A 71 year old man had transfemoral catheterization for coronary angiography which revealed the presence of severe atherosclerotic narrowing of all major coronary arteries. Within hours of the procedure, he developed severe left lower quadrant abdominal pain, which was later associated with rebound tenderness, livido reticularis (erythematous skin rash) of the abdominal skin, increasing hypertension, cold blue toes and progressively worsening renal failure. Laparotomy revealed necrosis of the descending colon. This was resected. Microscopic examination showed amorphous eosinophilic material containing slit-like spaces occluding arteries in the submucosa.
Which one of the following is the most likely explanation?
A. Thromboemboli secondary to myocardial infarction
B. Type B dissection of the Aorta
C. Hypersensitivity vasculitis
E. polyarteritis nodosa
The correct answer is D. Atheroembolism
Atheroembolic disease increasingly is being recognized as an important cause of morbidity and mortality in the developed world. The true incidence of atheroembolism is not known, but it is likely that many if not all adults older than 70 years will have evidence of atheroembolism if it is sufficiently sought.
Even when the disease presents with the classic signs of digital ischemia, livedo reticularis, and eosinophilia, other causes often are sought. More often, patients present with a myriad of symptoms because of cholesterol crystal deposition in small- and medium-sized vessels. The clinical consequences range from pancreatitis to penile gangrene. It is therefore not surprising that atheroembolism has been described as a great mimicker. To make matters worse, even when a diagnosis has been accurately established no treatment has been shown to have a significant impact on the attritional morbidity and mortality associated with atheroembolism.
- The clinical features of atheroembolism range from subclinical disease to multisystem involvement leading to multiorgan failure with an associated high mortality . The diseasetypically affects white men 60 years of age and older. Established precipitants of catastrophic atheroembolism are:
- Preceding history of angiography or any instrumentation to the aorta.
- Anticoagulant therapy
- Cardiovascular surgery.
- Diabetes, hypertension, and previous vascular disease.
- Thrombolytic therapy (controversial).
Ref: Atheroembolism, John S. Smyth, MD, MRCP and John E. Scoble, MD, FRCP;Current Treatment Options in Cardiovascular Medicine 2002, 4:255-265.