SFGH 2.23 report pearls: cholesterol crystal embolism

Takeaway pearl: in cholesterol embolism (as opposed to thromboembolism), proximal pulses are often palpable since the emboli are to the smaller arterioles.



  • thromboembolism: occur when thrombus superimposed on an atherosclerotic plaque breaks off post plaque rupture or other disruption
    • tends to be single and lodge in medium or large arteries
    • can result in acute ischemia of organs or extremities
  • cholesterol embolism: occur with atherosclerotic plaque is disrupted and cholesterol crystals from the plaque embolize
    • tends to occlude arterioles and affect multiple organs
    • can arise spontaneously or post instrumentation (cath, vascular surgery)
    • risk factors the same as risk of atherosclerosis
    • presentation: fever, myalgia, livedo reticularis, gangrene, cyanosis, acute or subacute renal failure, intestinal ischemia, Hollenhorst plaques (bright, refractile lesions in the retina)
    • pulse is often palpable since the emboli are to smaller arteries
    • treatment: treat cardiovascular disease risk factors, statins, anticoagulation is controversial (hemorrhagic complications may outweigh the benefits), manage ischemic complications



Tunick PA, Rosenzweig BP, Katz ES, Freedberg RS, Perez JL, Kronzon I. High risk for vascular events in patients with protruding aortic atheromas: a prospective study. J Am Coll Cardiol. 1994;23(5):1085.

Saric M and Kronzon I. Embolism from atherosclerotic plaque: Atheroembolism.  Uptodate.


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