Cholesterol Embolization Syndrome

Trash Feet and Mesenteric Ischemia as a Rare Manifestation of a Complicated Abdominal Aortic Aneurysm: A Case Report

BACKGROUND

Abdominal aortic aneurysms and atheromatous plaques are well-established potential culprits in the development of cholesterol embolization. This embolic phenomenon can result in the occlusion of peripheral arteries in the forefoot or toes, commonly referred to as "trash foot".

CASE

A 61-year old patient exhibited severe symptoms and signs of lower limb and mesenteric ischemia, represented clinically by abdominal pain, hematochezia, and bilateral plantar necrotic lesions, attributed to embolization from a previously unknown large infrarenal abdominal aortic aneurysm. Diagnosis was confirmed by performing angio-CT of the abdomen, an angiologic examination, as well as colonoscopy. The patient underwent open surgical repair of the aortic aneurysm and received intravenous prostanoids, resulting in a successful outcome with resolution of bowel ischemia and complete recovery of bilateral foot lesions with no tissue loss.

CONCLUSION

Cholesterol embolization syndrome seldom manifests with its complete clinical spectrum. Identifying and addressing the underlying cause is crucial, with a focus on potential abdominal aortic aneurysms. A combined approach involving surgical repair and prostanoid therapy may offer a viable option for patients experiencing severe manifestations.

Clinical Outcomes of Patients With Cholesterol Crystal Embolism Accompanied by Lower Extremity Wound

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.

Small-vessel vasculitis associated with cholesterol embolism: a case report

BACKGROUND

Cholesterol embolism causes various organ dysfunctions, including skin, kidney, and gastrointestinal tract dysfunction, as well as immunological abnormalities, such as hypocomplementemia and eosinophilia. However, only a few cases of vasculitis accompanied by cholesterol embolism have been reported.

CASE PRESENTATION

We present the case of an 82-year-old man with cholesterol embolism who also developed small-vessel vasculitis of the skin and muscles. The patient had a persistent fever, and blood tests showed eosinophilia and hypocomplementemia. Two months later, the patient developed a skin rash and myalgia in the thighs. Magnetic resonance imaging of the thighs revealed diffuse intramuscular hyperintensities on T2-weighted images and short tau inversion recovery sequences in the hamstrings and quadriceps femoris. Histological findings of the skin and muscle revealed small-vessel vasculitis, and random skin biopsy revealed cholesterol embolism. We diagnosed the patient with cholesterol embolism accompanied by small-vessel vasculitis of the skin and femoral muscles. Methylprednisolone was administered intravenously, and oral prednisolone was initiated. Muscle tenderness improved rapidly after the initiation of glucocorticoid therapy. However, he developed superior mesenteric artery embolization and died.

CONCLUSIONS

Our case demonstrates that cholesterol embolism can be accompanied by small-vessel vasculitis of the skin and muscles.

Rheocarna Effectively Treats Oral Medicinal Therapy-Resistant Cutaneous Symptoms and Renal Failure Induced by Cholesterol Crystal Embolism

An 80-year-old man presented to our hospital with worsening renal function and ambulation difficulties due to lower extremity symptoms that included livedo reticularis, gangrene, cyanosis, and ulcers in his legs. The patient was diagnosed with a cholesterol crystal embolism. Treatment with prednisolone and rosuvastatin was initiated; however, no improvements were observed in the patient's cutaneous symptoms or renal function. Therefore, we decided to treat the patient with a new low-density lipoprotein apheresis device (Rheocarna; Kaneka Corporation, Osaka, Japan). Following therapy, the lower extremity symptoms improved, and although dialysis was temporarily initiated, it was eventually discontinued.

The Controversial Role of Glucocorticoids in Atheroembolic Renal Disease: A Narrative Review

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.

Protruding Aortic Plaque and Coronary Plaque Vulnerability

BACKGROUND

Protruding aortic plaque is known to be associated with an increased risk for future cardiac and cerebrovascular events. However, the relationship between protruding aortic plaque and coronary plaque characteristics has not been systematically investigated.

METHODS AND RESULTS

A total of 615 patients who underwent computed tomography angiography, and preintervention optical coherence tomography imaging were included. Coronary plaque characteristics were compared to evaluate coronary plaque vulnerability in patients with protruding aortic plaque on computed tomography angiography. 615 patients, the 186 (30.2%) patients with protruding aortic plaque were older and had more comorbidities such as hypertension, chronic kidney disease, and a prior myocardial infarction than those without. They also had a higher prevalence of coronary plaques with vulnerable features such as thin-cap fibroatheroma (85 [45.7%] versus 120 [28.0%], P<0.001), lipid-rich plaque (165 [88.7%] versus 346 [80.7%], P=0.014), macrophages (147 [79.0%] versus 294 [68.5%], P=0.008), layered plaque (117 [62.9%] versus 213 [49.7%], P=0.002), and plaque rupture (96 [51.6%] versus 111 [25.9%], P<0.001). Patients with protruding aortic plaque experienced more major adverse cardiac and cerebrovascular events, including all-cause mortality, nonfatal acute coronary syndromes, and stroke (27 [14.7%] versus 21 [4.9%], P<0.001; 8 [4.3%] versus 1 [0.2%], P<0.001; 5 [2.7%] versus 3 [0.7%], P=0.030; and 5 [2.7%] versus 2 [0.5%], P=0.013, respectively).

CONCLUSIONS

The current study demonstrates that patients with protruding aortic plaque have more features of coronary plaque vulnerability and are at increased risk of future adverse events.

Different Characteristics and Interleukin-6 Ratios of Scattering-Type Aortic Plaques

Background Cholesterol crystals (CCs) are related to innate inflammation in spontaneously ruptured aortic plaques (SRAPs), and variability exists in the CCs and interleukin (IL)-6 ratio in SRAPs. Methods The prevalence of scattering-type ruptures that glittered against the light of angioscopic fibers (puff-chandelier ruptures) and those that did not (puff ruptures) was analyzed in 848 patients with suspected coronary artery disease. Overall, 177 puff-chandelier ruptures and 105 puff ruptures were sampled using nonobstructive general angioscopy (NOGA). The sampled plaques were analyzed by direct detection of CCs with polarized light microscopy. The characteristics of the plaque fragments from puff and puff-chandelier ruptures were compared. The Interleukin-6 (IL-6) ratios were calculated for 100 puff-chandelier ruptures and 100 puff ruptures. Results CCs were detected in 54% of puff-chandelier ruptures and 20% of puff ruptures. The longer and shorter dimensions of the puff ruptures were smaller than those of the puff-chandelier ruptures. CCs were more prevalent in puff chandeliers than in puff ruptures (54% vs. 20%, respectively; p<0.0001). The number of CCs was higher in puff chandeliers than in puff ruptures with CCs (median 12,727 (interquartile range (IQR) 3,636-25,909)/10 mL vs. median 3,182 ( IQR 909-9,318)/10 mL) in CC-positive samples (p=0.0120). The IL-6 ratio of puff-chandelier ruptures was higher than that of puff ruptures (p=0.0014). Conclusions Examination of plaque fragments from puff-chandelier and puff ruptures revealed a higher prevalence of CCs in puff-chandelier ruptures compared to puff ruptures. Puff chandeliers exhibited a significantly greater number of CCs, suggesting a potential correlation with inflammatory levels. The IL-6 ratio was also higher in puff-chandelier ruptures. Direct detection of CCs and hematoxylin and eosin staining for SRAPs demonstrated variations in CC degree and dimensions between puff-chandelier and puff ruptures. Puff-chandelier ruptures exhibited more CCs associated with innate inflammation and larger fragments than puff ruptures. NOGA proved effective in detecting diverse characteristics and inflammation levels, as indicated by IL-6, in scattering-type SRAPs.

Atherosclerosis of the aorta before blue toe syndrome: Spontaneously ruptured aortic plaques revealed by non-obstructive general angioscopy

A 50-year-old man who had undergone endovascular therapy 70 days previously was referred to us for the sudden onset of cyanosis with rest pain in the bilateral lower limbs. The patient was diagnosed with blue toe syndrome. Although computed tomography angiography showed irregular aortic wall thickness, preoperative aortic angioscopy detected a remarkable number of spontaneously ruptured aortic plaques, such as puff-chandelier ruptures, predominantly in the abdominal aorta. Continuous embolization of a large quantity of cholesterol crystals from puff-chandelier ruptures subsequently might be responsible for cholesterol embolization syndrome.

Learning objective

A patient presenting with cholesterol embolization syndrome had undergone a non-obstructive general angioscopy. We highlight the numerous spontaneously ruptured aortic plaques demonstrated by non-obstructive general angioscopy.

Cholesterol Embolization Syndrome Post Invasive Arterial Procedure: A Case Report

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.

Pathophysiology and targeted treatment of cholesterol crystal embolism and the related thrombotic angiopathy

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.

Acute type B aortic dissection with multiple cholesterol embolism: an autopsy case report

Background

Most cases of cholesterol embolism are known to be triggered by cardiac catheterization, cardiovascular surgery, anticoagulation, or fibrinolytic therapy; however, spontaneous cases after aortic dissection are rare. In this report, we describe a case of cholesterol embolism after type B aortic dissection, which rapidly developed into multiple organ failure and death.

Case summary

A 65-year-old man with untreated hypertension was admitted to our hospital with sudden back pain and diagnosed with type B aortic dissection. The patient experienced a rapid progression of inflammation and developed respiratory and renal failure, despite computed tomography showing no obvious progression of dissection. We attributed them to a cytokine storm and acute respiratory distress syndrome, but steroid pulse therapy did not alleviate the symptoms. Finally, the patient died on Day 6 after admission, and an autopsy was performed, which revealed cholesterol crystal occlusions in the kidney, spleen, and the left lower leg. The lumen in the aorta is filled with atheroma and thrombus, and we suspect that aortic dissection triggered failure of the aortic plaques and released cholesterol crystals to distal arteries that led to cholesterol embolism.

Discussion

We experienced a patient with a type B aortic dissection that led to cholesterol embolism and rapid progression of respiratory and renal failure, resulting in death. The aortic dissection combined with cholesterol embolism was considered to trigger the subsequent severe inflammation, leading to rapid respiratory and renal failure. Our case points to the possibility that cholesterol embolism can extensively escalate inflammation after aortic dissection.

Outcomes and Institutional Variation in Arterial Access Among Patients With AMI and Cardiogenic Shock Undergoing PCI

BACKGROUND

Contemporary data comparing the outcomes of transradial access (TRA) vs transfemoral access (TFA) among patients presenting with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI) are limited.

OBJECTIVES

This study examines in-hospital outcomes and institutional variation among patients with AMI-CS undergoing TRA-PCI vs TFA-PCI.

METHODS

Patients admitted with AMI-CS from the NCDR CathPCI registry between April 2018 and June 2021 were included. Multivariable logistic regression and inverse probability weighting models were used to assess the association between access site and in-hospital outcomes. A falsification analysis using non-access site-related bleeding was performed.

RESULTS

Among 35,944 patients with AMI-CS undergoing PCI, 25.6% were performed with TRA. The proportion of TRA-PCI increased over the study period (22.0% in the second quarter of 2018 vs 29.1% in the second quarter of 2021; P-trend <0.001). Significant institutional-level variability in the use of TRA-PCI was also observed: 20.9% of all sites using TRA in <2% of PCIs (low utilization) vs 1.9% of all sites using TRA in >80% of PCIs (high utilization). Patients undergoing TRA-PCI had a significantly lower adjusted incidence of major bleeding (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.67-0.76), mortality (OR: 0.73; 95% CI: 0.69-0.78), vascular complications (OR: 0.67; 95% CI: 0.54-0.84), and new dialysis (OR: 0.86; 95% CI: 0.77-0.97). There was no difference in non-access site related bleeding (OR: 0.93; 95% CI: 0.84-1.03). Sensitivity analyses revealed similar benefit with TRA-PCI among patients without arterial cross-over. There were no significant interactions observed between TRA-PCI with mechanical circulatory support and in-hospital outcomes.

CONCLUSIONS

In this large nationwide contemporary analysis of patients with AMI-CS, about quarter of PCIs were performed via TRA with wide variability across US institutions. TRA-PCI was associated with significantly lower incidence of in-hospital major bleeding, mortality, vascular complications, and new dialysis. This benefit was observed irrespective of mechanical circulatory support use.

Spontaneous Cholesterol Embolism Leading to Small Bowel Obstruction and Perforation

A spontaneous occurrence of cholesterol embolization syndrome causing small bowel obstruction and perforation is a highly scarce event. In this article, we report a case of spontaneous cholesterol embolism resulting in small bowel obstruction and perforation in a 52-year-old male with multiple cardiovascular and medical comorbidities. In our patient, the source was an eccentric left lateral atherosclerotic plaque from the abdominal aorta that was identified using computed tomography. A distal occlusion in numerous small intestinal arteries due to cholesterol embolism was confirmed on biopsy after surgical resection. (Level of Difficulty: Intermediate.).

Role of necroptosis in kidney health and disease

Cell death, particularly that of tubule epithelial cells, contributes critically to the pathophysiology of kidney disease. A body of evidence accumulated over the past 15 years has ascribed a central pathophysiological role to a particular form of regulated necrosis, termed necroptosis, to acute tubular necrosis, nephron loss and maladaptive renal fibrogenesis. Unlike apoptosis, which is a non-immunogenic process, necroptosis results in the release of cellular contents and cytokines, which triggers an inflammatory response in neighbouring tissue. This necroinflammatory environment can lead to severe organ dysfunction and cause lasting tissue injury in the kidney. Despite evidence of a link between necroptosis and various kidney diseases, there are no available therapeutic options to target this process. Greater understanding of the molecular mechanisms, triggers and regulators of necroptosis in acute and chronic kidney diseases may identify shortcomings in current approaches to therapeutically target necroptosis regulators and lead to the development of innovative therapeutic approaches.

The systemic immune response due to cholesterol crystal embolization syndrome: a case report

Background

Cholesterol crystal embolization syndrome (CES) occurs when an atherosclerotic plaque causes small-vessel embolization, resulting in multi-organ damage. Although CES is pathologically characterized by an infiltration of eosinophils, the implication of the systemic inflammatory response represented by hypereosinophilia is unclear in clinical practice. Herein we present the case of a patient diagnosed with CES who developed multiple allergic organ injuries, including daptomycin-related dermatitis and later vancomycin-induced acute tubulointerstitial nephritis, which was successfully treated by the withdrawal of each medicine with or without corticosteroid therapy, one by one.

Case presentation

A 76-year-old Japanese man diagnosed with thoracic aneurysm rupture underwent total arch replacement through the open stent graft technique. Postoperatively, he developed methicillin-resistant Staphylococcus epidermidis bacteremia, which was treated with daptomycin. Subsequently, he presented with palpable purpura on both dorsal feet, erythema around his body, and hypereosinophilia. Daptomycin was replaced with vancomycin due to suspicion of drug-induced erythema. The erythema gradually faded. On nine days after vancomycin therapy, the systemic erythema rapidly reappeared followed by acute renal failure. The renal function decline prompted hemodialysis. A skin biopsy revealed cholesterol embolization, whereas a kidney biopsy revealed acute tubulointerstitial nephritis. After vancomycin discontinuation and initiation of systemic corticosteroid treatment, his kidney function was restored to the baseline level.

Conclusions

The present case highlights cholesterol embolization can cause allergic complications in addition to direct organ damage.

Idiopathic cholesterol crystal embolism with atheroembolic renal disease and blue toes syndrome: A case report

BACKGROUND

Cholesterol crystal embolization (CCE) is a multisystemic and fatal disease with multiple clinical manifestations; however, there are few cases of idiopathic CCE. Here we report a patient with idiopathic CCE accompanied by atheroembolic renal disease and blue toes who had a relatively good prognosis in the short-term due to early treatment with corticosteroids and statins.

CASE SUMMARY

A 76-year-old man complained of coldness, numbness and purple color change in his left foot for 7 d. He had a feeling of fatigue, constipation, foamy urine, poor appetite and sleep. He had a lacunar infarction for 5 years and hypertension for 9 mo. Laboratory results showed elevated eosinophils, cholesterol, uric acid, serum creatinine, urea and 24 h urine analysis revealed proteinuria. A renal biopsy revealed atheroembolic renal disease. Taken together, these findings strongly supported the diagnosis of idiopathic CCE and atheroembolic renal disease.

CONCLUSION

Atheroembolic renal disease and blue toes syndrome can be caused by idiopathic CCE, and early treatment with corticosteroids is effective but requires further investigation.

Prevention and Management of AKI in ACS Patients Undergoing Invasive Treatments

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.

Incidence, Risk Factors, and Prognosis of Cholesterol Crystal Embolism Because of Percutaneous Coronary Intervention

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.

Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum

Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.

Cutaneous manifestations of acute kidney injury

Acute kidney injury (AKI) is a common medical problem with a multitude of aetiologies. Prompt diagnosis and management is key in the prevention of complications. Cutaneous signs can often give diagnostic clues of underlying systemic diseases causing AKI.

This review summarises cutaneous findings of diseases causing AKI in adults. Knowledge of such cutaneous signs could lead to earlier diagnosis of underlying kidney disease and facilitate management strategies in a timely manner.

Acute interstitial nephritis, polyarteritis nodosa, Kawasaki's disease, granulomatosis with polyangiitis (previously Wegener's granulomatosis), microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis (previously Churg-Strauss syndrome), Henoch-Schonlein purpura, cryoglobulinaemia, Sjogren's Syndrome, systemic sclerosis, nephrogenic systemic fibrosis, dermatomyositis, systemic lupus erythematosus, amyloidosis, and cholesterol embolisation syndrome were highlighted as diseases causing AKI with cutaneous manifestations.

An Unusual Presentation of Cholesterol Embolization Syndrome

Cholesterol embolization syndrome (CES) is a rare presentation of systemic atherosclerosis, which commonly presents in patients with risk factors of coronary artery disease and usually occurs after cardiac or vascular procedures. Laboratory tests are nonspecific, and imaging studies may visualize the plaque. Management includes supportive care directed to relieve the end-organ damage. The prognosis of CES is poor, with high mortality of up to 29% if the CES resulted in atheroembolic renal disease (AERD). In our report, we present a 90-year-old Caucasian female who was diagnosed with CES and complicated with AERD. The patient did not undergo any cardiac or vascular procedures. This case highlights the importance of considering CES and AERD as a potential cause of renal failure, especially in high-risk patients, even if the patients did not have any history of cardiac or vascular intervention.

Dynamic Decrease in Eosinophil After Intravenous Thrombolysis Predicts Poor Prognosis of Acute Ischemic Stroke: A Longitudinal Study

Background and Purpose

Blood eosinophil counts are thought to be associated with atherosclerosis in acute ischemic stroke (AIS) and AIS severity. We aimed to investigate 1): the temporal profile of eosinophil in AIS patients treated with recombinant tissue plasminogen activator (r-tPA); 2): The association between dynamic eosinophil and 3-month outcomes in different AIS etiologies; 3): incremental predictive ability of dynamic eosinophil adding to conventional model; and 4): the longitudinal change of neutrophil-to-lymphocyte ratio (NLR) and compared its prognostic value with eosinophils.

Methods

A total of 623 AIS patients with intravenous thrombolysis in two hospitals were included. Blood samples were obtained on admission, within 24 h after an intravenous thrombolysis and on the seventh day. A multivariate logistic regression model with restricted cubic spline was performed to explore the association between dynamic eosinophil and a 3-month poor outcome. C-statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were adopted to explore the incremental predictive ability.

Results

Percent change in eosinophil counts after intravenous thrombolysis was median -25.00% (IQR -68.25%-+14.29%). Decrease in eosinophil >75% after intravenous thrombolysis was associated with 2.585 times risk for poor outcome and 13.836 times risk for death. However, the association were weak for patients outside of cardioembolic stroke. Adding eosinophil changes to a conventional model improved the discriminatory ability of poor outcome (NRI = 53.3%; IDI = 2.2%) and death (NRI = 101.0%; IDI = 6.9%).

Conclusions

Dynamic decrease in eosinophil after intravenous thrombolysis predicts a 3-month poor outcome and death in AIS patients with r-tPA treatment and improved the predictive ability of conventional model. However, this result needs to be interpreted carefully in non-cardioembolic AIS patients.

Efficacy of LDL apheresis for the treatment of cholesterol crystal embolism: A prospective, controlled study

This study was performed to evaluate the efficacy and safety of LDL apheresis (LDL-A) for the treatment of cholesterol crystal embolism (CCE) after cardiovascular procedures. We conducted a prospective multicenter study of 34 patients with CCE and 15 historical control patients. The present participants underwent six sessions of LDL-A for 4 weeks and underwent medical therapy with corticosteroids and statins. The mean creatinine concentration and estimated glomerular filtration rate at baseline were 3.82 ± 2.29 mg/dL and 17.8 ± 9.9 mL/min/1.73 m² , respectively. The prevalence of maintenance dialysis at 24 weeks was significantly lower in the present participants than in the historical controls (3.1% vs. 40.0%, respectively; p < 0.0001), but the mortality rate at 24 weeks was comparable (19% vs. 33%, respectively). Although 45 adverse events occurred in 23 participants, there were no unexpected adverse events. LDL-A for CCE reduces the prevalence of maintenance dialysis 24 weeks later and is well tolerated. This study was registered in the Japan Registry of Clinical Trials (jRCTs022180029) and clinicaltrials.gov (NCT01726868).

Neurological Complications of Cardiac Procedures

Neurological complications after cardiac surgery and percutaneous cardiac interventions are not uncommon. These include periprocedural stroke, postoperative cognitive dysfunction after cardiac surgery, contrast-induced encephalopathy after percutaneous interventions, and seizures. In this article, we review the incidence, pathophysiology, diagnosis, and management of these complications. Improved understanding of these complications could lead to their prevention, faster detection, and facilitation of diagnostic workup and appropriate treatment.

An Autopsy Case of Acute Pancreatitis Caused by Cholesterol Crystal Embolization

Cholesterol crystal embolization (CCE) shows a poor prognosis and it can cause ischemic organ damage due to a cholesterol embolism from atherosclerotic lesions in large blood vessels. Such an embolism mainly affects the kidneys and skin, although cases involving digestive organs have also been reported. We encountered an autopsy case of CCE with damage mainly to the digestive organs, including the pancreas. The patient had non-specific abdominal symptoms or image findings. Symptomatic therapy failed to save him. CCE can involve the digestive organs, and so must be differentiated from abdominal pathologies. Moreover, conventional treatments may be ineffective, and new treatments might thus be necessary.

Cholesterol embolization syndrome and intra-abdominal bleeding immediately after initiation of hemodialysis: a case report with literature review

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.

Thoracic Endovascular Aortic Repair in "Shaggy Thoracic Aortic Aneurysms"

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.

Cholesterol embolization and arterial occlusion from the Heimlich maneuver

The Heimlich maneuver is a lifesaving bystander intervention to assist an individual with airway obstruction however, cholesterol embolization syndrome is a rare, but serious potential complication of the Heimlich maneuver. We present the case of the 56-year-old female presenting to the emergency department with acute right foot pain following performance of the Heimlich maneuver who was found to have distal arterial occlusion resulting from cholesterol embolization syndrome. The patient underwent right popliteal artery exploration, right popliteal and tibial thrombectomy, and popliteal patch angioplasty resulting in restoration of blood flow to her right foot.

Acalculous Cholecystitis Complicated by Liver Abscess as a Manifestation of Cholesterol Embolization Syndrome - Infrequent Manifestation Precipitated by a Common Procedure

Cholesterol embolization syndrome (CES) is an atherosclerotic complication affecting different systems with various clinical manifestations, usually triggered iatrogenically by interventional and surgical procedures or thrombolytic therapy, although spontaneous cases have been reported. The hepatobiliary system can also be affected when the showered cholesterol crystals obliterate small vessels within this system causing both ischaemic and inflammatory responses. We describe a case of a male patient who initially developed multiple lacunar cerebral infarcts 10 days post-thrombolytic therapy and percutaneous coronary intervention (PCI) due to acute myocardial infarction. Several weeks later he developed acalculous cholecystitis complicated by liver abscess and kidney injury. The consequences and latency of manifestations within different organs and the temporal relationship with well-known trigger factors raised the suspicion of CES.

Effect of Atheromatous Aorta on Thromboembolic Complications after Endovascular Aortic Aneurysm

Objective: The purpose of this study was to evaluate the effect of atheromatous aorta on thromboembolic complications after endovascular aortic aneurysm repair (EVAR) and to assess the risk factors for these complications. Materials and Methods: This retrospective study included patients who underwent EVAR for an abdominal aortic aneurysm at the Shizuoka Red Cross Hospital from 2007 to 2018. We defined atheromatous aorta as a thoracic shaggy aorta or abdominal aorta with neck thrombus. The main outcome was renal dysfunction and peripheral embolization (thromboembolic complications). We compared the incidence of thromboembolic complications between patients with normal aorta and atheromatous aorta. Moreover, we assessed the risk factors associated with thromboembolic complications in patients with atheromatous aorta. Results: Patients with atheromatous aorta had significantly more thromboembolic complications, such as renal dysfunction (24.5% vs. 3.9%; P<0.001) and peripheral embolization (12.3% vs. 0.0%; P<0.001) than those with normal aorta, respectively. We identified no risk factors associated with thromboembolic complications in patients with atheromatous aorta. Conclusion: Atheromatous aorta increases the risk of thromboembolic complications after EVAR. However, there is no established therapy for these thromboembolic complications. Further studies are necessary to determine the appropriate therapy, including appropriate preoperative medication, to prevent these complications.

Cholesterol Embolization Syndrome After Carotid Artery Stenting Associated with Delayed Cerebral Hyperperfusion Intracerebral Hemorrhage

BACKGROUND

The cholesterol embolization syndrome (CES) results from the distal embolization of cholesterol crystals from atheromatous plaques in large vessels such as the aorta and results in multiorgan damage.

CASE DESCRIPTION

We present the case of a patient with definite CES with skin manifestations (e.g., blue toes) and renal and neurological dysfunction, including parenchymal hematoma with cytotoxic and vasogenic edema after he had undergone left carotid artery stenting for symptomatic critical left carotid artery stenosis.

CONCLUSIONS

Our patient with CES had cutaneous involvement affecting the lower limbs and renal and neurological involvement. High clinical suspicion and early treatment can reduce the mortality and morbidity after endovascular procedures. The neurological symptoms had most likely resulted from delayed cerebral hyperperfusion syndrome resulting in intracerebral hemorrhage.

Diffuse Cutaneous Manifestations after Drug-Coated Balloon Angioplasty

We present here a case of an uncommon cutaneous manifestation after paclitaxel-coated balloon angioplasty. In this case, the patient underwent drug-coated balloon angioplasty for stenosis of a prior vein bypass graft. The patient subsequently developed extensive cutaneous lesions not confined to a single arterial distribution. This case represents a rare complication related to paclitaxel-eluting balloons and provides a cautionary tale as well as clinical acumen for providers in using such devices in their practice.

Radial versus femoral artery access for percutaneous coronary artery intervention in patients with acute myocardial infarction and multivessel disease complicated by cardiogenic shock: Subanalysis from the CULPRIT-SHOCK trial

BACKGROUND

The use and impact of transradial artery access (TRA) compared to transfemoral artery access (TFA) in patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) complicated by cardiogenic shock (CS) remain unclear.

METHODS

This is a post hoc analysis of the CULPRIT-SHOCK trial where patients presenting with MI and multivessel disease complicated by CS were randomized to a strategy of culprit-lesion-only or immediate multivessel PCI. Arterial access was left at operator's discretion. Adjudicated outcomes of interest were the composite of death or renal replacement therapy (RRT) at 30 days and 1 year. Multivariate logistic models were used to assess the association between the arterial access and outcomes.

RESULTS

Among the 673 analyzed patients, TRA and TFA were successfully performed in 118 (17.5%) and 555 (82.5%) patients, respectively. Compared to TFA, TRA was associated with a lower 30-day rate of death or RRT (37.3% vs 53.2%, adjusted odds ratio [aOR]: 0.57; 95% confidence interval [CI] 0.34-0.96), a lower 30-day rate of death (34.7% vs 49.7%; aOR: 0.56; 95% CI 0.33-0.96), and a lower 30-day rate of RRT (5.9% vs 15.9%; aOR: 0.40; 95% CI 0.16-0.97). No significant differences were observed regarding the 30-day risks of type 3 or 5 Bleeding Academic Research Consortium bleeding and stroke. The observed reduction of death or RRT and death with TRA was no longer significant at 1 year (44.9% vs 57.8%; aOR: 0.85; 95% CI 0.50-1.45 and 42.4% vs 55.5%, aOR: 0.78; 95% CI 0.46-1.32, respectively).

CONCLUSIONS

In patients undergoing PCI for acute MI complicated by CS, TRA may be associated with improved early outcomes, although the reason for this finding needs further research.

Stroke and spinal infarct caused by percutaneous coronary intervention

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.

Detecting Free Cholesterol Crystals in a Patient With Spontaneous Cholesterol Embolization Syndrome

Spontaneous cholesterol embolization is thought to be due to aortic plaque-derived shower emboli; however, flowing cholesterol crystals have not been detected. Free multilayer cholesterol crystals obtained from the femoral artery were observed using polarized light microscopy. Detection of these crystals may indicate the occurrence of spontaneous shower emboli. (Level of Difficulty: Intermediate.).

[Update on cholesterol crystal embolism]

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.

Approaches to Microthrombotic Wounds: A Review of Pathogenesis and Clinical Features

GENERAL PURPOSE

To discuss the pathogenesis and clinical features of wounds caused by microthrombi formation under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Recall the etiology, risk factors, and pathophysiology of the various types of microthrombotic wounds.2. Describe the clinical manifestations and treatment of the various types of microthrombotic wounds.

ABSTRACT

Typical wounds such as diabetic foot ulcers, venous leg ulcers, pressure ulcers, and arterial ulcers are responsible for more than 70% of chronic wounds. Atypical wounds have broad differential diagnoses and can sometimes develop as a combination of different conditions. Regardless of the etiology, impaired blood circulation is characteristic of all chronic and acute wounds. Chronic wounds associated with microthrombi formation are an important group of atypical wounds commonly linked to an underlying systemic disease. In this perspective article, the pathogenesis and clinical features of wounds caused by microthrombi formation are discussed under the following categories of systemic diseases: cold-related and immune-complex deposition diseases, coagulopathies, abnormalities in red blood cell structure, emboli, and vasospasm.

Spontaneous ruptured aortic plaque and injuries: insights for aging and acute aortic syndrome from non-obstructive general angioscopy

Recent advances in non-obstructive general angioscopy (NOGA) have enabled the detection of aortic atherosclerosis. The incidence of spontaneous ruptured aortic plaques (SRAPs) and aortic injuries was found to be high in patients diagnosed with or suspected of having coronary artery disease. These facts may result in a paradigm shift for diseases such as aging and acute aortic syndrome because the incidence of systemic embolic diseases and aortic disease are assumed be high. Aortic thromboembolism has been thought to be mainly iatrogenic and is referred to as "cholesterol embolization syndrome" or "cholesterol crystal embolization", although the cholesterol crystals (CCs) were not demonstrated routinely as real images. Atheromatous materials, fibrins, calcifications, macrophages, and a mixture of such substances are released through a puff or puff-chandelier rupture. Among atheromatous materials, CCs can be easily detected clinically in sampled blood via polarized light microscopy. Atheromatous materials include rich CCs and free monolayers, and multilayer CCs are released when the atheromatous materials from vulnerable plaques break into pieces, such as in puff or puff-chandelier rupture. Released SRAPs seem to be asymptomatic; however, accumulation of SRAPs referred to as accumulated spontaneous asymptomatic plaques may cause aging through systemic "embolic" processes, such as mechanical obstruction and an inflammasome pathway. Unique findings in "atherosclerotic" acute aortic syndrome, such as a clear boundary between the dissected lesion and the normal lesion, fissure/fissure bleeding suggesting an entry or a reentry, and subintimal blood flow detected through NOGA are reported. Fissure/fissure bleeding and subintimal blood flow may be the first or last triggers of "atherosclerotic" acute aortic syndrome. Pre-emptive diagnosis and risk stratification of acute "atherosclerotic" aortic dissection and feedback for endovascular therapy may be enabled through the use of NOGA in the future.