Cholesterol embolism syndrome, should be suspected in a patient who develops worsening renal function, hypertension, distal ischemia, or acute multisystem dysfunction after an invasive arterial procedure. Atheroemboli may also occur spontaneously. The protean manifestations of this syndrome make the diagnosis challenging. As the population ages, the incidence of cholesterol embolism syndrome will increase.

Cholesterol embolism (often cholesterol crystal embolism or atheroembolism, sometimes blue toe or purple toe syndrome or trash foot or warfarin blue toe syndrome occurs when cholesterol is released, usually from an atherosclerotic plaque, and travels along with the bloodsteam (embolism) to other places in the body, where it obstructs blood vessels. Most commonly this causes skin symptoms (usually livedo reticularis), gangrene of the extremities and sometimes renal failure; problems with other organs may arise, depending on the site at which the cholesterol crystals enter the bloodstream.

What causes it?

Fatty material, called cholesterol, builds up on the walls of the blood vessels. It can sometimes break off spontaneously and travel through the bloodstream. In some cases, the emboli can be released into the bloodstream during vascular surgery; thrombolysis, a procedure used to dissolve or destroy clots in a blood vessel or in a chamber of the heart; or diagnostic procedures such as angiography, a test used to detect a blockage or defect in an artery. It can also occur as a result of treatment with anticoagulants, which prevent blood clotting.

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What are the symptoms?

Patients with cholesterol emboli may not experience any symptoms until the kidneys are close to complete failure. When the kidneys fail, urine production decreases and toxins and fluids build up in the bloodstream. The excess fluid causes swelling, or edema, usually in the hands, feet, face, and abdomen. The extra fluid also causes the blood pressure to rise. Other symptoms may include nausea, fatigue, confusion, joint pain, reduced urination, blood in the urine, seizures, headaches, itching, and pain in the kidney area. Blockage of a renal artery can cause areas of the kidney tissue to die, called infarction.

Cholesterol embolisms often cause kidney failure, so when a patient presents with renal failure and he or she is at risk of a cholesterol embolism, the doctor may consider an embolism as a possible cause. It can also cause edema, a build-up of fluid in the extremities, and a variety of skin conditions which manifest in the form of splotchy or tender skin as the flow of blood to the skin is obstructed. Cholesterol embolisms have also been known to cause gangrene and a variety of problems with the nervous system and organs.

Treatment for a cholesterol embolism, once one has been diagnosed, typically focuses on mitigating the symptoms. In the case of kidney failure, dialysis may be used to help the failing kidneys. While the clot of cholesterol itself cannot be removed, the results of the clotting can be treated, and the human body is remarkably versatile, when given a chance; ultimately it can re-route its blood supply to address the blockage.

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