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Alwattar-Ceballos O, Martínez-Montalvo L, Montero-García M, Gómez-Manzanares M, Arambarri-Segura M. Blue toe syndrome due to crystal cholesterol embolism. Med Clin (Barc) 2024; 162:407. [PMID: 38042736 DOI: 10.1016/j.medcli.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Omar Alwattar-Ceballos
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España.
| | - Laura Martínez-Montalvo
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Marina Montero-García
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
| | - Mónica Gómez-Manzanares
- Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, España
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2
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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3
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Suzuki M, Watari T. Blue toe syndrome caused by spontaneous cholesterol embolization syndrome. QJM 2023; 116:936-937. [PMID: 37471693 DOI: 10.1093/qjmed/hcad169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Indexed: 07/22/2023] Open
Affiliation(s)
- M Suzuki
- Department of General Internal Medicine, National Hospital Organization Sendai Medical Center, Miyagi, Japan
| | - T Watari
- Department of Internal Medicine, University of Michigan Medical School, MI, USA
- General Medicine Centre, Shimane University Hospital, Shimane, Japan
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4
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Gargallo Martínez C, Lasierra Lavilla I, Martínez Oviedo A. [Blue finger syndrome for cholesterol embolism]. Semergen 2023; 49:101982. [PMID: 37487367 DOI: 10.1016/j.semerg.2023.101982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 07/26/2023]
Affiliation(s)
- C Gargallo Martínez
- Medicina de Familia y Comunitaria, Servicio de Urgencias, Hospital Obispo Polanco, Teruel, España
| | | | - A Martínez Oviedo
- Especialidad de Área, Servicio de Urgencias, Hospital Obispo Polanco, Teruel, España
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5
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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6
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Sessa C, Morale W, Zanoli L, Biancone L, Barreca A, Seminara G, Londrino F, Granata A. [Atheroembolic renal disease: risk factors, diagnostics, histology, and therapeutic approaches]. G Ital Nefrol 2021; 38:38-05-2021-07. [PMID: 34713643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The increase in patients' average age, the enhancement of anticoagulation therapy and the growth of vascular interventions represent the perfect conditions for the onset of atheroembolic renal disease. AERD is observed in patients with diffuse atherosclerosis, generally after a triggering event such as surgery on the aorta, invasive procedures (angiography, catheterization of the left ventricle, coronary angioplasty) and anticoagulant or fibrinolytic therapy. The clinical signs are heterogeneous, a consequence of the occlusion of downstream small arterial vessels by cholesterol emboli coming from atheromatous plaques of the aorta, or one of its main branches. The proximity of the kidneys to the abdominal aorta, and the high flow of blood they receive, make them a major target organ. For this reason, AERD represents a pathological condition that always needs to be taken into account in the nephropathic patient, although its systemic nature makes the diagnosis difficult. This manuscript presents a review of the existing literature on this pathology, to provide an updated summary of the state of the art: risk factors, diagnostics, histology and therapeutic approaches.
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Affiliation(s)
| | - Walter Morale
- U.O.C Nefrologia e Dialisi, P.O. "Maggiore" di Modica. Azienda Sanitaria Provinciale di Ragusa, Italy
| | - Luca Zanoli
- Nefrologia, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Catania, Italy
| | - Luigi Biancone
- Nefrologia Dialisi e Trapianto, AOU città della salute e della Scienza, Torino, Italy
| | - Antonella Barreca
- Anatomia Patologica, AOU città della salute e della Scienza, Torino, Italy
| | - Giuseppe Seminara
- U.O.C di Nefrologia e Dialisi, A.O. per l'Emergenza "Cannizzaro", Catania, Italy
| | - Francesco Londrino
- U.O.C. Nefrologia e Dialisi, ASL Roma 2, A.O. "Sant'Eugenio", Roma, Italy
| | - Antonio Granata
- U.O.C di Nefrologia e Dialisi, A.O. per l'Emergenza "Cannizzaro", Catania, Italy
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7
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Bhat KG, Jha VK, Kumar MH, Mahapatra D. A case of cholesterol embolization syndrome mimicking rapidly progressive renal failure causing end-stage kidney disease. Saudi J Kidney Dis Transpl 2021; 32:1489-1494. [PMID: 35532725 DOI: 10.4103/1319-2442.344775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
Cholesterol embolization syndrome is an uncommon complication of coronary angioplasty. Its clinical manifestations are nonspecific and may be ascribed to other causes mimicking vasculitis syndrome. In an appropriate clinical setting, the diagnosis can be confirmed by tissue biopsy. In this case report, we present a middle-aged male who presented with cutaneous and renal manifestations within two weeks of primary angioplasty. The patient had progressive clinical deterioration in the form of dry gangrene of toes and end-stage renal disease requiring surgical amputation and maintenance hemodialysis respectively within two months of symptoms onset.
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Affiliation(s)
| | - Vijoy Kumar Jha
- Department of Nephrology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - M Harish Kumar
- Department of Rheumatology, Command Hospital Air Force, Bengaluru, Karnataka, India
| | - Debasish Mahapatra
- Department of Nephrology, Command Hospital Air Force, Bengaluru, Karnataka, India
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8
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Oshima A, Horiuchi Y, Kishi S, Mise N. Spontaneous Cholesterol Crystal Embolism and Aortic Plaques. Intern Med 2021; 60:1981-1982. [PMID: 33456045 PMCID: PMC8263176 DOI: 10.2169/internalmedicine.6511-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Asahi Oshima
- Division of Internal Medicine, Mitsui Memorial Hospital, Japan
| | - Yu Horiuchi
- Division of Internal Medicine, Mitsui Memorial Hospital, Japan
| | - Satoru Kishi
- Division of Internal Medicine, Mitsui Memorial Hospital, Japan
| | - Naobumi Mise
- Division of Internal Medicine, Mitsui Memorial Hospital, Japan
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9
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Sato Y, Okamoto K, Fukuda M, Oyama Y, Kondo Y, Nishida H, Daa T, Togo K, Sonoda A, Fukuda K, Matsunari O, Ogawa R, Honda K, Mizukami K, Okimoto T, Kodama M, Murakami K. An Autopsy Case of Acute Pancreatitis Caused by Cholesterol Crystal Embolization. Intern Med 2021; 60:839-845. [PMID: 33055480 PMCID: PMC8024961 DOI: 10.2169/internalmedicine.5524-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Yuto Sato
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kazuhisa Okamoto
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Masahide Fukuda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Yuzo Oyama
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Yoshihiko Kondo
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Haruto Nishida
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Tsutomu Daa
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Japan
| | - Kazumi Togo
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Akira Sonoda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kensuke Fukuda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Osamu Matsunari
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Ryo Ogawa
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Koichi Honda
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kazuhiro Mizukami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Tadayoshi Okimoto
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Masaaki Kodama
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Japan
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10
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Affiliation(s)
- Masaki Kuwatani
- Division of Endoscopy, Hokkaido University Hospital, Japan
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Japan
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11
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Vermeulen M. 50-year-old man • foot pain • "purple" toe • history of smoking • Dx? J Fam Pract 2020; 69:E14-E16. [PMID: 32724917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
► Foot pain ► "Purple" toe ► History of smoking.
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Affiliation(s)
- Meagan Vermeulen
- Department of Family Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA.
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12
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Usui G, Hashimoto H, Sugiura Y, Nishi Y, Kusakabe M, Horiuchi H, Okubo S, Morikawa T. Aortogenic Embolic Stroke Diagnosed by a Pathological Examination of Endovascularly Removed Thrombus: An Autopsy Report. Intern Med 2019; 58:2851-2855. [PMID: 31178514 PMCID: PMC6815896 DOI: 10.2169/internalmedicine.2857-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Complex aortic atheroma is a high-risk factor for recurrent embolic stroke. An accurate identification of stroke etiology is clinically important; however, it can be challenging. A 91-year-old man with atrial fibrillation was diagnosed with cardioembolic stroke and treated with mechanical thrombectomy. The removed thrombus microscopically contained foamy cells, suggesting an atheroembolism. An autopsy revealed an atherosclerotic lesion with ulceration, located in the aortic arch. At the lesion, the plaque had microscopically ruptured into the lumen. We therefore concluded that the aortic atherosclerotic lesion was the embolic source. Removed thrombi should be pathologically examined even if a cardioembolic stroke is clinically suspected.
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Affiliation(s)
- Genki Usui
- Department of Diagnostic Pathology, NTT Medical Center Tokyo, Japan
| | | | - Yoshiya Sugiura
- Department of Diagnostic Pathology, NTT Medical Center Tokyo, Japan
- Division of Pathology, The Cancer Institute, Japanese Foundation for Cancer Research, Japan
| | - Yuji Nishi
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Japan
| | | | - Hajime Horiuchi
- Department of Diagnostic Pathology, NTT Medical Center Tokyo, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Japan
| | - Teppei Morikawa
- Department of Diagnostic Pathology, NTT Medical Center Tokyo, Japan
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13
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Kitamura N, Sasabe E, Kitaoka H, Yamamoto T. Unilateral necrosis of the tongue caused by embolisation of cholesterol crystals. Br J Oral Maxillofac Surg 2018; 56:340-342. [PMID: 29599050 DOI: 10.1016/j.bjoms.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/08/2018] [Indexed: 11/16/2022]
Abstract
Cholesterol crystals embolise when an aortic atherosclerotic lesion ruptures and cholesterol crystals are scattered and obstruct small peripheral arterioles. Risk factors include both iatrogenic factors such as intravascular catheterisation, and spontaneous factors for atherosclerosis such as aging, hypertension, dyslipidaemia, and smoking. We describe the case of an 83-year-old Japanese man who developed unilateral, superficial necrosis of the tongue as a result of spontaneous embolisation of cholesterol crystals.
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Affiliation(s)
- N Kitamura
- Department of Oral and Maxillofacial Surgery, Kochi Medical School, Kochi University, Kochi 783-8505, Japan.
| | - E Sasabe
- Department of Oral and Maxillofacial Surgery, Kochi Medical School, Kochi University, Kochi 783-8505, Japan.
| | - H Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi 783-8505, Japan.
| | - T Yamamoto
- Department of Oral and Maxillofacial Surgery, Kochi Medical School, Kochi University, Kochi 783-8505, Japan.
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14
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van Spil WE, Steenbergen E, Verhave JC. A fatty cause of acute renal failure. Neth J Med 2016; 74:365. [PMID: 27762223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- W E van Spil
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands
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15
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Abstract
Atheromatous embolization is a multisystem disease complicating advanced atherosclerosis. It occurs most often as a complication of angiography, an endovascular procedure or cardiovascular surgery. Atheromatous embolization can present in a subtle manner where it is often under-recognized, or with catastrophic results including myocardial infarction, strake or acute renal failure. It may mimic other disease processes and often goes underdiagnosed and undertreated. A high clinical suspicion is the key to diagnosis. Atheromatous embolization results in significant morbidity and mortality; therefore, early recognition followed by aggressive management may help to prevent end-organ damage and improve overall clinical outcomes. Management strategies should include risk factor modification, prevention of further insults by discontinuing or avoiding predisposing factors, supportive treatment and interventional or surgical approaches to remove the atheroembolic source. Atheromatous embolization is expected to increase as our population ages and the epidemics of diabetes mellitus and obesity increase.
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Affiliation(s)
- Yin Ping Liew
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Abstract
Distal peripheral microembolism is caused by embolization of atherosclerotic debris into small arteries and arterioles. The recent advances in endovascular technique have been met with a gradual increase in the incidence of iatrogenic atheroembolism. This review seeks to explore the nature of distal peripheral microembolism, pathophysiology, and the management options, with a focus on iatrogenic distal peripheral microembolism.
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Affiliation(s)
- Joe R Chauvapun
- Department of Surgery, State University of New York, Buffalo, NY, USA.
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17
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Hase H. [Chronic kidney disease caused by cholesterol embolization syndrome.]. Nihon Naika Gakkai Zasshi 2016; 105:850-856. [PMID: 29182837 DOI: 10.2169/naika.105.850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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18
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Affiliation(s)
- Grant K Ghahramani
- Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City
| | - Alison E Seline
- Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City
| | - Karolyn A Wanat
- Department of Dermatology and Pathology, University of Iowa Hospitals and Clinics, Iowa City
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Azuma S, Ikenouchi M, Akamatsu T, Seta T, Urai S, Uenoyama Y, Yamashita Y. Ileus caused by cholesterol crystal embolization: A case report. World J Gastroenterol 2016; 22:3502-3505. [PMID: 27022232 PMCID: PMC4806208 DOI: 10.3748/wjg.v22.i12.3502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 12/09/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Cholesterol crystal embolization (CCE) is a rare systemic embolism caused by formation of cholesterol crystals from atherosclerotic plaques. CCE usually occurs during vascular manipulation, such as vascular surgery or endovascular catheter manipulation, or due to anticoagulation or thrombolytic therapy. We report a rare case of intestinal obstruction caused by spontaneous CCE. An 81-year-old man with a history of hypertension was admitted for complaints of abdominal pain, bloating, and anorexia persisting for 4 mo. An abdominal computed tomography revealed intestinal ileus. His symptoms were immediately relieved by an ileus tube insertion, and he was discharged 6 d later. However, these symptoms immediately reappeared and persisted, and partial resection of the small intestine was performed. A histopathological examination indicated that small intestine obstruction was caused by CCE. At the 12-mo follow-up, the patient showed no evidence of CCE recurrence. Thus, in cases of intestinal obstruction, CCE should also be considered.
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20
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Fourgeaud C, El Nemer W, Michon Pasturel U, Bonhomme S, Brignier A, Lazareth I, Priollet P. [Vascular myeloproliferative neoplasm with normal cell blood count: Exploration and medical management]. ACTA ACUST UNITED AC 2015; 40:350-8. [PMID: 26362408 DOI: 10.1016/j.jmv.2015.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 06/12/2015] [Indexed: 02/06/2023]
Abstract
UNLABELLED Negative BCR ABL myeloproliferative neoplasm (MPN) such as polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (MFP) are clonal hematological malignancies and may lead to a high risk of venous, arterial or microcirculatory thrombosis. Atypical sites of thrombosis can sometimes reveal the neoplasm disorder. Their diagnoses are a major issue because of the propensity to develop acute myeloid leukemia and/or myelofibrosis. The acquired JAK2V617F variant (Janus kinase 2; 9p24) is a prevalent MPN and also a sensitive marker for PV diagnosis (95% positive mutation), but not specific since found in approximately 50% of patients with ET and MFP. PATIENT AND METHODS We present a diagnostic and a therapeutic approach based on one patient with microcirculatory ischemic manifestations in the toes, and who had strictly normal cell blood counts and was positive for JAK2V617F mutation: thrombotic risk factor evaluation; bone marrow biopsy; red cell adhesion assays. These experimental assays are promising for the development of new therapeutics in MPN; they assess red cell adherence to the vascular endothelium after the phosphorylation of Lu/BCAM subsequent to a positive JAK2V617F mutation. RESULTS Compared with controls, our patient exhibited increased Lu/BCAM receptor phosphorylation and red blood cell adhesion. CONCLUSION This development may lead to improved care for patients with thrombotic manifestations, normal blood cell counts, and a positive JAK2V617F mutation: multidisciplinary management, including regular hematological monitoring, could lead to the introduction of a cytoreductive treatment.
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Affiliation(s)
- C Fourgeaud
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
| | - W El Nemer
- Institut national de la transfusion sanguine, Inserm U1134, 6, rue Alexandre-Cabanel, 75739 Paris cedex 15, France
| | - U Michon Pasturel
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - S Bonhomme
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - A Brignier
- Service d'hématologie A, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
| | - I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
| | - P Priollet
- Service de médecine vasculaire, groupe hospitalier Paris-Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France
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21
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Fujikawa S, Iguchi R, Noguchi T, Sasaki M. [Cholesterol crystal embolization following urinary diversion: a case report]. Hinyokika Kiyo 2015; 61:99-102. [PMID: 25918267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Cholesterol crystal embolization (CCE) is a cardiovascular disorder with poor prognosis, causing multiple organ failure. The primary pathological condition of the disease is embolization of cholesterol crystals in peripheral vessels. We report a case of CCE following urinary diversion. The patient is a 82-year-old male with history of hypertention, pneumonectasia, interstitial pneumonia, and heavy smoking. He was afflicted with advanced bladder cancer. He underwent urinary diversion, and had been scheduled for palliative radiotherapy. The next day, he developed thromboembolism of the left lower leg as acomplication of urinary diversion. Thrombectomy by endovascular catheter procedure was performed immediately, and anticoagulant therapy was started. The day after the thrombectomy, his lower legs showed livedo reticularis and toes showed cyanosis (blue toe). Since the laboratory data showed acute deterioration in renal function, hemodialysis was initiated. Three days after the thrombectomy he died of multiple organ failure. At autopsy, diffuse atherosclerosis of the aorta was observed, and cholesterol crystalemboli were found in the skin of the left foot ; and, the diagnosis of CCE was confirmed. This case suggests that tissue examinations for early diagnosis and stopping anticoagulant therapy are preferred when CCE is suspected.
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Affiliation(s)
| | - Ryo Iguchi
- The Department of Urology, Shizuoka City Shizuoka Hospital
| | | | - Miharu Sasaki
- The Department of Urology, Shizuoka City Shizuoka Hospital
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Motegi SI, Abe M, Shimizu A, Tamura A, Hatori T, Nakano A, Hasegawa A, Kurabayashi M, Ishikawa O. Cholesterol Crystal Embolization: Skin Manifestation, Gastrointestinal and Central Nervous Symptom Treated with Corticosteroid. J Dermatol 2014; 32:295-8. [PMID: 15863854 DOI: 10.1111/j.1346-8138.2005.tb00766.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Accepted: 11/30/2004] [Indexed: 11/30/2022]
Abstract
Cholesterol crystal embolization (CCE) is characterized by tissue ischemia secondary to occlusion of small arteries. It may occur spontaneously but more often follows radiological interventional procedures or vascular surgery. This systemic disease affects multiple organs, including skin, kidney, brain, eye, and gastrointestinal tract. We reported a Japanese male CCE patient with cutaneous manifestations of livedo reticularis, diarrhea, clouding of consciousness, and acute renal failure. Histopathological examination demonstrated multiple biconvex clefts in a vessel of the subcutis. Corticosteroid administration improved his consciousness, diarrhea and skin lesions. Awareness of the skin manifestations of CCE is essential for dermatologists to make an early diagnosis and prescribe appropriate treatment.
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MESH Headings
- Administration, Oral
- Aged
- Anti-Inflammatory Agents/therapeutic use
- Crystallization
- Diagnosis, Differential
- Embolism, Cholesterol/complications
- Embolism, Cholesterol/diagnosis
- Embolism, Cholesterol/drug therapy
- Embolism, Cholesterol/pathology
- Humans
- Male
- Myocardial Infarction/complications
- Prednisolone/therapeutic use
- Renal Insufficiency/complications
- Renal Insufficiency/diagnosis
- Renal Insufficiency/drug therapy
- Renal Insufficiency/pathology
- Skin Diseases, Vascular/complications
- Skin Diseases, Vascular/diagnosis
- Skin Diseases, Vascular/drug therapy
- Skin Diseases, Vascular/pathology
- Syndrome
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Affiliation(s)
- Sei-ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
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Nasr B, Schneider F, Marques da Fonseca P, Gouny P. Cholesterol crystal embolism and delayed-onset paraplegia after thoracoabdominal aneurysm repair. Ann Vasc Surg 2014; 28:1320.e1-3. [PMID: 24456864 DOI: 10.1016/j.avsg.2013.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 09/30/2013] [Accepted: 11/28/2013] [Indexed: 11/17/2022]
Abstract
Postoperative paraplegia caused by ischemic injury of the spinal cord is the most disabling complication of thoracoabdominal surgery. We described the case of a 75-year-old patient who underwent a thoracoabdominal aneurysm repair (type IV aneurysm according to Crawford classification). The aorta clamping was done at the T11 level without specific medullary protection. The first postoperative week was uneventful. On the postoperative day 8, renal failure and livedo of the left lower limb occurred together with complete hypotonic paraplegia and severe sepsis. Exploratory laparotomy revealed a gangrenous cholecystitis, and skin biopsies showed cholesterol crystals embolisms in the hypodermis small arteries. The patient died on the postoperative day 28 from a multiorgan failure. In this case, paraplegia was due to cholesterol crystal embolism, which migrated secondarily after aortic clamping.
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Affiliation(s)
- Bahaa Nasr
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Brest, Brest, France.
| | - Fabrice Schneider
- Department of Thoracic and Vascular Surgery, University Hospital of Poitiers, Poitiers, France
| | | | - Pierre Gouny
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Brest, Brest, France
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Bakri SJ, Luqman A, Pathik B, Chandrasekaran K. Is carotid ultrasound necessary in the clinical evaluation of the asymptomatic Hollenhorst plaque? (An American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2013; 111:17-23. [PMID: 24072943 PMCID: PMC3783250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE To evaluate the utility of carotid ultrasound in patients with asymptomatic Hollenhorst plaques. METHODS Retrospective chart review of 237 patients diagnosed with Hollenhorst plaques between 1996 and 2004. The baseline cardiovascular risk profile, medications, and carotid ultrasound findings were documented. Retinal ischemia, myocardial ischemia, and cerebrovascular events during follow-up were noted. RESULTS There was no statistically significant difference in the proportion of patients with carotid stenosis >40% between symptomatic (n=60) and asymptomatic (n=177) patients (32.7% vs 22.7%; P=.192, one-way ANOVA). However, symptomatic patients were statistically more likely to have stenosis >69% (25% compared with 9.2% in the asymptomatic group; P=.008, one-way ANOVA). Among asymptomatic patients, those with carotid bruit (27.1%) were more likely to have moderate carotid stenosis >40% (55.6% vs 18.6% in patients without bruit; P=.0008, one-way ANOVA) and significant stenosis >69% (37% vs 4.3% in patients without bruit; P=.0001, one-way ANOVA). Follow-up data was obtained from 32 symptomatic patients (39.6 ± 22.9 months) and 100 asymptomatic patients (41.3 ± 21.8 months). Vascular and neurologic event rates were similar between the two groups. CONCLUSIONS Hollenhorst plaques are a marker of significant carotid disease irrespective of retinal symptoms. Carotid auscultation remains important in the examination of patients with Hollenhorst plaques and increases the yield of asymptomatic patients diagnosed with carotid stenosis. The presence of visual symptoms on presentation did not correlate with an increased risk of death or stroke compared to asymptomatic patients during follow-up. Therefore all patients with asymptomatic plaques should have a medical workup, including carotid ultrasonography.
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Affiliation(s)
- Sophie J Bakri
- Department of Ophthalmology (Dr Bakri, Dr Pathik), Department of Internal Medicine (Dr Luqman), and Department of Cardiovascular Diseases (Dr Chandrasekaran), Mayo Clinic, Rochester, Minnesota
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Prayaga S, Uretsky BF, Sachdeva R. ST-elevation myocardial infarction as a complication of retrograde chronic total occlusion recanalization. Catheter Cardiovasc Interv 2012; 80:611-5. [PMID: 21805592 DOI: 10.1002/ccd.23266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 05/31/2011] [Indexed: 11/07/2022]
Abstract
With the advent of new tools and techniques including the retrograde approach, success rates for recanalization of chronic total occlusion (CTO) have improved. Numerous cardiac and extracardiac complications during retrograde CTO recanalization have been described. To date the development of ST-segment elevation myocardial infarction (STEMI) with retrograde recanalization as a result of atheroembolization has not been reported. We report such a case following retrograde recanalization of a totally occluded right coronary artery.
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Affiliation(s)
- Sastry Prayaga
- Central Arkansas Veterans Healthcare System and University of Arkansas for Medical Sciences, Little Rock, AR, USA
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26
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Patro N, George R, Singh P, Joseph G. Cutaneous cholesterol embolization syndrome: A case report. Dermatol Online J 2012; 18:10. [PMID: 22863632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
An 81-year-old woman with chronic kidney disease, systemic hypertension, and a large infra-renal abdominal aortic aneurysm, developed bilateral calf muscle pain, altered sensorium, and deterioration of renal function following endovascular aneurysmal repair. On the third post-operative day she developed symmetrical purpuric macules with erythematous margins on the gluteal region and bluish reticulated patches on the soles and tips of toes. This was followed by melena development on the seventh post-operative day. Histology of the skin confirmed the diagnosis of cutaneous cholesterol embolization syndrome (CES). She was treated with hemodialysis and supportive management and she recovered.
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Affiliation(s)
- Nibedita Patro
- Department of Dermatology, Christian Medical College, Vellore, Tamilnadu, India
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27
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Granata A, Insalaco M, Di Pietro F, Di Rosa S, Romano G, Scuderi R. [Atheroembolism renal disease: diagnosis and etiologic factors]. Clin Ter 2012; 163:313-322. [PMID: 23007816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Atheromatous renal disease is the major cause of renal insufficiency in the elderly, and cholesterol embolism is a manifestation of this disease. Cholesterol embolism occurs in patients suffering from diffuse erosive atherosclerosis, usually after triggering causes, such as aortic surgery, arterial invasive procedures (angiography, left heart catheterization and coronary angioplasty) and anticoagulant or thrombolytic therapy. It is characterized by occlusion of small arteries with cholesterol emboli deriving from eroded atheromatous plaques of the aorta or large feeder arteries. The proximity of the kidneys to the abdominal aorta and the large renal blood supply make the kidney a frequent target organ for cholesterol atheroembolism. The exact incidence of atheroembolic renal disease (AERD) is not known. The reported incidence AERD varied in the literature because of the differences in study design and the different criteria used for making the diagnosis. Retrospective data derived from autopsy or biopsy studies may exaggerate the frequency by including many subclinical cases. Clinical observations that are based on a short duration of follow-up after an invasive vascular procedure and the infrequency of the confirmatory renal biopsies can lead to an underestimation of the true incidence of AERD. The initial signs and symptoms in patients diagnosed with cholesterol embolism were blue toes syndrome, livedo reticularis, gangrene, leg, toe or foot pain, abdominal pain and flank or back pain, gross haematuria, accelerated hypertension and renal failure. Cholesterol embolism may also be associated with fever, increased erythrocyte sedimentation rate and eosinophilia. Thus, in the cases of spontaneous cholesterol embolism, differential diagnosis includes, polyarteritis nodosa, allergic vasculitis and subacute bacterial endocarditis. Skin and renal biopsy specimens are the best sample for histologic diagnosis. There is, at present, no pharmacological treatments shown to be effective in altering the course of the disease. Management is limited to supportive therapy and avoidance of anticoagulation; aortic procedures should be postponed.
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Affiliation(s)
- A Granata
- U.O.C. Nefrologia Dialisi e Cardiologia, Ospedale "San Giovanni di Dio" ASP1, Agrigento, Italia.
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Shigeta K, Ohno K, Takasato Y, Masaoka H, Hayakawa T, Yatsushige H, Inaji M, Sumiyoshi K, Momose T, Maeda T, Kiyokawa J. Analysis of DWI ASPECTS and recanalization outcomes of patients with acute-phase cerebral infarction. J Med Dent Sci 2012; 59:57-63. [PMID: 23896997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 03/09/2012] [Indexed: 06/02/2023]
Abstract
In order to rapidly judge the response to intravenous tissue plasminogen activator (Ⅳ tPA) treatment, we retrospectively analyzed clinical data, such as MRI diffusion-weighted images (DWI), and treatment outcomes in 73 patients who developed anterior circulation disorders. The patients with favorable outcomes (modified Rankin Scale [mRS]: 2 or less) at discharge accounted for 32.9%. In these patients, the National Institutes of Health Stroke Scale (NIHSS) value, DWI Alberta Stroke Programme Early CT Score (ASPECTS), and the incidence of large artery (internal carotid artery [ICA]/sphenoidal segment of the middle cerebral artery [M1]) occlusion at their hospital visit were lower, higher, and lower, respectively (all P < 0.05 in univariate analysis). Multivariate analysis showed significant differences in DWI ASPECTS and the incidence of large artery occlusion. A DWI ASPECTS of at least 8 was found to be predictive of favorable outcomes. However, subclass analysis in the group with a DWI ASPECTS of 8 or higher predicting favorable outcome revealed 13 patients (41.9%) with unfavorable (mRS, 3-6) outcome. The factor associated with unfavorable outcomes is ICA occlusion. The combination of DWI ASPECTS and MRA appeared to be useful for predicting outcomes of Ⅳ tPA.
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Affiliation(s)
- Keigo Shigeta
- Department of Neurosurgery, Tokyo Medical and Dental University, Tokyo, Japan
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29
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Tokoyoda T, Tsujimoto I, Sugiura Y, Sezaki R. A hollenhorst plaque in cholesterol crystal embolism. Intern Med 2012; 51:223. [PMID: 22246495 DOI: 10.2169/internalmedicine.51.6710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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30
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Hu HD, Chang Q, Chen Z, Liu C, Ren YY, Cai YC, Zhang J, Xin SJ. [Management and prognosis of acute arterial embolism: a multivariable analysis of 346 patients]. Zhonghua Yi Xue Za Zhi 2011; 91:2923-2926. [PMID: 22333615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate the management of acute arterial embolism (AAE) and its prognostic factors. METHODS The clinical data of 346 AAE patients treated at our hospital between January 1998 and October 2008 were retrospectively reviewed. The prognostic factors, including age, gender, extremities, location of embolism, ischemic duration, ischemic categories, and therapeutic methods, postoperative complications were evaluated by multivariate Logistic regression analysis. RESULTS There were 210 males and 136 females with a mean age of (63 ± 14) years old. Fifty-six patients occurred in the upper extremities and 290 patients in the lower extremities. The causes included cardiogenic embolism (n = 301), vasogenic embolism (n = 33) and unknown origin (n = 12). The duration of ischemia ranged from 1 h to 7 d. Only 44 patients were admitted ≤ 8 h and the remainder > 8 h. The categories of extremity ischemia were level I (n = 17), level IIA (n = 69), level IIB (n = 221) and level III (n = 39). The procedures included embolectomy (n = 280), interventional thrombolysis (n = 19) and conservative treatment (n = 47). Thirteen patients (3.76%) died of complications during the perioperative periods. And 44 (12.72%) underwent amputations and 289 (83.53%) had excellent clinical outcome with extremity salvage. During a 5-year follow-up period, 38 patients had a recurrent embolism. The Logistic regression analysis showed that ischemic duration, ischemic category, therapeutic methods and complications had significant prognostic influences (all P < 0.05). And other factors such as age, gender, extremities and the location of embolism had insignificant influences (all P > 0.05). CONCLUSION Embolectomy is the first-choice therapy for AAE with an excellent outcome. Ischemic duration, ischemic grading, surgical treatment and complications have significant prognostic influences. Systematic medical treatments, such as effective anticoagulation, are vital in the prevention of recurrent AAE.
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Affiliation(s)
- Hai-di Hu
- Department of Surgery, China Medical University, Shenyang, China.
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31
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Yuda J, Honma R, Fukase S, Okawara S, Omoto E, Goto T, Suzuki M. [Case report: a case of cholesterol crystal embolism mimicking vasculitis]. Nihon Naika Gakkai Zasshi 2011; 100:2247-2249. [PMID: 21899155 DOI: 10.2169/naika.100.2247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Junichiro Yuda
- Department of Internal Medicine, Yamagata Prefecutural Central Hospital, Japan
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32
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Yasuda T. [Series: Diagnosis at a glance]. Nihon Naika Gakkai Zasshi 2011; 100:1705-1707. [PMID: 21770302 DOI: 10.2169/naika.100.1705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Takashi Yasuda
- Department of Internal Medicine, Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Japan
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33
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Mizuno M, Ito Y, Hayasaki T, Suzuki Y, Hiramatsu H, Toda S, Mizuno T, Tatematsu M, Ozaki T, Yasuda Y, Sato W, Tsuboi N, Ito I, Maruyama S, Imai E, Matsuo S. A case of acute renal failure caused by cholesterol embolization after carotid artery stenting that was improved by peritoneal dialysis. Intern Med 2011; 50:1719-23. [PMID: 21841332 DOI: 10.2169/internalmedicine.50.5358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 68-year-old man was admitted with acute renal failure caused by cholesterol embolization after undergoing carotid artery stenting. Hemodialysis therapy (HD) was immediately required because of uremia, using nafamostat mesilate as an anticoagulant for HD. However, blue toes and gangrene of the feet worsened. To prevent use of anticoagulants and stabilize BP, HD was changed to peritoneal dialysis (PD). After starting PD, blue toes and gangrene improved markedly. Residual renal function also partially recovered. Although BP was unstable during HD, stability of BP and avoidance of anticoagulants during PD therapy might have contributed to the good results.
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Affiliation(s)
- Masashi Mizuno
- Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Japan.
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Abstract
Atheroembolic renal disease develops when atheromatous aortic plaques rupture, releasing cholesterol crystals into the small renal arteries. Embolisation often affects other organs, such as the skin, gastrointestinal system, and brain. Although the disease can develop spontaneously, it usually develops after vascular surgery, catheterisation, or anticoagulation. The systemic nature of atheroembolism makes diagnosis difficult. The classic triad of a precipitating event, acute or subacute renal failure, and skin lesions, are strongly suggestive of the disorder. Eosinophilia further supports the diagnosis, usually confirmed by biopsy of an affected organ or by the fundoscopic finding of cholesterol crystals in the retinal circulation. Renal and patient prognosis are poor. Treatment is mostly preventive, based on avoidance of further precipitating factors, and symptomatic, aimed to the optimum treatment of hypertension and cardiac and renal failure. Statins, which stabilise atherosclerotic plaques, should be offered to all patients. Steroids might have a role in acute or subacute progressive forms with systemic inflammation.
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Fries C, Roos M, Gaspert A, Vogt P, Salomon F, Wüthrich RP, Vavricka SR, Fehr T. Atheroembolic disease--a frequently missed diagnosis: results of a 12-year matched-pair autopsy study. Medicine (Baltimore) 2010; 89:126-132. [PMID: 20517183 DOI: 10.1097/md.0b013e3181d5eb39] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Diagnosis of atheroembolic disease (AD) is challenging, because no specific test is available and AD often masquerades as other clinical conditions. We conducted the current study to investigate the relative frequency of autopsy-proven AD over time, to describe its clinical presentation, and to identify risk factors for AD. We screened 2066 autopsy reports from 1995 to 2006 for AD. For each AD case, a control patient without AD was matched for age, sex, and autopsy year. Diagnostic and therapeutic interventions (surgery, catheter interventions, and drug treatment) in the last 6 months before death, as well as clinical and laboratory parameters during the last hospitalization, were retrieved from electronic charts. We identified 51 patients with AD. Among these only 6 (12%) had been diagnosed clinically. The organs most often affected were kidney (71%), spleen (37%), and lower gastrointestinal tract (22%). The relative AD frequency decreased over time from 3.5 to 0.5 per 100 autopsies, whereas the frequency of clinically suspected and biopsy-proven AD remained constant. Among clinical signs, skin lesions such as livedo reticularis and blue toe (33% vs. 14%; p = 0.04) were significantly increased in AD patients compared with the matched controls. We also observed a trend for higher incidence of eosinophilia and proteinuria in AD patients. Vascular interventions within 6 months before death were highly associated with AD (55% vs. 29%; p = 0.01), and in a multivariable analysis this remained the only significant risk factor for AD. Thus, the diagnosis of AD is frequently missed. Vascular interventions represent the most important risk factor for AD and should be performed restrictively in high-risk patients.
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Affiliation(s)
- Caroline Fries
- From Division of Nephrology (CF, RPW, TF), Department of Pathology (AG, PV), Division of Gastroenterology and Hepatology (SRV), University Hospital Zürich, Zürich; Biostatistics Unit (MR), Institute of Social and Preventive Medicine, University of Zürich, Zürich; and Clinic for Internal Medicine (FS), Regional Hospital Lachen, Lachen, Switzerland
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Abstract
A 73-year-old man was admitted to our hospital because of bilateral foot pain. He was treated with thrombolysis for cerebral infarction about 5 months ago. Anticoagulants had not been used because of hemorrhagic infarction. The pulses of bilateral pedal arteries were palpable, but cyanosis was present in the bilateral toes. Laboratory data indicated azotemia and eosinophilia. Magnetic resonance imaging revealed multiple plaques of the thoracic and abdominal aorta, one of which was ulcerated. Skin biopsy proved the diagnosis of cholesterol crystal embolism (CCE). Because no invasive vascular procedure was performed, we assumed that CCE in this patient was related to thrombolysis. We should be cautious for late onset of CCE after thrombolysis.
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Affiliation(s)
- Kotaro Oe
- Division of Internal Medicine, Saiseikai Kanazawa Hospital.
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39
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Chazov EI, Mukhin NA, Zharova EA, Fomin VV. [Acute renal failure caused by cholesterol embolism of the intrarenal arteries after coronaroangiography: success of glucocorticosteroid treatment]. TERAPEVT ARKH 2008; 80:54-57. [PMID: 18807542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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40
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Bozkurt A, Demirtaş M, Cevlik F, Koç M, Tuncer I. [Spontaneous cholesterol embolism confused with peripheral arterial disease]. Anadolu Kardiyol Derg 2007; 7:460. [PMID: 18065361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Abdi Bozkurt
- Cukurova Universitesi, Tip Fakültesi, Kardiyoloji ve Patoloji, Anabilim Dallari, Adana, Türkiye.
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Xu CS, Liu WG, Ye W. [Meta-analysis of mesenteric arterial embolism or mesenteric arterial thrombosis]. Zhonghua Wei Chang Wai Ke Za Zhi 2007; 10:524-527. [PMID: 18000771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To summarize the clinical characteristics of mesenteric arterial embolism (MAE) and mesenteric arterial thrombosis (MAT), and to clarify the diagnosis and treatment status of MAE and MAT in China. METHODS A retrospective analysis of 111 cases suffering from MAE or MAT was performed. Data of these cases were collected from Chinese Journal Full-text Database from 1994 to 2006. RESULTS There were 61 cases (54.9%) with MAE and 50 cases (45.1%) with MAT. Fifty-two patients (46.8%) had arterial fibrillation. Ninety-seven cases (87.4%) were diagnosed by exploratory laparotomy or autopsy, and 14 cases (12.6%) by imageology. Embolism or thrombosis in superior mesenteric artery (SMA) accounted for 92.8%, 4.5% in SMA plus inferior mesenteric artery. 15.2%(14/92) necrosis were located in jejunum or ileum, 39.1%(36/92) in jejunum and ileum, 38.0%(35/92) in jejunum, ileum and colon. Thrombolysis or anticoagulation in artery were operated in 7 cases(6.3%). Extraction of embolism or thrombosis in operation were implemented in 18 cases(16.2%). Intestinal resection were finished in 76 cases(68.5%). Sixty-eight patients (61.3%) were misdiagnosed. Sixty-three cases (60.6%) died. CONCLUSION The manifestation of MAE or MAT is quite complicated and changeable, so that many cases are misdiagnosed. The clinic and image characteristics of MAE and MAT have not been well known by doctors.
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Affiliation(s)
- Chang-Sheng Xu
- Department of Emergency, Zhongda Hospital, Southeast University, Nanjing, China.
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Nadri Q, Aleouni WM. Renal disease masquerading vasculitis crescentic atheroembolic renal disease. Saudi J Kidney Dis Transpl 2007; 18:656-662. [PMID: 17951962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Affiliation(s)
- Quaid Nadri
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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Fehri W, Lahidheb D, Bouladi W, Rahal N, Smiri Z, Barakett N, Hajlaoui N, Salah O, Mhenni H, Haouala H. [Endo arterial investigation: suspicious for the cholesterol crystal embolism disease]. Tunis Med 2007; 85:975-978. [PMID: 19166153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Cholesterol crystal embolism (CCE) is a rare disorder which can complicate cardiac catheterization, angiographic studies and cardiovascular surgery. The CCE exposes to a great risk of renal failure and it can even threaten life by means of a multi visceral failing syndrome. AIM Report a new case of CCE following cardiac catheterization. CASE We report the observation of a 63-year-old patient who had a coronary angiography via the right femoral artery after a myocardial infarction. This examination has showed a multi-vessel coronary disease. 15 days later, the patient presented purplish and painful discoloration of his toes. The laboratory findings showed a mild inflammatory syndrome and eosinophilia at 700 / microL. There was not a renal dysfunction nor proteinuria nor hematuria. We performed a skin biopsy and made the diagnosis of CCE. Trans oesophageal echography objectified an irregular atherosclerotic plaque in the isthmic aorta. The CT scan revealed a spindle-shaped aneurysm in the end of the abdominal aorta. This aneurysm contains a marginal surrounding thrombosis with high embolic risk. The patient was put under clopidogrel, enoxaparin, simvastatin, colchicine and atenolol and operated successfully. CONCLUSION The two particularities of this observation are, on one hand, the absence of a renal involvement, which represents the main prognostic factor of the CCE. On the other hand, the CCE has revealed a very unstable aneurysm of the aorta which could be complicated during the cardiac catheterisation. The CCE is a difficult diagnosis that must be remembered before any cardiac catheterisation, because it often reflects unstable aortic atherosclerotic lesions.
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Affiliation(s)
- W Fehri
- Service de Cardiologie, Hôpital Militaire Principal d'lnstruction de Tunis
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Abstract
HISTORY AND ADMISSION FINDINGS A 73-year old woman was admitted to the hospital because of progressive renal failure with onset 2 months after an angiogram of the legs. She had diabetes mellitus and was hypertensive. Her feet were cold, painful and showed irregular blue and purple discolorations. INVESTIGATIONS Blood pressure was 170/80 mmHg, heart rate 72 bpm. Serum creatinine was 6,7 mg/dl (eGFR 7 ml/min) and she had proteinuria of 4,3 g/l. The erythrocyte sedimentation rate was markedly elevated, she had eosinophilia and hypocomplementemia. DIAGNOSIS AND THERAPY Because of the acute renal failure and proteinuria a renal biopsy was taken, as well as a skin biopsy from the patients foot. Both biopsies showed cholesterol crystal emboli with elongated, biconvex transparent clefts and an inflammatory reaction of the vessel wall which had caused obstruction. Renal function did not recover, and the patient was transferred to the chronic dialysis program. Treatment with a statin was initiated and her blood pressure normalized. CONCLUSION In most cases cholesterol crystal embolism is iatrogenic. This multiorgan syndrome occurs in patients at high risk of cardiovascular disease. Cholesterol crystals from ruptured atheromatous plaques become lodged in peripheral arteries and induce an obliterating inflammation of the vessel wall. Mortality is high (about 38 %).
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Affiliation(s)
- H Rupprecht
- Medizinische Klinik V, Klinikum Bayreuth, Germany.
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Nakazawa K, Ohta T, Fujimoto M, Imamura H, Hashimoto N. [Case report of cholesterol crystal embolism 1 month after carotid stenting]. No Shinkei Geka 2007; 35:807-11. [PMID: 17695780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Cholesterol crystal embolism (CCE) is a systemic disease resulting from shedding of cholesterol crystals into the small vessels of multiple organs, including skin, kidney, gastrointestinal tract and others. Recently, neuroendovascular therapeutic procedures for athrosclerosis disease is increasing. We report a case of CCE after carotid stenting (CAS). A 73-year-old man with asymptomatic carotid stenosis was treated by percutanenous transluminal angioplasty with stenting. CAS was achieved in a short time without trouble. About 1 month after CAS, his renal function deteriorated and purpura appeared on both toe tips (blue toe syndrome) with muscle pain of the lower extremities. Under diagnosis of CCE, he was treated by Predonisolone 20 mg/day and Valsartan 160 mg/day, Pravastatin 10 mg/day. His symptom's dramatically improved, with partial recovery of renal function. CCE rarely occurs after angiographic or interventional procedures, but is difficult to diagnose clinically and there is no established therapy. For early diagnosis of CCE strict follow-up of a patients clinical presentation and laboratory data, especially in high risk patients, is needed.
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Affiliation(s)
- Kazutomo Nakazawa
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Japan
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Scolari F, Ravani P, Gaggi R, Santostefano M, Rollino C, Stabellini N, Colla L, Viola BF, Maiorca P, Venturelli C, Bonardelli S, Faggiano P, Barrett BJ. The challenge of diagnosing atheroembolic renal disease: clinical features and prognostic factors. Circulation 2007; 116:298-304. [PMID: 17606842 DOI: 10.1161/circulationaha.106.680991] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Atheroembolic renal disease (AERD) is caused by showers of cholesterol crystals released by eroded atherosclerotic plaques. Embolization may occur spontaneously or after angiographic/surgical procedures. We sought to determine clinical features and prognostic factors of AERD. METHODS AND RESULTS Incident cases of AERD were enrolled at multiple sites and followed up from diagnosis until dialysis and death. Diagnosis was based on clinical suspicion, confirmed by histology or ophthalmoscopy for all spontaneous forms and for most iatrogenic cases. Cox regression was used to model time to dialysis and death as a function of baseline characteristics, AERD presentation (acute/subacute versus chronic renal function decline), and extrarenal manifestations. Three hundred fifty-four subjects were followed up for an average of 2 years. They tended to be male (83%) and elderly (60% >70 years) and to have cardiovascular diseases (90%) and abnormal renal function at baseline (83%). AERD occurred spontaneously in 23.5% of the cases. During the study, 116 patients required dialysis, and 102 died. Baseline comorbidities, ie, reduced renal function, presence of diabetes, history of heart failure, acute/subacute presentation, and gastrointestinal tract involvement, were significant predictors of event occurrence. The risk of dialysis and death was 50% lower among those receiving statins. CONCLUSIONS Clinical features of AERD are identifiable. These make diagnosis possible in most cases. Prognosis is influenced by disease type and severity.
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Affiliation(s)
- Francesco Scolari
- Division of Nephrology, University and Spedali Civili, Brescia, Italy.
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Rouvière O, Scherrer A. [Case no. 2. Atheroembolism of the kidney]. J Radiol 2007; 88:993-8. [PMID: 17878862 DOI: 10.1016/s0221-0363(07)89912-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- O Rouvière
- Hôpital E. Herriot, 69437, Lyon Cedex 03, France
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Abstract
Cholesterol crystal embolization is a well-established complication of arterial trauma and anticoagulation which may involve multiple organs including the skin and muscle, producing clinical features such as livedo reticularis, cyanosis and gangrene of the toes and intense myalgias. Cholesterol crystal embolization to bone marrow has been described in postmortem studies, but has been previously reported premortem in only two patients, both of whom had characteristic risk factors and clinical features. We report herein a case of spontaneous cholesterol crystal embolization to bone marrow in a patient with atypical clinical manifestations.
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Affiliation(s)
- Matthew D Reuter
- St. John's Mercy Medical Center, Department of Medicine, Suite 3019-B, 621 S. New Ballas Road, St. Louis, MO 63141, USA.
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Karadağ B, Döventaş A, Ozkan H, Erdinçler DS, Beğer T, Yüksel H. [A case of cholesterol emboli syndrome treated with iloprost]. Anadolu Kardiyol Derg 2007; 7:76-8. [PMID: 17347083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Affiliation(s)
- Berrin Karadağ
- Division of Geriartrics, Department of Internal Medicine, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey.
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Abstract
We report a 72 year-old male, that after a coronary angiogram presented pain, reduced distal skin temperature of both limbs, cyanosis of toes with preserved peripheral pulses and a rapidly progressive renal failure. Afterwards, the patient suffered a sudden bilateral amblyopia and hematochezia. Cholesterol embolism was confirmed with a skin biopsy and fundoscopy. A colonoscopy showed a possible ischemic colitis. After six months of follow up, the patient lost the distal phalanges of three toes, and renal failure stabilized, with a serum creatinine of 2.5 mg/dl. The diagnosis of cholesterol embolism is often missed, but it has a one year mortality of 80% and the presence of renal failure is the main prognostic indicator. Other prognostic indicators are the presence of high blood pressure, previous renal failure and peripheral artery disease.
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Affiliation(s)
- Carlos Dufrechou
- Clínica Médica 2, Facultad de Medicina, Universidad de la República Montevideo, Montevideo, Uruguay.
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