CardiologyTier 2Disease (DEADMAN)

Cholesterol embolus

Description

Showers of cholesterol crystals from ulcerated atherosclerotic plaque embolise to small vessels - typically after vascular intervention (angiography, angioplasty, vascular surgery) or anticoagulation/thrombolysis affecting a plaque

Epidemiology

Risk factors: extensive aortic atherosclerosis, recent vascular/endovascular procedure, anticoagulation

Aetiopathogenesis

Cholesterol crystals lodge in small arteries/arterioles -> local inflammatory/foreign body reaction + downstream ischaemia; can affect multiple organs simultaneously (skin, kidneys, GI tract, retina, CNS) given the systemic shower

Diagnosis

Livedo reticularis + "blue toe syndrome" (with palpable peripheral pulses, distinguishing it from acute limb ischaemia) + eosinophilia + acute/subacute kidney injury following a vascular procedure is the classic pattern
Skin or renal biopsy shows cholesterol clefts (biconvex, needle-shaped clefts in the vessel lumen) if confirmation is needed

Management

Supportive - no specific reversal treatment
Stop anticoagulation if feasible (may be perpetuating ongoing showering, though this is debated and must be balanced against the original indication)
Statins may reduce further plaque instability; manage end-organ complications (renal support if needed)

Associations

Recent angiography/vascular surgery/thrombolysis, extensive aortic atherosclerosis, livedo reticularis, eosinophilia

Natural history & complications

Renal function often does not recover fully; can mimic vasculitis or other causes of AKI + rash + eosinophilia, and the temporal link to a vascular procedure is the key diagnostic clue distinguishing it from these mimics

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