Management of Multiple Cholesterol Embolization Syndrome-A Case Report

Abstract

A sixty-two-year-old man who underwent coronary angiography and received acute thrombolytic and anticoagulant therapy for acute myocardial infarction developed multisystemic injury, including renal insufficiency and cutaneous manifestations. Fundoscopic examination and skin biopsy specimen led to the diagnosis of multiple cholesterol embolization syndrome (MCES). Discontinuation of anticoagulants and administration of hemostatic (carbazochrome, tranexamic acid, reptilase, and vitamin K) and antihyperlipidemic (cholestyramine and probucol) drugs resulted in temporary improvement of cutaneous and renal disorders and extended survival for about one year. Besides severe aortic atherosclerosis, postmortem examination revealed numerous cholesterol emboli to multiple organs. MCES is a rare but serious complication of left heart catheterization and anticoagulant therapy, and the optimal treatment remains to be established. The authors suggest here that the above-mentioned therapy might be effective for management of MCES.

Isolated splenic infarction following left cardiac catheterization: Case report and a review of the literature

“…The associated thrombolytic and anticoagulant therapy with heparin and warfarin is controversial and might even contribute to the migration of cholesterol crystals from atheromatous lesions [ 10,17,20]. In our patient, the promptness of the appearance of the characteristic clinical picture immediately after the angiographic procedure and the fact that an isolated splenic infarction from an isolated atheroembolic event is far more common than a diffuse atherosclerotic embolic course are very convincing evidence for the catheterization induced embolic event.…”

Isolated splenic infarction following left cardiac catheterization: Case report and a review of the literature

“…The associated thrombolytic and anticoagulant therapy with heparin and warfarin is controversial and might even contribute to the migration of cholesterol crystals from atheromatous lesions [ 10,17,20]. In our patient, the promptness of the appearance of the characteristic clinical picture immediately after the angiographic procedure and the fact that an isolated splenic infarction from an isolated atheroembolic event is far more common than a diffuse atherosclerotic embolic course are very convincing evidence for the catheterization induced embolic event.…”

Cholesterol embolization syndrome: An under‐recognized entity in cardiovascular interventions

“…Across 23 included studies, a total of 905 cases of CES have been reported, 648 of them were iatrogenic that is, after a vascular procedure. All the studies are summarized in Table . Among the retrospective studies included in this review, the incidence of CES varied from 2.9% (for endovascular stent graft for AAA repair) to 25.5% for cardiac catheterizations and 30 % for aortograms …”

Unusual Causes of Cutaneous Ulceration

“…When possible, anticoagulants should be withdrawn and further vascular procedures should be avoided after a diagnosis is established 67–68. Aggressive supportive treatment has been reported to improve one year survival rates 65.…”

Isolated splenic infarction following left cardiac catheterization: Case report and a review of the literature

“…The associated thrombolytic and anticoagulant therapy with heparin and warfarin is controversial and might even contribute to the migration of cholesterol crystals from atheromatous lesions [ 10,17,20]. In our patient, the promptness of the appearance of the characteristic clinical picture immediately after the angiographic procedure and the fact that an isolated splenic infarction from an isolated atheroembolic event is far more common than a diffuse atherosclerotic embolic course are very convincing evidence for the catheterization induced embolic event.…”

Cholesterol embolization syndrome: An under‐recognized entity in cardiovascular interventions

“…Across 23 included studies, a total of 905 cases of CES have been reported, 648 of them were iatrogenic that is, after a vascular procedure. All the studies are summarized in Table . Among the retrospective studies included in this review, the incidence of CES varied from 2.9% (for endovascular stent graft for AAA repair) to 25.5% for cardiac catheterizations and 30 % for aortograms …”

Unusual Causes of Cutaneous Ulceration

“…When possible, anticoagulants should be withdrawn and further vascular procedures should be avoided after a diagnosis is established 67–68. Aggressive supportive treatment has been reported to improve one year survival rates 65.…”

Isolated splenic infarction following left cardiac catheterization: Case report and a review of the literature

“…The associated thrombolytic and anticoagulant therapy with heparin and warfarin is controversial and might even contribute to the migration of cholesterol crystals from atheromatous lesions [ 10,17,20]. In our patient, the promptness of the appearance of the characteristic clinical picture immediately after the angiographic procedure and the fact that an isolated splenic infarction from an isolated atheroembolic event is far more common than a diffuse atherosclerotic embolic course are very convincing evidence for the catheterization induced embolic event.…”

Cholesterol embolization syndrome: An under‐recognized entity in cardiovascular interventions

“…Across 23 included studies, a total of 905 cases of CES have been reported, 648 of them were iatrogenic that is, after a vascular procedure. All the studies are summarized in Table . Among the retrospective studies included in this review, the incidence of CES varied from 2.9% (for endovascular stent graft for AAA repair) to 25.5% for cardiac catheterizations and 30 % for aortograms …”

Unusual Causes of Cutaneous Ulceration

“…When possible, anticoagulants should be withdrawn and further vascular procedures should be avoided after a diagnosis is established 67–68. Aggressive supportive treatment has been reported to improve one year survival rates 65.…”