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J Thorac Cardiovasc Surg 1994;108:593-594
© 1994 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of Cardiovascular Surgery
Hôpital Cardiologique
Lyon, France
To the Editor:
Cholesterol embolizations are related to the migration of cholesterol crystals from atheromatous plaques. Until recently, they were regarded as a classic although rarely occurring complication of atheroma. 
1 At present, their frequency is on the increase again, owing to the development of left-sided catheterization, known to be a triggering factor for these vascular accidents. 2-4 Recently, we performed a coronary bypass procedure in a patient with symptoms of cholesterol embolization after cardiac catheterization. The poor postoperative prognosis and outcome, in view of recurrent peroperative and postoperative cholesterol embolizations, led us to raise questions as to the advisability of cardiac surgery in such a situation. Furthermore, no approach to this problem has been reported in the literature.
Our patient was a 72-year-old man with non-insulin-dependent diabetes, hypertension, and multiple vessel disorders. He presented with Canadian Cardiac Society class III coronary failure and New York Heart Association class III heart failure. Coronary angiography performed in December 1992 revealed triple-vessel coronary impairments with moderate left ventricular dysfunction (left ventricular ejection fraction 50%). Two hours after catheterization, the patient had a transient ischemic stroke with rapidly subsiding right-sided hemiplegia. A brain scan showed an ischemic blank that confirmed the diagnosis of brain embolism. During the following days, progressive renal failure developed, with blood creatinine levels up to 380µmol/ L. The carotid arteries were not involved. A 35 mm aneurysm of the subrenal abdominal aorta was noted, with atheromatous stenosis of the left renal artery. The results of kidney function tests were clearly indicative of nephropathy of both diabetic and hypertensive origin. Indications for coronary revascularization were established, and the patient was discharged, returned home, and received a platelet-inhibiting treatment (aspirin) until the day scheduled for the operation.
In February 1993, the patient came to the hospital 2 days before the scheduled operation. Renal function had improved (blood creatinine level 180µmol/L), but on examination the purple toe syndrome was discovered. Diagnosis of embolization of cholesterol crystals was established retrospectively and the decision to perform coronary revascularization was maintained. The procedure was carried out with extracorporeal circulation and heparinization (3 mg/kg). Three bypass grafts were constructed—an internal mammary bypass and two saphenous grafts. During the immediate postoperative follow-up period, we observed renal failure with anuria necessitating dialysis, and a neurologic coma developed necessitating prolonged assisted ventilation because of an ischemic lesion demonstrated by a blank on brain scans. The diagnosis of recurrent cholesterol embolization was obvious. This was confirmed by the results of skin biopsy. The patient's neurologic condition improved progressively, allowing withdrawal of tubing on the fifteenth postoperative day. His state of consciousness was rated satisfactory and no neurologic deficit was found, but severe renal failure was persistent, necessitating dialysis three times a week. One month after the operation, the patient lapsed into a sudden neurologic coma evocative of a massive ischemic stroke that was eventually responsible for his death.
Cholesterol embolization is recognized infrequently, in part because of its diverse presentations, which parallel the degree of organ involvement. 5 Estimates of its prevalence after vascular procedures have ranged from 0.15% in clinical studies 3 to 27% in pathologic series. 2,6 A fatal outcome is reported in 80% of cases. 1,4
In the case reported, the initial diagnosis of cholesterol embolization was established on the basis of the purple toe syndrome. The transient stroke and the occurrence of moderate renal failure after cardiac catheterization had been attributed to the patient's preexisting diabetes, hypertension, and multiple vessel disorders. The actual cause of the disorders was cholesterol embolization with the multivisceral involvement that illustrates the polymorphism of this disease. To this day, only preventive therapy has proved effective. By contrast, heart surgery has the disadvantage of combining all the factors that promote cholesterol embolization: high heparin doses, cannulation of the ascending aorta, aortic clamping, and reimplantation of the vein graft into the ascending aorta. It is difficult to evaluate the role of extracorporeal circulation. Restrospectively, maintaining our decision to operate exposed the patient to a high risk of recurrent cholesterol embolization. No effective therapy is known. The postoperative prognosis depends on whether renal function necessitates dialysis, which exposes the patient to a new risk of recurrent cholesterol embolization because of heparin use. It appears that this pathologic entity ineluctably leads to a poor outcome after heart surgery, and we regret, restrospectively, having operated on this patient. We now think that cholesterol crystal emboli are a contraindication to heart surgery, even in a patient who has symptoms, when the spontaneous course of the existing cardiac disease is not life-threatening in the short term.
References
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