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.

Potential embolization by atherosclerotic debris dislodged from aortic wall during cardiac catheterization:: Histological and clinical findings in 7,621 patients

“…Embolizations from disrupted aortic atheroma as a complication of invasive vascular procedures can produce ischemic effects in various organs [5][6][7][8]19]. Since atherosclerotic lesions of the aorta are often found in coronary artery disease [12], these patients are at increased risk of stroke or peripheral embolization during cardiac catheterization [13].…”

“…Since more invasive cardiac procedures are performed, more clinical cases of peripheral cholesterol embolization in relation to cardiac catheterization have been reported [5,6,10,11,19]. Clinical manifestations and course of this disease have well been documented [1][2][3][4][5][6][7][8][9][10][11]14,15,23].…”

“…It has been described after retrograde angiography [1][2][3][4], after left heart catheterization, and percutaneous transluminal coronary angioplasty (PTCA) [5][6][7][8][9][10][11]. Manipulation with catheters or guidewires is the generally accepted mechanical trauma dislodging and spreading atheromatous material from the arterial wall [2].…”

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 Embolisation after Thrombolytic Therapy

“…[32,40] Duration of warfarin administration in these patients was 2 and 4 weeks, long enough to allow anticoagulation to contribute to or cause the cholesterol embolisation. 15 patients were treated with heparin (intravenous or subcutaneous) before cholesterol embolisation arose, although most authors felt that this was incidental rather than causative.…”