Atheroemboli to the lower urinary tract: a marker of atherosclerotic vascular disease--a case report

Cholesterol crystal embolization diagnosed on bladder transurethral resection

Cholesterol crystal embolization (CCE) is a severe systemic disorder caused by vascular migration of cholesterol crystals originating from ulcerative atherosclerotic plaques located in large arteries. We report 2 cases of CCE diagnosed on bladder transurethral resection in 2 men aged 94 and 72 years. Both patients had atherosclerosis disease. One patient had been treated by heparin 1 month before for pulmonary embolism and the other had had a coronary angiography and bypass graft surgery 5 months before for silent myocardial infarction. One patient presented with hematuria and the other with acute renal failure. Cystoscopy showed multiple papillary tumors of the bladder wall. Bladder transurethral resections showed transitional cell carcinoma with cholesterol crystals occluding the lumen of small arterioles in the submucosa. Eight cases of CCE in the bladder wall have been reported in the literature in 3 women and 5 men aged 56 to 79 years. Cholesterol crystal embolization is often discovered in the bladder wall on necropsy specimens. Only 2 cases have been fortuitously discovered on bladder transurethral resection performed for transitional cell carcinoma. Cholesterol crystal embolization in the bladder wall is often a marker of severe disease although the evolution is quite favorable in our patients, still alive 1 and 2 years after diagnosis.

Changing patterns of atheroembolism

Among 1011 patients undergoing infrarenal aortic and infrainguinal vascular surgery in a 90-month period (1986-1993), 29 patients (2.9%) with clinical, angiographic and pathologic evidence of atheroembolism were identified. Over one-third (44.8%) of atheroemboli were iatrogenic and the rest spontaneous. All iatrogenic atheroemboli were precipitated by angiographic (n = 11; 84.6%) or operative manipulation (n = 2; 15.4%). The sources of emboli were in the abdominal arota (16), iliac (seven) and femoropopliteal (six) arteries. 'Trash foot' occurred in 19 patients (seven bilateral) and occlusions of tibioperoneal/digital arteries were seen in seven, renal and dermal microcirculation in two each, and calf muscles in one. Larger conduits were affected in three instances (common femoral, popliteal and in situ saphenous vein graft). The management consisted of 54 (43 surgical and 11 endovascular) procedures concurrently with thrombolytic, anticoagulant and antiplatelet therapy. Three early (10.3%) and two late (6.9%) deaths (overall mortality rate 17.2%), eight major (27.6%) and five minor (17.2%) amputations, and four (13.8%) instances of renal failure occurred in 17 patients resulting in a 58.6% complication rate. Besides initial angiography, 53 invasive procedures were required in 25 patients. Among these, 12 patients could be managed with a single definitive procedure in contrast to a group of 13 patients that required 41 (average 3.2 per patient) procedures. The incidence of foot ischemia, reoperation and amputation was higher in the spontaneous group, whereas, the iatrogenic group incurred a higher incidence of endovascular interventions, greater mortality and new onset renal failure. The high morbidity and mortality of atheroemboli demand prompt recognition and treatment, as well as attempts at prevention to achieve good results.

Acute arterial insufficiency of the male genitalia

Three patients developed severe ischemia of the penis or scrotum from acute arterial occlusion. In one case, nonhealing ulceration of the glans developed after atheroembolism to the dorsal penile artery. One patient had penile ischemia after ligation of pelvic and femoral collateral circulation during repair of an aorto-bilateral-iliac artery aneurysm. A third patient had ischemia of the penis and scrotum from thromboembolism to the iliac arteries during repair of an aortoenteric fistula. Only seven patients have been described with acute arterial occlusion and severe ischemia of the male genitalia. A rare phenomenon because of rich collateral circulation, acute ischemia of the genitalia nevertheless must be recognized as a sign of severe vascular disease and a consequence of major arterial ligation or occlusion in the pelvis and groins.