Cholesterol crystal embolization syndrome: Systemic and end-organ injury

Cholesterol embolization syndrome (CES) is characterized by the embolization of cholesterol crystals from atherosclerotic plaques into small and medium-size arteries. It predominantly occurs spontaneously in individuals with severe atherosclerosis or following vascular interventions. The dislodgment of cholesterol crystals triggers an inflammatory cascade in the affected vessels, leading to tissue ischemia and multi-organ dysfunction. Commonly affected are the kidneys, skin, and gastrointestinal tract, although any affected, though any organ system may be involved with varied presentations often making the diagnosis challenging. CES is diagnosed based on clinical suspicion supported by laboratory findings, such as eosinophilia, elevated inflammatory markers, imaging and/or histopathological evidence of cholesterol emboli. Treatment focuses on supportive care, addressing end-organ damage, and minimizing further embolization by optimizing atherosclerotic risk factors. Anticoagulation is generally avoided unless there is an alternative indication. Statins are commonly used for their pleiotropic effects on inflammation and plaque stabilization. In conclusion, CES is an underrecognized condition with significant morbidity. A high index of suspicion is essential for early diagnosis and intervention.