Development of cholesterol embolization syndrome after intravenous streptokinase for acute myocardial infarction

The purple digit: an algorithmic approach to diagnosis

The acute onset of purple digits is a concerning manifestation and may represent underlying, potentially life-threatening disease. Correctly identifying the etiology of purple digits is essential to proper management, and can aid in the diagnosis of systemic disease. Multiple causes of purple digits and significant overlap in clinical presentation can make diagnosis difficult. Despite the various causes of acute purple digits in the published literature, an algorithmic approach to the evaluation and management of the most common and alarming etiologies has yet to be established. The initial step in evaluating a patient with purple digits is to determine if the cause is associated with hypoxemia or trauma. If the patient is in a stable condition, the dermatologist needs to determine if the process could be related to cold exposure such as Raynaud phenomenon, acrocyanosis, pernio, cryoglobulinemia or frostbite. If the disease occurs independent of temperature, physical examination and histological evaluation of the skin is recommended. The lack of peripheral pulses are concerning for acute arterial thrombosis from peripheral vascular disease or arterial embolism. Non-blanching skin changes on the digit that lack inflammation and microthrombosis most likely represent a bleeding or platelet abnormality; however, if microthrombi are identified a more life-threatening processes such as purpura fulminans or embolic phenomenon may be occurring. Evidence of blood vessel inflammation suggests a leukocytoclastic vasculitis. The patient with a purple blanching digit and normal pulses requires an extensive historical review to help determine the cause. This review presents an algorithmic approach to assist in the evaluation and management of the purple digit.

Cholesterol embolization syndrome induced by thrombolytic therapy

Cholesterol embolization syndrome (CES) induced by thrombolytic therapy is a rare syndrome with a high incidence of morbidity and mortality. The variability in clinical presentations may cause a delay in diagnosis of CES. This article presents a comprehensive review of the English literature from January 1980 to December 2007 identifying all published case reports of CES induced by thrombolytic therapy. Multiple electronic databases were searched and relevant reference lists were hand searched to identify all case reports. Thirty cases of thrombolytic-induced CES were identified. Indications for thrombolysis were acute myocardial infarction (28 patients) and deep venous thrombosis (two patients). Skin and renal involvement were the most common presentations. Skin manifestations included livedo reticularis, rash, and skin mottling. Other clinical symptoms included cyanotic toes, gastrointestinal bleeding, or perforation, myalgias, retinal emboli, and CNS involvement. Morbidity and mortality were high. Outcomes included chronic hemodialysis in eight patients, four patients underwent amputations, seven patients developed or had progression of their chronic kidney disease, and seven deaths occurred.CES presents as multiorgan dysfunction and should be considered in the differential diagnosis of the symptom complex that may develop after thrombolytic therapy. Diagnosis of CES can be difficult as a result of the variable clinical presentations. A thorough clinical history and physical examination are essential first steps in establishing a diagnosis. Confirmatory diagnosis requires biopsy of the target organs. Measures to reduce the likelihood of recurrence should be taken and include avoidance of anticoagulation therapy and vascular procedures. Unfortunately, therapy remains supportive and the outcome is invariably poor.

Complications of aortic atherosclerosis: Atheroemboli and thromboemboli

Patients with severe aortic atherosclerosis are at high risk for stroke and other embolic complications. Therapy to prevent emboli from aortic plaque is not yet established. Therefore, patients with atherosclerosis or risk factors for embolic disease should be identified and treated aggressively. Aspirin, smoking cessation, and control of blood pressure and glucose are important. Retrospective data in patients with severe aortic plaque support the use of statins to prevent stroke. Iatrogenic embolization can occur as a result of aortic manipulation during invasive vascular procedures or cardiovascular surgery. The risks and benefits of these procedures must be carefully weighed, and alternate approaches should be considered for patients with severe aortic atherosclerosis. For those who require coronary artery bypass graft (CABG) surgery, off-pump CABG is an option. Prophylactic aortic arch atherectomy should not be routinely performed. Aortic filters or stenting have been introduced but have not yet been fully evaluated. For patients who require angiography and have severe descending aortic, aortic arch, or abdominal aortic plaque, it is possible that a brachial (rather than a femoral) approach may avoid embolic complications.

Atheroembolic disease following administration of tissue plasminogen activator (TPA)

Atheroembolic disease is an uncommon condition with many interesting manifestations and has been reported following various procedures. Its occurrence following thrombolytic therapy is extremely rare, with only a few case reports in the literature. However, with a widespread application of thrombolysis in patients with acute myocardial infarction, its incidence is likely to increase and therefore this entity needs to be recognized. Early recognition of the illness may help avoid further expensive and unnecessary investigations. We report two cases of atheroembolic disease following the administration of human recombinant tissue plasminogen activator (TPA).

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

A cardiac catheterization was performed in a 57-year-old man for post-infarction angina. A severe left flank pain developed following the angiography. Ultrasonography, computed tomography, and radionuclear scanning of the abdomen showed splenic infarction. An isolated cholesterol atheroembolism of spleen from disrupted atheromatous plaques so far has not been reported.

Foot lesions in patients with diabetes mellitus

Diabetic foot ulcers are common. If treatment is delayed or is inappropriate, the lesions can become infected, resulting in gangrene and amputation. Physicians and clinics that perform aggressive therapy for these ulcers, provide revascularization when indicated, practice a team approach, suggest the use of therapeutic shoes, and repeatedly educate patients in foot care have reduced their amputation rates by 50% or greater. Goals of the United States Department of Health for the year 2000 include a 40% reduction in the amputation rate in patients with diabetes. This should be the goal of everyone providing care for patients with diabetes.

Redefining the incidence of clinically detectable atheroembolism

BACKGROUND AND OBJECTIVES

Atheroembolism, caused by peripheral embolization of small cholesterol crystals that fracture off of ruptured atherosclerotic plaques in the major vessels, leads to multifocal ischemic lesions and progressive tissue loss. The end result is often ischemic injury in the skin, kidney, brain, myocardium, and intestine, but any organ distal to the culprit lesion may be affected. The precise incidence of this serious clinical syndrome has been difficult to ascertain from the available literature, but it appears to be much more common than has been assumed. The objective of the present study is to clarify the incidence of atheroembolism among inpatients in an acute hospital setting.

PATIENTS AND METHODS

We surveyed inpatient nephrology consultations during a 7-month period from January through July 1994. From a pool of 402 consultation charts, 99 were identified with two or more substantive risk factors for atheroembolism. The records of 85 of these patients were available for careful review. More than 300 additional patients were found to have ICD-9 discharge codes for other vascular conditions, but we were unable to confirm that any of these were in fact cases of atheroembolism, since there is no specific ICD-9 discharge code for this entity. In the 85 cases reviewed, a diagnosis of atheroembolism was made only if the patient had identifiable substantive risk factors, suggestive physical findings, and supporting laboratory results.

RESULTS

Eleven of the 85 surveyed records documented strong evidence supporting a "probable" diagnosis of atheroembolism. Tissue was examined in 4 of these 11, resulting in definitive histologic confirmation in 3. Another 5 of the 85 surveyed records were "suggestive" of atheroembolism. Altogether, atheroembolism was a likely diagnosis in a total of 16 cases during this 7-month period, or 1 case in every 2 weeks. These cases comprised 19% of nephrology consultations in which 2 or more risk factors were present, or 4% or all nephrology consultations. The patients' records confirmed the serious implications of clinically detectable atheroembolism. Several patients underwent lower extremity amputation, nearly half required acute or chronic dialysis, and more than half died within several months of diagnosis

CONCLUSIONS

The present study suggests that at least 4% of all inpatient nephrology consultations, representing approximately 5% to 10% of the acute renal failure encountered, involve clinically significant atheroembolism. Patients with atheroembolism appear at a rate of at least 1 case every 2 weeks. They often have identifiable substantive risk factors at initial consultation, and probably represent only the most severe cases of atheroembolism. In view of the serious implications of this basically untreatable syndrome, heightened awareness and preventive maneuvers in the population at risk are essential.

Cholesterol embolisation after thrombolytic therapy

Cholesterol embolisation has been reported in 27 patients receiving thrombolytic therapy for acute myocardial infarction (MI). Since cholesterol embolisation is so difficult to diagnose ante mortem, it is possible that these cases represent the 'tip of the iceberg', and that cholesterol embolisation in this setting is far more common than usually suspected. However, the risks of cholesterol embolisation are far outweighed by the survival benefits of thrombolytic therapy in patients with MI. Nevertheless, clinicians should maintain a high level of suspicion when clinical manifestations suggestive of cholesterol embolisation appear after thrombolytic therapy, as the risk of morbidity and mortality can be high.

Acute renal failure after streptokinase therapy in a patient with acute myocardial infarction

Cholesterol embolization syndrome (CES) usually occurs after the performance of invasive vascular procedures. With the frequent use of thrombolytic agents, an increasing number of reported cases of renal CES attributed to the use of such agents has appeared. In most of these reports, the diagnosis was made on the basis of either clinical presentations or skin biopsy. We report a patient who developed acute renal failure as a result of histologically proven renal CES occurring after the use of streptokinase for the treatment of an acute myocardial infarction. The acute renal failure later became chronic; consequently, the patient was placed on continuous ambulatory peritoneal dialysis. Although the prognosis of renal CES has been described to be poor, our patient regained enough of his renal function 8 months after the onset of renal failure to make it possible to discontinue the dialytic therapy.

Prospective assessment of cholesterol embolization in patients with acute myocardial infarction treated with thrombolytic vs conservative therapy

PURPOSE

To determine whether subclinical cholesterol embolization is a frequent sequela of thrombolytic therapy. Case reports of catastrophic cholesterol embolization temporally associated with thrombolytic therapy in 19 patients have suggested a causal relationship.

PATIENTS AND METHODS

We prospectively followed 60 patients with acute myocardial infarction who underwent coronary bypass surgery within 1 month. Twenty-nine received thrombolytic therapy for myocardial infarction; 31 were treated conservatively. Two muscle biopsy specimens and one skin biopsy specimen were obtained from the vein harvest site at the time of bypass surgery. Paraffin block and frozen sections from each biopsy specimen were analyzed for evidence of cholesterol embolization.

RESULTS

Cholesterol emboli were found in biopsy specimens from 4 of 29 patients who had undergone thrombolytic therapy (14%) and in 3 of 31 patients who had not undergone thrombolytic therapy (10%, p = NS). Clinical evidence of cholesterol embolization occurred in one patient. Cholesterol emboli were distributed inhomogeneously; they were not observed in any skin biopsy specimen and were never present in more than one muscle biopsy specimen from each patient.

CONCLUSIONS

The prevalence of cholesterol embolization in patients with acute myocardial infarction treated with thrombolytic therapy is not significantly higher than in those treated without thrombolytic therapy. The cholesterol embolization seen in 12% of our patients was mostly subclinical and was probably spontaneous and/or catheterization induced. Isolated case reports of severe cholesterol embolization temporally associated with thrombolytic therapy do not represent a phenomenon that has widespread subclinical occurrence.

Pain relief and clinical improvement temporally related to the use of pentoxifylline in a patient with documented cholesterol emboli--a case report

A sixty-six-year-old man with known severe atherosclerosis was admitted with painful feet and nonblanching purpuric lesions of his toes. He had undergone cardiac catheterization and coronary artery bypass five and three months, respectively, prior to admission. Initial treatment included: stopping the patient's lisinopril, increasing his nifedipine dose, and adding pentoxifylline 400 mg po tid. Within twenty-four hours pain was markedly decreased. Skin biopsy confirmed a diagnosis of cholesterol embolism. Pentoxifylline was stopped and intravenous heparin therapy was initiated. Within twenty-four hours, pain returned. Nitrol paste applied to the top of each foot had no effect. After forty-eight hours, pentoxifylline was restarted. Once again, pain relief was noted within twenty-four hours, and after forty-eight hours both feet were visibly improved. Heparin and analgesics were discontinued. On the ninth hospital day, the patient was able to walk and was discharged to home. The innocuous nature of the intervention combined with the prompt nature of the therapeutic response support a short trial of pentoxifylline in patients with cholesterol emboli who are not responding to other therapy.

Coronary embolization after balloon angioplasty or thrombolytic therapy: an autopsy study of 32 cases

OBJECTIVES

This study was undertaken to examine the nature, extent and clinical relevance of coronary embolism after balloon angioplasty or thrombolytic therapy, or both.

BACKGROUND

Histopathologic documentation of postinterventional coronary embolization has been reported in only 10 patients from five studies.

METHODS

This retrospective autopsy-based study included 32 patients, treated with balloon angioplasty or thrombolysis, or both, who died within 3 weeks of the procedure and underwent autopsy at the Mayo Clinic. Clinical variables included patient age and gender, artery treated, site and type of obstruction, type of intervention, success of the procedure, and postprocedural changes in the electrocardiogram (ECG), cardiac enzymes and hemodynamic status. Histopathologic variables included characteristics of treated plaques, acutely infarcted myocardium and coronary microemboli. Associations between microemboli and clinical and microscopic factors were evaluated by t tests and simple and multiple linear regression.

RESULTS

Emboli were observed in 26 (81%) of the 32 patients. Among 83 emboli, 95% were thrombotic or atheromatous. The presence of microemboli was associated statistically with the development of postprocedural infarct extension, new myocardial infarction or new ECG abnormalities. Moreover, the greatest number of microemboli were associated with intervention in the left anterior descending coronary artery, multiple interventional sites, postprocedural medial dissection and plaque rupture or extrusion.

CONCLUSIONS

Among patients undergoing balloon angioplasty or thrombolytic therapy who die and undergo autopsy, coronary microemboli occur in a substantial percent. The frequency in survivors is unknown. However, in living patients who develop acute myocardial ischemia or new ECG abnormalities after these interventions, coronary microembolization should be considered a potential cause.

Recurrent anaemia due to ischaemic colonic ulceration caused by cholesterol embolism

We describe an elderly patient with generalized atherosclerosis who presented with recurrent iron-deficiency anaemia. He underwent right hemicolectomy which revealed ischaemic colonic ulceration caused by cholesterol embolism. Surgery appeared to be curative. Cholesterol embolism should be considered as a possible cause of unexplained gastrointestinal blood loss in the elderly.

How common is cholesterol embolism?

Histological sections of spleen and both kidneys from 372 necropsies were examined for the presence of cholesterol emboli. These were identified in nine (2.4%) cases and the clinical histories of these cases were reviewed. All the subjects with cholesterol emboli were older than 60 years and eight out of nine were male. Lesions of differing ages were found in individual cases, suggesting that the process of embolism was recurrent. Two of the cases had undergone arteriography procedures in the month before death and, if these were excluded, then the incidence of "spontaneous" cholesterol embolism was 1.9%. This incidence is much lower than that of previously published studies and may be due to a lower incidence of cholesterol embolism in Britain compared with North America or a decrease in incidence over the past two decades. In three of the subjects with cholesterol embolism the cause of death could be related to systemic atherosclerosis, but in the other six cases there was no apparent correlation between the finding of cholesterol embolism and the cause of death. The clinical relevance of the histological finding of cholesterol embolism can only be assessed in conjunction with clinical information.