Cholesterol Emboli Research Articles

Atheroembolic Disease—A Frequently Missed Diagnosis: Results of a 12-Year Matched-Pair Autopsy Study

Atheroembolic Disease—A Frequently Missed Diagnosis: Results of a 12-Year Matched-Pair Autopsy Study

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Cholesterol Embolization to Bladder in Setting of Transient Ischemic Attack and Hematochezia: An Unusual Presentation of Cholesterol Embolization Syndrome

Cholesterol Embolization to Bladder in Setting of Transient Ischemic Attack and Hematochezia: An Unusual Presentation of Cholesterol Embolization Syndrome

Cholesterol Embolization Syndrome

Cholesterol embolization syndrome refers to embolization of the contents of an atherosclerotic plaque (primarily cholesterol crystals) from a proximal large-caliber artery to distal small to medium arteries causing end-organ damage by mechanical plugging and an inflammatory response. Synonyms used in the medical literature include atheromatous embolization, cholesterol crystal embolization, and atheroembolism. Cholesterol embolization syndrome should be distinguished from the related and much more common syndrome of arterio-arterial thromboembolism in which fragments of a thrombus that forms atop an atheromatous plaque in the aorta or a large artery travel distally and occlude medium to large arteries.1 Cholesterol embolization syndrome is generally characterized by a multitude of small emboli (showers of microemboli) occurring over time. This is in contrast to arterio-arterial thromboembolism, which is usually characterized by an abrupt release of 1 or a few large emboli, leading to severe ischemia of target organs. Cholesterol embolization syndrome has a variety of clinical presentations. Cholesterol emboli originating in the descending thoracic and abdominal aorta may lead to renal failure, gut ischemia, and emboli to the skeletal muscles and the skin. Dermatologic manifestations (most commonly livedo reticularis and blue toe syndrome) are usually confined to the lower extremities but may extend to the abdomen and the chest. Cholesterol emboli originating in the ascending aorta may in addition cause neurological damage that is typically diffuse and due to small infarcts. Cholesterol embolization syndrome is also characterized by a nonspecific acute inflammatory response leading to constitutional symptoms (such as fever and malaise) and abnormalities in laboratory tests (such as hypereosinophilia and elevated erythrocyte sedimentation rate). These manifestations will be discussed in detail later in the text. Danish physician Fenger and his colleagues appear to have provided the first description of atheroembolism in the Danish medical brochure Ugeskrift for Laeger (Doctors’ Weekly).2 In 1844, they …

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic Disease

TABLE OF CONTENTSPreamble ……………………………….280 Introduction ………………………281 1.1. Methodology and Evidence Review … . .2811.2. Organization of the Writing Committee …2831.3. Document Review and Approval …… .2831.4. Scope of the Guideline ……………283 1.4.1. Critical Issues …………… . .2831.5. Glossary of Terms and

Filters Placed in the Superficial Femoral Arteries for Limb Salvage in a High-Surgical-Risk Patient With Atheroembolism: Results at 2 Years

To report the off-label use of Emboshield filters as a treatment for bilateral atheroembolism (trash foot) in an inoperable patient. A 64-year-old man with a juxtarenal abdominal aortic aneurysm (jAAA) presented with necrotic wounds of the forefoot and toes of both feet. Doppler imaging showed triphasic signals. He was on oral anticoagulants because of a mechanical valve. The patient was admitted for evaluation and administration of intravenous antibiotics; other than the jAAA, no other source of emboli was detected. Since the patient was inoperable, Emboshield filters were placed bilaterally through antegrade femoral accesses at the level of the superficial femoral arteries to prevent embolism to the feet. Two years later, the patient has no symptoms; debris is present in both filters but does not compromise arterial flow into the legs. This case demonstrates the successful off-label use of an Emboshield filter for trash foot in an inoperable patient.

Atheroembolic renal disease: analysis of clinical and therapeutic factors that influence its progression

Cholesterol embolism is a disease caused by distal showering of cholesterol crystal released from disintegration of arterial atheromatous plaques. It may occur spontaneously or more often after invasive vascular procedures or thrombolytic/anticoagulant agents. Forty five cases were diagnosed between 1989 and 2005 in three Spanish hospitals. The diagnosis was confirmed by histology or diagnostic ophthalmoscopic findings. The majority were male (93.3%), elder (55.5% were older than 70 years), smoker (91.1%), had hypertension (95.6%), with high prevalence of cardiovascular risk factors. At the time of diagnosis all patients presented acute renal failure. Mean serum creatinine at diagnosis was 4.3+/- 2.4 mg/dl. The acute renal failure was accompanied with eosinophilia (64.4%) and cutanous lesions (57.7%). 20% of cases occur spontaneously and 46.7% after endovascular manipulation (coronary angiography/arteriography) and only 8% after changes in anticoagulant treatment. After a follow-up of 12 +/- 16.3 months the 55.6% of patients need chronic dialysis, 64.4% died, 8 of them after the beginning of dialysis. Nine patients recovered renal function, with a mean creatinine of 3 +/- 1.7 mg/dl at the end of follow-up. The cardiovascular comorbididy and the clinical severity of the embolism don t have impact in the renal or patient survival. Renal survival (Kaplan-Mier) were better in spontaneous than in iatrogenic cholesterol embolism. Fifteen of 45 patients were treated with steroids. In treated patients we observed a high incidence of death (73.3% versus 60%) and fewer recovery of renal function (13.3% versus 23%), without statistical significance. The mean time to dialysis was shorter in treatment patients (p= 0.017). Statins treatment was not associated with outcome (renal or individual). In summary, atheroembolic renal disease represents an acute renal failure with special characteristics. Renal and individual outcome is poor, but some patients have spontaneous recovery of renal function. Renal survival was significantly better in spontaneous disease. We don t observe beneficial effect of steroid treatment.

A Case of Subacute Testicular Infarction Following Endovascular Abdominal Aortic Aneurysm Repair Secondary to Cholesterol Embolisation

We report the case of 62-year-old male who underwent Endovascular Aneurysm Repair (EVAR) for a large infrarenal AAA. Following investigation for a contralateral benign epididymal cyst he was found to have a left testicular mass and underwent urgent orchidectomy. The histological features were of subacute testicular infarction secondary to cholesterol emboli following his EVAR. We believe this is the first reported case of subacute testicular infarction due to cholesterol emboli reported following EVAR. Clinicians should be aware of the risk of cholesterol embolisation following EVAR.

A Case of Subacute Testicular Infarction Following Endovascular Abdominal Aaortic Aneurysm Repair Secondary to Cholesterol Embolisation

We report the case of 62-year-old male who underwent Endovascular Aneurysm Repair (EVAR) for a large infrarenal AAA. Following investigation for a contralateral benign epididymal cyst he was found to have a left testicular mass and underwent urgent orchidectomy. The histological features were of subacute testicular infarction secondary to cholesterol emboli following his EVAR. We believe this is the first reported case of subacute testicular infarction due to cholesterol emboli reported following EVAR. Clinicians should be aware of the risk of cholesterol embolisation following EVAR. A Case of Subacute Testicular Infarction Following Endovascular Abdominal Aortic Aneurysm Repair Secondary to Cholesterol EmbolisationEJVES ExtraVol. 19Issue 5PreviewWe report the case of 62-year-old male who underwent Endovascular Aneurysm Repair (EVAR) for a large infrarenal AAA. Following investigation for a contralateral benign epididymal cyst he was found to have a left testicular mass and underwent urgent orchidectomy. The histological features were of subacute testicular infarction secondary to cholesterol emboli following his EVAR. We believe this is the first reported case of subacute testicular infarction due to cholesterol emboli reported following EVAR. Full-Text PDF Open Access

Cutaneous reactive angiomatosis associated with cholesterol embolism

Cholesterol embolism (CE) is characterized by emboli containing cholesterol crystal in the arterioles, most commonly found in the skin and the kidney. The skin presentations of CE include livedo reticularis, blue toe syndrome, ulceration and gangrene. Cutaneous reactive angiomatosis (CRA) is a recently proposed term to describe a group of reactive vascular proliferation in skin caused by various diseases. Its occurrence in association with CE is extremely uncommon. An 82-year-old man with a history of cerebral infarction and on long-term warfarin therapy developed progressive, multiple violaceous papules and nodules on the dorsal feet, soles and toes, simulating Kaposi's sarcoma. Skin biopsy showed marked vascular endothelial cell proliferations characteristic of CRA affecting the full thickness of dermis. In addition, cholesterol crystal emboli were found in dermal arterioles. The skin lesions improved after the warfarin dose was reduced. We emphasize the possible presence of CE in a patient presented with CRA, especially in those with a pre-existing atherosclerotic disease, on anticoagulation therapy, or having a prior history of invasive vascular procedure.

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: Executive Summary

Systemic cholesterol embolization syndrome in a patient positive for anti-cardiolipin antibody

Cholesterol embolization syndrome (CES) is caused by a cholesterol crystal embolization from atherosclerotic plaques on the walls of arteries. It often occurs after an invasive vascular procedure. CES exhibits several cutaneous manifestations before systemic symptoms take place. Here, we report a case of CES, positive for an anti-cardiolipin antibody, with a history of cerebral infarction. The existence of anti-phospholipid antibody may be a risk factor for CES after an invasive vascular procedure.

Natural history and progression of atherosclerotic renal vascular stenosis

Date written: December 2008Final submission: October 2009

Atheroembolic Disease-A Frequently Missed Diagnosis

Diagnosis of atheroembolic disease (AD) is challenging, because no specific test is available and AD often masquerades as other clinical conditions. We conducted the current study to investigate the relative frequency of autopsy-proven AD over time, to describe its clinical presentation, and to identify risk factors for AD. We screened 2066 autopsy reports from 1995 to 2006 for AD. For each AD case, a control patient without AD was matched for age, sex, and autopsy year. Diagnostic and therapeutic interventions (surgery, catheter interventions, and drug treatment) in the last 6 months before death, as well as clinical and laboratory parameters during the last hospitalization, were retrieved from electronic charts. We identified 51 patients with AD. Among these only 6 (12%) had been diagnosed clinically. The organs most often affected were kidney (71%), spleen (37%), and lower gastrointestinal tract (22%). The relative AD frequency decreased over time from 3.5 to 0.5 per 100 autopsies, whereas the frequency of clinically suspected and biopsy-proven AD remained constant. Among clinical signs, skin lesions such as livedo reticularis and blue toe (33% vs. 14%; p = 0.04) were significantly increased in AD patients compared with the matched controls. We also observed a trend for higher incidence of eosinophilia and proteinuria in AD patients. Vascular interventions within 6 months before death were highly associated with AD (55% vs. 29%; p = 0.01), and in a multivariable analysis this remained the only significant risk factor for AD. Thus, the diagnosis of AD is frequently missed. Vascular interventions represent the most important risk factor for AD and should be performed restrictively in high-risk patients.

Doença renal ateroembólica: uma causa de insuficiência renal aguda pouco explorada

Atheroembolism is a multisytemic disease which affects many organs, including the kidneys, by the release of cholesterol emboli to tissues from an erosed atherosclerotic plaque, causing vascular obstruction in many tissues. The atheroembolic renal disease (AERD) is histologically represented by cholesterol crystals in renal arterioles with an inflammatory infiltrate around the vessels, and causes acute renal failure that may be severe and prolonged, weeks or even months after the embolic episode. The AERD carries a bad prognosis, with a high mortality. We herein report a case of a patient presenting AERD which was manifested two months after he was submitted to a cardiac catheterism and coronary angioplasty. The prevalence, clinical findings, renal histology, treatment and prognosis of AERD are discussed.

Atherosclerotic renovascular disease in the United States

Atherosclerotic renovascular disease (ARVD) is an increasingly recognized clinical condition that is diagnosed predominantly in older patients. Here we used annual United States Medicare 5% Denominator Files and studied 16,036,904 patients, 66 years of age and older, to quantify trends in diagnostic rates, associations, treatment, and outcomes of ARVD over a 13-year period. Overall, there was an ARVD rate of 3.09 per 1000 patient-years, which rose progressively with an adjusted hazard ratio of 3.35, comparing data from 1992 to 2004. Within 6 months of disease diagnosis, 13.4% of patients had undergone revascularization. A biphasic pattern of revascularization was found where the adjusted hazard ratios significantly increased in a progressive manner until 1999, following which there was a decline through 2004, which was not significant. The method of revascularization changed markedly over time with endovascular intervention steadily replacing direct surgical revascularization. As a time-dependent variable, ARVD was associated with excess mortality in each calendar year, albeit with declining hazard ratio estimates in more recent years. Among patients with this disease, revascularization was associated with mortality adjusted hazard ratios <1 in each year. Our study shows the diagnosis of ARVD has substantially risen in the United States but the survival implications were not fully explained by other comorbid vascular diseases.

Endovascular Treatment of Massive Thoracic Aortic Thrombus and Associated Ruptured Atheroma

Atheroembolic disease typically presents with isolated lower extremity digital ischemia. Treatment traditionally includes optimization of medical management, with open surgery reserved for complicated or recurrent embolic events. We present a novel endovascular approach for treatment of complicated thoracic aortic atherosclerotic disease incidentally discovered in a 63-year-old female. The patient demonstrated visceral artery embolization from a mobile 2.6 cm atherosclerotic plaque despite maximal medical therapy. Thoracic aortic stent graft placement successfully excluded the atheroma and prevented further embolization. This case demonstrates a unique treatment option for complicated thoracic aortic atheroembolic disease utilizing a minimally invasive endovascular approach.

Blurred Vision after Cardiac Catheterization

A 56-year-old woman with hypertension presented with a sudden onset of painless impaired vision in the right eye. On the previous day, she had undergone cardiac catheterization for evaluation of hypertensive emergency (chest pain and blood pressure of 235/110 mm Hg) with mild troponin elevation. On physical examination, the visual acuity in the right eye was 20/100 with significant visual-field defects in the inferior temporal quadrant. Biomicroscopy revealed cholesterol emboli (Panel A, arrows) with surrounding white lucency representing retinal edema. Fluorescein angiography confirmed occlusion of the cilioretinal artery with nonperfusion of the tissue bed in the hypofluorescent areas (Panel B). . . .

Cholesterol embolization and severe vascular rejection in a renal allograft recipient

Cholesterol embolization (CE) is a well-known cause of renal dysfunction, often leading to irreversible renal failure most often in elderly patients. However, because of its unspecific and subclinical appearance, CE is often misdiagnosed. As donors and recipients of increasing age or with prominent atherosclerotic disease are accepted for transplantation, CE in renal allografts may become more prevalent. Here, we report a case of a 31-year-old second renal allograft recipient with CE as a cause of early graft failure, followed by severe vascular rejection, eventually requiring nephrectomy.