How is cholesterol embolism syndrome treated?

Updated: Oct 25, 2019
  • Author: Lisa Kirkland, MD, FACP, FCCM, MSHA; Chief Editor: Vincent Lopez Rowe, MD  more...
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Answer

Medical management is supportive. [13] Hemodynamic monitoring, including pulmonary artery catheterization, may be helpful for fluid and vasopressor adjustments. If acute respiratory distress syndrome (ARDS) occurs, mechanical ventilation may be required for a prolonged period. Dialysis should be started when indicated because patients can recover limited renal function. Aggressive nutritional and metabolic support is essential because these patients often lose considerable lean body mass to ongoing catabolism.

Pharmacologic therapy has not been particularly successful in patients with cholesterol embolism syndrome (CES). Vasodilator therapy with calcium-channel blockers may help relieve the local ischemia resulting from vasospasm, but angiotensin-converting enzyme (ACE) inhibitors should not be used, because of their negative effects on renal afferent arterioles and the glomerular filtration rate (GFR).

Patients presumed to have vasculitis have been treated with high-dose steroids and anti-inflammatory agents, with anecdotal reports of recovery. However, steroids may predispose patients to infectious, metabolic, and nutritional complications and difficulties with wound healing. In a report of four cases of cholesterol embolism after cardiac catheterization that were associated with deteriorating renal function, low-dose (0.3 mg/kg/day) corticosteroid therapy yielded improved renal function in three of the four patients. [14]

The use of anticoagulants is controversial because anticoagulants and thrombolytics have been shown to induce atheroemboli. Anecdotal reports of treatment with apheresis, as well as with iloprost, statins, colchicine, or combinations of these drugs with steroids, reported improvement in some cases. [15, 16, 17, 18, 19]

A study by Ishiyama et al found that low-density-lipoprotein (LDL) apheresis (LDL-A) reduced the incidence of maintenance dialysis and mortality at 24 weeks in 49 patients with cholesterol crystal embolism. [20]  In a subsequent study, the same group found that LDL-A plus corticosteroids restored deteriorated renal function better than corticosteroids alone did in patients with cholesterol crystal embolism. [21]

Further invasive vascular procedures and anticoagulant or thrombolytic therapies should be avoided. If such treatments are unavoidable, downstream protection devices to trap atheromatous debris after stenting or angioplasty are suggested. [22]


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