Cholesterol crystal embolism (CCE) is a rare but important complication of endovascular procedures or anticoagulation therapy. An 84-year-old man was referred to the Gunma University Graduate School of Medicine with the diagnosis of acute myocardial infarction. After successful emergency coronary angioplasty, his serum creatinine level increased continuously. A subsequent skin biopsy confirmed that the patient had CCE. Transesophageal echocardiography (TEE) clearly demonstrated the mobile mass protruding from the complex atheroma. Three-dimensional TEE provides more precise and attractive volumetric images of the atherosclerotic plaque than two-dimensional TEE. In addition, the findings of this case revealed contrast media-induced nephropathy and CCE as possible causes of renal dysfunction after endovascular procedures.
Cholesterol crystal embolism (CCE) is a rare but important complication of coronary intervention, vascular surgery, or anticoagulation therapy in patients with atherosclerosis and ulcerated aortic plaques. CCE was first identified by Panum in 1862, and the prevalence of CCE has increased with the advent of invasive endovascular procedures.
Clinical Summary
An 84-year-old man was referred to the Gunma University Graduate School of Medicine with the diagnosis of acute myocardial infarction. Emergency coronary angiography revealed abrupt occlusion of the right coronary artery. Emergency coronary angioplasty was successfully performed via a right femoral approach. The patient’s serum creatinine level was 1.5 mg/dL on admission and increased to 1.7 mg/dL with normal eosinophil counts and elevated C-reactive protein level (4 mg/dL) on the fourth hospital day. Despite hydration to prevent contrast agent-induced nephropathy, his creatinine level gradually increased to 2.5 mg/dL with an eosinophil level of 1410/mm 3 and a C-reactive protein level of 0.6 mg/dL on the 22nd hospital day.
Abdominal ultrasound showed diminished diastolic flow in the left renal artery with normal systolic flow velocity ( Figure 1 A, arrows ), suggesting increased resistance of the distal renal arteries or capillaries. 99m Tc-Mercaptoacetyltriglycine scintigram showed decreased clearance of the tracers in both right and left kidneys, where 99m Tc-Mercaptoacetyltriglycine clearances were 68.7 and 31.3 mL/min, respectively (normal: >150 mL/min), and the times to maximum count in the renogram were both 6.7 minutes (normal: 3-5 minutes) ( Figure 1 B). Skin biopsy confirmed the diagnosis of CCE, showing cholesterol crystals which are consisting of clusters of elongated, biconvex, and needle-shaped transparent clefts ( Figure 1 C, right ).
Transesophageal echocardiography (TEE) was performed to show the source of the crystals. Heavily thickened atherosclerotic plaques with a large ulceration at the distal aortic arch ( Figure 1 D) were demonstrated. Three-dimensional TEE clearly showed the mobile mass protruding from the complex atheroma ( Video 1 ). Holes and valleys at the surface of the aortic arch resembled a sea-bed ( Figure 2 A, B).
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