Postaortographic Cholesterol (Atheromatous) Embolization

Abstract

IN 1945, FLORY (3) described 9 cases of atheromatous emboli in a series of 267 consecut ive postmortem examinations. Haney (6), Harri ngton (7), and ot hers hav e shown that this syndrome may occur foIlowing diagnost ic angiographic procedures. This paper pre sents a case demonstrating a tempora l corr elat ion between needle and cathet er manipulation of a severely arteriosclerotic aorta dur ing two separa te angiogra phic procedures. Case Report A 56-year-old mildly hyper tensive Caucas ian man was admitted in March 1967, with a two-week history of sudden painless decrease in vision in the left eye. A left reti nal telangiectat ic lesion was photocoagu la ted, and he was discharged three days later. Thorough out -patient evaluation proved to be essentiaIly unremarkable except that left sub clavian, epigas tric, and bilate ra l iliac bru its were heard, and both dorsalis pedi s pulses were absent. In another hospit al in May a translumbar aortogram demonstrat ed aort ic arte riosclerotic disease but limited visualization of the ren al vessels (Fig. 1). The pat ient was discharged the next da y feeling well. Later, on the afternoon of discharge, low back and bilateral leg pain develop ed. A bl otchy, purple, non-elevated skin discoloration or livedo reticulari s extended from the mid-trun k over both legs and persis ted intermittent ly for several days. Over the ensuing three weeks, the patient cont inued to complain of increasing numbers of headaches, malaise, nausea, and episodes of emesis. Transient numbness of his right hand, dysar thria, and mild mental confusion occurr ed once. Upon his second UCLA hospital admission, in June, his laboratory stud ies showed mild anemia and azotemia for the first time, and the diastolic hypertension had slightly incre ased. After multiple consultations it was elected to examine angiographically the ext racra nial aortic arch and renal va scular systems. With the patient well hydrated, the left axillar y arte ry was percutaneously punctured under local anesthesia. Under fluoroscopic cont rol a flexible tipp ed 0.0315-inch-diameter guide was passed throu gh the left sub clav ian artery in to the aorta. This was then exchanged for an end- and side-hole polyethylene catheter of O.083-inch O.D., connected to an adjustable wire guide system. The left carotid, left subclavian, and inn ominat e arteries were selectively injected with meglumine iothalamate 60 per cent. There was minimal atheromatous irr egular ity of the proximal fifth of the left verte bral artery, but no stenosis The catheter was then passed down the aor ta, curved end first, and the right renal artery was select ively cathet erized. An aor tic atheromatous pla que exten ded into the ost ia, but the intra renal vessels were th ought to be normal. The proximal left renal artery filled by reflux, and no stenosis was visible. At this tim e the fluoroscopic image failed, and the procedure was terminated.