Clinical Review Lesson of the week

Cholesterol emboli syndrome

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7268.1065 (Published 28 October 2000) Cite this as: BMJ 2000;321:1065
  1. Peter J Dupont, specialist registrara,
  2. Liz Lightstone, honorary consultanta,
  3. Elaine J Clutterbuck, honorary consultanta,
  4. Gillian Gaskin, honorary consultanta,
  5. Charles D Pusey, professora,
  6. Terry Cook, reader in renal pathologyb,
  7. Anthony N Warrens, honorary consultant (a.warrens@ic.ac.uk)a
  1. a Renal Section, Imperial College School of Medicine, Hammersmith Hospital, London W12 0NN,
  2. b Department of Histopathology, Hammersmith Hospital
  1. Correspondence to: A N Warrens
  • Accepted 20 January 2000

Cholesterol embolism is a common but underrecognised complication arising from a variety of vascular insults

Cholesterol embolisation is a common complication of arteriography, vascular surgery, thrombolysis, and anticoagulation in elderly patients, but the diagnosis is often not considered. We present three cases of cholesterol embolism seen at our renal unit over a six month period. The initial presentation in each case was acute renal failure.

Case reports

Case 1

A 75 year old Indian Asian man presented to his local hospital with unstable angina where he received conventional treatment with intravenous nitrates and heparin. His pain subsided but he subsequently developed recurrent episodes of “flash” pulmonary oedema and recalcitrant hypertension. These were accompanied by an inexorable decline in renal function over four weeks until eventually he became dependent on dialysis.

Severe hypertension and signs of peripheral vascular disease were found on physical examination, but there were no audible renal bruits. Non-blanching purpuric lesions suggestive of embolisation were noted on his toes. Blood tests showed a marked peripheral blood eosinophilia of 0.59 × 109/l (normal range <0.40) and a C3 complement component just below the lower limit of normal, at 0.59 g/l (normal range 0.6-1.6). An angiogram performed using spiral computed tomography showed an atheromatous aorta but no evidence of renal artery stenosis. A percutaneous renal biopsy showed clefts in the lumen of intrarenal arterioles, confirming a diagnosis of cholesterol embolism.

The patient later underwent coronary angioplasty for treatment of intractable angina. He died within 72 hours after massive gastrointestinal bleeding, probably the result of fresh cholesterol embolisation.

Case 2

A 62 year old man …

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