Cholesterol emboli after invasive cardiac procedures

Successfully treated hemi-central retinal artery occlusion following cardiac catheterization; case report

Introduction and importance

Here we report a case of a middle-aged man who complained of blurred vision in his left eye 1 h post cardiac catheterization and proved to have central retinal artery occlusion, a dangerous but potentially treatable sight-threatening complication of cardiac-catheterization. The patient was successfully treated through an Ophthalmological surgical intervention.

Case presentation

A 49- year-old male patient admitted to the coronary care unit as a case of non-ST-elevation-myocardial infarction. The patient underwent cardiac catheterization and stenting of the right coronary artery. One hour later, he complained of blurred vision in his left eye.

Clinical discussion

Ophthalmological examination showed an inferior visual field defect in the left eye. Fundus fluorescein angiography revealed that the patient had a hemi-central retinal artery occlusion, a rare complication of cardiac catheterization. A pars plana vitrectomy eye surgery was performed with an excellent result.

Conclusion

This case highlights the importance of early recognition and treatment of central retinal artery occlusion post cardiac catheterization

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Rarely, central retinal occlusion can complicate cardiac catheterization.

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Meaningful spontaneous recovery in vision in cases of central retinal artery occlusion occurs in less than 10%.

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What is peculiar about our case is that prompt surgical intervention resulted in an unexpectedly excellent result.

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The case highlights the need for prompt diagnosis and referral of patients with visual symptoms post cardiac catheterization.

Atheroembolism to the Breast

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

Non-invasive evaluation of coronary heart disease in patients with chronic kidney disease using photoplethysmography

Background

Chronic kidney disease (CKD) patients have an increased risk for coronary artery disease (CAD) and myocardial infarction. Therefore, there is a need to identify CKD patients at high risk of CAD. Coronary angiography, the gold standard for detecting CAD, carries a risk of serious adverse events.

Methods

Here, we assessed the validity of a novel non-invasive reflectance mode photoplethysmography (PPG) sensor for the evaluation of CAD in patients with advanced CKD. PPG signals were generated using green and infrared wavelengths and recorded from fingers of 98 patients. The detected signal has the shape of the pulse wave contour carrying information about the vascular system, that is, arterial stiffness. We studied four patient groups: (i) controls—patients without CKD or CAD; (ii) CKD alone; (iii) CAD alone (confirmed by coronary angiography); and (iv) CKD and CAD combined.

Results

With advancing age, we observed a steeper ascending signal during systole and greater signal decline during diastole (infrared wavelength: Slopes 4–6, P = 0.002, P = 0.003 and P = 0.014, respectively; green wavelength: Slopes 2–3, P = 0.006 and P = 0.005, respectively). Presence of CAD was associated with a slower signal decline during diastole in CKD patients compared with those without CAD (infrared wavelength: Slope 1, P = 0.012). CKD was associated with lower blood volume amplitude during each cardiac cycle compared with those without CKD (R-value, P = 0.022).

Conclusions

PPG signal analyses showed significant differences between our groups, and it may be a potentially useful tool for the detection of CAD in CKD patients.

Acute Cutaneous Necrosis: A Guide to Early Diagnosis and Treatment

Acute cutaneous necrosis is characterised by a wide range of aetiologies and is associated with significant morbidity and mortality, warranting complex considerations in management. Early recognition is imperative in diagnosis and management of sudden gangrenous changes in the skin. This review discusses major causes of cutaneous necrosis, examines the need for early assessment, and integrates techniques related to diagnosis and management. The literature, available via PubMed, on acute cutaneous necrotic syndromes was reviewed to summarise causes and synthesise appropriate treatment strategies to create a clinician’s guide in the early diagnosis and management of acute cutaneous necrosis. Highlighted in this article are key features associated with common causes of acute cutaneous necrosis: warfarin-induced skin necrosis, heparin-induced skin necrosis, calciphylaxis, pyoderma gangrenosum, embolic phenomena, purpura fulminans, brown recluse spider bite, necrotising fasciitis, ecthyma gangrenosum, antiphospholipid syndrome, hypergammaglobulinemia, and cryoglobulinemia. This review serves to increase recognition of these serious pathologies and complications, allowing for prompt diagnosis and swift limb- or life-saving management.

Optimizing Common Femoral Artery Access

Common femoral artery (CFA) access is an important step of many vascular interventional procedures such as peripheral arterial, aortic, and endovascular oncologic interventions. The anatomical location of the CFA as it crosses over the femoral head provides a unique location to establish a relatively large arterial access to a vessel that is conveniently located near the aorta and its major branches. A proper access helps the interventionist with the remainder of the procedure and diminishes the risk of severe complications leading to surgery, thrombolysis, patient morbidity, or occasionally mortality. On the contrary, a suboptimal access can jeopardize the entire procedure and may lead to limb and life-threatening complications. With the introduction of ultrasonography-assisted CFA access, the process has become more predictable and possibly less adventurous; however, there remain tips and tricks that can guarantee a safe and proper start for any arterial procedure. We review the preprocedural evaluation, procedural techniques, and postprocedural care to optimize CFA access.

Risks and complications of coronary angiography: a comprehensive review

Coronary angiography and heart catheterization are invaluable tests for the detection and quantification of coronary artery disease, identification of valvular and other structural abnormalities, and measurement of hemodynamic parameters. The risks and complications associated with these procedures relate to the patient’s concomitant conditions and to the skill and judgment of the operator. In this review, we examine in detail the major complications associated with invasive cardiac procedures and provide the reader with a comprehensive bibliography for advanced reading.

Clinical significance of retinal emboli during diagnostic and therapeutic cardiac catheterization in patients with coronary artery disease

BACKGROUND

Cardiac catheterization may cause retinal embolization, a risk factor for cerebrovascular emboli and stroke. We describe the incidence of clinically silent and apparent retinal emboli following diagnostic and interventional coronary catheterization and associated risk factors.

METHODS

Three hundred selected patients attending a tertiary referral center for diagnostic and therapeutic cardiac catheterization were studied. Retinal examination and examination of the visual field and acuity were done before and after catheterization by a retinal specialist.

RESULTS

There were 5 case of retinal embolus before catheterization, and 19 patients (incidence 6.3%) developed new retinal arteriolar emboli after catheterization. Only 1 patient developed clinically apparent changes in vision. Two conventional risk factors (age and hypertension) were significantly associated with new retinal emboli. The risk of retinal emboli was also significantly associated with operator expertise.

CONCLUSIONS

Retinal embolism was found after coronary catheterization in 6.3% of our patients. This finding indicates that the retinal, and possibly the cerebral circulation, may be compromised more frequently than is clinically apparent as a complication of coronary catheterization. Age and hypertension are independent predictors of retinal embolism.

Effect of elective coronary angiography on glomerular filtration rate in patients with advanced chronic kidney disease

BACKGROUND AND OBJECTIVES

Preemptive transplantation is ideal for patients with advanced chronic kidney disease (CKD). The practice has been to perform coronary angiography (CA) on all patients aged >50, all diabetics, and all patients with cardiac symptoms or disease with a view to revascularization before transplantation. Historically patients have delayed CA until established on renal replacement therapy due to concerns of precipitating the need for chronic dialysis. The objectives of this study were to establish the risk of contrast nephropathy in patients with advanced CKD who undergo screening CA, and to determine whether or not preemptive transplantation is achievable.

DESIGN AND SETTING

This retrospective analysis included 482 patients with stage IV/V CKD seen in West London predialysis clinics from 2004 to 2007. Seventy-six of 482 (15.8%) patients considered as potential transplant recipients met the authors' criteria for coronary angiography. Modification of Diet in Renal Disease (MDRD) GFR measurements were recorded for the 12 mo preceding and 12 mo following CA unless a defined endpoint was reached (transplantation, dialysis, or death).

RESULTS

Mean MDRD GFR at CA was 12.51 +/- 3.51 ml/min. The trend was not significantly different 6 mo pre- and postangiography. Cumulative dialysis-free survival was 89.1% 6 mo postangiography. Twenty-three of 76 (30.3%) patients had flow-limiting coronary artery disease. Twenty-five of 76 (32.9%) patients underwent transplantation with 22 of 25 (88.0%) transplants being performed preemptively.

CONCLUSIONS

The data suggest CA screening does not accelerate the decline in renal function for patients with advanced CKD, facilitating a safe preemptive transplant program.

Simultaneous multiple branch retinal artery occlusions after diagnostic cardiac catheterization

PURPOSE

We describe a 53-year-old man with a decrease in visual acuity in the left eye 2 weeks after diagnostic cardiac catheterization.

DESIGN

Interventional case report.

METHODS

A 53-year-old man with a decrease in visual acuity in the left eye 2 weeks after diagnostic cardiac catheterization underwent ophthalmoscopic, angiographic, and laboratory evaluations. Both funduscopy and fluorescein angiography confirmed the diagnosis of simultaneous multiple branch retinal artery occlusions in the left eye.

RESULTS

The left eye had a mildly positive (1+) relative afferent pupillary defect. Slit-lamp biomicroscopy was unremarkable except for 2+ nuclear cataract bilaterally. Intraocular pressure was 12 mmHg in the right eye and 11 mmHg in the left eye by applanation tonometry. Funduscopy revealed a normal right eye.

CONCLUSION

This case report of multiple branch retinal artery occlusions due to cholesterol embolus after diagnostic cardiac catheterization is extremely rare. Visual symptoms after cardiac catheterization should alert both ophthalmologists and cardiologists to this potential post-cardiac catheterization complication.

Treatment of end-stage "trash feet" with the end-diastolic pneumatic boot

This study reassessed the clinical effect of Circulator Boot (CB) therapy in patients with cholesterol embolization syndrome (CES) of the lower extremities. The medical records were reviewed of 27 patients consecutively referred to the Bryn Mawr Wound Care and Vascular Center with CES who had not responded to previous therapies. All patients with CES referred from January 1, 1997, to September 19, 2005, were followed up and included in the study. The alternate therapy offered for most patients at the time of referral was limb amputation. The median age of the patients was 65 years (age range, 46-84 years) at the time of diagnosis. Healing of CES was observed after a median interval of 11 months (range, 3-32 months) following the initiation of CB therapy. The total number of legs treated was 41. Of 41 legs, 33 (81%) were totally healed, 6 (15%) improved, and 2 (5%) were amputated. After an initial period of improvement, one patient died a month later of causes unrelated to CES or CB therapy. Another patient improved and discontinued treatment before he was totally healed. Cholesterol embolization syndrome is seen predominantly in patients following cardiac or vascular procedures but may occur spontaneously. The CB seems to be the only effective noninvasive therapy for CES. Early initiation of therapy is essential to minimize tissue loss and patient discomfort.