{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T00:24:38Z","timestamp":1778199878830,"version":"3.51.4"},"reference-count":20,"publisher":"MDPI AG","issue":"18","license":[{"start":{"date-parts":[[2025,9,16]],"date-time":"2025-09-16T00:00:00Z","timestamp":1757980800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2025,9,16]],"date-time":"2025-09-16T00:00:00Z","timestamp":1757980800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>We report a rare case of cholesterol embolization syndrome (CES) presenting with multifocal cerebral infarctions following thoracic endovascular aortic repair (TEVAR). A 75-year-old male with a 6.1 cm thoracic aortic aneurysm and extensive atherosclerotic disease (\u201cshaggy aorta\u201d) underwent zone 2 TEVAR with left subclavian artery embolization after left carotid-subclavian bypass surgery. Postoperatively, the patient developed altered mental status with multifocal cerebral infarctions involving the left middle cerebral artery territory, bilateral cerebellar hemispheres, and pons. The characteristic findings included livedo reticularis, blue toe syndrome, leukocytosis (21,190\/\u03bcL), elevated C-reactive protein (11.4 mg\/dL), and acute kidney injury (creatinine 3.81 mg\/dL). Despite supportive care, including continuous renal replacement therapy, the patient died of sudden cardiac arrest on hospital day 123. This case demonstrates the devastating potential of CES following TEVAR in patients with a shaggy aorta, emphasizing the importance of preoperative risk stratification and early recognition of the characteristic clinical triad of neurological symptoms, cutaneous lesions, and renal dysfunction.<\/jats:p>","DOI":"10.3390\/jcm14186507","type":"journal-article","created":{"date-parts":[[2025,9,16]],"date-time":"2025-09-16T14:31:41Z","timestamp":1758033101000},"page":"6507","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Cholesterol Embolization Syndrome Presenting with Multifocal Cerebral Infarction After Thoracic Endovascular Aortic Repair: A Case Report"],"prefix":"10.3390","volume":"14","author":[{"given":"Seung Woo","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0477-683X","authenticated-orcid":false,"given":"In Sook","family":"Kang","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, College of Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1161\/CIRCULATIONAHA.109.886465","article-title":"Cholesterol embolization syndrome","volume":"122","author":"Kronzon","year":"2010","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1016\/S0735-1097(03)00579-5","article-title":"The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: A prospective study","volume":"42","author":"Fukumoto","year":"2003","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","first-page":"e16993","article-title":"An Unusual Presentation of Cholesterol Embolization Syndrome","volume":"13","author":"Abdelazeem","year":"2021","journal-title":"Cureus"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"100388","DOI":"10.1016\/j.ensci.2021.100388","article-title":"Cholesterol crystal embolism-related cerebral infarction: Magnetic resonance imaging and clinical characteristics","volume":"25","author":"Kondo","year":"2021","journal-title":"eNeurologicalSci"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1016\/j.jtcvs.2006.07.040","article-title":"Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: A multicenter comparative trial","volume":"133","author":"Bavaria","year":"2007","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1016\/j.jacc.2009.11.047","article-title":"Endovascular aortic repair versus open surgical repair for descending thoracic aortic disease a systematic review and meta-analysis of comparative studies","volume":"55","author":"Cheng","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"808","DOI":"10.1161\/CIRCULATIONAHA.108.769695","article-title":"Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: A comparison of endovascular and open techniques","volume":"118","author":"Greenberg","year":"2008","journal-title":"Circulation"},{"key":"ref_8","first-page":"95","article-title":"Strategies for Stroke Prevention During TEVAR: From Embolic Protection to Device Preparation and Delivery","volume":"18","author":"Spanos","year":"2019","journal-title":"Endovasc. 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Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"209","DOI":"10.2147\/VHRM.S175150","article-title":"Cholesterol-embolization syndrome: Current perspectives","volume":"15","author":"Ozkok","year":"2019","journal-title":"Vasc. Health Risk Manag."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"680","DOI":"10.1007\/s10157-020-01886-9","article-title":"Association between eosinophilia and renal prognosis in patients with pathologically proven cholesterol crystal embolism","volume":"24","author":"Mochida","year":"2020","journal-title":"Clin. Exp. Nephrol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"54.e1","DOI":"10.1016\/j.avsg.2020.01.077","article-title":"Use of a Dual-Filter Cerebral Embolic Protection Device in Thoracic Endovascular Aortic Repair","volume":"65","author":"Shah","year":"2020","journal-title":"Ann. Vasc. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"262","DOI":"10.1016\/j.atherosclerosis.2017.12.027","article-title":"The NLRP3 inflammasome and the emerging role of colchicine to inhibit atherosclerosis-associated inflammation","volume":"269","author":"Martinez","year":"2018","journal-title":"Atherosclerosis"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1014","DOI":"10.1093\/rheumatology\/keg252","article-title":"Efficiency of colchicine and corticosteroids in a leg ulceration with cholesterol embolism in a woman with rheumatoid arthritis","volume":"42","author":"Verneuil","year":"2003","journal-title":"Rheumatology"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Li, X., Bayliss, G., and Zhuang, S. (2017). Cholesterol Crystal Embolism and Chronic Kidney Disease. Int. J. Mol. 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