Cholesterol embolization and arterial occlusion from the Heimlich maneuver.

The Heimlich maneuver is a lifesaving bystander intervention to assist an individual with airway obstruction however, cholesterol embolization syndrome is a rare, but serious potential complication of the Heimlich maneuver. We present the case of the 56-year-old female presenting to the emergency department with acute right foot pain following performance of the Heimlich maneuver who was found to have distal arterial occlusion resulting from cholesterol embolization syndrome. The patient underwent right popliteal artery exploration, right popliteal and tibial thrombectomy, and popliteal patch angioplasty resulting in restoration of blood flow to her right foot.

Atheroembolism to the Breast.

We report the case of a woman presenting with livedo reticularis of the breast who was found to have atheroembolism to the breast following upper extremity percutaneous access. Atheroembolism is the embolization of cholesterol crystals off an atherosclerotic plaque that can occur spontaneously or as a result of vascular intervention. This is a unique presentation of an otherwise well-described complication of vascular catheterization, and we propose that livedo reticularis of the breast can be interpreted as a sign of atheroembolism in the appropriate clinical context.

Successful treatment of cholesterol crystal embolism with anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) antibody: a case report.

Background: We report a unique case of renal cholesterol crystal embolism (CCE) induced by carotid artery stenting that was successfully treated with evolocumab, a fully human monoclonal antibody against proprotein convertase subtilisin kexin type 9 (PCSK9).Case presentation: A 77-year-old man with hypertension, hyperlipidemia, and chronic kidney disease was referred to our department for decreased estimated glomerular filtration rate (eGFR)-from 32.0 to 13.9 mL/min/1.73 m2-5 weeks after carotid artery stenting. Further examination revealed livedo reticularis in the bilateral toes and eosinophilia (723/µL). Skin biopsy from livedo reticularis tissue in the bilateral toes showed cholesterol clefts in the small arteries. The patient was therefore diagnosed with CCE. After 25 weeks' administration of evolocumab at a dose of 140 mg subcutaneously administered every 2 weeks, his eGFR had improved from 10.7 to 18.1 mL/min/1.73 m2.Conclusion: Evolocumab may have a beneficial effect on renal involvement in patients with CCE.

[Benign Presentation of a Potentially Fatal Disease]. / Ateroembolismo cutâneo: relato de três casos clínicos.

Atheroembolism is a rare multisystemic disorder that is characterized by release of cholesterol crystals and particles from atheromatous plaques, which can occlude distal vessels and induce an inflammatory response. Most affected individuals are males, older than 60 years of age, with advanced atherosclerotic disease. The abdominal aorta is the most common origin of cholesterol emboli, being the peripheral arteries a rarer source. Cholesterol embolization syndrome is often associated with invasive vascular procedures, although, more rarely, it may occur spontaneously. In this paper, the authors present three cases of spontaneous atheroembolism with cutaneous manifestations and their clinical management. Being an underdiagnosed pathology, knowledge about its clinical manifestations is essential in order to allow an early diagnosis and treatment, to ensure a better prognosis for the patient.

O ateroembolismo é uma doença multissistémica rara caraterizada pela libertação de cristais de colesterol e partículas de placas ateroscleróticas, que podem ocluir vasos sanguíneos periféricos e induzir uma resposta inflamatória. A maioria dos indivíduos afetados é do sexo masculino, com idade superior a 60 anos e doença aterosclerótica avançada. A origem mais frequente de embolização de colesterol é a aorta abdominal, sendo as artérias periféricas uma fonte mais rara. A síndrome de embolização por colesterol surge frequentemente associada a procedimentos vasculares invasivos, embora, mais raramente, possa ocorrer de forma espontânea. Neste artigo os autores apresentam três casos clínicos de ateroembolismo espontâneo com envolvimento cutâneo e respetiva abordagem clínica. Sendo uma patologia subdiagnosticada, torna-se fundamental o conhecimento acerca das suas manifestações clínicas, para permitir um diagnóstico e tratamento precoces de forma a garantir um melhor prognóstico para o doente.

"Pseudo aortoiliac bifurcation" leading to significant plaque shifting in the endovascular treatment of an aortoiliac bifurcation lesion: a case report.

BACKGROUND: Plaque shifting is a serious complication of endovascular treatment (EVT) for aortoiliac bifurcation lesions. It is challenging to predict the occurrence of unfavorable plaque shifting correctly. CASE PRESENTATION: We report the case of an 88-year-old Japanese woman who experienced constant pain at rest in her left leg. The ankle-brachial pressure index of her left leg was 0.57. Computed tomography (CT) angiography revealed severe stenosis of the left common iliac artery (CIA) and total occlusion of the left external iliac artery (EIA). We diagnosed the patient with acute exacerbation of a chronic limb ischemia and administered endovascular treatment (EVT) to treat the left CIA and EIA. The results of initial angiography agreed with those of CT angiography. After placing a self-expandable stent for the left CIA lesion, significant unfavorable plaque shifting occurred. From a comparison between pre- and post-stenting angiography, we realized that the plaque protrusion into the terminal aorta had formed a "pseudo aortoiliac bifurcation" that was situated more proximally compared to the true bifurcation. We had incorrectly assessed the height of the aortoiliac bifurcation and exact plaque position and had underestimated the risk of plaque shifting because of this misunderstanding. The patient ultimately developed fatal cholesterol embolization after EVT. CONCLUSIONS: Plaque protrusion into the terminal aorta can form a "pseudo aortoiliac bifurcation", causing the wrong estimation of the height of the aortoiliac bifurcation; "angiographically", the highest point is not always the true bifurcation. Careful assessment of initial angiography to detect the true aortoiliac bifurcation and exact plaque position is essential to avoid unfavorable plaque shifting.

Multiple small intestinal ulcers associated with protein-losing enteropathy secondary to cholesterol crystal embolism:a case report.

A 78-year-old man with hypertension, nephrosclerosis, and angina pectoris visited his family doctor with a history of fatigue and leg edema. He had a history of percutaneous coronary intervention 5 years prior, and was taking low-dose aspirin. Blood tests revealed hypoalbuminemia, gastrointestinal 99mTc-HSA scintigraphy was positive, and alpha-1 antitrypsin clearance was high;therefore, the hypoalbuminemia was thought to be secondary to a protein-losing enteropathy. A small bowel series revealed multiple, ring-shaped, longitudinal ulcers in the ileum. Balloon-assisted enteroscopy from the anus showed severe stenosis with an ileal ulcer. Since we were not able to diagnose the ulcers, mesalazine and supplemental nutritional care were provided. Four years after the hypoalbuminemia had been diagnosed, the patient died because of pulmonary congestion secondary to renal failure. An autopsy revealed severe atherosclerosis in his aorta and multiple cholesterol embolisms in his small intestine, kidney, stomach, colon, liver, and spleen. The multiple ulcers in the small intestine were thought to be caused by cholesterol crystal embolism, which should be considered in the differential diagnosis of small intestinal ulcers in elderly men or patients after cardiovascular intervention.

[Cholesterol crystal embolization following urinary diversion: a case report].

Cholesterol crystal embolization (CCE) is a cardiovascular disorder with poor prognosis, causing multiple organ failure. The primary pathological condition of the disease is embolization of cholesterol crystals in peripheral vessels. We report a case of CCE following urinary diversion. The patient is a 82-year-old male with history of hypertention, pneumonectasia, interstitial pneumonia, and heavy smoking. He was afflicted with advanced bladder cancer. He underwent urinary diversion, and had been scheduled for palliative radiotherapy. The next day, he developed thromboembolism of the left lower leg as acomplication of urinary diversion. Thrombectomy by endovascular catheter procedure was performed immediately, and anticoagulant therapy was started. The day after the thrombectomy, his lower legs showed livedo reticularis and toes showed cyanosis (blue toe). Since the laboratory data showed acute deterioration in renal function, hemodialysis was initiated. Three days after the thrombectomy he died of multiple organ failure. At autopsy, diffuse atherosclerosis of the aorta was observed, and cholesterol crystalemboli were found in the skin of the left foot ; and, the diagnosis of CCE was confirmed. This case suggests that tissue examinations for early diagnosis and stopping anticoagulant therapy are preferred when CCE is suspected.

The cholesterol emboli syndrome in atherosclerosis.

Cholesterol emboli syndrome is a relatively rare, but potentially devastating, manifestation of atherosclerotic disease. Cholesterol emboli syndrome is characterized by waves of arterio-arterial embolization of cholesterol crystals and atheroma debris from atherosclerotic plaques in the aorta or its large branches to small or medium caliber arteries (100-200 µm in diameter) that frequently occur after invasive arterial procedures. End-organ damage is due to mechanical occlusion and inflammatory response in the destination arteries. Clinical manifestations may include renal failure, blue toe syndrome, global neurologic deficits and a variety of gastrointestinal, ocular and constitutional signs and symptoms. There is no specific therapy for cholesterol emboli syndrome. Supportive measures include modifications of risk factors, use of statins and antiplatelet agents, avoidance of anticoagulation and thrombolytic agents, and utilization of surgical and endovascular techniques to exclude sources of cholesterol emboli.

Central retinal artery occlusion caused by fat embolism following endoscopic sinus surgery.

Endoscopic sinus surgery (ESS) can lead to a variety of ophthalmic complications. Central retinal arterial occlusion (CRAO) is one such complication, usually due to orbital compartment syndrome. We report a case of CRAO following endoscopic sinus surgery as a result of fat embolism.

ST-elevation myocardial infarction as a complication of retrograde chronic total occlusion recanalization.

With the advent of new tools and techniques including the retrograde approach, success rates for recanalization of chronic total occlusion (CTO) have improved. Numerous cardiac and extracardiac complications during retrograde CTO recanalization have been described. To date the development of ST-segment elevation myocardial infarction (STEMI) with retrograde recanalization as a result of atheroembolization has not been reported. We report such a case following retrograde recanalization of a totally occluded right coronary artery.

Intraplaque haemorrhages as the trigger of plaque vulnerability.

Atherothrombosis remains one of the main causes of morbidity and mortality in the western countries. Human atherothrombotic disease begins early in life in relation to circulating lipid retention in the inner vascular wall. Risk factors enhance the progression towards clinical expression: dyslipidaemia, diabetes, smoking, hypertension, ageing, etc. The evolution from the initial lipid retention in the arterial wall to clinical events is a continuum of increasingly complex biological processes. Current strategies to fight the consequences of atherothrombosis are orientated either towards the promotion of a healthy life style and preventive treatment of risk factors, or towards late interventional strategies. Despite this therapeutic arsenal, the incidence of clinical events remains dramatically high, dependent, at least in part, on the increasing frequency of type 2 diabetes and ageing. But some medical treatments, focusing only on prevention of the metabolic risk, have failed to reduce cardiovascular mortality, thus illustrating that our understanding of the pathophysiology of human atherothrombosis leading to clinical events remain incomplete. New paradigms are now emerging which may give rise to novel experimental strategies to improve therapeutic efficacy and prediction of disease progression. Recent studies strengthen the concept that the intraplaque neovascularization and bleeding (Figure 1, upper panel) are events that could play a major role in plaque progression and leucocyte infiltration, and may also serve as a measure of risk for the development of future events. The recent advances in our understanding of IntraPlaque Hemorrhage as a critical event in triggering acute clinical events have important implications for clinical research and possibly future clinical practice.

Cutaneous cholesterol embolization syndrome: A case report.

An 81-year-old woman with chronic kidney disease, systemic hypertension, and a large infra-renal abdominal aortic aneurysm, developed bilateral calf muscle pain, altered sensorium, and deterioration of renal function following endovascular aneurysmal repair. On the third post-operative day she developed symmetrical purpuric macules with erythematous margins on the gluteal region and bluish reticulated patches on the soles and tips of toes. This was followed by melena development on the seventh post-operative day. Histology of the skin confirmed the diagnosis of cutaneous cholesterol embolization syndrome (CES). She was treated with hemodialysis and supportive management and she recovered.

Atheroembolic renal disease.

Atheroembolic renal disease develops when atheromatous aortic plaques rupture, releasing cholesterol crystals into the small renal arteries. Embolisation often affects other organs, such as the skin, gastrointestinal system, and brain. Although the disease can develop spontaneously, it usually develops after vascular surgery, catheterisation, or anticoagulation. The systemic nature of atheroembolism makes diagnosis difficult. The classic triad of a precipitating event, acute or subacute renal failure, and skin lesions, are strongly suggestive of the disorder. Eosinophilia further supports the diagnosis, usually confirmed by biopsy of an affected organ or by the fundoscopic finding of cholesterol crystals in the retinal circulation. Renal and patient prognosis are poor. Treatment is mostly preventive, based on avoidance of further precipitating factors, and symptomatic, aimed to the optimum treatment of hypertension and cardiac and renal failure. Statins, which stabilise atherosclerotic plaques, should be offered to all patients. Steroids might have a role in acute or subacute progressive forms with systemic inflammation.

Cannula design reduces particulate and gaseous emboli during cardiopulmonary bypass for coronary revascularization.

PURPOSE: The incidence of neurocognitive deficits after coronary bypass surgery remains problematic, with atheroembolism being one of the major causes. External manipulation of aorta and the "sandblasting" effect of the high-velocity perfusion jet can cause dislodgement of atheromatous debris. DESCRIPTION: A new arterial cannula features a tip configuration that diffuses the flow through multiple outlets, providing reduced velocity and shear with one central and three diverted flow streams. EVALUATION: Between March 2007 and July 2008 twenty patients having isolated coronary artery bypass operations were instrumented with an Embolus Detection and Classification transducer. These data were compared to 43 patients from a previous study using similar techniques except for a standard open-tip arterial cannula. Total embolic counts were markedly lower in the new cannula group (20±25 vs 174±378) as were both gaseous (11±15 vs 95±211) and particulate counts (9±11 vs 80±194). CONCLUSIONS: The select 3D cannula design reduces the sandblasting effect of the perfusion jet and, also, may direct emboli from the heart and cardiopulmonary bypass equipment away from the cerebral circulation.

[Lethal cholesterol crystal embolization syndrome after operation for abdominal aortic aneurysm].

A 70-year-old man underwent graft replacement for infrarenal abdominal aortic aneurysm, 50 mm in diameter. Postoperatively, he suffered from bilateral lower extremital ischemia. Although he underwent emergency embolectomy of both legs under general anesthesia, severe purplish discoloration of the distal lower extremities developed, and acute renal dysfunction occurred. He was diagnosed with cholesterol crystal embolization syndrome (CCE). We initiated intravenous steroid therapy and infused prostagrandin intraarterially and conducted low density lipoprotein (LDL) apheresis. However, his renal function did not improve and his bilateral toes became necrotic completely. Multiple organ failure rapidly worsened and he died at 38 days after surgery. CCE complicated with severe renal dysfunction is a lethal iatrogenic complication after surgery for abdominal aortic aneurysm. Because the number of CCE is likely to increase in the near future, we should study about CCE more seriously.

A rare case of fatal multi-organ polymer graft material and cholesterol embolization following aortic repair.

Ischemia is a common complication of various endovascular procedures including endovascular aortic aneurysm repair. Multiple mechanisms can contribute to the pathogenesis of ischemia: thrombosis, arterial dissection, graft malpositioning, cholesterol embolization, and polymer graft embolization which is an underrecognized complication. To the best of our knowledge, only 38 cases of polymer graft embolization have been reported in the literature. The phenomenon has been reported in different organs including brain, heart, lungs, kidneys, bowel, liver, and skin. We report a unique case of fatal simultaneous cholesterol and polymer graft embolization with subsequent ischemic infarction of multiple organs (liver, kidneys, spleen, pancreas, duodenum, and stomach) in a 76-year-old woman following endovascular repair for an enlarging thoracic aortic aneurysm.