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Hata Y, Iida O, Okamoto S, Ishihara T, Nanto K, Tsujimura T, Higashino N, Toyoshima T, Nakao S, Fukunaga M, Kawasaki D, Fujihara M, Takahara M, Mano T. Clinical Outcomes of Patients With Cholesterol Crystal Embolism Accompanied by Lower Extremity Wound. Angiology 2025; 76:32-39. [PMID: 37615068 DOI: 10.1177/00033197231195671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Cholesterol crystal embolism (CCE) accompanied by a lower extremity wound is occasionally difficult to differentiate from chronic limb-threatening ischemia (CLTI) and treat. The present multi-center retrospective observational study investigated the clinical characteristics and prognosis of CCE with lower extremity wounds. Consecutive patients (n = 58) clinically diagnosed as CCE with lower extremity wounds between April 2010 and December 2019 were studied. CCE was diagnosed using histological findings, foot condition, renal impairment, and eosinophilia. The primary outcome was 1-year wound healing rate. Patients with CCE were compared with 1309 patients diagnosed with CLTI with tissue loss during the same study period. The CCE group had a significantly more severe Wound, Ischemia, and foot Infection (WIfI) classification compared with the CLTI group. After Kaplan-Meier analysis, the CCE group had a similar 1-year wound healing (55.1 vs 58.3%, P = .096) as the CLTI group. In multivariate stratified Cox regression analysis by WIfI stages, CCE was significantly associated with poor wound healing compared with CLTI [hazard ratio .36 (95% confidence interval .21-.62)]. In conclusion, among the similar WIfI clinical stages, wound healing was significantly worse in the CCE group than in the CLTI group.
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Affiliation(s)
- Yosuke Hata
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Shin Okamoto
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | - Kiyonori Nanto
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | - Naoko Higashino
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Taku Toyoshima
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | - Sho Nakao
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
| | | | - Daizo Kawasaki
- Department of Cardiology, Morinomiya Hospital, Osaka, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Toshiaki Mano
- Cardiovascular Center, Kansai Rosai Hospital, Amagasaki, Japan
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Pacchiarini MC, Di Mario F, Greco P, Fiaccadori E, Rossi GM. The Controversial Role of Glucocorticoids in Atheroembolic Renal Disease: A Narrative Review. J Clin Med 2024; 13:6441. [PMID: 39518580 PMCID: PMC11546646 DOI: 10.3390/jcm13216441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Revised: 10/20/2024] [Accepted: 10/22/2024] [Indexed: 11/16/2024] Open
Abstract
Cholesterol crystal embolism (CCE) is an underrecognized multisystemic disease caused by the displacement of cholesterol crystals from atheromatous aortic plaques to distal vascular beds, leading to ischemic injury of target organs, particularly the kidneys, i.e., atheroembolic renal disease (ARD). According to recent research, cellular necrosis, induced by crystal-induced cytotoxicity, enhances the autoinflammatory cascade of the NLPR3 inflammasome, leading in turn to the so-called "necroinflammation". The purported involvement of the latter in CCE offers a rationale for the therapeutic approach with anti-inflammatory drugs such as glucocorticoids, the use of which has long been a matter of debate in CCE. Diagnostic delay and no consistent evidence regarding efficacious treatment, leading to inconsistency in clinical practice, may worsen the already poor prognosis of ARD. The possible role of glucocorticoids in the treatment of ARD is thereby herein explored in a narrative fashion, analyzing the limited data from case reports and clinical trials.
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Affiliation(s)
- Maria Chiara Pacchiarini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Francesca Di Mario
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Paolo Greco
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
| | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
- Laboratorio di Immunopatologia Renale “Luigi Migone”, University of Parma, 43126 Parma, Italy
| | - Giovanni Maria Rossi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Nephrology Unit, University Hospital of Parma, 43126 Parma, Italy
- Laboratorio di Immunopatologia Renale “Luigi Migone”, University of Parma, 43126 Parma, Italy
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3
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Pyae Kyaw M, Tanaka T, Ito J, Matsuoka R, Komuta M, Matsuno A. Cholesterol Crystal Embolism Following Mechanical Thrombectomy for Acute Ischemic Stroke. Cureus 2024; 16:e72022. [PMID: 39569281 PMCID: PMC11577971 DOI: 10.7759/cureus.72022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2024] [Indexed: 11/22/2024] Open
Abstract
Cholesterol crystal embolism (CCE) is a rare but serious complication of atherosclerotic plaque rupture, often occurring after endovascular interventions. We report the case of a 73-year-old man who developed CCE following mechanical thrombectomy (MT) for an acute ischemic stroke (AIS) due to left internal carotid artery occlusion. The patient, with a history of hypertension and hyperlipidemia, underwent successful MT with complete recanalization. However, four weeks after the procedure, he presented with blue toe syndrome and acute kidney injury. Histopathological analysis of a skin biopsy confirmed the diagnosis of CCE. The patient's renal function partially improved with corticosteroid therapy. Clinicians should maintain a high level of suspicion for CCE in patients who develop renal dysfunction or peripheral ischemia after MT, particularly in those with significant atherosclerotic risk factors. Early detection and timely intervention are critical for improving outcomes. Further research is warranted to clarify the incidence and optimal management of CCE in the context of MT for AIS.
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Affiliation(s)
- May Pyae Kyaw
- Department of Neurosurgery, International University of Health and Welfare Narita Hospital, Narita, JPN
| | - Tatsuya Tanaka
- Department of Neurosurgery, International University of Health and Welfare Narita Hospital, Narita, JPN
| | - Jun Ito
- Department of Nephrology, International University of Health and Welfare Narita Hospital, Narita, JPN
| | - Ryosuke Matsuoka
- Department of Anatomic Pathology, International University of Health and Welfare Narita Hospital, Narita, JPN
| | - Mina Komuta
- Department of Anatomic Pathology, International University of Health and Welfare Narita Hospital, Narita, JPN
| | - Akira Matsuno
- Department of Neurosurgery, International University of Health and Welfare Narita Hospital, Narita, JPN
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van den Beukel BAW, Poot A, Beuk R. Fatal Course of Cutaneous Cholesterol Embolization Syndrome: A Case Report. INT J LOW EXTR WOUND 2023; 22:753-758. [PMID: 34791924 DOI: 10.1177/15347346211058590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cholesterol embolization syndrome is an increasing but underestimated problem after endovascular intervention or after the start of thrombolytic therapies. Embolies from the aortic wall involves abdominal organs and the skin of the lower extremities or buttocks. In our case a progressive ulceration and necroses occurs spontaneously. Endovascular treatment of the lower extremities was successful for a short period. Due to the progression of necrosis, both legs were amputated. Biopsies were taken from the skin were initially no directions to the diagnosis of Cholesterol embolization syndrome. After a second elliptical excision biopsy the diagnosis of cholesterol embolization syndrome was confirmed. Because the rapid progression of skin necroses despite the treatment of prednisone, patient died due to sepsis and renal failure. This case shows when arterial revascularization is performed and progression in skin necrosis occurs despite optimal arterial vascular status the diagnosis CES should be considered and treated in an early state of disease.
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Affiliation(s)
| | - A Poot
- Medisch Spectrum Twente, Netherlands
| | - R Beuk
- Medisch Spectrum Twente, Netherlands
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5
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Akpala C, Kim G, Froehling D, Comfere N, Sominidi Damodaran S. Cholesterol Embolization Syndrome Post Invasive Arterial Procedure: A Case Report. Cureus 2023; 15:e46986. [PMID: 38022197 PMCID: PMC10640895 DOI: 10.7759/cureus.46986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Cholesterol embolization syndrome (CES) is a rare but systemic severe disease caused by the distal showering of cholesterol crystals after angiography, major surgery, thrombolysis, or anticoagulation. Here, we present a case of a 74-year-old male with a history of coronary artery disease, chronic kidney disease, peripheral vascular disease, antiphospholipid syndrome, and right internal carotid artery occlusion who developed purple discoloration and ulceration involving several toes two months after coronary artery bypass surgery. A broad differential diagnosis for blue toes was considered, and a biopsy was obtained, which revealed an arterial lumen filled with large cholesterol crystal spaces, confirming the diagnosis of CES. Treatment of CES remains a bimodal approach of supportive and prophylactic care. Although there is no direct evidence in favor of antiplatelet agents, their use seems reasonable because they have been shown to reduce the risk of other cardiovascular events in patients with extensive atherosclerosis. In this case, the patient's toe pain improved with the use of topical amitriptyline ketamine and has achieved complete resolution of pain and skin discoloration at a seven-month follow-up.
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Affiliation(s)
| | - Grace Kim
- Dermatology, Mayo Clinic, Rochester, USA
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Chaudhary S, Kashani KB. Acute Kidney Injury Management Strategies Peri-Cardiovascular Interventions. Interv Cardiol Clin 2023; 12:555-572. [PMID: 37673499 DOI: 10.1016/j.iccl.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
In many countries, the aging population and the higher incidence of comorbid conditions have resulted in an ever-growing need for cardiac interventions. Acute kidney injury (AKI) is a common complication of these interventions, associated with higher mortalities, chronic or end-stage kidney disease, readmission rates, and hospital and post-discharge costs. The AKI pathophysiology includes contrast-associated AKI, hemodynamic changes, cardiorenal syndrome, and atheroembolism. Preventive measures include limiting contrast media dose, optimizing hemodynamic conditions, and limiting exposure to other nephrotoxins. This review article outlines the current state-of-art knowledge regarding AKI pathophysiology, risk factors, preventive measures, and management strategies in the peri-interventional period.
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Affiliation(s)
- Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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7
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Shi C, Mammadova-Bach E, Li C, Liu D, Anders HJ. Pathophysiology and targeted treatment of cholesterol crystal embolism and the related thrombotic angiopathy. FASEB J 2023; 37:e23179. [PMID: 37676696 DOI: 10.1096/fj.202301316r] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023]
Abstract
Cholesterol crystal (CC) embolism is a complication of advanced atherosclerotic plaques located in the major arteries. This pathological condition is primarily induced by interventional and surgical procedures or occurs spontaneously. CC can induce a wide range of tissue injuries including CC embolism syndrome, a spontaneous or intervention-induced complication of advanced atherosclerosis, while treatment of CC embolism has remained empiric. Vascular occlusions caused by CC embolism may exceed the ischemia tolerance of many tissues, particularly when small arteries are affected. The main approach to CC embolism is primary prophylaxis in patients at risk by stabilizing atherosclerotic plaques and avoiding unnecessary catheter interventions. During CC embolism, the use of platelet inhibitors to avoid abnormal activation and aggregation and anticoagulants may reduce the risk of vascular occlusions and tissue ischemia. This probably explains the relatively low prevalence of clinical manifestations of CC embolism, which are frequently found in autopsy studies. In this review, we summarized the current knowledge on the pathophysiology of CC embolism syndrome deriving from clinical observations and experimental mouse models. Furthermore, we described the risk factors of CC embolism in humans as well as the experimental studies based on empiric treatments. We also discuss potential therapeutic interventions based on recent experimental data and emerging drug options evolving from other research domains. Given the substantial unmet medical need to improve the outcomes of CC embolism, the identification of effective treatment strategies is urgently needed.
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Affiliation(s)
- Chongxu Shi
- Nantong Laboratory of Development and Diseases, School of Life Sciences, Medical College, Nantong University, Nantong, China
| | - Elmina Mammadova-Bach
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
- Walther-Straub-Institute for Pharmacology and Toxicology, Ludwig-Maximilians University Munich, Munich, Germany
| | - Cong Li
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
| | - Dong Liu
- Nantong Laboratory of Development and Diseases, School of Life Sciences, Medical College, Nantong University, Nantong, China
| | - Hans-Joachim Anders
- Renal Division, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians University Munich, Munich, Germany
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Zebrauskaite A, Ziubryte G, Mackus L, Lieponyte A, Kairyte E, Unikas R, Jarusevicius G. A Simple Strategy to Reduce Contrast Media Use and Risk of Contrast-Induced Renal Injury during PCI: Introduction of an "Optimal Contrast Volume Protocol" to Daily Clinical Practice. J Cardiovasc Dev Dis 2023; 10:402. [PMID: 37754831 PMCID: PMC10531638 DOI: 10.3390/jcdd10090402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/28/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023] Open
Abstract
Contrast-induced acute kidney injury is the leading cause of iatrogenic acute nephropathy. Development of contrast-induced nephropathy (CIN) increases the risk of adverse long- and short-term patients outcomes, the hospital costs, and length of hospitalization. There are a couple of methods described for CIN prevention (statin prescription, prehydration, contrast media (CM) clearance from the blood system, and decrease amounts of contrast volume). The CM volume to patient's creatinine clearance ratio is the main factor to predict the risk of CIN development. The safe CM to creatinine clearance ratio limits have been established. The usage of CM amount depends on personal operators habits and inside center regulations. There is no standardized contrast usage protocol worldwide. The aim of this study was to establish an easy to use, cheap, and efficient protocol to estimate a personalized safe CM dose limit for every patient based on their kidney function. These limits are announced during the "Time Out" before the procedure. Our study included 519 patients undergoing interventional coronary procedures: 207 patients into the "Optimal Contrast Volume" arm and 312 into the control group. Applying the protocol into a daily clinical practice leads to a significant reduction in CM volume used for all type of procedures and the development of CIN in comparison with a control group.
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Affiliation(s)
- Aiste Zebrauskaite
- Clinic of Cardiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, 50161 Kaunas, Lithuania; (G.Z.); (L.M.); (A.L.); (E.K.); (R.U.); (G.J.)
- Faculty of Medicine, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Greta Ziubryte
- Clinic of Cardiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, 50161 Kaunas, Lithuania; (G.Z.); (L.M.); (A.L.); (E.K.); (R.U.); (G.J.)
| | - Lukas Mackus
- Clinic of Cardiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, 50161 Kaunas, Lithuania; (G.Z.); (L.M.); (A.L.); (E.K.); (R.U.); (G.J.)
| | - Austeja Lieponyte
- Clinic of Cardiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, 50161 Kaunas, Lithuania; (G.Z.); (L.M.); (A.L.); (E.K.); (R.U.); (G.J.)
| | - Evelina Kairyte
- Clinic of Cardiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, 50161 Kaunas, Lithuania; (G.Z.); (L.M.); (A.L.); (E.K.); (R.U.); (G.J.)
| | - Ramunas Unikas
- Clinic of Cardiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, 50161 Kaunas, Lithuania; (G.Z.); (L.M.); (A.L.); (E.K.); (R.U.); (G.J.)
- Faculty of Medicine, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
| | - Gediminas Jarusevicius
- Clinic of Cardiology, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, 50161 Kaunas, Lithuania; (G.Z.); (L.M.); (A.L.); (E.K.); (R.U.); (G.J.)
- Faculty of Medicine, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
- Institute of Cardiology, Lithuanian University of Health Sciences, 50161 Kaunas, Lithuania
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Karch J, Raja A, De La Garza H, De Jesus Diaz Zepeda A, Shih A, Maymone MBC, Phillips TJ, Secemsky E, Vashi N. Part I: Cutaneous manifestations of cardiovascular disease. J Am Acad Dermatol 2023; 89:197-208. [PMID: 35504486 DOI: 10.1016/j.jaad.2021.06.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 11/25/2022]
Abstract
In this part 1 of a 2-part continuing medical education series, we review the epidemiology and pathophysiology of cardiovascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of cardiovascular syndromes, including infective endocarditis, acute rheumatic fever, Kawasaki disease, cholesterol embolization syndrome, lipid disorders, cardiac amyloidosis, and cardiac myxomas. As the incidence and prevalence of cardiovascular diseases increase, dermatologists play an essential role in recognizing the cutaneous manifestations of cardiovascular diseases in order to appropriately connect patients with follow-up care.
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Affiliation(s)
- Jamie Karch
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aishwarya Raja
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Henriette De La Garza
- Departments of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Allen Shih
- Departments of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Mayra B C Maymone
- Department of Dermatology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tania J Phillips
- Departments of Dermatology, Boston University School of Medicine, Boston, Massachusetts
| | - Eric Secemsky
- Smith Center for Outcomes Research, Departments of Cardiology and Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Neelam Vashi
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; Department of Dermatology, US Department of Veteran Affairs, Boston Health Care System, Boston, Massachusetts.
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Nguyen Tuan L, Nguyen Thi Bach Y, Nguyen Duc H, Nguyen Hoai V. A Massive Renal Infarction Due to Atheroemboli: A Case Report. Cureus 2023; 15:e41842. [PMID: 37575805 PMCID: PMC10423079 DOI: 10.7759/cureus.41842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
The symptoms of acute renal infarction (ARI) caused by atheroemboli are vague, making it rare. Early diagnosis of renal infarction can be made through contrast-enhanced CT of the abdomen. However, diagnosing atheroemboli is more challenging. Kidney biopsy is the most accurate method to determine the cause, but it may not always be available in clinical settings. In cases where a thrombectomy is performed, white substances in thrombus aspiration or the patient's blood can suggest a diagnosis. Intervention is an effective technique, but there is controversy due to a lack of data, particularly in lobular artery infarction. We successfully treated one case using thrombus aspiration, and the specimens suggested atherosclerosis as the cause.
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Bahloul M, Makni A, Kharrat S, Alila I, Suissi B, Bouaziz M. A possible cause of cholesterol crystal embolism in a polytrauma patient? JOURNAL DE MEDECINE VASCULAIRE 2023; 48:88-90. [PMID: 37422333 DOI: 10.1016/j.jdmv.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023]
Affiliation(s)
- M Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax University, Sfax, Tunisia.
| | - A Makni
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax University, Sfax, Tunisia
| | - S Kharrat
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax University, Sfax, Tunisia
| | - I Alila
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax University, Sfax, Tunisia
| | - B Suissi
- Department of Radiology, Habib Bourguiba Hospital, Sfax University, Sfax, Tunisia
| | - M Bouaziz
- Department of Intensive Care, Habib Bourguiba University Hospital, Sfax University, Sfax, Tunisia
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12
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Association of Radial Artery Access with Reduced Incidence of Acute Kidney Injury. J Interv Cardiol 2023; 2023:1117379. [PMID: 36712998 PMCID: PMC9876675 DOI: 10.1155/2023/1117379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023] Open
Abstract
Objectives To determine if radial artery (RA) access compared with femoral artery (FA) access for percutaneous coronary intervention (PCI) is associated with a lower incidence of acute kidney injury (AKI). Background AKI results in substantial morbidity and cost following PCI. Prior studies comparing the occurrence of AKI associated with radial artery (RA) versus femoral artery (FA) access have mixed results. Methods Using a large state-wide database, 14,077 patients (8,539 with RA and 5,538 patents with FA access) were retrospectively compared to assess the occurrence of AKI following PCI. To reduce selection bias and balance clinical data across the two groups, a novel machine learning method called a Generalized Boosted Model was conducted on the arterial access site generating a weighted propensity score for each variable. A logistic regression analysis was then performed on the occurrence of AKI following PCI using the weighted propensity scores from the Generalized Boosted Model. Results As shown in other studies, multiple variables were associated with an increase in AKI after PCI. Only RA access (OR 0.82; 95% CI 0.74-0.91) and male gender (OR 0.80; 95% CI 0.72-0.89) were associated with a lower occurrence of AKI. Based on the calculated Mehran scores, patients were stratified into groups with an increasing risk of AKI. RA access was consistently found to have a lower risk of AKI compared with FA access across these groups of increasing risk. Conclusions Compared with FA access, RA access is associated with an 18% lower rate of AKI following PCI. This effect was observed among different levels of risk for developing AKI. Although developed from a retrospective analysis, this study supports the use of RA access when technically possible in a diverse group of patients.
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Woo S, Lee CA, Lee JW, Moon J, Cho YS, Nah S, Han S. Predictors for Distinguishing Renal Infarction From Urolithiasis in the Emergency Department: A Randomly Matched Retrospective Case-Control Study. J Emerg Med 2023; 64:31-39. [PMID: 36641258 DOI: 10.1016/j.jemermed.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Emergency department (ED) clinicians may misdiagnose renal infarction (RI) as urolithiasis because RI is a rare disease with presenting symptoms similar to the symptoms of urolithiasis. However, earlier diagnosis of RI can improve patient prognosis. OBJECTIVES We investigated potential predictors for distinguishing RI from urolithiasis based on clinical findings and laboratory results. METHODS This randomly matched retrospective case-control study included patients who had been diagnosed with acute RI or acute urolithiasis between January 2016 and March 2020. Patients were excluded if they were aged under 18 years, had a history of trauma, or had incomplete medical records. Using a matching ratio of 1:4, RI patients were randomly matched to urolithiasis patients. Multivariable logistic regression was performed to identify factors that could distinguish RI from urolithiasis. RESULTS In total, 48 patients were included in the RI group and 192 patients were included in the urolithiasis group. Multivariable logistic regression showed that age ≥ 65 years (odds ratio [OR] 6.155; p = 0.022), atrial fibrillation (OR 18.472; p = 0.045), current smoking (OR 17.070; p = 0.001), costovertebral angle tenderness (OR 0.179; p = 0.037), aspartate aminotransferase level ≥ 27.5 U/L (OR 6.932; p = 0.009), sodium level ≥ 138.5 mEq/L (OR 0.079; p = 0.004), and hematuria (OR 0.042; p = 0.001) were significant predictors that could distinguish RI from urolithiasis. Based on these results, a nomogram was constructed. CONCLUSION Age ≥ 65 years, atrial fibrillation, current smoking, absence of costovertebral angle tenderness, aspartate aminotransferase level ≥ 27.5 U/L, sodium level < 138.5 mEq/L, and absence of hematuria were predictors that can distinguish between RI and urolithiasis.
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Affiliation(s)
- Seungho Woo
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Choung Ah Lee
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Jae Wook Lee
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Jieun Moon
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Young Soon Cho
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Sangun Nah
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
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Liu L, Zhou L, Li W, Chen H, Li H. Role of modified hydration for preventing contrast-associated acute kidney injury in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention. Intern Emerg Med 2023; 18:67-76. [PMID: 36539602 PMCID: PMC9883347 DOI: 10.1007/s11739-022-03109-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/19/2022] [Indexed: 12/24/2022]
Abstract
To assess the efficacy of modified hydration on contrast-associated acute kidney injury (CA-AKI) in ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (pPCI). A total of 438 patients were randomly assigned to 2 groups. The traditional hydration group (group I) was given at a rate of 1 ml/kg/h for 24 h, and the modified hydration group (group II) was given at a rate of 3 ml/kg/h in the first 4 h, and then reduced to 1 ml/kg/h for 12 h. 0.3 mg/kg of furosemide was given 1-h after hydration. The primary endpoint was the incidence of CA-AKI, and the secondary endpoint was the incidence of major adverse cardiovascular events (MACEs) during a median of 22.4 months (IQR 9.6, 32.6 months) follow-up. The incidence of CA-AKI was 8.7%. Among these, Group I was 9.1% and group II was 8.2%, respectively. There was no significant difference in CA-AKI and creatinine levels between the two hydration groups. Multivariable logistics regression analysis revealed that creatinine, white blood cells, and N-terminal pro-B-type natriuretic peptide were associated with CA-AKI. Moreover, CA-AKI was an independent predictor for all-cause death and cardiac death during the follow-up period. The modified hydration may reduce the incidence of CA-AKI, although this difference was not statistically significant. The relationship between CA-AKI and mortality strengthened as creatinine times above baseline increased. Mitigating the occurrence of CA-AKI may reduce all-cause death and cardiac death.
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Affiliation(s)
- Lei Liu
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Beijing, 100050, China
| | - Li Zhou
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Beijing, 100050, China
| | - Weiping Li
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Beijing, 100050, China
- Beijing Key Laboratory of Metabolic Disorder Related Cardiovascular Disease, Beijing, China
| | - Hui Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Beijing, 100050, China.
| | - Hongwei Li
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Beijing, 100050, China.
- Beijing Key Laboratory of Metabolic Disorder Related Cardiovascular Disease, Beijing, China.
- Department of Geriatrics, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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15
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Maksimczuk J, Galas A, Krzesiński P. What Promotes Acute Kidney Injury in Patients with Myocardial Infarction and Multivessel Coronary Artery Disease-Contrast Media, Hydration Status or Something Else? Nutrients 2022; 15:nu15010021. [PMID: 36615678 PMCID: PMC9824824 DOI: 10.3390/nu15010021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Multivessel coronary artery disease (MVCAD) is found in approximately 50% of patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Although we have data showing the benefits of revascularization of significant non-culprit coronary lesions in patients with AMI, the optimal timing of angioplasty remains unclear. The most common reason for postponing subsequent percutaneous treatment is the fear of contrast-induced acute kidney injury (CI-AKI). Acute kidney injury (AKI) is common in patients with AMI undergoing PCI, and its etiology appears to be complex and incompletely understood. In this review, we discuss the definition, pathophysiology and risk factors of AKI in patients with AMI undergoing PCI. We present the impact of AKI on the course of hospitalization and distant prognosis of patients with AMI. Special attention was paid to the phenomenon of AKI in patients undergoing multivessel revascularization. We analyze the correlation between increased exposure to contrast medium (CM) and the risk of AKI in patients with AMI to provide information useful in the decision-making process about the optimal timing of revascularization of non-culprit lesions. In addition, we present diagnostic tools in the form of new biomarkers of AKI and discuss ways to prevent and mitigate the course of AKI.
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16
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Kanai D, Fujii H, Nakai K, Kono K, Watanabe K, Goto S, Nishi S. Statin Use Influence on the Occurrence of Acute Kidney Injury in Patients with Peripheral Arterial Disease. J Atheroscler Thromb 2022; 29:1646-1654. [PMID: 35013022 PMCID: PMC9623082 DOI: 10.5551/jat.63265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/03/2021] [Indexed: 11/11/2022] Open
Abstract
AIM Acute kidney injury (AKI) is an important clinical issue in the diagnosis and treatment of cardiovascular diseases. The association between pretreatment by statins and the occurrence of AKI in patients with peripheral arterial diseases (PAD) remains unclear. Therefore, we examined the association between statin therapy and the occurrence of AKI in patients with PAD. METHODS We retrospectively analyzed data from the endovascular treatment (EVT) database in our hospital. A total of 295 patients who underwent angiography and/or intervention for PAD between October 2011 and March 2016 were enrolled and divided into two groups: those without statins (control group; N=157) and those with statins (statin group; N=138) for at least 1 month before admission. We examined the occurrence of AKI and its related factors in these patients. RESULTS The serum creatinine levels, dose of contrast medium, use of a renin-angiotensin system inhibitor, smoking habit, and blood pressure were similar in both groups. The statin group had more diabetes patients, had patients who were significantly younger, had patients with a higher body mass index (BMI), and had patients with lower low-density lipoprotein cholesterol than the control group. With regard to the occurrence of AKI, there was a significantly lower incidence in the statin group compared with the control group (5% vs. 16%, p<0.05). The result of the multivariate analysis indicated that statin therapy was significantly correlated with lower occurrence rates of AKI (p<0.05). CONCLUSIONS Our study suggests that statin therapy might prevent the occurrence of AKI after angiography and/or intervention for PAD.
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Affiliation(s)
- Daisuke Kanai
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Nephrology and Kidney Center, Kakogawa Central City Hospital, Hyogo, Japan
| | - Hideki Fujii
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kentaro Nakai
- Department of Nephrology and Kidney Center, Kakogawa Central City Hospital, Hyogo, Japan
| | - Keiji Kono
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kentaro Watanabe
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
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17
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Prevention and Management of AKI in ACS Patients Undergoing Invasive Treatments. Curr Cardiol Rep 2022; 24:1299-1307. [PMID: 35925513 DOI: 10.1007/s11886-022-01742-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Management of patients presenting with acute coronary syndrome (ACS) includes invasive procedures that may increase the risk of acute kidney injury (AKI). AKI adversely affects the outcomes of such procedures and complicates the management of ACS. We have summarized several strategies for the prevention and management of AKI in this critical patient group including in the pre-procedural, intraprocedural, and post-procedural settings. RECENT FINDINGS Definitive prevention and management strategies for AKI in patients presenting with ACS requiring invasive management can be confounded by the variation in data outcomes. Pre-procedural hydration with normal saline when accounting for time to catheterization, radial artery access, contrast stewardship, and close monitoring of renal function after catheterization should be implemented.
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18
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Tomoi Y, Soga Y, Imada K, Kodama K, Katsuki T, Hiramori S, Ando K. Use of Proprotein Converse Subtilisin/Kexin Type 9 Inhibitor to Treat Cholesterol Crystal Embolisms after Catheterization: A Report of Three Cases. Intern Med 2022; 61:857-860. [PMID: 34471031 PMCID: PMC8987251 DOI: 10.2169/internalmedicine.8088-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Cholesterol crystal embolism (CCE) is a serious complication that occurs after cardiac and vascular procedures. CCE involves multiple organs, and the prognosis and renal function of patients is poor. Although the efficacy of steroid, statin, and low-density lipoprotein apheresis has been reported, no definitive treatment has been established. We herein report three consecutive cases treated with conventional steroid therapy with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor after catheterization. The renal function was preserved, steroid therapy was stopped, and wound healing of blue toes was achieved. PCSK9 inhibitor therapy was safe in the present patient and may be a potential treatment option for CCE.
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Affiliation(s)
- Yusuke Tomoi
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | | | - Kazuaki Imada
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | - Kenji Kodama
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | | | | | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Japan
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19
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Takahashi K, Omuro A, Ohya M, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Incidence, Risk Factors, and Prognosis of Cholesterol Crystal Embolism Because of Percutaneous Coronary Intervention. Am J Cardiol 2022; 167:15-19. [PMID: 34986990 DOI: 10.1016/j.amjcard.2021.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/13/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
Abstract
Cholesterol crystal embolism (CCE) is a rare but serious complication of percutaneous coronary intervention (PCI). However, its incidence, risk factors, and prognosis in the contemporary era are not well known. We included 23,184 patients who underwent PCI in our institution between January 2000 and December 2019 in this study. The diagnosis of CCE was made histologically or by the combination of cutaneous signs and specific blood test results. In patients with CCE, we evaluated the incidence, risk factors, and prognosis. A total of 88 patients (0.38%) were diagnosed with CCE. The incidence of CCE seemed to decline through the investigated 20 years. Positive predictors of CCE were age ≥70 years (68% vs 59%, p = 0.012), aortic aneurysm (23% vs 7.2% p <0.001), and a femoral approach (71% vs 45%, p <0.001), whereas a negative predictor of CCE was the use of an inner sheath (63% vs 77%, p <0.001). The rate of 1-year mortality and the requirement for chronic hemodialysis within 1 year after PCI in patients with CCE were 10% and 11%, respectively. The use of an inner sheath and a nonfemoral approach was associated with a lower incidence of CCE. In conclusion, because the prognosis of patients with CCE is still poor, preprocedural identification of high-risk patients and selection of low-risk procedures could be important for preventing CCE.
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Affiliation(s)
- Kotaro Takahashi
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Ayumi Omuro
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Masanobu Ohya
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shunsuke Kubo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Tada
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiroyuki Tanaka
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yasushi Fuku
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
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20
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Transradial versus Transfemoral Access and the Risk of Acute Kidney Injury following Primary Percutaneous Coronary Intervention in Patients with ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Propensity-Score-Matched Studies. J Interv Cardiol 2022; 2022:6774439. [PMID: 35360090 PMCID: PMC8930211 DOI: 10.1155/2022/6774439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives The aim of this study is to examine the association between vascular access sites and the incidence of AKI in patients with STEMI undergoing primary PCI. Background Emerging evidence has suggested that transradial access (TRA) may be associated with lower rates of acute kidney injury (AKI) as compared with transfemoral access (TFA). However, most of these studies have included a nonselected study population undergoing diagnostic cardiac catheterization or percutaneous coronary intervention (PCI). Data on the association between TRA and AKI in this setting of STEMI are limited and with conflicting results. Methods We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to July 13th of 2021. Studies included were randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies evaluating the association of TRA versus TFA access with AKI in patients undergoing primary PCI for STEMI. Data were integrated using the random effects model and generic inverse‐variance method of DerSimonian and Laird. Results A total of 10,093 studies were found. After applying our inclusion criteria, 5 studies from 2014 to 2021 with a total of 8,536 STEMI patients were included. TRA was not significantly associated with a reduced risk for AKI compared with TFA (odds ratio 0.85, 95% CI 0.71–1.01, p 0.07, I2 = 40%). Conclusions Transradial access was not significantly associated with lower risk of AKI in patients undergoing primary PCI for STEMI compared with TFA. Larger studies are needed to clarify this outcome.
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21
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Bender ST, Ganz MJ, Mertens PR. [71-year-old patient with violet toes after cardiac catheterization]. Dtsch Med Wochenschr 2022; 147:149-150. [PMID: 35158376 DOI: 10.1055/a-1719-8388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sascha T Bender
- Universitätsklinik für Nieren- und Hochdruckkrankheiten, Diabetologie und Endokrinologie, Otto-von-Guericke-Universität Magdeburg, Magdeburg
| | - Maximilian J Ganz
- Universitätsklinik für Nieren- und Hochdruckkrankheiten, Diabetologie und Endokrinologie, Otto-von-Guericke-Universität Magdeburg, Magdeburg
| | - Peter R Mertens
- Universitätsklinik für Nieren- und Hochdruckkrankheiten, Diabetologie und Endokrinologie, Otto-von-Guericke-Universität Magdeburg, Magdeburg
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22
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Kondo Y, Kanzaki M, Ishima D, Usui R, Kimura A, Usui K, Amoh Y, Takeuchi Y, Kumabe T, Ako J, Miyaji K, Nishiyama K, Akutsu T. Cholesterol crystal embolism-related cerebral infarction: Magnetic resonance imaging and clinical characteristics. eNeurologicalSci 2021; 25:100388. [PMID: 34977369 PMCID: PMC8683713 DOI: 10.1016/j.ensci.2021.100388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/30/2021] [Accepted: 12/04/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND AIMS Cholesterol crystal embolism-related cerebral infarction (CCE-CI) is frequently misdiagnosed due to the lack of specific symptoms. To aid in differential diagnosis, this study comprehensively characterized the magnetic resonance imaging (MRI) and clinical manifestations of CCE-CI and compared these features to those of atherothrombotic cerebral infarction (ACI). METHODS This single-center, retrospective, observational study was conducted at Kitasato University Hospital, Kanagawa, Japan. We identified 37 clinically or histopathologically confirmed CCE-CI cases and 110 ACI cases treated from January 2006 to May 2020. Groups were compared for mean age, sex ratio, clinical presentations, imaging manifestations, precipitating factors, comorbid conditions, medications, and smoking history. RESULTS Of 37 eligible patients with CCE-CI, 10 (27.0%) received brain MRI, of which 8 (21.6%) exhibited high-intensity signals indicative of brain lesions on diffusion-weighted imaging (DWI). However, two patients with DWI lesions exhibited no detectable neurological abnormalities. Patients with CCE-CI frequently demonstrated bilateral DWI lesions involving the bilateral anterior and posterior circulation, a pattern absent in ACI (50% vs. 0%, p < 0.001). Compared to patients with ACI, CCE-CI patients also demonstrated significantly lower estimated glomerular filtration rate (p < 0.001) as well as more frequent eosinophilia (p = 0.006), atherosclerotic plaques ≥4-mm thick in the ascending aorta or proximal arch (p = 0.001), and aortic aneurysm (p < 0.001). CONCLUSIONS Patients with CCE-CI develop multiple DWI lesions across several vascular territories, even in the absence of neurological symptoms. Comorbid aortic aneurysm may increase CCE-CI risk. These findings could help in the differential diagnosis of CCE-CI.
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Key Words
- ACI, Atherothrombotic cerebral infarction
- Atheroembolism
- Atherothrombotic cerebral infarction
- CAS, Carotid artery stenting
- CCE, Cholesterol crystal embolism
- CI, Confidence intervals
- CRP, C-reactive protein
- CTA, Computed tomography angiography
- Cerebral infarction
- Cholesterol crystal embolism
- Cholesterol crystal embolism-related cerebral infarction
- DWI, Diffusion-weighted imaging
- Diffusion-weighted imaging
- IRB, Institutional review board
- LDL, Low-density lipoprotein
- MRA, Magnetic resonance angiography
- MRI, Magnetic resonance imaging
- OR, Odds ratios
- PCI, Percutaneous coronary intervention
- TIA, Transient ischemic attack
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Affiliation(s)
- Yuko Kondo
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Mami Kanzaki
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Daisuke Ishima
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Ryo Usui
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Ayato Kimura
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Kotaro Usui
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Yasuyuki Amoh
- Department of Dermatology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Toshihiro Kumabe
- Department of Neurosurgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kazutoshi Nishiyama
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
| | - Tsugio Akutsu
- Department of Neurology, Kitasato University School of Medicine, Kanagawa, Japan
- Cerebrovascular Center, Kitasato University Hospital, Kanagawa, Japan
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23
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Atheroembolic renal disease associated with dabigatran overdose. J Nephrol 2021; 35:1053-1057. [PMID: 34727351 DOI: 10.1007/s40620-021-01158-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/17/2021] [Indexed: 10/19/2022]
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24
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Haensig M, Kuntze T, Gonzalez-Lopez D, Lapp H, Lauten P, Owais T. Thromboembolic complications in transfemoral aortic valve implantation due to aortic wall thrombus and shaggy aorta syndrome. Eur J Cardiothorac Surg 2021; 60:253-260. [PMID: 33637994 DOI: 10.1093/ejcts/ezab093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/13/2021] [Accepted: 01/22/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Aortic wall thrombus (AWT) can affect suitability to endovascular repair, while its most aggressive entity is better known as shaggy aorta syndrome. Primary objective was to study the procedural and clinical outcome with regard to atherothrombotic AWT in transfemoral aortic valve implantation. METHODS In a retrospective, single-centre analysis, a qualitative 0-10 AWT score classification system was used. The most severely affected aortic area in computed tomography angiography cross-section was assessed for the number of affected segments, thrombus type, thickness, area and circumference. Primary endpoints were 30-day mortality, neurologic, renal and pulmonary events and signs of solid organ infarction. RESULTS Between November 2017 and September 2019, 604 patients underwent transfemoral transcatheter aortic valve implantation in our institution. Computed tomography-guided analysis revealed AWT in 11.3% and shaggy aorta syndrome in 6 patients (1.0% with 83.3% male). AWT was mainly present in the descending thoracic and abdominal aorta and was associated with acute renal failure (11.8% vs 3.2%, P ≤ 0.001) and a seven-fold increased rate of disabling peri-interventional stroke (4.4% vs 0.6%, P ≤ 0.001). In all patients with disabling peri-interventional stroke a balloon-expandable prosthesis was used (P ≤ 0.001). In case of shaggy aorta, mortality was more than six-fold increased (2.8% vs 16.7%, P = 0.046). CONCLUSIONS Severe and irregular thrombus of the descending thoracic and abdominal aorta has been strongly associated with acute respiratory failure and peri-interventional stroke in transfemoral aortic valve implantation, being more likely using balloon-expandable devices. Our results imply important changes with regard to device design and present international transcatheter aortic valve implantation guidelines.
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Affiliation(s)
- Martin Haensig
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Thomas Kuntze
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - David Gonzalez-Lopez
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Harald Lapp
- Department of Cardiology and Internal Medicine, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Philipp Lauten
- Department of Cardiology and Internal Medicine, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Tamer Owais
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany.,Department of Cardiothoracic Surgery, Cairo University, Cairo, Egypt
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25
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Yan X, Zhu Y, Wang X, Li Z. A case of acute renal injury and renal artery stenosis caused by cholesterol crystal embolization after coronary stenting: Improved by a combination therapy. Chronic Dis Transl Med 2021; 7:206-210. [PMID: 34505021 PMCID: PMC8413122 DOI: 10.1016/j.cdtm.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Indexed: 12/04/2022] Open
Affiliation(s)
- Xiaohui Yan
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
| | - Yanting Zhu
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
| | - Xiaoming Wang
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
| | - Zhenjiang Li
- Center of Nephropathy and Hemodialysis, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi 710061, China
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26
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Maningding E, Kermani TA. Mimics of vasculitis. Rheumatology (Oxford) 2021; 60:34-47. [PMID: 33167039 DOI: 10.1093/rheumatology/keaa495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/07/2020] [Accepted: 07/06/2020] [Indexed: 11/14/2022] Open
Abstract
While prompt diagnosis of vasculitis is important, recognition of vasculitis mimics is equally essential. As in the case of vasculitis, an approach to mimics based on the anatomic size of vessels can be useful. Infections can mimic vasculitis of any vessel size, including the formation of aneurysms and induction of ANCAs. Genetic disorders and vasculopathies are important considerations in large and medium vessel vasculitis. Cholesterol emboli, thrombotic conditions and calciphylaxis typically affect the medium and small vessels and, like vasculitis, can cause cutaneous, renal and CNS manifestations. Reversible cerebral vasoconstriction syndrome is important to distinguish from primary angiitis of the CNS. As an incorrect diagnosis of vasculitis can result in harmful consequences, it is imperative that the evaluation of suspected vasculitis includes consideration of mimics. We discuss the above mimics and outline a systematic and practical approach for differentiating vasculitis from its mimics.
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Affiliation(s)
- Ernest Maningding
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tanaz A Kermani
- Division of Rheumatology, University of California, Los Angeles, Los Angeles, CA, USA
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27
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Daniolou S, Rapp A, Haase C, Ruppert A, Wittwer M, Scoccia Pappagallo A, Pandis N, Kressig RW, Ienca M. Digital Predictors of Morbidity, Hospitalization, and Mortality Among Older Adults: A Systematic Review and Meta-Analysis. Front Digit Health 2021; 2:602093. [PMID: 34713066 PMCID: PMC8521803 DOI: 10.3389/fdgth.2020.602093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 12/17/2020] [Indexed: 12/17/2022] Open
Abstract
The widespread adoption of digital health technologies such as smartphone-based mobile applications, wearable activity trackers and Internet of Things systems has rapidly enabled new opportunities for predictive health monitoring. Leveraging digital health tools to track parameters relevant to human health is particularly important for the older segments of the population as old age is associated with multimorbidity and higher care needs. In order to assess the potential of these digital health technologies to improve health outcomes, it is paramount to investigate which digitally measurable parameters can effectively improve health outcomes among the elderly population. Currently, there is a lack of systematic evidence on this topic due to the inherent heterogeneity of the digital health domain and the lack of clinical validation of both novel prototypes and marketed devices. For this reason, the aim of the current study is to synthesize and systematically analyse which digitally measurable data may be effectively collected through digital health devices to improve health outcomes for older people. Using a modified PICO process and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework, we provide the results of a systematic review and subsequent meta-analysis of digitally measurable predictors of morbidity, hospitalization, and mortality among older adults aged 65 or older. These findings can inform both technology developers and clinicians involved in the design, development and clinical implementation of digital health technologies for elderly citizens.
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Affiliation(s)
- Sofia Daniolou
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | | | | | | | | | | | - Nikolaos Pandis
- Department of Orthodontics and Dentofacial Orthopedics, School of Dentistry, University of Bern, Bern, Switzerland
| | - Reto W. Kressig
- University Department of Geriatric Medicine FELIX PLATTER, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Marcello Ienca
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
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Kakeshita K, Koike T, Imamura T, Arisawa Y, Murai S, Shimizu A, Kiyosawa T, Yamazaki H, Kinugawa K. Cholesterol embolization syndrome and intra-abdominal bleeding immediately after initiation of hemodialysis: a case report with literature review. RENAL REPLACEMENT THERAPY 2020. [DOI: 10.1186/s41100-020-00305-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cholesterol embolization syndrome (CES) is a disease associating with the systemic cholesterol crystal embolism and end-organ dysfunction due to the atherosclerotic plaque rupture, which is dominantly triggered by the intravascular intervention. There is no consensus for which types of anticoagulants we should use during the hemodialysis in patients with CES and end-stage renal disease.
Case presentation
We had a 68-year-old man with CES due to intravascular intervention, who suffered the omental bleeding, instead of the embolism, immediately after the initiation of hemodialysis with heparinization. An emergent laparotomy found active bleeding from the omentum, which was surgically repaired. The histopathological analysis showed the embolization of cholesterol crystal clefts in the omentum artery and the injury of arterial wall structure accompanied by the infiltration of inflammatory cells. We preferred nafamostat mesylate during hemodialysis and he had no adverse events following the surgery.
Conclusions
It should be noticed that, in addition to the embolic events, bleeding events can develop in patients with CES, particularly following the initiation of hemodialysis with anticoagulation therapy.
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29
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Isaka Y, Hayashi H, Aonuma K, Horio M, Terada Y, Doi K, Fujigaki Y, Yasuda H, Sato T, Fujikura T, Kuwatsuru R, Toei H, Murakami R, Saito Y, Hirayama A, Murohara T, Sato A, Ishii H, Takayama T, Watanabe M, Awai K, Oda S, Murakami T, Yagyu Y, Joki N, Komatsu Y, Miyauchi T, Ito Y, Miyazawa R, Kanno Y, Ogawa T, Hayashi H, Koshi E, Kosugi T, Yasuda Y. Guideline on the use of iodinated contrast media in patients with kidney disease 2018. Clin Exp Nephrol 2020; 24:1-44. [PMID: 31709463 PMCID: PMC6949208 DOI: 10.1007/s10157-019-01750-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Hiromitsu Hayashi
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazutaka Aonuma
- Cardiology Department, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihide Fujigaki
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hideo Yasuda
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Taichi Sato
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tomoyuki Fujikura
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Toei
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ryusuke Murakami
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Akira Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadateru Takayama
- Division of General Medicine, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Takamichi Murakami
- Department of Radiology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yukinobu Yagyu
- Department of Radiology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Nobuhiko Joki
- Division of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasuhiro Komatsu
- Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine, Gunma, Japan
| | | | - Yugo Ito
- Department of Nephrology, St. Luke's International Hospital, Tokyo, Japan
| | - Ryo Miyazawa
- Department of Radiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Tomonari Ogawa
- Department of Nephrology and Hypertension, Saitama Medical Center, Saitama, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Aichi, Japan
| | - Eri Koshi
- Department of Nephrology, Komaki City Hospital, Aichi, Japan
| | - Tomoki Kosugi
- Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshinari Yasuda
- Department of CKD Initiatives/Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
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30
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Bellamoli M, Venturi G, Pighi M, Pacchioni A. Transradial artery access for percutaneous cardiovascular procedures: state of the art and future directions. Minerva Cardiol Angiol 2020; 69:557-578. [PMID: 33146480 DOI: 10.23736/s2724-5683.20.05391-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The transradial access (TRA) for cardiac catheterization and percutaneous coronary intervention (PCI) has been widely adopted in the last decades since its first description in the late 40s. The transradial approach has been associated with favorable outcomes as compared with transfemoral access (TFA) in several registries and randomized clinical trials, mainly due to the lower incidence of access-site bleedings, vascular complications and improved patient comfort. This review aimed to summarize the body of evidence supporting the use of TRA, to discuss clinical implications, possible technical limitations and future directions, such as the implementation of TRA as the primary access for complex procedures and structural interventions.
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Affiliation(s)
- Michele Bellamoli
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Venturi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Michele Pighi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Andrea Pacchioni
- Department of Cardiology, Civil Hospital, Mirano, Venice, Italy -
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Thoracic Endovascular Aortic Repair in "Shaggy Thoracic Aortic Aneurysms". Cardiovasc Intervent Radiol 2020; 44:220-229. [PMID: 33078232 DOI: 10.1007/s00270-020-02676-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To report the outcomes of thoracic endovascular aortic repair (TEVAR) for shaggy thoracic aortic aneurysms (STA). METHODS It is a single center, retrospective, observational, cohort study. Data were collected prospectively between January 2005 and May 2019. STA was defined, based on computed tomography angiography findings, as the presence of an irregular/ulcerated atheroma protruding and/or thrombus thickness ≥ 5 mm protruding into the aortic lumen, and/or occupying more than two thirds of the circumference of the aortic diameter axially. Primary outcomes were early (≤ 30 days) and late survival and freedom from major complication due to end-organ or peripheral ischemic embolization. RESULTS Nine (2.3%) of 391 patients met the inclusion criteria. Mean age was 71 years ± 10 (range 55-83). Mean aneurysm diameter was 68 mm ± 0.5 (range 60-75). Four patients presented symptomatic: rupture (n = 2), blue toe syndrome (n = 2). TEVAR was performed in 7 of the 9 patients. Operative-related embolization occurred in 1 patient (transient ischemic attack and acute kidney injury). In-hospital mortality was observed in 1 patient following spinal cord ischemia and multiple organ failure development. Median follow-up was 48 months (IQR 5-84). Freedom from major complication due to end-organ or peripheral ischemic embolization was achieved in all patients. No patient developed further localization of STA in the proximal or distal aorta, and did not experience reno-visceral or peripheral atheroembolization episodes. CONCLUSIONS Risk of atheroembolism in STA is still threatening but TEVAR proved to be an effective and durable treatment in this high-risk cohort.
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Cholesterol Embolization Syndrome After Carotid Artery Stenting Associated with Delayed Cerebral Hyperperfusion Intracerebral Hemorrhage. World Neurosurg 2020; 142:274-282. [PMID: 32679361 DOI: 10.1016/j.wneu.2020.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/02/2020] [Accepted: 07/05/2020] [Indexed: 11/21/2022]
Abstract
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.
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33
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Spindel J, Karmali D, Chen E, Ghafghazi S. Stroke and spinal infarct caused by percutaneous coronary intervention. BMJ Case Rep 2020; 13:13/6/e234804. [PMID: 32606119 DOI: 10.1136/bcr-2020-234804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute ischaemic stroke is a known risk of percutaneous coronary intervention (PCI). The incidence of such complications has increased in frequency over the last decade due to higher comorbidity burden and increased complexity of PCI procedures. The overall incidence of post-PCI ischaemic stroke remains low at 0.56%, but some groups of patients have significantly higher risk. Risk factors include atherosclerotic plaques, atrial fibrillation, cardiogenic shock, older age and arterial disease. Although the overall incidence of acute ischaemic stroke following PCI is low, it can result in lifelong disability and is associated with high morbidity, mortality and significant costs. Spinal infarctions due to PCI are exceedingly rare. Here, we discuss a 71-year-old woman who presented with a non ST-elevation myocardial infarction and developed both stroke and spinal infarction post PCI due to a thromboembolic event resulting in long-term debility.
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Affiliation(s)
- Jeffrey Spindel
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Dipan Karmali
- Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Elizabeth Chen
- College of Osteopathic Medicine, Marian University, Indianapolis, Indiana, USA
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Nakahashi T, Tada H, Sakata K, Yakuta Y, Yoshida T, Tanaka Y, Nomura A, Terai H, Horita Y, Ikeda M, Namura M, Takamura M, Kawashiri MA. Impact of concomitant peripheral artery disease on contrast-induced acute kidney injury and mortality in patients with acute coronary syndrome after percutaneous coronary intervention. Heart Vessels 2020; 35:1360-1367. [PMID: 32342211 DOI: 10.1007/s00380-020-01614-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/17/2020] [Indexed: 11/28/2022]
Abstract
Subclinical peripheral artery disease (PAD) might be associated with pathophysiology of contrast-induced acute kidney injury (CI-AKI). We hypothesized that concomitant PAD in patients with the acute coronary syndrome (ACS) would represent a high-risk subgroup with a greater incidence of CI-AKI, both of which lead to higher mortality after percutaneous coronary intervention (PCI). Six hundred and seventy-five consecutive patients with ACS who underwent PCI and examination of ankle-brachial index (ABI) were analyzed retrospectively. The presence of PAD was defined as an ABI < 0.9. We investigated whether (1) PAD was an independent predictor of CI-AKI (≥ 0.3 mg/dL or ≥ 50% relative increase in serum creatinine within 48 h after PCI) and (2) PAD and CI-AKI were independently associated with long-term mortality. Of the 675 patients with ACS, 114 (17%) exhibited PAD. The incidence of CI-AKI was significantly higher in PAD patients, compared with the remaining patients (12% vs. 4%, p < 0.001). Multivariate logistic regression analysis revealed that the presence of PAD was an independent predictor for the development of CI-AKI [odds ratio 2.50, 95% confidence interval (CI) 1.07-5.73, p < 0.05]. During the median 4-year follow-up, there were 65 incidents of all-cause death. In the multivariate Cox proportional hazard regression analysis, the presence of PAD [hazard ratio (HR) 2.08, 95% CI 1.17-3.65, p < 0.05] and CI-AKI (HR 2.23, 95% CI 1.08-4.26, p < 0.05) were associated with an increased risk of all-cause mortality. Assessment of ABI provides useful information for predicting CI-AKI and long-term mortality in patients with ACS after PCI.
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Affiliation(s)
- Takuya Nakahashi
- Department of Cardiology, Takaoka City Hospital, 4-1, Takara-machi, Takaoka, Toyama, 933-8550, Japan.
| | - Hayato Tada
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Kenji Sakata
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Yohei Yakuta
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Taiji Yoshida
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Yoshihiro Tanaka
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Akihiro Nomura
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Hidenobu Terai
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Yuki Horita
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masatoshi Ikeda
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masanobu Namura
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masayuki Takamura
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Masa-Aki Kawashiri
- Department of Cardiology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
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Tanaka H, Yamana H, Matsui H, Fushimi K, Yasunaga H. Proportion and risk factors of cholesterol crystal embolization after cardiovascular procedures: a retrospective national database study. Heart Vessels 2020; 35:1250-1255. [PMID: 32277287 DOI: 10.1007/s00380-020-01593-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/27/2020] [Indexed: 01/30/2023]
Abstract
Cholesterol crystal embolization (CCE) is a rare, mainly iatrogenic condition. The proportion of CCE after cardiovascular procedures has not been fully elucidated. The purpose of this study was to determine the proportion of CCE diagnosed after cardiovascular procedures and to identify risk factors for CCE occurrence. Data on patients aged older than 40 years who underwent cardiovascular procedures between July 2010 and March 2017 were extracted from the Japanese Diagnosis Procedure Combination database. Inpatients diagnosed with CCE within 1 year after procedures in the same hospital were identified. Logistic regression analysis was performed to identify factors associated with the occurrence of CCE. There were 962 patients with CCE in 2,190,300 patients who underwent cardiovascular procedures. The overall proportion of CCE after cardiovascular procedures was 4.4 per 10,000 patients (95% confidence interval 4.1-4.7). The overall in-hospital mortality among patients with CCE was 11% (107/962). Older age, male sex, smoking, heart failure, peripheral vascular disease, cerebrovascular disease, renal insufficiency, diabetes mellitus, hypertension, and aortic aneurism and dissection were significantly associated with the higher occurrence of CCE. Compared with cardioangiography, several procedures were significantly associated with higher occurrence of CCE, including intra-aortic balloon pumping, percutaneous transluminal angioplasty of the renal artery, and transcatheter aortic valve implantation or balloon aortic valvuloplasty. CCE is rare but remains a severe complication of cardiovascular procedures. Atherosclerotic risk factors and certain cardiovascular procedures were associated with CCE.
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Affiliation(s)
- Hiroyuki Tanaka
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of Nephrology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
| | - Hayato Yamana
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Firouzi A, Alemzadeh-Ansari MJ, Mohammadhadi N, Peighambari MM, Zahedmehr A, Mohebbi B, Kiani R, Sanati HR, Shakerian F, Rashidinejad A, Ghadrdoost B, Asghari R, Shokrollahi Yancheshmeh S. Association between the risks of contrast-induced nephropathy after diagnostic or interventional coronary management and the transradial and transfemoral access approaches. J Cardiovasc Thorac Res 2020; 12:51-55. [PMID: 32211138 PMCID: PMC7080339 DOI: 10.34172/jcvtr.2020.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 01/17/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction: The risk of contrast-induced nephropathy (CIN) as a common and important complication of coronary procedures may be influenced by the vascular access site. We compared the risks of CIN in diagnostic or interventional coronary management between patients treated via the transradial access (TRA) and those treated via the transfemoral access (TFA). Methods: Patients undergoing invasive coronary catheterization or percutaneous coronary intervention (PCI) were enrolled. We excluded patients with congenital or structural heart disease and those with end-stage renal disease on dialysis. Based on the vascular access site used for invasive coronary catheterization, the patients were divided into 2 study groups: the TFA and the TRA. CIN was defined as an absolute (≥0.5 mg/dL) or relative (>25%) increase in the baseline serum creatinine level within 48 hours following cardiac catheterization or PCI. Results: Overall, 410 patients (mean age = 61.3 ± 10.8 years) underwent diagnostic or interventional coronary management: 258 were treated via the TFA approach and 152 via the TRA approach. The patients treated via the TFA had a significantly higher incidence of postprocedural CIN (15.1% vs 6.6%; P= 0.01). The multivariate analysis showed that the TFA was the independent predictor of CIN (OR: 2.37, 95% CI: 1.11 to 5.10, and P= 0.027). Moreover, the BARC (Bleeding Academic Research Consortium) and Mehran scores were the other independent predictors of CIN in our study. Conclusion: The risk of CIN was lower with the TRA, and the TFA was the independent predictor of CIN after the diagnostic or interventional coronary management.
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Affiliation(s)
- Ata Firouzi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Javad Alemzadeh-Ansari
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Naser Mohammadhadi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Peighambari
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Zahedmehr
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Kiani
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Sanati
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farshad Shakerian
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Rashidinejad
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behshid Ghadrdoost
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Raana Asghari
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Simin Shokrollahi Yancheshmeh
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Shibata J, Yoshihara M, Kato T. Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report. BMC Surg 2020; 20:54. [PMID: 32192489 PMCID: PMC7082983 DOI: 10.1186/s12893-020-00716-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Distal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization. Case presentation A 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired. Conclusions Gastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.
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Affiliation(s)
- Jumpei Shibata
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan.
| | - Motoi Yoshihara
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan
| | - Takehito Kato
- Department of General Surgery, Toyohashi Municipal Hospital, 441-8570, 50 Aza Hachiken Nishi, Aotake-Cho, Toyohashi, Aichi, 441-8570, Japan
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38
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Denis Le Seve J, Gourraud Vercel C, Connault J, Artifoni M. [Update on cholesterol crystal embolism]. Rev Med Interne 2020; 41:250-257. [PMID: 32088097 DOI: 10.1016/j.revmed.2020.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 12/19/2019] [Accepted: 02/01/2020] [Indexed: 10/25/2022]
Abstract
Cholesterol crystal embolism is a systemic pathology associated with diffuse atherosclerosis. Pathophysiology corresponds to tissue necro-inflammation secondary to arteriolar occlusion associated with microembolism from atherosclerotic plaques of large diameter arteries. The clinical presentation is heterogeneous and polymorphic. Multiple organs may be the targets, but preferential damage is skin, kidneys and digestive system. It is a serious pathology, underdiagnosed, with a poor prognosis. The risk factors for developing the disease remain the same risk factors as atheroma. The factors favouring migration of microembolism remain mainly vascular interventional procedures; easy to diagnose, they oppose spontaneous embolic migrations or secondary to the introduction of antithrombotic treatment, whose diagnosis is more difficult and the prognosis more severe. The diagnosis of the disease remains mostly a diagnosis of elimination and often refers to a bundle of clinical, biological, morphological and histologic arguments. The treatment is poorly codified and the subject of few publications. It will favour both symptomatic treatment (and mainly that of pain) and complications (high blood pressure, renal insufficiency). The aetiological support remains less consensual. The treatment of atherosclerotic plaques consists, of course, in the correction of classical cardiovascular risk factors, the introduction of a statin. It will be discussed in the implementation of surgery or angioplasty to exclude potentially responsible atherosclerotic lesions. Eviction of antithrombotic therapy should be considered in terms of the benefit-risk balance, but often in favour of maintaining it. Finally, other treatments may be proposed in a case-by-case basis, such as oral or intravenous corticosteroid therapy, colchicine or LDL aphaeresis.
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Affiliation(s)
- J Denis Le Seve
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - C Gourraud Vercel
- Service de néphrologie et immunologie clinique, centre hospitalier universitaire de Nantes, 30, boulevard Jean-Monnet, immeuble Jean-Monnet, 44093 Nantes cedex 1, France
| | - J Connault
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - M Artifoni
- Service de médecine interne-vasculaire, centre hospitalier universitaire de Nantes, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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Pather K, Tenorio ER, Kärkkäinen JM, Mendes BC, DeMartino RR, Macedo TA, Gloviczki P, Oderich GS. Outcomes of fenestrated-branched endovascular aortic repair in patients with a solitary functional kidney. J Vasc Surg 2020; 72:457-469.e2. [PMID: 31987670 DOI: 10.1016/j.jvs.2019.10.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/08/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal abdominal aortic aneurysms or thoracoabdominal aortic aneurysms (TAAAs) in patients with a solitary functional kidney (SFK). METHODS We analyzed the outcomes of 287 consecutive patients (206 male; mean age, 74 ± 8 years old) enrolled in a prospective nonrandomized study to investigate use of F-BEVAR for treatment of patients with pararenal abdominal aortic aneurysms or TAAAs between 2013 and 2018. Outcomes were analyzed in patients with solitary kidney (functional or congenital) and compared with control patients who had two functioning kidneys. Acute kidney injury (AKI) was defined using Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease criteria, and renal function deterioration (RFD) was defined by a decline in estimated glomerular filtration the estimated glomerular filtration rate of more than 30% from baseline. End points included 30-day mortality and major adverse events, AKI, freedom from RFD, and patient survival. RESULTS There where 30 patients (10%) with a SFK and 257 patients with two functioning kidneys. Patients with a SFK were younger and had significantly (P < .05) higher baseline creatinine (+0.3 mg/dL), lower estimated glomerular filtration rate (-16 mL/minute/1.73 m2) and more often had stage III to V chronic kidney disease (73% vs 43%). There were no differences in cardiovascular risk factors and aneurysm extent. Technical success was achieved in 98.9% of patients with SFK and in 99.8% of controls (P = .10). At 30 days, there was no significant differences in mortality (0% vs 1%) and major adverse events (40% vs 24%; P = .08), including rates of AKI (20% vs 12%) and new-onset dialysis (3% vs 1%) between patients with a SFK and the control group, respectively. Mean follow-up was 18 ± 15 months. At 2 years, there was no difference (P = .36) in patient survival (92 ± 5% vs 84 ± 3%) and freedom from RFD (100 ± 0% vs 84 ± 3%) for patients with SFK and controls, respectively. Presence of a SFK was not a predictor for AKI or RFD. By multivariable analysis, estimated blood loss of more than 1 L (odds ratio [OR], 2.9; P = .04) and total fluoroscopy time (OR, 1.8; P = .05) were predictors for AKI, and postoperative AKI (OR, 4.9; P < .001), renal branch occlusion/stenosis (OR, 3.1; P = .001), and Crawford extent II TAAA (OR, 2.4; P = .007) were predictors for RFD. CONCLUSIONS Despite the worse baseline renal function, F-BEVAR is safe and effective with nearly identical outcomes in patients with a SFK as compared with patients with two functioning kidneys. Development of postoperative AKI is the most important predictor for RFD.
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Affiliation(s)
- Keouna Pather
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Emanuel R Tenorio
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Jussi M Kärkkäinen
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Bernardo C Mendes
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Randall R DeMartino
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Thanila A Macedo
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Peter Gloviczki
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Research Program, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
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40
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Singh N, Gupta A, Kaur G. Atheroembolic renal disease. Indian J Nephrol 2020; 30:1-2. [PMID: 32015591 PMCID: PMC6977374 DOI: 10.4103/ijn.ijn_382_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/16/2019] [Accepted: 03/09/2019] [Indexed: 11/17/2022] Open
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41
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Isaka Y, Hayashi H, Aonuma K, Horio M, Terada Y, Doi K, Fujigaki Y, Yasuda H, Sato T, Fujikura T, Kuwatsuru R, Toei H, Murakami R, Saito Y, Hirayama A, Murohara T, Sato A, Ishii H, Takayama T, Watanabe M, Awai K, Oda S, Murakami T, Yagyu Y, Joki N, Komatsu Y, Miyauchi T, Ito Y, Miyazawa R, Kanno Y, Ogawa T, Hayashi H, Koshi E, Kosugi T, Yasuda Y. Guideline on the Use of Iodinated Contrast Media in Patients With Kidney Disease 2018. Circ J 2019; 83:2572-2607. [PMID: 31708511 DOI: 10.1253/circj.cj-19-0783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshitaka Isaka
- Japanese Society of Nephrology.,Department of Nephrology, Osaka University Graduate School of Medicine
| | - Hiromitsu Hayashi
- Japan Radiological Society.,Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School
| | - Kazutaka Aonuma
- the Japanese Circulation Society.,Cardiology Department, Institute of Clinical Medicine, University of Tsukuba
| | - Masaru Horio
- Japanese Society of Nephrology.,Kansai Medical Hospital
| | - Yoshio Terada
- Japanese Society of Nephrology.,Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University
| | - Kent Doi
- Japanese Society of Nephrology.,Department of Acute Medicine, The University of Tokyo
| | - Yoshihide Fujigaki
- Japanese Society of Nephrology.,Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Hideo Yasuda
- Japanese Society of Nephrology.,First Department of Medicine, Hamamatsu University School of Medicine
| | - Taichi Sato
- Japanese Society of Nephrology.,First Department of Medicine, Hamamatsu University School of Medicine
| | - Tomoyuki Fujikura
- Japanese Society of Nephrology.,First Department of Medicine, Hamamatsu University School of Medicine
| | - Ryohei Kuwatsuru
- Japan Radiological Society.,Department of Radiology, Graduate School of Medicine, Juntendo University
| | - Hiroshi Toei
- Japan Radiological Society.,Department of Radiology, Graduate School of Medicine, Juntendo University
| | - Ryusuke Murakami
- Japan Radiological Society.,Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School
| | - Yoshihiko Saito
- the Japanese Circulation Society.,Department of Cardiovascular Medicine, Nara Medical University
| | - Atsushi Hirayama
- the Japanese Circulation Society.,Department of Cardiology, Osaka Police Hospital
| | - Toyoaki Murohara
- the Japanese Circulation Society.,Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Akira Sato
- the Japanese Circulation Society.,Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Hideki Ishii
- the Japanese Circulation Society.,Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Tadateru Takayama
- the Japanese Circulation Society.,Division of General Medicine, Department of Medicine, Nihon University School of Medicine
| | - Makoto Watanabe
- the Japanese Circulation Society.,Department of Cardiovascular Medicine, Nara Medical University
| | - Kazuo Awai
- Japan Radiological Society.,Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Seitaro Oda
- Japan Radiological Society.,Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Takamichi Murakami
- Japan Radiological Society.,Department of Radiology, Kobe University Graduate School of Medicine
| | - Yukinobu Yagyu
- Japan Radiological Society.,Department of Radiology, Kindai University, Faculty of Medicine
| | - Nobuhiko Joki
- Japanese Society of Nephrology.,Division of Nephrology, Toho University Ohashi Medical Center
| | - Yasuhiro Komatsu
- Japanese Society of Nephrology.,Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine
| | | | - Yugo Ito
- Japanese Society of Nephrology.,Department of Nephrology, St. Luke's International Hospital
| | - Ryo Miyazawa
- Japan Radiological Society.,Department of Radiology, St. Luke's International Hospital
| | - Yoshihiko Kanno
- Japanese Society of Nephrology.,Department of Nephrology, Tokyo Medical University
| | - Tomonari Ogawa
- Japanese Society of Nephrology.,Department of Nephrology & Hypertension, Saitama Medical Center
| | - Hiroki Hayashi
- Japanese Society of Nephrology.,Department of Nephrology, Fujita Health University School of Medicine
| | - Eri Koshi
- Japanese Society of Nephrology.,Department of Nephrology, Komaki City Hospital
| | - Tomoki Kosugi
- Japanese Society of Nephrology.,Nephrology, Nagoya University Graduate School of Medicine
| | - Yoshinari Yasuda
- Japanese Society of Nephrology.,Department of CKD Initiatives/Nephrology, Nagoya University Graduate School of Medicine
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Isaka Y, Hayashi H, Aonuma K, Horio M, Terada Y, Doi K, Fujigaki Y, Yasuda H, Sato T, Fujikura T, Kuwatsuru R, Toei H, Murakami R, Saito Y, Hirayama A, Murohara T, Sato A, Ishii H, Takayama T, Watanabe M, Awai K, Oda S, Murakami T, Yagyu Y, Joki N, Komatsu Y, Miyauchi T, Ito Y, Miyazawa R, Kanno Y, Ogawa T, Hayashi H, Koshi E, Kosugi T, Yasuda Y. Guideline on the use of iodinated contrast media in patients with kidney disease 2018. Jpn J Radiol 2019; 38:3-46. [PMID: 31709498 DOI: 10.1007/s11604-019-00850-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan.
| | - Hiromitsu Hayashi
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazutaka Aonuma
- Cardiology Department, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Yoshio Terada
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihide Fujigaki
- Division of Nephrology, Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hideo Yasuda
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Taichi Sato
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tomoyuki Fujikura
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Toei
- Department of Radiology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Ryusuke Murakami
- Department of Clinical Radiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Akira Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadateru Takayama
- Division of General Medicine, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Takamichi Murakami
- Department of Radiology, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yukinobu Yagyu
- Department of Radiology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Nobuhiko Joki
- Division of Nephrology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yasuhiro Komatsu
- Department of Healthcare Quality and Safety, Gunma University Graduate School of Medicine, Gunma, Japan
| | | | - Yugo Ito
- Department of Nephrology, St. Luke's International Hospital, Tokyo, Japan
| | - Ryo Miyazawa
- Department of Radiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, Tokyo, Japan
| | - Tomonari Ogawa
- Department of Nephrology and Hypertension, Saitama Medical Center, Saitama, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Aichi, Japan
| | - Eri Koshi
- Department of Nephrology, Komaki City Hospital, Aichi, Japan
| | - Tomoki Kosugi
- Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshinari Yasuda
- Department of CKD Initiatives/Nephrology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Zaveri S, Price LZ, Tupper H, Tadros RO. Atheroembolism to the Breast. Ann Vasc Surg 2019; 64:411.e17-411.e20. [PMID: 31669478 DOI: 10.1016/j.avsg.2019.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/26/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Shruti Zaveri
- Division of General Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Lucyna Z Price
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Haley Tupper
- Icahn School of Medicine, The Mount Sinai Hospital, New York, NY
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, The Mount Sinai Hospital, New York, NY.
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44
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Munawar T, Ibe U, Jiwa N, Raissi S. Renal cholesterol crystal embolism in the setting of warfarin use. BMJ Case Rep 2019; 12:12/8/e230314. [PMID: 31439554 DOI: 10.1136/bcr-2019-230314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 73-year-old man presented for evaluation of weakness and black tarry stools that occurred 1 day prior to admission. His medical history is significant for diabetes mellitus, stage 3 chronic kidney disease and deep vein thrombosis on warfarin. He was admitted to the hospital and was found to have acute kidney injury and gastrointestinal bleeding due to a supratherapeutic International Normalized Ratio. His hospital course was complicated by persistent decline in his renal function. He was given intravenous fluid resuscitation, fresh frozen plasma and packed red blood cells for his acute blood loss anaemia. Urinalysis was consistent with acute tubular necrosis. Given the persistent rise in creatinine, a kidney biopsy was obtained, and was significant for mild inflammatory changes, without evidence of vasculitis or allergic interstitial nephritis. Histopathological examination with tissue fixation revealed cholesterol embolisation. Given that he had no recent endovascular procedure or instrumentation, this atheroembolic event was attributed to his warfarin use.
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Affiliation(s)
- Tooba Munawar
- Internal Medicine, St. Mary's Hospital, Waterbury, Connecticut, USA
| | - Uzochukwu Ibe
- Internal Medicine, St. Mary's Hospital, Waterbury, Connecticut, USA
| | - Nasheena Jiwa
- Internal Medicine, St. Mary's Hospital, Waterbury, Connecticut, USA
| | - Sina Raissi
- Nephrology, St. Mary's Hospital, Waterbury, Connecticut, USA
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45
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Lo K, Penalver J, Mostafavi Toroghi H, Jeon H, Habib N, Hung Pinto W, Ram P, Gupta S, Rangaswami J. Invasive Hemodynamic Predictors of Renal Outcomes after Percutaneous Coronary Interventions. Cardiorenal Med 2019; 9:382-390. [DOI: 10.1159/000500949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/10/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives: To determine the association of right heart invasive hemodynamic parameters with post-percutaneous coronary intervention (PCI) acute kidney injury (AKI). Background: AKI after PCI is associated with a high morbidity and mortality. Various mechanisms are implicated in AKI after PCI. However, the association between filling pressures and invasive hemodynamic measures of right heart function with post-PCI AKI has not been described. Methods: This is a retrospective single-center analysis of patients of who underwent simultaneous right heart catheterization (RHC) and left heart catheterization with PCI at the Einstein Medical Center, Philadelphia, between January 2010 and December 2016. We included patients who had hemodynamic parameters from the concomitant RHC as well as measurements of kidney function up to 1 month after the procedure. We excluded patients with ST elevation myocardial infarction, end-stage renal disease, cardiogenic shock, and PCI with a need for mechanical circulatory device support. Multivariate linear regression analysis was used to analyze the association between the various right ventricular hemodynamic parameters and eGFR within 1 week and 1 month after catheterization after adjusting for age, race, gender, diabetes and hypertension, contrast volume, cardiac index, and baseline eGFR. Results: Right atrial (RA) pressure was inversely associated with eGFR within 1 week (β = –1.66; 95% CI –3.06 to –0.25; p = 0.021) and 1 month after PCI (β = –2.14; 95% CI –4.08 to –0.20; p = 0.031). Conclusion: Elevated RA pressure is associated with a worsening kidney function after cardiac catheterization and PCI.
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46
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Ozkok A. Cholesterol-embolization syndrome: current perspectives. Vasc Health Risk Manag 2019; 15:209-220. [PMID: 31371977 PMCID: PMC6626893 DOI: 10.2147/vhrm.s175150] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/10/2019] [Indexed: 12/16/2022] Open
Abstract
Cholesterol-embolization syndrome (CES) is a multisystemic disease with various clinical manifestations. CES is caused by embolization of cholesterol crystals (CCs) from atherosclerotic plaques located in the major arteries, and is induced mostly iatrogenically by interventional and surgical procedures; however, it may also occur spontaneously. Embolized CCs lead to both ischemic and inflammatory damage to the target organ. Therefore, anti-inflammatory agents, such as corticosteroids and cyclophosphamide, have been investigated as treatment for CES in several studies, with conflicting results. Recent research has revealed that CES is actually a kind of autoinflammatory disease in which inflammasome pathways, such as NLRP3 and IL1, are induced by CCs. These recent findings may have clinical implications such that colchicine and IL1 inhibitors, namely canakinumab, may be beneficial in the early stages of CES.
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Affiliation(s)
- Abdullah Ozkok
- Department of Internal Medicine and Nephrology, Memorial Şişli Hospital, Istanbul, Turkey
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47
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Long-term outcome of biopsy-proven cholesterol crystal embolism. Clin Exp Nephrol 2019; 23:1181-1187. [PMID: 31161263 DOI: 10.1007/s10157-019-01749-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/21/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Cholesterol crystal embolism (CCE) causes renal damage, and there is an extremely high risk of end-stage renal disease. However, the time course of CCE-related renal deterioration varies and little is known about the subsequent risk of dialysis among patients with biopsy-proven CCE. METHODS We performed a retrospective cohort study of 38 Japanese patients in whom a histological diagnosis of CCE was made from September 1992 to July 2005. Competing risk regression analysis was used to investigate the association between declining renal function ( ≥ 1.5 elevation of serum creatinine within 26 weeks after CCE) or its subtypes (acute [ < 1 week after CCE], subacute [1 to < 6 weeks], and chronic [6 to < 26 weeks]) and the risk of dialysis, with adjustment for age, baseline serum creatinine, and the precipitating event (iatrogenic or spontaneous). RESULTS During a median follow-up period of 25.9 weeks, 14 patients (35.9%) started dialysis. Multivariable analysis showed that patients with declining renal function had a higher risk of commencing dialysis than those without declining function (subdistribution hazard ratio [SHR] 9.47; 95% confidence interval [CI] 1.34-66.8). Patients with different renal presentations had a similarly increased risk of commencing dialysis, with the risk being significantly higher for the subacute and chronic patterns of declining renal function (adjusted SHR [95% CI] for acute, subacute, and chronic declining renal function[vs. no decline]: 7.36 [0.85-63.6], 11.9 [1.36-101], and 10.7 [1.49-77.0], respectively). CONCLUSION Declining renal function after CCE, even later than 6 weeks, was significantly associated with the subsequent risk of dialysis.
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48
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Tian M, Matsukuma KE. Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case. AUTOPSY AND CASE REPORTS 2019; 9:e2018082. [PMID: 31086777 PMCID: PMC6455701 DOI: 10.4322/acr.2018.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Miao Tian
- University of California, Davis Medical Center, Department of Pathology and Laboratory Medicine. Sacramento, CA, USA
| | - Karen E Matsukuma
- University of California, Davis Medical Center, Department of Pathology and Laboratory Medicine. Sacramento, CA, USA
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49
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Jung SM. Treatment of Cholesterol Embolism With Corticosteroids and Alprostadil. Ann Geriatr Med Res 2019; 23:31-34. [PMID: 32743283 PMCID: PMC7387603 DOI: 10.4235/agmr.18.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/28/2018] [Accepted: 01/27/2019] [Indexed: 11/24/2022] Open
Abstract
Cholesterol embolism is a rare but serious disease that can lead to chronic renal failure or death. Despite the recent increase in the incidence of this disease, there is no consensus on the optimal treatment modality. Supportive care is usually the mainstay of treatment. We report a case of cholesterol embolism after renal artery stenting that was successfully treated with corticosteroids and alprostadil.
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Affiliation(s)
- Seung Mook Jung
- Department of Internal Medicine, Gimpowoori Hospital, Gimpo, Korea
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50
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Rothenbühler M, Valgimigli M, Odutayo A, Frigoli E, Leonardi S, Vranckx P, Turturo M, Moretti L, Amico F, Uguccioni L, Contarini M, Gómez-Hospital JA, Mainar V, Creaco M, Petronio AS, Cremonesi A, Tamburino C, Fresco C, Bonmassari R, Díaz Fernández JF, Romagnoli E, Beyersmann J, Heg D, Jüni P. Association of acute kidney injury and bleeding events with mortality after radial or femoral access in patients with acute coronary syndrome undergoing invasive management: secondary analysis of a randomized clinical trial. Eur Heart J 2019; 40:1226-1232. [DOI: 10.1093/eurheartj/ehy860] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/29/2018] [Accepted: 11/30/2018] [Indexed: 01/01/2023] Open
Affiliation(s)
- Martina Rothenbühler
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Freiburgstrasse 8, Bern, Switzerland
| | - Ayodele Odutayo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada
| | - Enrico Frigoli
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, Pavia, Italy
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium, and Faculty of Medicine and Life Sciences, University of Hasselt, Martelarenlaan 42, Hasselt, Belgium
| | - Maurizio Turturo
- Division of Cardiology, P.O. Di Venere, Via Ospedale di Venere 1, Bari, Italy
| | - Luciano Moretti
- Division of Cardiology, Mazzoni Hospital, Via Degli Iris, Ascoli Piceno, Italy
| | - Francesco Amico
- Cardiology Unit, S. Elia Hospital, Via Luigi Russo 6, Caltanissetta, Italy
| | - Lucia Uguccioni
- Interventional Cardiology, Ospedali Riuniti Marche Nord, Piazzale Cinelli 4, Pesaro, Italy
| | - Marco Contarini
- Interventional Cardiology Unit, Umberto I Hospital, Via Testaferrata 1, Siracusa, Italy
| | - Joan Antoni Gómez-Hospital
- Heart Diseases Institute, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet, Barcelona, Spain
| | - Vicente Mainar
- Department of Cardiology, Hospital General of Alicante, Pintor Baeza 11, Alicante, Spain
| | - Manuela Creaco
- Cardiology Unit, Gravina Hospital, Via Portosalvo 9, Caltagirone, Italy
| | - Anna Sonia Petronio
- Unit of Interventional Cardiology, Cardiothoracic and Vascular Department, Ospedale di Cisanello, University of Pisa, Via Paradisa 2, Pisa, Italy
| | - Alberto Cremonesi
- Cardiovascular Department, Humanitas Gavazzeni Hospital, Via M. Gavazzeni 21, Bergamo, Italy
| | - Corrado Tamburino
- Cardiology Division, C.A.S.T. Policlinico University Hospital, Cardio-Thorax-Vascular and Transplant Department, Via S. Sofia 76, Catania, Italy
| | - Claudio Fresco
- Cardiology Unit, Azienda Sanitaria Universitaria Integrata di Udine, Piazzale S. Maria della Misericordia 15, Udine, Italy
| | - Roberto Bonmassari
- Division of Cardiology, Santa Chiara Hospital, Largo Medaglie D'oro 9, Trento, Italy
| | | | - Enrico Romagnoli
- Department of Cardiology, Fondazione Policlinico Universitario A. Gemelli, Largo Agostino Gemelli 8, Rome, Italy
| | - Jan Beyersmann
- Institute of Statistics, Ulm University, Helmholtzstrasse 20, Ulm, Germany
| | - Dik Heg
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Mittelstrasse 43, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada
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