Cholesterol Crystal Embolization Research Articles

“Purple Toe: A Syndrome from Head to Toe”

Cholesterol crystal embolization is a rare multisystem disorder that originates from atherosclerotic plaques showering to different sites causing end organ damage. We present a 79-year-old man who developed purple discoloration of the left toe. Physical exam revealed tender purple toes with palpable distal pulses. The diagnosis of cholesterol emboli syndrome was made while differential diagnoses were ruled out. Despite medical management, his condition continued to slowly worsen.

胆囊癌との鑑別を要する胆囊内隆起性病変を形成したコレステロール塞栓症の1例

症例は82歳の男性で，高血圧，狭心症，閉塞性動脈硬化症，腹部大動脈瘤，肺癌術後のため通院中であった．スクリーニングで施行した腹部超音波検査で胆囊壁に隆起性病変を認めた．超音波内視鏡検査では筋層を越える浸潤はないと考えられたが，悪性を否定できず，開腹全層胆囊摘出術を施行した．切除標本では体部に25×15 mm大の黒色の隆起性病変を認め，病理組織標本では，病変は虚血，炎症に伴う肉芽種形成が主体であり，周辺の小動脈に針状の空隙を認めコレステロール塞栓症（cholesterol crystal embolization；以下，CCEと略記）に伴い隆起性病変が形成されたと考えられた．PubMedで検索するかぎりCCEによる胆囊の隆起性病変の報告例はなく，極めてまれな症例と考えられた．

Atheroembolic Renal Disease: A Beneficial Effect of Steroids

Atheroembolic renal disease (AERD) or cholesterol crystal embolisation often is an under diagnosed clinical illness. It is a multisystemic disease with progressive renal failure due to foreign body reaction of cholesterol crystals flushed into a small vessel system of the kidneys from the arteriosclerotic plaques. It usually occurs after vascular catheterization, anticoagulation and less frequently spontaneously. Renal and patient prognosis are usually poor. We hereby are reporting a case report of a 62-year-old male patient with dyslipidemia who underwent percutaneous coronary intervention for unstable angina and consecutive AERD with typical clinical appearance few days after the event. Rapid improvement of renal function was noticed after treatment with systemic corticosteroids.

コレステロール結晶塞栓症による小腸穿孔・狭窄の1例

コレステロール結晶塞栓症による小腸穿孔・狭窄の1例

コレステロール塞栓症に続発した上行結腸壊死の1例

症例は70代，男性．当院循環器内科で下肢閉塞性動脈硬化症に対して血管内カテーテル治療施行後，コレステロール塞栓症を合併し，その加療中に急激な腹痛を主訴に発症した．腹部所見では右下腹部に圧痛を認め，血液検査で炎症反応の上昇，腹部造影CT検査にて腎臓，肝臓，脾臓の梗塞像に加え，上行結腸間膜内のガス像，腸管壁の破綻をみとめた．コレステロール塞栓症による上行結腸壊死と診断し緊急手術を施行した．盲腸から横行結腸肝弯曲にかけて壊死に陥っている結腸をみとめ，結腸右半切除および回腸人工肛門造設術を行った．病理組織検査で上行結腸間膜内の血管にコレステロール塞栓が確認され，コレステロール塞栓が原因による腸管壊死と診断した．コレステロール塞栓症にて上行結腸壊死，間膜内穿通をきたした症例に対して手術を施行し生存し得た1例を経験したので報告する．

コレステロール結晶塞栓症により繰り返した小腸穿孔の1例

コレステロール結晶塞栓症は血管内粥腫の崩壊，飛散により全身の末梢動脈を閉塞し，多臓器障害をきたす疾患である．症例は86歳の男性で，腹痛を主訴に受診し，CT検査で腹腔内遊離ガスを認めた．消化管穿孔による汎発性腹膜炎の診断で手術を施行し，小腸穿孔を認め小腸部分切除を行った．病理組織学的に小腸壁内の動脈にコレステロール結晶の塞栓を認めた．術後13日目に腹痛を訴え，再度消化管穿孔が示唆され手術を行った．前回吻合部と異なる位置の小腸に穿孔を認め小腸部分切除を施行した．病理組織学的に前回同様の所見であり，コレステロール結晶塞栓症に伴う腸管虚血による穿孔と考えられた．術後，肺炎から敗血症をきたし，初回手術より64日目に死亡した．コレステロール結晶塞栓症による消化管穿孔は致死率が極めて高く，救命のためには術式選択について十分に検討する必要があるとともに，全身状態に応じた対症療法の継続が必要不可欠である．

Abstract 15240: Cholesterol Crystal Embolization: The Incidence as a Cardiac Procedural Complication and the Comparison of the Outcomes Between its Causes

Background: Cholesterol crystal embolization (CCE) is very rare, but has a poor prognosis and no proven therapy. Although CCE occurs from various causes, the incidence and outcomes of CCE remain unclear. Purpose: 1) to investigate the incidence of CCE as a complication of percutaneous coronary intervention (PCI), percutaneous transluminal angioplasty (PTA), and cardiovascular surgery; and 2) to investigate patient characteristics and outcomes of CCE on the basis of its causes: idiopathic CCE, catheter-related CCE, and cardiovascular surgery-related CCE. Methods: We registered 75 patients having CCE in the medical records between May 2004 and April 2014 and compared their patient characteristics and outcomes according to the causes of CCE: idiopathic CCE, 31 patients (41%); catheter-related CCE, 32 (43%); and cardiovascular surgery-related CCE, 12 (16%). CCE was diagnosed by clinical findings (blue toe syndrome or livedo) or laboratory findings (elevated serum creatinine level, eosinophil count, or skin biopsy). Results: The incidences of catheter-related CCE were 0.7% in PTA on arteriosclerotic obliterans and 0.17% in PCI. The incidence of CCE after PCI was significantly higher in patients treated with femoral approach than in those treated with nonfemoral approach (0.32% vs. 0.01%, p<0.001). The incidences of cardiovascular surgery-related CCE were relatively high in endovascular aortic repair (1.3%) and in abdominal aortic replacement (0.6%). In the comparison of patient characteristics between idiopathic CCE, catheter-related CCE, and cardiovascular surgery-related CCE, there were significant differences in age and aortic aneurysm. Of the 75 patients, 24 (32%) died, 10 (13%) initiated dialysis, and 7 (9%) underwent leg or toe amputation. There was no significant difference in the outcomes of CCE depending on its causes. Conclusion: The incidences of CCE were significantly high in transfemoral procedures and in surgery for abdominal aortic aneurysm. Between the causes of CCE, there were significant differences in patient characteristics, but no significant differences in the outcomes.

Late Onset of Cholesterol Embolism Leading to Graft Failure After Renal Transplantation: Report of Two Cases

Cholesterol-crystal embolization (CE) usually presents as an acute or subacute multisystemic disease. When affecting native kidneys prognosis is poor, often leading to chronic kidney disease. Presentation in renal allografts is a rare condition although probably underdiagnosed. If renal CE originates from the recipient, allograft survival is usually good, whereas if the donor is the origin, graft dysfunction and subsequent graft loss are common. Associated risk factors are common to native and transplanted kidneys. We report 2 renal graft recipients of different cadaveric donors, both male and 68 years old, diagnosed with CE in renal grafts at 19 and 72 months after transplantation, respectively. They presented previous risk factors for CE, including severe atherosclerosis. They presented insidious and asymptomatic impairment of renal function initially. Renal graft biopsy specimens showed CE in the interlobular arteries. Potential triggers for CE were suspended and high doses of steroids were started. However, progressive decline in renal function and requirement of chronic dialysis occurred within the first year after diagnosis in both cases. Herein we discuss the causal or incidental role of CE in the graft failure of these cases, highlighting the serious outcome despite the recipient origin of the CE and the initiation of treatment.

Low-Density Lipoprotein Apheresis Ameliorates Renal Prognosis of Cholesterol Crystal Embolism.

Drugs such as corticosteroids and statins have been used to treat cholesterol crystal embolism (CCE), but the prognosis remains poor. This study evaluated the efficacy of low-density lipoprotein apheresis (LDL-A) in patients with CCE. Patients with CCE who showed renal deterioration after vascular interventions were studied retrospectively. Information on demographic variables, clinical measurements, and medication use was collected. The outcomes were incidence of maintenance dialysis and mortality at 24 weeks. A total of 49 patients with CCE were included, among whom 37 (76%) were diagnosed pathologically and the remainder were diagnosed clinically. The median estimated GFR at baseline and at diagnosis were 40.5 and 13.4 mL/min per 1.73 m(2) , respectively. Corticosteroids were used in 42 patients (86%), statins in 30 patients (61%), and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in 29 patients (59%). LDL-A was performed in 25 patients (LDL-A group), and not in 24 patients (control group). Smoking (100% vs. 72%, P = 0.02), white blood cell count (8900/mm(3) vs. 7000/mm(3) ) and corticosteroid use (96% vs. 75%) were higher in the LDL-A group compared with the control group, but there were no differences in other demographic and clinical parameters between the groups. Patients in the LDL-A group had a lower incidence of maintenance dialysis (2/25 (8%) vs. 8/24 (33%), P < 0.05), and a trend towards lower mortality (2/25 (8%) vs. 7/24 (29%), P = 0.074). These results suggest that LDL-A decreases the risk of maintenance dialysis in severe renal CCE patients after vascular interventions.

Low-density lipoprotein apheresis ameliorates monthly estimated glomerular filtration rate declines in patients with renal cholesterol crystal embolism.

The incidence of cholesterol crystal embolism (CCE) has increased along with increases in the prevalence of atheromatous diseases and intravascular procedures. CCE frequently results in the deterioration of renal function, which sometimes leads to end-stage renal failure. Although there has been no established therapy for CCE, the possibility that low-density lipoprotein apheresis (LDL-A) is an effective therapy for renal CCE was previously reported. However, whether LDL-A improves renal CCE remains uncertain. This study aimed to evaluate the effectiveness of LDL-A in renal CCE patients. Twelve renal CCE patients (9 men and 3 women, mean age 70.6 ± 1.7 years) were included in this retrospective study. All patients had received LDL-A therapy, and estimated glomerular filtration rate (eGFR) values were examined before and after LDL-A. In addition, monthly changes in eGFR before and after LDL-A were calculated for each patient. At initial diagnosis of renal CCE, the eGFR was 35.2 ± 4.8 mL/min/1.73 m(2). At the initiation of LDL-A, the eGFR significantly decreased to 11.0 ± 1.2 mL/min/1.73 m(2), and monthly changes in eGFR reached -7.2 ± 2.5 mL/min/1.73 m(2)/month. After the initiation of LDL-A, the progression of renal dysfunction stabilized in nearly two-thirds of patients, and monthly changes in eGFR after LDL-A significantly diminished to -0.3 ± 0.7 mL/min/1.73 m(2)/month (p < 0.05 vs. before LDL-A). Although 4 patients had to undergo hemodialysis, all patients were alive over 1 year after the initiation of LDL-A. LDL-A therapy ameliorated renal dysfunction in renal CCE patients.

Benefits and Problems of Transarterial Therapy in Patients with Hepatocellular Carcinoma and Chronic Kidney Disease

PurposeTo evaluate the feasibility of transarterial therapy (transcatheter arterial chemoembolization and transcatheter arterial infusion) for patients with hepatocellular carcinoma and chronic kidney disease (CKD). Materials and MethodsThe study enrolled 35 patients who received transarterial therapy. The patients were classified into a CKD group (n = 10 nondialysis chronic kidney disease [NDCKD] and n = 9 end-stage renal disease [ESRD]) or a non-CKD group (n = 16). The survival rates between the two groups were compared using two different starting points: (a) from initial diagnosis of hepatocellular carcinoma and (b) from enrollment in the study. The tolerance of transarterial therapy in patients with CKD was evaluated by comparing the incidence of major adverse events. ResultsThe 2-year and 5-year survival rates from initial diagnosis were 83.9% and 53.8% in the CKD group and 70.1% and 40.4% in the non-CKD group (P = .478). The corresponding 3-year survival rate from enrollment in the two groups was 25.6% and 41.2%, respectively (P = .995). The 2-year and 5-year survival rates from initial diagnosis were 70.1% and 40.4% in the non-CKD group, 90.0% and 39.4% in NDCKD patients, and 76.2% and 76.2% in ESRD patients (P = .380). The corresponding 2-year survival rates from enrollment in these groups were 54.9%, 48.0%, and 48.6% (P = .943). Severe contrast-induced nephropathy (n = 3) and late-onset death caused by cholesterol crystal embolism (n = 1) were observed in the NDCKD group. ConclusionsTranscatheter arterial chemoembolization is feasible in patients with CKD by instituting periprocedural hemodialysis with similar 2-year and 5-year survival compared with patients without CKD.

Cholesterol Embolization Syndrome Developing after Coronary Angiography in a Hemodialysis Patient

Cholesterol Embolization Syndrome (CES) is a systemic disorder due to cholesterol crystal embolization from atherosclerotic plaques of the aorta and its major branches to the small arterioles, resulting in local ischemia and organ damage. The diagnosis is mostly missed, especially in dialysis patients. There is no definite treatment available and the mortality is relatively high. We present a hemodialysis patient with cholesterol embolization syndrome who developed discoloration of the toes and necrotic ulcers after coronary angiography and whose diagnosis was confirmed with skin biopsy, and discuss the case with literature information.

Compromiso peneano por embolización de cristales de colesterol secundaria a cateterismo cardiaco: primer reporte de caso en Latinoamérica

Of all the reported cases of cholesterol crystal embolisms, penile involvement is extremely rare. From 1982 to 2012, eight cases have been reported in the literature. The case is presented of a sixty year-old man, who underwent a percutaneous coronary angioplasty for an acute coronary event. Ten days after the procedure, he complained of an intense and painful ulcer on the penis. He also had discolored lesions on thighs, legs and plantar surface of the feet. Skin biopsy reported cholesterol crystals embolism. Penile involvement secondary to cholesterol crystal embolism is a rare complication in endovascular interventional procedures with severe atherosclerosis. It is estimated that this condition can be a predictor of morbidity and mortality in those patients.© 2014 Sociedad Colombiana de Urología. Published by Elsevier España, S.L. All rights reserved.

Spontaneous Renal Cholesterol Crystal Embolism In A Patient with Functionally Solitary Kidney

Renal cholesterol crystal embolism (also called renal atheroembolism) is a cause of acute kidney injury with increasing frequency. It is usually seen in patients older than 60 years of age with diffuse atherosclerotic disease. Although it develops usually following vascular interventions; it may occur spontaneously. It presents with partial or total occlusion of small arteries due to distal embolization from cholesterol crystals from ruptured atherosclerotic plaques. It is in fact a part of systemic disease called cholesterol crystal embolization disease affecting kidneys, eyes, brain and gastrointestinal system. Livedo reticularis, especially purple discoloration of toes are clues for diagnosis. The pathognomonic finding of renal cholesterol crystal embolism is the cholesterol crystal clefts in renal biopsy specimen. Herein, we present a atypical case of acute kidney injury due to spontaneous cholesterol crystal embolization in a patient with functionally solitary kidney.

コレステロール塞栓症による小腸多発穿孔の1例

コレステロール塞栓症による小腸多発穿孔の1例

CAS後に生じたコレステロール結晶塞栓症の危険因子に関する検討

CAS後に生じたコレステロール結晶塞栓症の危険因子に関する検討

Embolic complications after endovascular repair of abdominal aortic aneurysms

This retrospective study aimed to review our experiences with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs), along with the incidence, risk factors and prognoses of associated embolic events. Our goal was to present the EVAR results and related risk factors from a single center, with a focus on embolic complications. We retrospectively reviewed the data of 539 patients with AAAs who underwent elective EVAR at Jikei University from July 2006 to April 2009. Of these, 438 patients were selected after excluding those requiring fenestrated and branched EVAR. The technical success rate was 91.1 % (399/438) with no surgical mortality. Embolic complications occurred in nine patients (2 %), four of whom developed ischemic colitis and were successfully treated with bowel rest and hydration. Lower extremity atheroembolization and stroke occurred in three and one patients, respectively. Two patients died of cholesterol crystal embolization. Seven of the nine embolic complications (77.8 %) were associated with the use of Zenith stent-grafts. A Cox proportional-hazard regression analysis of the adjusted risk factors showed that smoking and severe arterial degeneration of the aorta, referred to as a shaggy aorta, to be independent predictors of embolic complications. The presence of a shaggy aorta and a history of smoking are independent predictors of embolic complications associated with EVAR.

Atheroembolic renal disease

Atherosclerotic plaques are prone for thromboembolism with clots and atheroembolisation with cholesterol crystals. Atheroembolism occurs when the atherosclerotic plaque is disrupted causing multiple showers of cholesterol crystal embolization resulting in partial or total occlusion of small arteries of multiple organs. Atheroembolic renal disease (AERD) refers to cholesterol crystal embolization of the renal arteries and is often associated with multiorgan involvement. Diagnosis requires a high degree of suspicion in the clinical setting with renal failure, skin lesions, and sometimes hypocomplementemia and eosinophiluria. Treatment is mainly supportive and overall prognosis is poor.

Cholesterol Crystal Embolism Following Coronary Angiography: A Case Report

Cholesterol Crystal Embolism Following Coronary Angiography: A Case Report

Teaching Video Neuro Images : Hollenhorst plaque

A 73-year-old man with hypertension and hyperlipidemia was seen in clinic complaining of decreased vision in his right eye. Bedside examination demonstrated a right eye inferior lateral visual field defect due to ischemic optic neuropathy and 2 bright intraluminal yellow plaques located in 2 different arteriolar bifurcations (figure). Carotid ultrasound showed an unstable, mobile, nonocclusive, ulcerated plaque in the right carotid bifurcation (see video on the Neurology® Web site at www.neurology.org). Hollenhorst plaques1 are cholesterol crystal emboli thought to originate from the ipsilateral carotid artery bifurcation that, in the absence of amaurosis fugax or stenosis, are not associated with an increased risk of ipsilateral cerebral infarct.2