Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Embolism from atherosclerotic plaque: Atheroembolism (cholesterol crystal embolism)

Muhamed Saric, MD, PhD, FACC, FASE
Itzhak Kronzon, MD, FACC, FAHA, FASE
Section Editors
Catherine M Otto, MD
Jose Biller, MD, FACP, FAAN, FAHA
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Aortic atherosclerotic plaques are a manifestation of systemic atherosclerosis. They are associated with general risk factors for atherosclerotic disease, including age, hypertension, and hypercholesterolemia, and are more common in patients with coronary artery disease [1,2].

Aortic atherosclerotic plaques are an important source of emboli, leading to cerebral (eg, transient ischemic attack, stroke), extremity, or visceral embolization (picture 1) [3-6]. Embolic events can occur spontaneously or can be induced by interventions, including cardiac catheterization, arteriography, peripheral interventions, intraaortic balloon pumping, and cardiac or vascular surgery [7,8].

The general manifestations and treatment of cholesterol crystal embolism, diagnosis, and medical and surgical management will be reviewed. Thromboembolism from unstable aortic plaques is discussed elsewhere. (See "Embolism from aortic plaque: Thromboembolism".)

Specific considerations related to end-organ ischemia (kidney, gut, extremity) that may result from cholesterol crystal embolus are discussed in separate topic reviews.


Two types of emboli originate from atherosclerotic plaques: thromboemboli and atheroemboli (cholesterol crystal emboli). Although the underlying risk factors may be similar, the two can often be differentiated based upon associated conditions and clinical manifestations. This is an important distinction, since the prognosis and treatment differ. Thromboembolism from complex aortic plaques is common, particularly from thoracic aortic plaques. In comparison, cholesterol crystal embolism is fairly rare but is probably underrecognized given its diverse presentations. (See 'Epidemiology and risk factors' below and "Embolism from aortic plaque: Thromboembolism".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 15, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Fazio GP, Redberg RF, Winslow T, Schiller NB. Transesophageal echocardiographically detected atherosclerotic aortic plaque is a marker for coronary artery disease. J Am Coll Cardiol 1993; 21:144.
  2. Matsuzaki M, Ono S, Tomochika Y, et al. 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; 56:592.
  3. Tunick PA, Kronzon I. Atheromas of the thoracic aorta: clinical and therapeutic update. J Am Coll Cardiol 2000; 35:545.
  4. Amarenco P, Duyckaerts C, Tzourio C, et al. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med 1992; 326:221.
  5. Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994; 331:1474.
  6. French Study of Aortic Plaques in Stroke Group, Amarenco P, Cohen A, et al. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996; 334:1216.
  7. Karalis DG, Quinn V, Victor MF, et al. Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta. Am Heart J 1996; 131:1149.
  8. Katz ES, Tunick PA, Rusinek H, et al. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol 1992; 20:70.
  9. Tunick PA, Rosenzweig BP, Katz ES, et al. High risk for vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol 1994; 23:1085.
  10. Kronzon I, Saric M. Cholesterol embolization syndrome. Circulation 2010; 122:631.
  11. Hiramoto J, Hansen KJ, Pan XM, et al. Atheroemboli during renal artery angioplasty: an ex vivo study. J Vasc Surg 2005; 41:1026.
  12. Fine MJ, Kapoor W, Falanga V. Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology 1987; 38:769.
  13. Tunick PA, Nayar AC, Goodkin GM, 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; 90:1320.
  14. Sharma PV, Babu SC, Shah PM, Nassoura ZE. Changing patterns of atheroembolism. Cardiovasc Surg 1996; 4:573.
  15. Doty JR, Wilentz RE, Salazar JD, et al. Atheroembolism in cardiac surgery. Ann Thorac Surg 2003; 75:1221.
  16. Fukumoto Y, Tsutsui H, Tsuchihashi M, et al. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol 2003; 42:211.
  17. Lin PH, Bush RL, Conklin BS, et al. Late complication of aortoiliac stent placement- atheroembolization of the lower extremities. J Surg Res 2002; 103:153.
  18. Jucgla A, Moreso F, Muniesa C, et al. Cholesterol embolism: still an unrecognized entity with a high mortality rate. J Am Acad Dermatol 2006; 55:786.
  19. 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.
  20. Cross SS. How common is cholesterol embolism? J Clin Pathol 1991; 44:859.
  21. THURLBECK WM, CASTLEMAN B. Atheromatous emboli to the kidneys after aortic surgery. N Engl J Med 1957; 257:442.
  22. Mayo RR, Swartz RD. Redefining the incidence of clinically detectable atheroembolism. Am J Med 1996; 100:524.
  23. Agmon Y, Khandheria BK, Meissner I, et al. Independent association of high blood pressure and aortic atherosclerosis: A population-based study. Circulation 2000; 102:2087.
  24. Baumann DS, McGraw D, Rubin BG, et al. An institutional experience with arterial atheroembolism. Ann Vasc Surg 1994; 8:258.
  25. Scolari F, Ravani P, Pola A, et al. Predictors of renal and patient outcomes in atheroembolic renal disease: a prospective study. J Am Soc Nephrol 2003; 14:1584.
  26. Scolari F, Ravani P, Gaggi R, et al. The challenge of diagnosing atheroembolic renal disease: clinical features and prognostic factors. Circulation 2007; 116:298.
  27. Carroccio A, Olin JW, Ellozy SH, et al. The role of aortic stent grafting in the treatment of atheromatous embolization syndrome: results after a mean of 15 months follow-up. J Vasc Surg 2004; 40:424.
  28. Tunick PA, Perez JL, Kronzon I. Protruding atheromas in the thoracic aorta and systemic embolization. Ann Intern Med 1991; 115:423.
  29. Karalis DG, Chandrasekaran K, Victor MF, et al. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 1991; 17:73.
  30. 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.
  31. 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.
  32. Koppang JR, Nanda NC, Coghlan C, Sanyal R. Histologically confirmed cholesterol atheroemboli with identification of the source by transesophageal echocardiography. Echocardiography 1992; 9:379. http://onlinelibrary.wiley.com/doi/10.1111/j.1540-8175.1992.tb00481.x/abstract (Accessed on November 10, 2010).
  33. Freedberg RS, Tunick PA, Kronzon I. Emboli in transit: the missing link. J Am Soc Echocardiogr 1998; 11:826.
  34. Meissner I, Khandheria BK, Sheps SG, et al. Atherosclerosis of the aorta: risk factor, risk marker, or innocent bystander? A prospective population-based transesophageal echocardiography study. J Am Coll Cardiol 2004; 44:1018.
  35. Tunick PA, Kronzon I. Atherosclerosis of the aorta: a risk factor, risk marker, or an innocent bystander? J Am Coll Cardiol 2005; 45:1907; author reply 1907.
  36. Harloff A, Simon J, Brendecke S, et al. Complex plaques in the proximal descending aorta: an underestimated embolic source of stroke. Stroke 2010; 41:1145.
  37. Rudnick MR, Berns JS, Cohen RM, Goldfarb S. Nephrotoxic risks of renal angiography: contrast media-associated nephrotoxicity and atheroembolism--a critical review. Am J Kidney Dis 1994; 24:713.
  38. 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.
  39. Holden A, Hill A, Jaff MR, Pilmore H. Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy. Kidney Int 2006; 70:948.
  40. Edwards MS, Craven BL, Stafford J, et al. Distal embolic protection during renal artery angioplasty and stenting. J Vasc Surg 2006; 44:128.
  41. Glassock RJ, Ritz E, Bommer J, et al. Acute renal failure, hypertension and skin necrosis in a patient with streptokinase therapy. Am J Nephrol 1984; 4:193.
  42. Hitti WA, Wali RK, Weinman EJ, et al. Cholesterol embolization syndrome induced by thrombolytic therapy. Am J Cardiovasc Drugs 2008; 8:27.
  43. Nevelsteen A, Kutten M, Lacroix H, Suy R. Oral anticoagulant therapy: a precipitating factor in the pathogenesis of cholesterol embolization? Acta Chir Belg 1992; 92:33.
  44. Hyman BT, Landas SK, Ashman RF, et al. Warfarin-related purple toes syndrome and cholesterol microembolization. Am J Med 1987; 82:1233.
  45. Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Ann Intern Med 1998; 128:639.
  46. Blackshear JL, Zabalgoitia M, Pennock G, et al. Warfarin safety and efficacy in patients with thoracic aortic plaque and atrial fibrillation. SPAF TEE Investigators. Stroke Prevention and Atrial Fibrillation. Transesophageal echocardiography. Am J Cardiol 1999; 83:453.
  47. Falanga V, Fine MJ, Kapoor WN. The cutaneous manifestations of cholesterol crystal embolization. Arch Dermatol 1986; 122:1194.
  48. Olin JW. Other Peripheral Arterial Diseases. In: Goldman: Cecil Textbook of Medicine, 21st ed, WB Saunders, Philadelphia 2000. p.362.
  49. Turakhia AK, Khan MA. Splinter hemorrhages as a possible clinical manifestation of cholesterol crystal embolization. J Rheumatol 1990; 17:1083.
  50. 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.
  51. Rosansky SJ. Multiple cholesterol emboli syndrome. South Med J 1982; 75:677.
  52. Quintart C, Treille S, Lefebvre P, Pontus T. Penile necrosis following cholesterol embolism. Br J Urol 1997; 80:347.
  53. Zhang WW, Chauvapun JP, Dosluoglu HH. Scrotal necrosis following endovascular abdominal aortic aneurysm repair. Vascular 2007; 15:113.
  54. Mittal BV, Alexander MP, Rennke HG, Singh AK. Atheroembolic renal disease: a silent masquerader. Kidney Int 2008; 73:126.
  55. Sarwar S, Al-Absi A, Wall BM. Catastrophic cholesterol crystal embolization after endovascular stent placement for peripheral vascular disease. Am J Med Sci 2008; 335:403.
  56. Ben-Horin S, Bardan E, Barshack I, et al. Cholesterol crystal embolization to the digestive system: characterization of a common, yet overlooked presentation of atheroembolism. Am J Gastroenterol 2003; 98:1471.
  57. Moolenaar W, Lamers CB. Cholesterol crystal embolization to liver, gallbladder, and pancreas. Dig Dis Sci 1996; 41:1819.
  58. Moolenaar W, Lamers CB. Gastrointestinal blood loss due to cholesterol crystal embolization. J Clin Gastroenterol 1995; 21:220.
  59. Bourdages R, Prentice RS, Beck IT, et al. Atheromatous embolization to the stomach: an unusual cause of gastrointestinal bleeding. Am J Dig Dis 1976; 21:889.
  60. Abdelmalek MF, Spittell PC. 79-year-old woman with blue toes. Mayo Clin Proc 1995; 70:292.
  61. Caplan LR. The aorta as a donor source of brain embolism. In: Brain embolism, Caplan, LR, Manning, WJ (Eds), Informa Healthcare, New York 2006. p.187.
  62. Petty GW, Khandheria BK, Meissner I, et al. Population-based study of the relationship between atherosclerotic aortic debris and cerebrovascular ischemic events. Mayo Clin Proc 2006; 81:609.
  63. Russo C, Jin Z, Rundek T, et al. Atherosclerotic disease of the proximal aorta and the risk of vascular events in a population-based cohort: the Aortic Plaques and Risk of Ischemic Stroke (APRIS) study. Stroke 2009; 40:2313.
  64. Cohen A, Tzourio C, Bertrand B, 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; 96:3838.
  65. Di Tullio MR, Russo C, Jin Z, et al. Aortic arch plaques and risk of recurrent stroke and death. Circulation 2009; 119:2376.
  66. Ezzeddine MA, Primavera JM, Rosand J, et al. Clinical characteristics of pathologically proved cholesterol emboli to the brain. Neurology 2000; 54:1681.
  67. HOLLENHORST RW. Significance of bright plaques in the retinal arterioles. JAMA 1961; 178:23.
  68. Chawluk JB, Kushner MJ, Bank WJ, et al. Atherosclerotic carotid artery disease in patients with retinal ischemic syndromes. Neurology 1988; 38:858.
  69. Bunt TJ. The clinical significance of the asymptomatic Hollenhorst plaque. J Vasc Surg 1986; 4:559.
  70. Dunlap AB, Kosmorsky GS, Kashyap VS. The fate of patients with retinal artery occlusion and Hollenhorst plaque. J Vasc Surg 2007; 46:1125.
  71. Wijman CA, Babikian VL, Matjucha IC, et al. Cerebral microembolism in patients with retinal ischemia. Stroke 1998; 29:1139.
  72. Babikian V, Wijman CA, Koleini B, et al. Retinal ischemia and embolism. Etiologies and outcomes based on a prospective study. Cerebrovasc Dis 2001; 12:108.
  73. Thadhani RI, Camargo CA Jr, Xavier RJ, et al. Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases. Medicine (Baltimore) 1995; 74:350.
  74. Cosio FG, Zager RA, Sharma HM. Atheroembolic renal disease causes hypocomplementaemia. Lancet 1985; 2:118.
  75. Kasinath BS, Lewis EJ. Eosinophilia as a clue to the diagnosis of atheroembolic renal disease. Arch Intern Med 1987; 147:1384.
  76. Wilson DM, Salazer TL, Farkouh ME. Eosinophiluria in atheroembolic renal disease. Am J Med 1991; 91:186.
  77. Tunick PA, Krinsky GA, Lee VS, Kronzon I. Diagnostic imaging of thoracic aortic atherosclerosis. AJR Am J Roentgenol 2000; 174:1119.
  78. Tenenbaum A, Garniek A, Shemesh J, et al. Dual-helical CT for detecting aortic atheromas as a source of stroke: comparison with transesophageal echocardiography. Radiology 1998; 208:153.
  79. Khatri IA, Mian N, Alkawi A, et al. Catheter-based aortography fails to identify aortic atherosclerotic lesions detected on transesophageal echocardiography. J Neuroimaging 2005; 15:261.
  80. Warren BA, Vales O. The ultrastructure of the stages of atheroembolic occlusion of renal arteries. Br J Exp Pathol 1973; 54:469.
  81. Case records of the Massachusetts General Hospital. Weekly Clinicopathological Exercises. Case 11-1996. A 69-year-old man with progressive renal failure and the abrupt onset of dyspnea. N Engl J Med 1996; 334:973.
  82. Smith SC Jr, Allen J, Blair SN, 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; 113:2363.
  83. Mann SJ, Sos TA. Treatment of atheroembolization with corticosteroids. Am J Hypertens 2001; 14:831.
  84. Motegi S, Abe M, Shimizu A, et al. Cholesterol crystal embolization: skin manifestation, gastrointestinal and central nervous symptom treated with corticosteroid. J Dermatol 2005; 32:295.
  85. Matsumura T, Matsumoto A, Ohno M, et al. A case of cholesterol embolism confirmed by skin biopsy and successfully treated with statins and steroids. Am J Med Sci 2006; 331:280.
  86. Koga J, Ohno M, Okamoto K, et al. Cholesterol embolization treated with corticosteroids--two case reports. Angiology 2005; 56:497.
  87. Yücel AE, Kart-Köseoglu H, Demirhan B, Ozdemir FN. Cholesterol crystal embolization mimicking vasculitis: success with corticosteroid and cyclophosphamide therapy in two cases. Rheumatol Int 2006; 26:454.
  88. Fabbian F, Catalano C, Lambertini D, et al. A possible role of corticosteroids in cholesterol crystal embolization. Nephron 1999; 83:189.
  89. Elinav E, Chajek-Shaul T, Stern M. Improvement in cholesterol emboli syndrome after iloprost therapy. BMJ 2002; 324:268.
  90. Minatohara K. Renal failure associated with blue toe syndrome: effective treatment with intravenous prostaglandin E-1. Acta Derm Venereol 2006; 86:364.
  91. Hasegawa M, Sugiyama S. Apheresis in the treatment of cholesterol embolic disease. Ther Apher Dial 2003; 7:435.
  92. Tamura K, Umemura M, Yano H, et al. Acute renal failure due to cholesterol crystal embolism treated with LDL apheresis followed by corticosteroid and candesartan. Clin Exp Nephrol 2003; 7:67.
  93. Muso E, Mune M, Fujii Y, et al. Significantly rapid relief from steroid-resistant nephrotic syndrome by LDL apheresis compared with steroid monotherapy. Nephron 2001; 89:408.
  94. Kronzon I, Tunick PA. Aortic atherosclerotic disease and stroke. Circulation 2006; 114:63.
  95. Fujimoto S, Yasaka M, Otsubo R, et al. Aortic arch atherosclerotic lesions and the recurrence of ischemic stroke. Stroke 2004; 35:1426.
  96. Kawahara T, Nishikawa M, Kawahara C, et al. Atorvastatin, etidronate, or both in patients at high risk for atherosclerotic aortic plaques: a randomized, controlled trial. Circulation 2013; 127:2327.
  97. Lansberg MG, O'Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e601S.
  98. http://packageinserts.bms.com/pi/pi_coumadin.pdf (Accessed on October 20, 2010).
  99. Keen RR, McCarthy WJ, Shireman PK, et al. Surgical management of atheroembolization. J Vasc Surg 1995; 21:773.
  100. Renshaw A, McCowen T, Waltke EA, et al. Angioplasty with stenting is effective in treating blue toe syndrome. Vasc Endovascular Surg 2002; 36:155.
  101. Kumins NH, Owens EL, Oglevie SB, et al. Early experience using the Wallgraft in the management of distal microembolism from common iliac artery patholology. Ann Vasc Surg 2002; 16:181.
  102. Matchett WJ, McFarland DR, Eidt JF, Moursi MM. Blue toe syndrome: treatment with intra-arterial stents and review of therapies. J Vasc Interv Radiol 2000; 11:585.
  103. Ridker PM, Cannon CP, Morrow D, et al. C-reactive protein levels and outcomes after statin therapy. N Engl J Med 2005; 352:20.