Embolia por colesterol en miembros inferiores: reporte de caso

La embolia por cristales de colesterol es efecto de la desestabilización de una placa de ateroma tras un evento desencadenante, produciendo la migración de cristales de colesterol hasta arteriolas periféricas, desencadenando un proceso inflamatorio endotelial; el espectro clínico varía desde ser asintomático hasta con un compromiso multiorgánico; la sospecha diagnóstica es principalmente clínica y será la biopsia de piel por su fácil accesibilidad, la que confirme el diagnóstico. El tratamiento es aún controvertido y no existe un consenso de las medidas terapéuticas para aplicar. A continuación, se presenta el caso de un paciente varón de 72 años de edad con una ateroembolia por cristales de colesterol en miembros inferiores, secundaria a una manipulación endovascular por angioplastia previa.

Cholesterol crystal embolism is the effect of the destabilization of an atherosclerotic plaque after a triggering event, producing the migration of cholesterol crystals to peripheral arterioles, triggering an endothelial inflammatory process; the clinical spectrum varies from being asymptomatic to having multiple organ involvement; diagnostic suspicion is mainly clinical and the skin biopsy will confirm the diagnosis due to its easy accessibility. The treatment is still controversial and there is no consensus on the therapeutic measures to apply. Below is the case of a 72-year-old male patient with atheroembolism due to cholesterol crystals in the lower limbs, secondary to endovascular manipulation by prior angioplasty.

Embolia colesterínica en miembro superior izquierdo asociado a fístula arteriovenosa / Cholesterol embolism in the left upper limb associated with venous artery fistula

RESUMEN El embolismo por cristales de colesterol (ECC) es una complicación de la enfermedad arterioesclerótica en la que el desprendimiento de fragmentos de placa de ateroma, principalmente de grandes arterias, provoca oclusión de pequeños vasos. Esta entidad, también llamada ateroembolia o síndrome de los dedos del pie azules, es más frecuente en pacientes de edad avanzada y después de procedimientos invasivos intravasculares. Se manifiesta con cianosis, livedo reticularis, necrosis y úlceras asociado a manifestaciones renales y gastrointestinales. Se presenta un paciente trasplantado renal y portador de fístula arteriovenosa trombosada izquierda con ateroembolia localizada en mano homolateral.

ABSTRACT The cholesterol crystal embolism (ECC) is a complication of arteriosclerotic disease in which the detachment of fragments of atheromatous plaque mainly from large arteries, causes occlusion of small vessels. This entity, also called atheroembolism or blue toe syndrome, is more common in elderly patients and after intravascular invasive procedures. It manifests with cyanosis, livedo reticularis, necrosis and ulcers associated with renal and gastrointestinal manifestations. We present a renal transplant patient with a left thrombosed arteriovenous fistula with atheroembolism located in homolateral hand.

Síndrome del dedo azul secundario a ateroembolia por colesterol: reporte de un caso y revisión de la literatura / Síndrome do dedo azul secundário a ateroembolia por colesterol: reporte de um caso e revisão da literatura / Blue toe syndrome secondary to cholesterol atheroembolia: Report of a case and literature review

Se describe el caso de una mujer de 68 años, con muy alto riesgo cardiovascular, quien consultó por cianosis en los dedos de los pies, asociada a síntomas neurológicos focales transitorios de 5 días de evolución. Se hospitalizó con la impresión diagnóstica de síndrome del dedo azul e isquemia crítica arterial de miembros inferiores de posible origen embólico. Luego de un procedimiento endovascular, presentó deterioro neurológico súbito y se documentaron múltiples infartos cerebrales y falla renal aguda. En la biopsia de los dedos afectados se observaron cristales de colesterol en el interior de los vasos sanguíneos. Con base en el caso se presenta una corta revisión del síndrome del dedo azul y su principal causa: la ateroembolia...

We describe the case of a 68 year-old woman with very high cardiovascular risk. She consulted because of cyanosis in the toes, associated with transient focal neurological symptoms. Evolutionhad been 5 days. She was hospitalized with the diagnostic impression of blue toe síndrome and critical arterial ischemia of the lower limbs possibly due to embolic events. After an endovascular procedure, she developed sudden neurological impairment due to multiple strokes, as well as acute renal failure. Biopsy of the affected toes revealed cholesterol crystals inside the blood vessels. Based on the case, a short review about the blue toe syndrome and its main cause, atheroembolism, is presented...

Se descreve o caso de uma mulher de 68 anos, com alto risco cardiovascular, quem consulto por cianose nos dedos dos pés, associada a síntomas neurológicos focais transitórios de 5 dias de evolução. Se hospitalizou com a impressão diagnóstica de síndrome do dedo azul e isquemia crítica arterial de membros inferiores de possível origem embólico. Logo de um procedimento endovascular, presentou deterioro neurológico súbito e se documentaram múltiplos infartos cerebrais e falha renal aguda. Na biopsia dos dedos afetados se observaram cristais de colesterol o interior dos vasos sanguíneos. Com base no caso se apresenta uma curta revisão da síndrome do dedo azul e sua principal causa: a ateroembolia...

Blue toe syndrome treated with sympathectomy in a patient with acute renal failure caused by cholesterol embolization

Blue toe syndrome is the most frequent manifestation of tissue ischemia caused by cholesterol embolization (CE), which can lead to amputation of affected lower extremities, if severe. However, any effective treatment is lacking. We experienced a case of spontaneously presenting blue toe syndrome and concomitant acute renal failure in a patient with multiple atherosclerotic risk factors. CE was confirmed by renal biopsy. Despite medical treatment including prostaglandin therapy and narcotics, the toe lesion progressed to gangrene with worsening ischemic pain. Therefore, we performed lumbar sympathectomy, which provided dramatic pain relief as well as an adequate blood flow to the ischemic lower extremities, resulting in healing of the gangrenous lesion and avoiding toe amputation. This is the first reported case of a patient with intractable ischemic toe syndrome caused by CE that was treated successfully by sympathectomy. Our observations suggest that sympathectomy may be beneficial in some patients with CE-associated blue toe syndrome.

Cutaneous Cholesterol Embolism / 대한피부과학회지

A cholesterol embolism is a systemic disease resulting from the occlusion of arteries by cholesterol crystals released from atheromatous plaques. It has been associated with inflammation, sheering forces from blood flow due to hypertension, aneurysm formation, infection, mechanical manipulation during surgery or vascular procedures, and anticoagulation. We report a case of a cutaneous cholesterol embolism in a 66-year old man who had purpuric skin lesions on both feet associated with diabetes mellitus, hypertension, and anticoagulation for a cerebral infarction.

A Case of Cholesterol Embolism / 대한피부과학회지

The occlusion of arterioles by cholesterol microcrystals and subsequent ischemic change give rise to so called "cholesterol embolism". Usually cholesterol emboli are released from atheromatous plaque in great arteries by various provoking factors-by direct physical impacts during the cardiovascular interventions, such as CABG (coronary artery bypass graft) and CAG (coronary angiography), and by intricate biologic processes which weakens fibrous cap of atheromatous plaque, such as thrombolytic and anticoagulant therapy. Herein we report cholesterol embolism occurred in a 71-year old man who has underlying atherosclerosis after cardiovascular surgery and follow-up angiography, and concomitant anticoagulant therapy.

A Case of Cutaneous Cholesterol Embolism / 대한피부과학회지

Cutaneous cholesterol embolism is a disease due to the embolism of cholesterol crystals from ulcerated atheromatous plaques to peripheral vessels of the skin. It has been associated with major vessel surgery, angiography, angioplasty, intra-aortic balloon pump placement, anticoagulation, thrombolytic therapy and cardiopulmonary resuscitation. In addition, it may occur spontaneously. In paraffin-fixed sections, the cholesterol crystals are dissolved and leave needle-like clefts within the lumina of arterioles. We report a case of cutaneous cholesterol embolism in a 72-year-old woman who had purplish gangrenous lesions on both her feet after coronary angiography and percutaneous transluminal coronary angioplasty.

A Case Report of Purple Toe Syndrome Associated with Acute Renal Failure during Warfarin Therapy / 대한내과학회지

"Purple toe" syndrome is an extremely rare complication of warfarin therapy. The occurrence of purple toe syndrome is characterized by a sudden appearance of purplish discoloration of toes and the sides of feet. The skin lesions usually develop 3-8 weeks after beginning anticoagulation. The pathogenesis was not clearly defined but the presence of atherosclerosis in most of patients led to suggest that the mechanism was related to cholesterol emboli from the atherosclerotic plaques and warfarin- induced bleeding into the plaques. These microemboli are commonly associated with irreversible organ dysfunction such as renal failure, distal gangrene, pancreatitis, and multifocal myocardial necrosis. Therefore purple toe syndrome may be considered as a sentinel of cholesterol crystal embolism. Once established, anticoagulation and thrombolysis are contraindicated. Necrosis and gangrenous changes may result in loss of limb and occasional mortality has been reported. We report a case of purple toe syndrome associated with acute renal failure after warfarin therapy with a review of literatures.