Cholesterol emboli in atherosclerotic patients: reports of four cases occurring spontaneously or complicating angioplasty and aortorenal bypass

Cholesterol Embolism in Intensive Care Patients

Four case reports are presented, followed by a discussion of the acute, potentially life-threatening manifestations of the cholesterol embolism syndromes. Every major organ system except the lungs may be directly affected by cholesterol emboli; devastating consequences encompass cerebral, myocardial, spinal cord, intestinal, renal, and other visceral organ infarction, as well as peripheral and perineal gangrene. Additional complications include severe hypertension, gastrointestinal bleeding, and hemodynamic instability. Anticoagulants and thrombolytic therapy may exacerbate atheromatous embolism and are relatively contraindicated. Aggressive supportive therapy may improve chances of survival, but long-term prognosis is poor. Prevention remains the most important aspect in this devastating disorder.

Branch retinal artery occlusion associated with directional coronary atherectomy after percutaneous transluminal coronary angioplasty

PURPOSE

To report a case of branch retinal artery occlusion after atherectomy.

METHODS

A 51-year-old man complained of visual loss in the right eye after directional coronary atherectomy, performed secondary to a complicated percutaneous transluminal coronary angioplasty. He underwent a full ophthalmologic examination, including fluorescein angiography and Doppler ultrasound.

RESULTS

Visual Acuity was 20/30 with an inferior scotoma present in the right eye. There were three Hollenhorst plaques present inside the superotemporal vascular arcade.

CONCLUSIONS

There is a small but definite risk of retinal microinfarctions after atherectomy.

Cholesterol embolization: clinical findings and implications

The clinical characteristics of 13 patients with cholesterol embolization are described. Embolization occurred spontaneously in 2 patients and after a vascular procedure in 11. Acute but vague symptoms were reported by 11 of the 13 patients; skin findings of purple toes or livedo reticularis and renal dysfunction were present in 12 patients, 5 of whom required dialysis. Blood pressure elevation occurred in all 13 patients, eosinophilia in 9 of 10 and elevated sediment rate in 5 of 6. Death occurred within 6 months in three patients. Two distinct patterns were observed: mild (five patients) and severe (eight patients). Compared with the severe pattern, patients with mild cholesterol embolization had early symptoms less frequently (two of five versus eight of eight), less severe renal insufficiency (serum creatinine 1.7 versus 7.4 mg/100 ml), less of an increase in blood pressure (22 versus 34 mm Hg) and later development of skin lesions (14 versus 6 weeks). Baseline blood pressure and development of eosinophilia were comparable in both groups. The presentation of cholesterol embolization is often subtle and may go unrecognized, particularly in its mild form. As vascular interventions increase in elderly atherosclerotic and hypertensive patients, so too will the incidence of this disorder.

Branch retinal artery occlusion secondary to percutaneous transluminal coronary angioplasty

We report on a patient suffering a branch retinal artery occlusion immediately following percutaneous transluminal coronary angioplasty. Balloon angioplasty may produce ocular embolic events consistent with previously reported neurological complaints.