/Cornell Medical Center, New York 10021, USA.
Am J Hypertens 2001 Aug;14(8 Pt 1):831-4 Abstract quote
Aortic atheroembolization is a feared complication of invasive procedures such as arteriography, often leading to devastating complications including renal insufficiency. To date, even in cases with evolving renal failure, there is no recommended treatment.

This case report describes the successful treatment with corticosteroids of a patient with deteriorating renal function after renal arteriography and angioplasty, resulting in rapid and sustained improvement in renal function. The implications of this observation are discussed.

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Weedon D. Weedon's Skin Pathology. Second Edition. Churchill Livingstone. 2002.
Fitzpatrick's Dermatology in General Medicine. 5th Edition. McGraw-Hill. 1999.
Robbins Pathologic Basis of Disease. Sixth Edition. WB Saunders 1999.

Commonly Used Terms

Atherosclerosis

Last Updated 8/29/2002

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Epidemiology
Histopathological Features and Variants
Prognosis and Treatment
Commonly Used Terms
Internet Links

EPIDEMIOLOGY	CHARACTERIZATION
INCIDENCE
How common is cholesterol embolism? Cross SS. Department of Pathology, University of Sheffield Medical School	J Clin Pathol 1991 Oct;44(10):859-61 Abstract quote Histological sections of spleen and both kidneys from 372 necropsies were examined for the presence of cholesterol emboli. These were identified in nine (2.4%) cases and the clinical histories of these cases were reviewed. All the subjects with cholesterol emboli were older than 60 years and eight out of nine were male. Lesions of differing ages were found in individual cases, suggesting that the process of embolism was recurrent. Two of the cases had undergone arteriography procedures in the month before death and, if these were excluded, then the incidence of "spontaneous" cholesterol embolism was 1.9%. This incidence is much lower than that of previously published studies and may be due to a lower incidence of cholesterol embolism in Britain compared with North America or a decrease in incidence over the past two decades. In three of the subjects with cholesterol embolism the cause of death could be related to systemic atherosclerosis, but in the other six cases there was no apparent correlation between the finding of cholesterol embolism and the cause of death. The clinical relevance of the histological finding of cholesterol embolism can only be assessed in conjunction with clinical information.
AGE RANGE-MEDIAN
SEX (M:F)
GEOGRAPHY

HISTOLOGICAL TYPES	CHARACTERIZATION
GENERAL
VARIANTS
BRAIN
Cerebral protection during carotid artery stenting: collection and histopathologic analysis of embolized debris. Angelini A, Reimers B, Della Barbera M, Sacca S, Pasquetto G, Cernetti C, Valente M, Pascotto P, Thiene G. Department of Pathology, University of Padua Medical School, Italy.	Stroke 2002 Feb;33(2):456-61 Abstract quote BACKGROUND AND PURPOSE: Histopathologic analysis was performed to better understand quantity, particle size, and composition of embolized debris collected in protection filters during carotid artery stent implantation. METHODS: Elective carotid stent implantation with the use of a distal filter protection was attempted in 38 consecutive lesions (36 patients) of the internal carotid artery presenting >70% diameter stenosis (mean, 82.1+/-11.1%). Mean age of the patients was 70.7+/-7.7 years; 75% were men, and 50% of patients had previous neurological symptoms. RESULTS: In 37 lesions (97.4%) it was possible to position the filter device, and in all lesions a stent was successfully implanted. The only complication occurring in the hospital and during the 30-day follow-up was 1 death due to acute myocardial infarction. Neurological sequelae did not occur. Histomorphometric analysis was performed on the filters. Presence of debris was detected in 83.7% of filters. The mean surface area of the polyurethane membrane filter covered with material was 53.2+/-19.8%. Particle size ranged from 1.08 to 5043.5 microm (mean, 289.5+/-512 microm) in the major axis and 0.7 to 1175.3 microm (mean, 119.7+/-186.7 microm) in the minor axis. Collected debris consisted predominantly of thrombotic material, foam cells, and cholesterol clefts. CONCLUSIONS: By the use of distal protection filters during carotid artery stenting, it was possible to collect particulate debris potentially leading to distal vessel occlusion in a high percentage of cases. Qualitative analysis of embolized material showed debris dislocated during the percutaneous intervention from atheromatous plaques.
EYE
Echocardiographic findings of patients with retinal ischemia or embolism. Mouradian M, Wijman CA, Tomasian D, Davidoff R, Koleini B, Babikian VL. Department of Neurology, Boston University School of Medicine, Boston, MA, USA.	J Neuroimaging 2002 Jul;12(3):219-23 Abstract quote BACKGROUND AND PURPOSE: A potential source of emboli is not detected in more than 50% of patients with retinal arterial occlusive events. Echocardiographic studies are not always included in the diagnostic workup of these patients. The authors studied the diagnostic yield of transthoracic (TTE) and/or transesophageal (TEE) echocardiography in identifying potential sources of emboli in patients with retinal ischemia or embolism. METHODS: In a prospective study, 73 consecutive patients with clinically diagnosed retinal ischemia or embolism received a standardized diagnostic workup including retinal photography, echocardiography, and imaging studies of the internal carotid arteries. TTE was performed in 83.6% of patients, TEE was performed in 5.5% of patients, and both TTE and TEE were performed in 11.0% of patients. Ophthalmological diagnoses consisted of amaurosis fugax (n = 28), asymptomatic cholesterol embolism to the retina (n = 34), and branch or central retinal artery occlusion (n = 11). RESULTS: Echocardiography identified a potential cardiac or proximal aortic source for embolism in 16 of 73 (21.9%) patients, including 8 who also had either atrial fibrillation or internal carotid artery stenosis of more than 50% on the side of interest. Thus, 8 of 73 (11.0%) patients had lesions detected only by echocardiography. The most commonly identified lesions were proximal aortic plaque of more than 4 mm thickness (n = 7, 9.6%) and left ventricular ejection fraction of less than 30% (n = 6, 8.2%). TEE was particularly helpful in identifying prominent aortic plaques. CONCLUSION: Echocardiography frequently identifies lesions of the heart or aortic arch that can act as potential sources for retinal ischemia or embolism. Further studies are needed to evaluate the prognostic and therapeutic relevance of these findings.
GASTROINTESTINAL TRACT
Ischemic colitis and acalculous necrotizing cholecystitis as rare manifestations of cholesterol emboli in the same patient. Moolenaar W, Kreuning J, Eulderink F, Lamers CB. Department of Gastroenterology, University Hospital, Leiden, The Netherlands.	Am J Gastroenterol 1989 Nov;84(11):1421-2 Abstract quote A case is reported of a patient with ischemic colitis and acalculous necrotizing cholecystitis, rare manifestations of cholesterol emboli in one patient. Cholesterol emboli are often encountered at autopsy, suggesting that such abnormalities frequently are missed during life time, as happened initially in our patient. We conclude that multisystemic disease in elderly patients can be due to cholesterol emboli. The sooner the diagnosis is made, the more beneficial prophylactical measures will be.
SKIN
Perplexing papules and plaques. Tran T, Morgan J, Morgan MB. Suncoast Hospital Dermatology Residency.	Am J Dermatopathol 2002 Aug;24(4):374-6 Abstract quote Dermatologic diseases are capable of presenting in a variety of clinical and pathologic guises. We present the clinicopathologic features of an unusual case misinterpreted initially as a dermal hypersensitivity reaction that was later deemed to be the cholesterol emboli syndrome. Salient histologic features of this case were the presence of numerous dermal eosinophils and the diagnostic finding of an intravascular cholesterol embolus. The presence of dermal eosinophilia should prompt a search for cholesterol emboli in the appropriate context.

PROGNOSIS AND TREATMENT	CHARACTERIZATION
PROGNOSTIC FACTORS
TREATMENT
STEROIDS
Treatment of atheroembolization with corticosteroids. Mann SJ, Sos TA. New York Presbyterian Hospital--Weill/Cornell Medical Center, New York 10021, USA.	Am J Hypertens 2001 Aug;14(8 Pt 1):831-4 Abstract quote Aortic atheroembolization is a feared complication of invasive procedures such as arteriography, often leading to devastating complications including renal insufficiency. To date, even in cases with evolving renal failure, there is no recommended treatment. This case report describes the successful treatment with corticosteroids of a patient with deteriorating renal function after renal arteriography and angioplasty, resulting in rapid and sustained improvement in renal function. The implications of this observation are discussed.