Caracterización de la placa de Hollenhorst mediante tomografía de coherencia óptica / Characterization of the Hollenhorst plaque by Optical Coherence Tomography

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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.

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.

A patient with idiopathic cholesterol crystal embolization: effectiveness of early detection and treatment.

A 72-year-old man was admitted to our hospital because of progressive renal dysfunction persisting for 1.5 months. Physical examination showed livedo reticularis of the toes of both feet, peripheral edema, and gait disturbance due to the toe pain. The levels of blood urea nitrogen (50.0 mg/dL) and creatinine (2.81 mg/dL) were elevated, and eosinophilia (10%, 870/µL) was noted. A biopsy of the area of livedo reticularis revealed cholesterin crystals. The patient had not undergone angiography, anticoagulation therapy, or antithrombotic treatment. Idiopathic cholesterol crystal embolization was diagnosed. Transesophageal echocardiography revealed intimal thickening of the aorta and plaque. Oral steroid therapy was started because of the progressive renal dysfunction. After steroid therapy, the symptoms improved. Early diagnosis and treatment are important. Renal dysfunction is a common symptom in elderly patients. Cholesterol crystal embolization should also be considered as a cause of unexplained renal dysfunction, especially in such patients.

Mobile masses in the aortic arch in a patient with acute embolic event.

We describe a 45-year-old woman with peripheral embolism in whom echocardiography revealed mobile masses in the aortic arch that were characterized as atherothrombi. The masses were resected surgically 2 months later, since treatment with antiplatelets, anticoagulants and statins failed to resolve them.

CT angiography of the lower extremities.

CT angiography (CTA) of the lower extremities has evolved into a robust noninvasive angiographic technique with the advent of 16 and 64 multidetector computed tomographic systems and advances in system design. CTA has displaced conventional catheter arteriography in a large range of applications and is predominantly used in the evaluation of atherosclerotic peripheral arterial occlusive disease in symptomatic patients who are candidates for intervention. Other disease entities including atheroembolism and thromboembolism, aneurysmal disease, and arteritides including Buerger disease and Takayasu arteritis can be precisely evaluated by CTA. Particular applications include arterial vascular mapping for free flap transfers and fibular grafts and evaluation of trauma, before and following orthopedic and plastic surgery interventions. Patients with intravascular stents and arterial bypass grafts who usually undergo serial evaluation by noninvasive, nonangiographic testing are potential candidates for angiographic study when clinical findings of noninvasive tests are in disagreement. The key to a successful clinical application is in understanding how to acquire, display, and interpret high-quality CTA in diverse clinical circumstances.

Filters placed in the superficial femoral arteries for limb salvage in a high-surgical-risk patient with atheroembolism: results at 2 years.

PURPOSE: To report the off-label use of Emboshield filters as a treatment for bilateral atheroembolism (trash foot) in an inoperable patient. CASE REPORT: 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. CONCLUSION: This case demonstrates the successful off-label use of an Emboshield filter for trash foot in an inoperable patient.

Cholesterol emboli syndrome--a rare complication of cardiac catheterization.

We are reporting the case of a 57 years old male, hypertensive, diabetic, dyslipidaemic who presented with exertional angina. He had a coronary artery bypass surgery, one year ago. He underwent left heart catheterization with graft study which showed critical native triple vessel disease with patent arterial graft to left anterior descending and occluded venous grafts to obtuse marginal and right coronary artery. The procedure was complicated by catheter induced dissection of the ascending aorta. Three days later he developed cholesterol emboli syndrome, that was treated symptomatically.

The seabed-like appearance of atherosclerotic plaques: three-dimensional transesophageal echocardiographic images of the aortic arch causing cholesterol crystal emboli.

Cholesterol crystal embolism (CCE) is a rare but important complication of endovascular procedures or anticoagulation therapy. An 84-year-old man was referred to the Gunma University Graduate School of Medicine with the diagnosis of acute myocardial infarction. After successful emergency coronary angioplasty, his serum creatinine level increased continuously. A subsequent skin biopsy confirmed that the patient had CCE. Transesophageal echocardiography (TEE) clearly demonstrated the mobile mass protruding from the complex atheroma. Three-dimensional TEE provides more precise and attractive volumetric images of the atherosclerotic plaque than two-dimensional TEE. In addition, the findings of this case revealed contrast media-induced nephropathy and CCE as possible causes of renal dysfunction after endovascular procedures.

Combined assessment of carotid vulnerable plaque, renal insufficiency, eosinophilia, and hs-CRP for predicting risky aortic plaque of cholesterol crystal embolism.

BACKGROUND: Cholesterol crystal embolism (CCE) is a serious complication of vascular procedures and based on the clinical features of patients with CCE, the aim of the present study was to establish screening criteria for aortic complex plaques (ACP) at high-risk of CCE. METHODS AND RESULTS: For the first study, 10 patients diagnosed as having CCE were recruited. They had prior multiple atherosclerotic disease and a high proportion of complex plaques of the carotid artery and aorta. Elevated levels of high-sensitivity C-reactive protein (hs-CRP), eosinophilia, and renal insufficiency were already recognized before CCE diagnosis. The second study prospectively enrolled 102 patients. ACP is related to CCE and predictive criteria of ACP were established. Among 19 patients with ACP, 2 presented with CCE. Multivariate analysis revealed carotid complex plaque, eosinophilia and multiple atherosclerotic risk factors as independent predictors of ACP. The criteria including these factors (multiple atherosclerotic risk factors, carotid complex plaque, hs-CRP > or =0.2 mg/dl, eGFR < or =60 ml . min(-1) . 1.73 m(-2), eosinophil count > or =400 /microl) could detect patients with ACP with 95% sensitivity, 94% specificity, and 79% positive predictive value. CONCLUSIONS: Multiple atherosclerotic risk factors, elevated hs-CRP, renal insufficiency, eosinophilia before CCE diagnosis and carotid complex plaques were features of patients with CCE. Diagnostic criteria including these characteristics effectively predict ACP patients at high-risk of CCE. (Circ J 2010; 74: 51 - 58).

Athero-embolic isolated splenic infarction following left cardiac catheterization.

Instrumentation of the aorta during cardiac catheterization, resulting in peripheral embolization, is an underdiagnosed clinical entity. Such an atheromatous embolization can present in a subtle way or could be catastrophic. Isolated splenic infarction as a complication of the procedure is extreme rare. We report a 59-year-old man with risk factors for atherosclerotic vascular disease who underwent percutaneous coronary intervention and presented 3 days later with isolated splenic infarction. He was managed conservatively with heparin. Further evaluation revealed a concomitant mural thrombus in an abdominal aortic aneurysm, which could be a contributing factor along with atheroembolization from advanced atherosclerosis. Our case highlights the importance of using a right brachial or radial approach in an individual with significant atherosclerotic vascular disease and with an abdominal aortic aneurysm.

Rate of arterial occlusion in patients with acute ischemic stroke.

OBJECTIVE: Computed tomographic angiography (CTA) was invented more than 20 years ago, but only gained acceptance recently, thanks to advancements in the computer technology. It can demonstrate areas of arterial stenosis or occlusion with accuracy nearly that of digital subtraction angiography (DSA). It is also able to clearly illustrate calcification, which is more difficult to define on magnetic resonance angiography and is not clearly depicted on DSA. METHODS: Our retrospective study attempted to clarify the rate of occlusion or stenosis in the patients with acute ischemic stroke. RESULTS: Over the period of 7 months, 93 consecutive patients were admitted with acute ischemic stroke. Fifty-six patients underwent CTA and were included in this study. Most of the patients were admitted after 6 hours following onset of symptoms. There were 28 men and 28 women, and 80.4% of the cohort was of African-American origin. The majority of strokes were attributed to small-vessel disease (25/56). The rest of the cases were deemed secondary to atheroembolism (15/56), cardioembolism (9/56) or of unclear etiology (7/56). In 24 (42.9%) patients, CTA failed to reveal any abnormalities of the cerebrovascular tree. CTA demonstrated arterial occlusion in ten (17.9%) patients and stenosis of extracranial or intracranial arteries on the symptomatic side in 22 (39.2%) patients. There was very good correlation between CTA and ultrasound techniques (carotid duplex and transcranial Doppler). CTA was superior in demonstrating distal intracranial stenosis. CONCLUSION: Overall, CTA is an extremely valuable and fast way to emergently evaluate the cerebrovascular anatomy, making it very useful for pre-thrombolysis evaluation of patients with ischemic stroke.

Partial recovery of delayed graft function due to cholesterol emboli after renal transplantation.

A 65-year-old man who received a deceased renal allograft in September 2001. The donor of the allograft was a 54-year-old hypertensive man who expired from intracerebral hemorrhage. Atheroma with hard plaques was present in both renal arteries and aortic patches. After vascular anastomosis and clamp release, the allograft recoloration was inadequate, and the patient remained anuric. Computerized tomography scan demonstrated disseminated infarction areas, suggesting cholesterol emboli, which was confirmed later by a graft biopsy. As approximately 50% of the renal parenchyma was perfused, graft nephrectomy was not indicated and dialysis was restarted. Diuresis was over 3000 ml/day and serum creatinine decreased and stabilized at 360 micromol/L by the 32nd postoperative day. The allograft supported the patient for only two years, and he eventually was successfully retransplanted in June 2003. We believe that delayed graft function due to cholesterol emboli disease may be reversible if areas of infarction are not too large.