Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 24-1998. A 76-year-old woman with cardiac and renal failure and gastrointestinal bleeding

Cholesterol crystal embolization to the digestive system: characterization of a common, yet overlooked presentation of atheroembolism

In the 1359 published patients with multiorgan cholesterol crystal embolism (CCE), the digestive system seems to be the third most frequently affected system. Yet, this system received hitherto only little attention in the medical literature. Therefore, the aim of the present study was to clinically characterize the subset of patients with CCE involving the digestive system, based on our institutional experience and a review of the literature. Cases with CCE in a 7-yr period (1995-2001) were sought in the computerized records of our medical center. Of the CCE patients, those with digestive system involvement that could be related to CCE were included in this study. The clinical features of CCE were determined and compared with those found in published series. Fourteen cases with CCE were identified, giving an annual incidence of 0.8 per 10(5). Digestive system involvement was found in five (36%) of the 14 patients. All five patients had established atherosclerosis. Precipitating factors were vascular manipulations or anticoagulation treatment in four of these five patients. Two patterns of disease appeared: acute catastrophic multiorgan disorder with poor prognosis and chronic and more indolent GI disease. Abdominal pain, GI bleeding, fever, and diarrhea were the most common manifestations, resulting from bowel infarction, mucosal ulcerations, hepatocellular liver disorder, and/or pancreatitis. CCE is a systemic disorder with a frequent involvement of the digestive system and protean clinical manifestations. It should, therefore, be considered in any gastroenterological patient with atherosclerosis and recent vascular manipulations or systemic anticoagulation.

Cholesterol crystal embolization demonstrated on GI biopsy

OBJECTIVES

Cholesterol crystal embolism is a severe complication of atherosclerosis responsible for nonspecific cutaneous, renal, and, less often, digestive manifestations that may mimic other systemic diseases.

METHODS

We reviewed retrospectively 10 patients with histologically proven cholesterol crystal emboli diagnosed by endoscopic GI biopsy.

RESULTS

All patients had prior clinical manifestations of severe atherosclerosis and predisposing factors for cholesterol migration. They all had cutaneous manifestations of cholesterol crystal embolism, acute renal failure, and biological inflammatory syndrome. Digestive symptoms were found in the 10 patients: abdominal pain in eight, diarrhea in four, and GI bleeding in three. GI endoscopy ruled out specific digestive diseases, showing only a congestive or erosive mucosa. Histological diagnosis of cholesterol crystal emboli was based on gastric biopsy in nine patients, duodenal biopsy in four, colonic biopsy in three, and rectal biopsy in one, with six having positive biopsies on multiple sites. Outcome after the diagnosis of cholesterol crystal embolism was poor, with all patients requiring permanent hemodialysis. Death by atherosclerosis complications occurred in five patients.

CONCLUSIONS

This cohort suggests that upper GI endoscopy may be helpful in demonstrating the presence of cholesterol crystal embolism, and that diagnosis of cholesterol crystal emboli on digestive tract biopsy indicates advanced systemic atherosclerosis disease of poor prognosis.

Cholesterol embolism causing delayed healing of a foot ulcer

A cholesterol embolism presents with various systemic and local manifestations giving rise to a diagnostic dilemma. We report a case of cholesterol embolism of the leg that delayed the healing of a foot ulcer, necessitating a toe amputation. This report points to the potential of cholesterol emboli to cause a significant compromise in the vascular supply.

Embolism from the Aorta: Atheroemboli and Thromboemboli

To date, there are no evidence-based data to support specific drug therapy for a patient with atheroembolism. It makes sense to use HMG CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors (statins) in any patient with atherosclerosis, as these drugs have been shown to reduce the risk of myocardial infarction and stroke, and have a theoretical benefit on plaque stabilization. Surgical treatment should be considered for patients with abdominal aortic or popliteal artery aneurysms and downstream atheroembolism. There are case reports of atheroemboli in patients worsening after given warfarin or heparin. For this reason, some institutions are reluctant to prescribe these drugs for patients with atheroemboli or thromboemboli from aortic plaque. However, the incidence of this complication is quite low. Anticoagulation probably should be stopped if a patient develops atheroembolism. Similarly, the current state of knowledge does not allow for selecting specific pharmacologic intervention in patients with thromboemboli from aortic plaque. Statin therapy does make sense, as these drugs theoretically stabilize plaques and prevent plaque hemorrhage, thrombosis, and subsequent embolization. Unstable aortic plaques may develop superimposed thrombi (red thrombi on pathologic examination), easily seen as mobile elements on transesophageal echocardiography. Therefore, it is possible that anticoagulation with warfarin might prevent embolic events in these patients. For this reason, we are often in the position of recommending warfarin therapy for patients with emboli and severe atheromas seen on transesophageal echocardiography, especially when superimposed mobile thrombi are seen. There are small series in the literature that indicate the potential benefit of warfarin. However, until a large multicenter randomized clinical trial is done, the use of warfarin can not be definitively recommended. Antiplatelet agents, although safer than warfarin (less risk of hemorrhage), have not been proven beneficial in patients with thromboembolism from the aorta. Surgery (endarterectomy) of the aortic arch is a very risky procedure that should not be performed routinely, but may be used in highly selected patients.

No-touch technique for reducing aortic wall trauma during renal artery stenting

Cholesterol embolism, a serious but infrequent complication of renal artery stenting, may be avoided by minimizing contact between the guide catheter and the atherosclerotic aorta. In this report, we illustrate the "no-touch" technique for stenting renal arteries. By placing a second 0.035-inch J-wire within the guide catheter during cannulation of the renal artery to prevent the tip of the guide from rubbing the aortic wall, we minimize the contact between the guide catheter and atherosclerotic plaques and reduce the potential for intimal disruption and cholesterol embolization.