Chapter 103 - Atheromatous embolization and its management

Question 1

Synonyms of atheromatous embolization

Answer 1

1) cholesterol crystal emboli
2) Blue/purple toe syndrome
3) Atheroembolism
4) Pseudovasculitis

Question 2

Treatment goals of atheromatous embolization

Answer 2

1) treat organ damage
2) prevent further embolization
3) risk factor modification for cardiovascular m&m

Question 3

Incidence of atheromatous embolization

Answer 3

0.8-2.4%
Elder: 8.6-12.3%
Pt with cardiac/vascular procedure: 22-27%
Pt with AAA 77%

Question 4

First description of atheromatous embolization

Answer 4

Panum in Germany centry ago

Flory 1945 characterized it accurately

Question 5

Risks of atheromatous embolization: plaque characteristics

Answer 5

1) high plaque ulceration
2) thin fibrous cap with large lipid core
3) protruding mobile atheroma > 4 mm
4) lack of plaque calcification

Question 6

Causes of atheromatous embolization

Answer 6

1) spontaneous
2) traumatic
3) iatrogenic

Question 7

Histology of cholesterol crystal

Answer 7

1) white
2) rhomboidal/rectangular
3) elongate needle shape (if fixed in paraffin since it’ll dissolve)
4) 10 - 250 micron
5) double refractile crystal
6) Schultz stain: blue green

Question 8

Pathogenesis of atheromatous embolization

Answer 8

1) inflammatory response with immediate infiltration of PMN and eosinophil
2) chronic inflammation 2-4 weeks
3) endothelial proliferation with fibrous tissue
4) luminal obliteration

Question 9

Risk factors of atheromatous embolization: patient factors

Answer 9

1) aortic atherosclerosis
2) age > 60
3) CAD
4) PAD
5) AAA

Question 10

Incidence of atheromatous embolization in cardiac surgery

Answer 10

0.2%

Question 11

Incidence of atheromatous embolization in vascular surgery

Answer 11

2.9%

Question 12

Use of anticoagulation in atheromatous embolization

Answer 12

controversial may increase embolization

Question 13

Thrombolysis in atheromatous embolization

Answer 13

controversial

Question 14

Cutaneous manifestation of atheromatous embolization

Answer 14

1) Livedo reticularis: net-like blue-red mottling
2) blue toe syndrome
3) petechiae
4) purpura
5) splinter hemorrhage
6) ulcers
7) raised nodules

Question 15

Livedo reticularis differential

Answer 15

1) obstructive: antiphosphiolipid antibody, cryoglobulinemia, endocarditis, atrial myxoma
2) vasculitis
3) drug induced: quinidine, quinine, amantidine, catecholamine
4) physiologic: cutis marmorata
5) idiopathic: livedo vasculitis

Question 16

Blue toe syndrome

Answer 16

cool painful cyanotic toes in presence of palpable distal pulses

Question 17

Most common manifestation of atheromatous embolization

Answer 17

1) extremity
2) renal
3) GI

Question 18

Pathogenesis of renal atheromatous embolization

Answer 18

1) mechanical obstruction
2) inflammatory reaction
3) glomerular sclerosis
4) tubular atrophy
5) intestinal fibrosis

Question 19

Four different patterns of renal embolic disease

Answer 19

1) marked immediate impairment: massive embolization with catastrophic consequences
2) subacute disease (most frequent) with onset weeks after due to delayed inflammation
3) Insidious with stable subclinical chronic renal failure
4) HD-dependence with 21-39% resolve with partial recovery

Question 20

Classic sign of atheromatous embolization renal failure

Answer 20

resistent hypertension

Question 21

Mechanism of spontaneous renal recovery after atheromatous embolization HD dependence

Answer 21

1) reversal of inflammation
2) resolution of ATN
3) hypertrophy of surviving nephrons

Question 22

Risk factors of poor renal recovery following atheromatous embolization

Answer 22

1) CHF
2) iatrogenic emboli
3) CKD
4) age > 70
5) acute/subacute onset
6) leg/GI involvement
7) DM

Question 23

Protective factor for renal recovery following atheromatous embolization

Answer 23

Statins

Question 24

Most common GI site for atheromatous embolization

Answer 24

1) colon 42%
2) SB 33%
3) stomach 12%
4) pancreas and liver –> rarely pancreatitis/hepatitis
5) gall bladder –> rare site but will cause chronic acaculous or acute gangrene cholecystitis

Question 25

Most common GI symptoms following atheromatous embolization

Answer 25

1) GI bleed
2) abd pain
3) diarrhea

Question 26

Diagnosis for GI embolism following atheromatous embolization

Answer 26

1) biopsy for cholesterol crystal

2) endoscopy - non-specific

Question 27

Retinal involvement of atheromatous embolization manifest as this

Answer 27

Hollenhorst plaque

Question 28

Hollenhorst plaque are

Answer 28

1) yellow
2) high refractile
3) retinal cholesterol emboli
4) low rate of concurrent ICA disease overall

Question 29

Cerebral manifestation of atheromatous embolization

Answer 29

1) TIA/stroke
2) mental status change
3) headache
4) dizziness
5) organic brain syndrome

Question 30

Laboratory investigations for atheromatous embolization

Answer 30

non-specific

only organ failure tests

Question 31

atheromatous embolization vs ATN differences

Answer 31

1) ATN has pigmented cast and renal tubular cell, emboli is clear or microhematuria
2) ATN onset 48-72 hr while emboli has 7-10d delay
3) ATN likely full recovery while emboli rarely recover fully
4) ATN has normal BP while emboli has refractory HTN

Question 32

Preventing atheromatous embolization

Answer 32

1) pre-op planning
2) proper endo technique
3) distal protection
4) glycoprotein IIb/IIIa inhibitor Abciximab

Question 33

Treatment following atheromatous embolization: targeting source

Answer 33

1) steroids - poor evidence
2) statin for plaque stabilization
3) iloprost (prostacyclin analogue)
4) LDL apheresis

Question 34

Surgical principles in treating atheromatous embolization source plaque

Answer 34

1) infrarenal aortic recon safer than suprarenal
2) endarterectomy or interpositional vs extraanatomical
3) endo may not be safe but covered stent better

Question 35

Pain control following lower extremity atheromatous embolization

Answer 35

1) sympathectomy

2) spinal cord stimulation

Question 36

1 year mortality following diseminated embolization

Answer 36

64-81%