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Skin diseases of the elderly
Published in Robert A. Norman, Geriatric Dermatology, 2020
Cutaneous cholesterol embolism appears in patients with severe arteriosclerosis (Figure 17). The atheroembolism results from cholesterol crystals, which become detached from ameromatous plaques; it may occur spontaneously or complicate intravascular studies and surgical procedures. The microemboli affect small arteries and arterioles of the viscera — gastrointestinal tract, kidney — and the central nervous system and retina. The cutaneous manifestations are paroxysmal painful ischemia of the feet and legs, livedo reticularis, gangrene (i.e. ‘warfarin’ toes) and ulcers. The differential diagnosis includes the coagulopathy syndromes and periarteritis nodosa.
The kidneys
Published in C. Simon Herrington, Muir's Textbook of Pathology, 2020
The kidney may also be affected in the cholesterol emboli syndrome; multiple cholesterol microemboli from atheromatous plaques in the aorta become lodged in the renal vasculature, causing renal failure. Other clinical features due to cholesterol emboli occur in the skin, gastrointestinal tract, and the lower limbs. In younger patients, hypertension may result from fibromuscular dysplasia of the renal arteries. Senile arteriosclerosis in the kidneys of elderly normotensive people presents features similar to those of benign essential hypertension and does not seriously impair renal function.
Vasculitis mimics
Published in Biju Vasudevan, Rajesh Verma, Dermatological Emergencies, 2019
Debdeep Mitra, Ajay Chopra, Neerja Saraswat
Cholesterol embolization (atheroembolism) can occur from the arterial wall because of trauma from catheter manipulation, direct trauma, surgery, anticoagulation, or thrombolysis. Extremities are more commonly affected. The patient presents with limb ischemia with a livedo reticularis-like rash and normal pulses. Other cutaneous presentations include purpura, ulcers, nodules, cyanosis, and frank gangrene [3]. Other sites of embolization include the gastrointestinal tract and CNS. Bedsides, ophthalmoscopy may reveal retinal cholesterol emboli.
Asymptomatic retinal emboli and current practice guidelines: a review
Published in Clinical and Experimental Optometry, 2023
Nicole Riese, Yelena Smart, Melissa Bailey
The Beaver Dam Eye Study found an association between participants with asymptomatic emboli and higher overall serum cholesterol levels.18 The BMES did not find an association between retinal emboli and serum total cholesterol levels, triglyceride, or HDL cholesterol levels; they also checked specifically with cholesterol emboli and did not find an association.7 Similarly, a case–control study by Bruno et al. in 1991 did not find a correlation.12 The SEEDS also did not find an association between retinal emboli and hypercholesterolaemia. Therefore, while an assessment of serum cholesterol levels may be a prudent test to order as part of a general cardiovascular assessment and cholesterol control should always be encouraged, the association between serum cholesterol levels and an asymptomatic cholesterol embolus is not well established.
Results of renal artery revascularization in the post-ASTRAL era with 4 years mean follow-up
Published in Blood Pressure, 2020
Karin Zachrisson, Ferid Krupic, Mikael Svensson, Ann Wigelius, Andreas Jonsson, Angeliki Dimopoulou, Anna Stenborg, Gert Jensen, Hans Herlitz, Anders Gottsäter, Mårten Falkenberg
In four patients with bilateral RAS, revascularization was possible in only one renal artery. All other revascularizations (256 of 260, 98%) were successful. There were four major complications (1.8%). Two patients had cholesterol embolism with rapid renal impairment, and one suffered from thrombo-embolism to the lower extremities and to a kidney. Puncture site occlusion of an atherosclerotic common femoral artery in one patient was treated with thromboendarterectomy. Minor complications occurred in 24 patients (10.71%). They were mainly small puncture site haematomas, 14 in the groyne and 2 after puncture of the brachial artery. Three patients with haematomas adjacent to the revascularized kidney were treated conservatively and their haematomas resolved spontaneously. Two patients had minor allergic reactions to the contrast medium, and two suffered from transient pain associated with the procedure.
Successful treatment of cholesterol crystal embolism with anti-proprotein convertase subtilisin/kexin type 9 (PCSK9) antibody: a case report
Published in Renal Failure, 2020
Junki Morino, Keiji Hirai, Shohei Kaneko, Saori Minato, Katsunori Yanai, Yuko Mutsuyoshi, Hiroki Ishii, Momoko Matsuyama, Taisuke Kitano, Mitsutoshi Shindo, Akinori Aomatsu, Haruhisa Miyazawa, Kiyonori Ito, Yuichiro Ueda, Susumu Ookawara, Yoshiyuki Morishita
Several studies have indicated that PCSK9 inhibitors have an anti-inflammatory effect on atherosclerotic plaque [9]. PCSK9 inhibition suppresses the production of inflammatory cytokines in macrophages via activation of ApoE receptor 2 [21] and down-regulation of NF-κβ [22]. With CCE, cholesterol emboli lodge in small arteries, inducing infiltration of macrophages to the affected arteries and granuloma formation. This inflammatory reaction contributes to thrombus formation and endothelial proliferation, leading to arterial obstruction. Finally, these processes result in ischemic damage and infarction [11]. These findings suggest that evolocumab might suppress macrophage activation and inflammatory cytokine production, which would alleviate renal disease caused by CCE. However, in our case, neither C-reactive protein nor eosinophil showed significant change during evolocumab administration. Serum LDL-cholesterol level is positively correlated with plasma viscosity [23]. It has been reported that intense reduction in LDL-cholesterol by aggressive lipid lowering therapy such as statin and LDL-apheresis improved blood viscosity and increased peripheral arterial blood flow in patients with familial hypercholesterolemia [24,25]. In our case, improvement of renal function was observed, following the marked decrease in serum LDL-cholesterol level. These findings suggest that evolocumab might increase renal blood flow through reduction in LDL-cholesterol, which would ameliorate renal function decline caused by CCE.