Cholesterinembolie-Syndrom: eine seltene, aber schwerwiegende Komplikation bei Atherosklerose

Zusammenfassung

Cholesterinembolien sind eine schwerwiegende Komplikation der Atherosklerose. Hauptsächlich durch Gefäßmanipulation bei endovaskulären oder gefäßchirurgischen Eingriffen kann Cholesterin aus atheromatösen Plaques freigesetzt und über den Blutstrom verschleppt werden. Etwa 20 % der Fälle treten spontan auf. Die Cholesterinkristalle bleiben in kleinen Gefäßen stecken und verursachen eine Entzündung.

Bei typischem Verlauf kommt es 2 bis 6 Wochen nach einem Gefäßeingriff zur progredienten Niereninsuffizienz und zu charakteristischen Hautveränderungen. Livedo reticularis und „blue toes“ sind klassische Symptome, aber nicht pathognomonisch und können fehlen. Differenzialdiagnostisch müssen vor allem Systemerkrankungen wie Vaskulitiden abgegrenzt werden. Die Diagnose kann nur mittels Biopsie aus Haut, Muskel oder Niere bewiesen werden. Alternativ ist der Nachweis retinaler Cholesterinembolien per Fundoskopie. Die Therapie beschränkt sich größtenteils auf symptomatische Maßnahmen. Kortikosteroide haben keine nachgewiesene Wirksamkeit und sind möglicherweise sogar von Nachteil. Statine gehören aufgrund ihrer plaquestabilisierenden und antiinflammatorischen Effekte zur Basistherapie. Randomisierte klinische Studien fehlen. Die Prognose ist eingeschränkt. 30–55 % der Patienten mit Nierenbeteiligung entwickeln ein dialysepflichtiges Nierenversagen. Die Sterblichkeit ist hoch und liegt bei 15- 30 % im ersten Jahr.

Abstract

Cholesterol embolization is a serious complication of atherosclerosis. Mainly, vascular manipulations during endovascular procedures or vascular surgery can release cholesterol crystals from atheromatous plaques. About 20 % are spontaneous emboli without precipitating event. The cholesterol crystals are distributed by the blood stream, occlude small arteries and induce inflammation.

Typically, 2 to 6 weeks after a vascular procedure renal failure and characteristic cutaneous signs develop.  Livedo reticularis and blue toes, although classic symptoms, are not pathognomonic and may be even absent. Vasculitis is an important differential diagnosis. Diagnosis can only be proven by skin, muscle or kidney biopsy. Alternatively, fundoscopy can show retinal cholesterol emboli. Therapy is mostly limited to symptomatic measures. Corticosteroids have no proven efficacy and may be harmful. Statins should be given to all patients due to their plaque stabilizing and anti-inflammatory properties. Randomized clinical trials are lacking in this field. Prognosis is limited. About 30–55 % patients with renal involvement need renal replacement therapy. Mortality is high with 15–30 % of patients dying during the first year.

Schlüsselwörter

Cholesterinembolie - Niereninsuffizienz - Livedo reticularis - Kortikosteroide - Statine

Keywords

cholesterol embolism - Renal failure - livedo reticularis - corticosteroids - statins

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