Cholesterol Embolization Syndrome Induced by Thrombolytic Therapy

Abstract

Cholesterol embolization syndrome (CES) induced by thrombolytic therapy is a rare syndrome with a high incidence of morbidity and mortality. The variability in clinical presentations may cause a delay in diagnosis of CES. This article presents a comprehensive review of the English literature from January 1980 to December 2007 identifying all published case reports of CES induced by thrombolytic therapy. Multiple electronic databases were searched and relevant reference lists were hand searched to identify all case reports. Thirty cases of thrombolytic-induced CES were identified. Indications for thrombolysis were acute myocardial infarction (28 patients) and deep venous thrombosis (two patients). Skin and renal involvement were the most common presentations. Skin manifestations included livedo reticularis, rash, and skin mottling. Other clinical symptoms included cyanotic toes, gastrointestinal bleeding, or perforation, myalgias, retinal emboli, and CNS involvement. Morbidity and mortality were high. Outcomes included chronic hemodialysis in eight patients, four patients underwent amputations, seven patients developed or had progression of their chronic kidney disease, and seven deaths occurred.CES presents as multiorgan dysfunction and should be considered in the differential diagnosis of the symptom complex that may develop after thrombolytic therapy. Diagnosis of CES can be difficult as a result of the variable clinical presentations. A thorough clinical history and physical examination are essential first steps in establishing a diagnosis. Confirmatory diagnosis requires biopsy of the target organs. Measures to reduce the likelihood of recurrence should be taken and include avoidance of anticoagulation therapy and vascular procedures. Unfortunately, therapy remains supportive and the outcome is invariably poor.

Cholesterol embolization syndrome: report of two cases

“…[2] LDL apheresis has been reported to improve brain and skin damage related to CES. [22] Iloprost as a vasodilator treatment was found to be beneficial for treatment of CES. [7] In spite of recent improvements in supportive care and targeted therapies, high rates of morbidity and mortality remain.…”

Cutaneous Cholesterol Embolization

“…5 Thrombolytic therapy and anticoagulants appear to precipitate cholesterol emboli by dissolving protective thrombi and fibrin deposits coating an atheromatous plaque, permitting the release of cholesterol. 6 In addition, CES may occur spontaneously. Diabetes, hypertension and diffuse vascular disease are major risk factors for both iatrogenic and spontaneous CES.…”

“…However, there is no single tissue spared by CES. 6 Almost every organ can be affected in this syndrome, but the three areas of greatest involvement are the skin, kidneys and digestive system. 2 Cutaneous changes are seen in 69.4% of patients throughout the course of CES.…”

Blue toe syndrome, ischemic pain treated with digital block

“…Controversy arises over the use of antiplatelet, anticoagulation, and thrombolytic drugs in Blue Toe Syndrome as these have been shown to be ineffective, and may predispose patients to further atheroembolism events. [4,[8][9][10].…”