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.

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.

Cholesterol Embolization Syndrome After Carotid Artery Stenting Associated with Delayed Cerebral Hyperperfusion Intracerebral Hemorrhage.

BACKGROUND: The cholesterol embolization syndrome (CES) results from the distal embolization of cholesterol crystals from atheromatous plaques in large vessels such as the aorta and results in multiorgan damage. CASE DESCRIPTION: We present the case of a patient with definite CES with skin manifestations (e.g., blue toes) and renal and neurological dysfunction, including parenchymal hematoma with cytotoxic and vasogenic edema after he had undergone left carotid artery stenting for symptomatic critical left carotid artery stenosis. CONCLUSIONS: Our patient with CES had cutaneous involvement affecting the lower limbs and renal and neurological involvement. High clinical suspicion and early treatment can reduce the mortality and morbidity after endovascular procedures. The neurological symptoms had most likely resulted from delayed cerebral hyperperfusion syndrome resulting in intracerebral hemorrhage.

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.

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.

Aortogenic Embolic Stroke Diagnosed by a Pathological Examination of Endovascularly Removed Thrombus: An Autopsy Report.

Complex aortic atheroma is a high-risk factor for recurrent embolic stroke. An accurate identification of stroke etiology is clinically important; however, it can be challenging. A 91-year-old man with atrial fibrillation was diagnosed with cardioembolic stroke and treated with mechanical thrombectomy. The removed thrombus microscopically contained foamy cells, suggesting an atheroembolism. An autopsy revealed an atherosclerotic lesion with ulceration, located in the aortic arch. At the lesion, the plaque had microscopically ruptured into the lumen. We therefore concluded that the aortic atherosclerotic lesion was the embolic source. Removed thrombi should be pathologically examined even if a cardioembolic stroke is clinically suspected.

Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case

Cholesterol crystal embolism is a rare and easily overlooked cause of colonic ischemia. The gastrointestinal tract is the third most common organ system affected by cholesterol emboli, second only to kidney and skin. Here we present a catastrophic case of gastrointestinal cholesterol crystal embolism leading to extensive post-operative bowel infarction and ultimately death. For a practicing pathologist, careful attention to the vessels of any ischemic bowel and recognition of the subtle but distinct angular imprint of cholesterol crystals facilitates prompt identification of the atheroemboli. In some cases, early identification may help mitigate further tissue damage. In more acute and severe cases, identification of the cholesterol crystal emboli may be important primarily for documentation of procedural complications.

[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.

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.

"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.