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| | = cholesterol emboli
Aetiology
- atheroma a pre-requisite
- may be spontaneous but usually iatrogenic
- surgical manipulation of atheromatous aorta
- intra-arterial catheterization
- warfarin
- thrombolysis
Pathophysiology
- proximal aortic aneurysm or ulcerated plaque
- microemboli of cholesterol crystals and other atherosclerotic debris
occludes arterioles of 50-900 m m diameter. Often
in more than one organ
- abdominal viscera, kidneys and lower extremities most commonly affected
Clinical features
- clinical presentation fairly consistent
- cyanotic and severely painful toes often with bluish patches and
haemorrhagic areas resulting from occlusion of digital arterioles
- livedo reticularis
- hypertension, renal impairment, haematuria, WBCs in urine and proteinuria
without red cell casts result from renal involvement. Kidneys are most
commonly affected visceral organs. Renal failure due to atheromatous emboli
usually develops over 1-4 weeks after angiographic procedure whereas contrast
induced renal failure typically appears soon after the study and reaches
maximum severity within 7-10 days
Laboratory features
Differential diagnosis
- other causes of systemic emboli
- hyperviscosity syndromes
- hypercoagulable states: malignancy, antiphospholipid
syndrome, DM, essential thrombocytopaenia, DIC, erythromelalgia
- vasculitis
Treatment
- symptomatic
- local vasodilatation with topical GTN
- use of heparin controversial as some claim that it may prevent the formation
of organized clot over the ulcerated plaques and thus allow continued
embolization
Prevention
- increased awareness of problem
- minimization of intra-arterial procedures in atherosclerotic aortas and
femoral arteries
- use of brachial approach in patients with atheromatous disease of aorta and
iliac arteries
- minimizing catheter manipulation
- use of softer and more flexible catheters
Further reading
Rohrer MJ, Giansiracusa DF. Arterial disease of the extremities. In Rippe 3rd
ed. 1996, pp1804
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