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Treatment of Cholesterol Embolization Syndrome in the Setting of an Acute Indication for Anticoagulation Therapy
Hidong Kim1, David B Zhen1, John C Lieske2
1Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Insights
Cholesterol embolization syndrome (CES) management can include anticoagulation. This case study shows warfarin and corticosteroids were safely used in a patient with CES and an urgent need for anticoagulation.
Area of Science:
- Cardiology
- Vascular Medicine
- Nephrology
Background:
- Cholesterol embolization syndrome (CES) is a rare complication of endovascular procedures.
- CES involves cholesterol crystal release from atheromatous plaques, leading to distal vessel occlusion and end-organ damage.
- Standard management often suggests withdrawing anticoagulation due to concerns of plaque hemorrhage.
Purpose of the Study:
- To report a case of CES following percutaneous coronary intervention and intra-aortic balloon pump placement.
- To evaluate the safety and feasibility of anticoagulation in a CES patient with an urgent indication.
Main Methods:
- A 66-year-old male presented with ST-elevation myocardial infarction and received percutaneous coronary intervention with an intra-aortic balloon pump.
- The patient later developed CES symptoms including livedo reticularis, acrocyanosis, and acute renal failure.
- Warfarin anticoagulation and corticosteroid therapy were initiated for the CES and an existing indication for anticoagulation.
Main Results:
- The patient's renal function improved significantly during treatment.
- Discharge occurred without the need for dialysis, indicating successful management of acute renal failure.
- The combined therapy of warfarin and corticosteroids appeared safe and effective in this CES case.
Conclusions:
- Anticoagulation therapy with warfarin can be feasible and safe in patients with CES.
- Corticosteroids may help suppress the inflammatory response to cholesterol crystals.
- This case challenges the routine withdrawal of anticoagulation in CES patients with concurrent indications for anticoagulation.
Abstract:
Cholesterol embolization syndrome (CES) is a complication sometimes occurring after invasive endovascular procedures. CES is characterized by release of cholesterol crystals and particles from atheromatous plaques, which can occlude distal vessels and induce an inflammatory response, resulting in end-organ damage. We report the case of a 66-year-old man who presented with an acute ST-elevation myocardial infarction. An intra-aortic balloon pump was placed due to hemodynamic instability following percutaneous coronary intervention. Ten weeks after discharge, he presented with signs and symptoms of CES (e.g., livedo reticularis, acrocyanosis, acute renal failure), and a new left ventricular apical thrombus. Withdrawal of anticoagulation is often recommended in the setting of CES, on the presumption that anticoagulants favor plaque hemorrhage and subsequent cholesterol micro-embolization. Because of the potential disastrous consequences of an embolus, the patient was anticoagulated with warfarin concurrently with corticosteroids to suppress the inflammatory response to cholesterol crystals. His renal function continued to improve and was discharged without the need for dialysis. This case illustrates that anticoagulation therapy in CES is feasible and appears to be safe in patients with a coexisting urgent indication for anticoagulation.
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