Subacute Superior Mesenteric Artery
Embolization with Bowel Infarction � A Rare
Complication of Catheterized Angiography
Tung-Lin Tsui,1,2 Teng-Fu Tsao,4 Yao-Tsung Chuang,2,3 Hsiang-Lin Lee5 and Chun-Hung Su2,3
Cholesterol embolization syndrome (CES) is an atheroembolization caused by cholesterol crystals from aortic
atheromatous plaques. The reported incidence of CES as a complication of catheterized angiography, which usually
presents as acute renal failure and blue toe syndrome, is low in clinical studies. Only a small number of CES cases
presenting as acute mesentery artery occlusion after invasive catheterization have been reported. We report a case of
a 73-year-old man with CES-caused subacute mesenteric artery occlusion followed by life-threatening bowel
infarction; 24 hours after catheterized carotid angiography, he was successfully treated by emergent operation.
Key Words: Catheterized angiography � Cholesterol embolization syndrome � Complication � Ischemic
bowel disease
INTRODUCTION
The rates of life-threatening complications such as
catheter-related cardiac arrhythmia and vessel perfora-
tion have been low in non-interventional angiography.
Cholesterol embolization syndrome (CES) is an athero-
embolization caused by cholesterol crystals from aortic
atheromatous plaques. It was first reported in 1945 by
Flory and may involve eyes, kidneys, and extremities.1,2
Complications from angiography such as blue toe syn-
drome or acute renal failure have been reported.3-5 CES
often occurs after a vascular procedure in patients with
systemic inflammation. Even though it is not a rare oc-
currence, only a minority of patients can be clinically
recognized; the clinical characteristics of CES and actual
incidence of this syndrome remain uncertain. Estimates
of the incidence of CES after vascular procedures have
ranged from 0.15% in clinical studies4 to 25% to 30% in
pathologic series.3 Only a few cases6,7 presented with
acute superior mesenteric artery embolization as a com-
plication of invasive catheterizations; the incidence is
unknown, and there is an extremely high mortality rate,
which may be up to 93%.6 Here, we present a case of
CES-caused subacute superior mesenteric artery occlu-
sion followed by bowel infarction after a catheterized
carotid angiography, which was quickly diagnosed and
successfully treated with emergent operation.
CASE REPORT
A 73-year-old man presented with right leg clau-
dication and dizziness for a period of 2 weeks. He had a
long history of hypertension, type 2 diabetes mellitus
and dementia for more than ten years with regular me-
dical control. The initial heart rhythm in ECG showed
Acta Cardiol Sin 2011;27:60�4 60
Subacute Superior Mesenteric Artery EmbolizationCase Report Acta Cardiol Sin 2011;27:60�4
Received: May 12, 2010 Accepted: October 7, 20101Intensive Care Unit, Puli Christian Hospital, Nantou; 2Institute of
Medicine, Chung Shan Medical University; 3Cardiac Intensive Care
Unit, Division of Cardiology, Department of Internal Medicine;4Diagnostic Radiology; 5Division of General Surgery, Chung Shan
Medical University Hospital, Taichung, Taiwan.
Address correspondence and reprint requests to: Dr. Chun-Hung Su,
Division of Cardiology, Department of Internal Medicine, Chung
Shan Medical University Hospital and Institute of Medicine, Chung
Shan Medical University, No. 110, Jian-Guo N. Rd., Sec. 1, Taichung
402, Taiwan. Tel: 886-4-2375- 7426; Fax: 886-4-2473-9220; E-mail:
normal sinus rhythm, and the coagulation profile was
normal in prothrombin time, activated partial thrombo-
plastin time, and platelet count. There was neither sign
nor clinical history of hypercoagulation state. Therefore,
we did not check fibrinogen and fibrin degradation
products. On closer examination, the patient’s right fe-
moral pulsation could not be detected, and Doppler
exam revealed total occlusion of the left internal carotid
artery. He was then admitted for diagnostic angiography.
Catheterized angiography was arranged via a left
transfemoral approach. Total occlusion of the left inter-
nal carotid artery and diffuse atherosclerosis with 95%
stenosis over the right external iliac artery were de-
tected, which were compatible with both the carotid
Doppler examination and clinical manifestations. An im-
mediate percutaneous transluminal angioplasty (PTA) of
the right iliac artery was indicated to prevent critical
right leg ischemia. The right iliac artery lesion was
crossed by a 0.035 cm � 150 cm guide-wire (Terumo),
and then PTA was performed by deployment of a 10 �
49-mm Wall-stent (Boston Scientific) followed by an 8 �
40-mm Smash balloon (Boston Scientific) for secondary
dilatation at maximal 8 atm. The final angiography re-
vealed 5% residual stenosis with optimal distal blood
flow. At the time we finished this procedure, the patient
did not feel abdominal pain, and there were no signifi-
cant complications.
However, about 18 hours after the procedure, the pa-
tient started to complain of abdominal distension and
poor appetite. On physical examination, mild abdominal
tenderness without muscle guarding or rebounding pain
was detected. In the following 2 hours, tachycardia
(heart rate: 120 beats per minute), shock (a gradual sys-
tolic blood pressure decrease from 160 to 120 mmHg)
and fever (body temperature: 37.8 �C) were detected.
The patient developed a disoriented consciousness, and
livedo reticularis was found bilaterally over the lower
extremities. A complete blood cell count revealed leu-
kocytosis (white blood cell count: 10,640/mm3) with an
extremely left-shifting and young cell presentation (seg-
ments: 36% and bands: 57%). Additionally, serology
analysis showed a high C-reactive protein (CRP) con-
centration (17.7 mg/dl) and acute renal failure. Arterial
blood gas revealed metabolic acidosis. Given the impres-
sion of septic shock, the patient was transferred to inten-
sive care unit 20 hours after procedure.
We surveyed possible sources of infection and de-
tected no significant evidence of pneumonia, pyuria, or
subcutaneous wound infection. Gastric fluid drained
from the nasogastric tube revealed positive for occult-
blood. Abdominal distension was found, and abdominal
sonography showed dilated bowel lumen without either
ascites or intra-abdominal abscess formation. Emergent
abdominal computed tomography (CT) scan for further
infection surveillance showed multiple mixed non-calci-
fied and calcified plaques along the wall of the ab-
dominal aorta and loss of contrast enhancement in some
of the superior mesenteric artery and vein branches. In
addition, diffuse segmental and distended small bowel
loops were also found (Figures 1A, B). The CT scan
suggested the possibility of ischemic bowel disease. Ap-
proximately 24 hours after the procedure, operation was
performed and a large part of the ischemic and conges-
tive intestine (from the jejunum to the descending colon)
was resected (Figure 2A). The pathology report of the
resected small intestine and colon also revealed a diffuse
ischemic infarct with focal hemorrhage, which con-
firmed the diagnosis (Figure 2B).
Both hemodynamic status and toxic signs improved
significantly after the operation. The patient was ob-
served as having returned to alert consciousness 8 hours
after the operation, and he was successfully weaned
from mechanical ventilation. He was transferred to
general ward on the 4th post-operation day, and an oral
diet was started on the 6th post-operation day. Although
anorexia and bilateral gangrenous toes were noted, there
were no more clinical septic signs seen as of 120 days
after the operation.
DISCUSSION
Atheromatous material may dislodge either from
atherosclerotic debris within the thoracic aorta spon-
taneously or from manipulation of the aorta during car-
diac surgery or angiography. However, the actual mecha-
nism of how inflammation leads to CES is unknown.
Most commonly, embolism is thought to result from
dislodgement of atheromatous material as the catheter is
manipulated across areas of severe atherosclerosis within
the aorta. The abdominal aorta is one of the most heavily
involved areas containing atherosclerotic plaques; there-
61 Acta Cardiol Sin 2011;27:60�4
Subacute Superior Mesenteric Artery Embolization
fore, procedures involving catheter-related mechanical
injury to these regions could potentially disrupt plaque
material and induce CES. Therefore, the frequency of
CES should be decreased if procedures are performed
via the brachial artery approach. In our patient, PTA of
the right external iliac artery was performed in the
downstream site of the mesenteric artery. Thus, we be-
lieved the CES and bowel infarction was caused by the
Acta Cardiol Sin 2011;27:60�4 62
Tung-Lin Tsui et al.
Figure 1. (A) Coronal reconstructed contrast-enhanced CT scan shows multiple bowel loop dilatation with loss of the normal wall enhancement
(white arrows), multiple plaques with or without calcification (black arrows) along the wall of abdominal aorta. A linear air density (white
arrowhead) noted in one of the right mesenteric vein is thought to be a possible venous gas embolism due to bowel ischemia and necrosis. The right
iliac artery (black arrowheads) is high-density change due to a metallic stent in place. (B) Oblique thin-labeled maximum-intensity projection of a
contrast-enhanced CT scan shows the filling defects (white arrows) in the jejunal and ileal branches of the superior mesenteric artery. The thrombi
(white arrowheads) are also noted in some branches of the superior mesenteric vein.
Figure 2. (A) The photograph of the resected small intestine (from jejunum) to the descending colon reveals grossly diffuse distended and ischemic
bowel wall. In addition, hemorrhage and congestion were noted over omentum with some engorged vessels. (B) Sections of the bowel show varying
degrees of ischemic or hemorrhagic infarction with necrotizing inflammation, villi or mucosal sloughing, severe congestion, edema and/or
submucosal hemorrhage, as well as severe serosal congestion. Evidence of intimal thickening is seen in sections of the medium-sized muscular
arteries.
A B
A B
carotid angiography procedure.
Among 1,786 consecutive patients in one prospec-
tive study,2 25 patients were diagnosed as having CES
(1.4%); 12 patients were diagnosed with definite CES,
and 13 patients were diagnosed with possible CES. The
in-hospital mortality rate was 16.0% (4 patients) among
patients with CES, which was significantly higher than
in those without CES (0.5%, p < 0.01). Although the in-
cidence of catheter-related embolism has been low in
clinical studies, the incidence of embolism after cardiac
catheterization in necropsy studies has been reported to
be as high as 30%.3 Acute coronary syndromes and
multivessel coronary artery disease are univariate pre-
dictors of CES. Hypertension, smoking, cerebrovascular
disease, and aortic aneurysm are also associated with an
increased post-procedure CES risk. No significant dif-
ferences in atrial fibrillation, hypercholesterolemia, and
diabetes mellitus were found between patients with and
without CES. The elevated baseline CRP level was an
independent predictor of CES (> 1.0 mg/dl).
In another study, an embolic event temporally re-
lated to femoral catheterization occurred in 10 (17%) of
59 patients with atherosclerotic aortic debris compared
to 2 (3%) of 71 control patients without atherosclerotic
aortic debris (p = 0.01).8 This may also imply the exis-
tence of debris as a risk factor of CES: interestingly, no
patients with atherosclerotic aortic debris who under-
went brachial catheterization had an embolic event.8 The
strongest correlation of aortic debris in the clinical litera-
ture has been between advanced age and peripheral vas-
cular disease, which is similar to our case. Our patient
received carotid angiography by a femoral approach, and
severe atherosclerotic aortic debris was confirmed by
abdominal CT, which is compatible with previous re-
ported risk factors for catheter-related CES.
Clinical manifestations of CES range from mild to
catastrophic. In the ACC/AHA guidelines for percu-
taneous coronary intervention, “definite CES” is defined
as a patient who has cutaneous signs including livedo
reticularis, blue toe syndrome, and digital gangrene with
or without renal impairment. In our patient, livedo
reticularis and acute renal failure were noted 18 hours
after the procedure, but possibly caused by septic shock.
Specifically, the CES presented with subacute me-
senteric artery occlusion and bowel infarction. In addi-
tion, CES also caused gangrene in the toes that was
found 5 days subsequently. Although a pathologic study
did not find any definite cholesterol crystals in the
mesenteric artery, the diagnosis of CES should be seri-
ously considered. The other possibility, namely throm-
bus formation caused by routine premedication of he-
parin 5000 units, was thought to be low; however, we
could not exclude this possibility completely. Staphylo-
coccus Lugdunensis endocarditis may cause bowel is-
chemia which related to possible embolization, but there
was no positive blood culture for infective endocarditis
or echocardiographic evidence of endocardial involve-
ment in this patient.9
Despite the availability of aggressive means to man-
age acute ischemic events, the prognosis of patients with
catheter-related embolisms remains poor. The reported
mortality rate among patients with catheter-related em-
bolism has been reported to be between 16% and
81%.2,4,8,10 The mortality rate was higher in elderly pa-
tients and patients with peripheral vascular disease.
In patients without detected aortic cholesterol de-
bris, the risk of CES wasn’t different between trans-
femoral approach and transradial approach.2 Invasive
aortic procedures are planned in a patient with echo-
cardiographically-detected atherosclerotic aortic debris
(especially mobile aortic debris); the risk of embolism
can be significantly reduced by substituting brachial for
femoral catheterization and by avoiding intra-aortic bal-
loon pump placement.8 Better understanding and early
recognition of CES will reduce patient mortality and
morbidity after cardiac catheterization. Transesophageal
echocardiography (TEE) images of the aorta can be used
to assess the risk of embolism.8 In our patient, we ar-
ranged carotid and right iliac angiography for both
definite diagnosis and simultaneous PTA after Doppler
exam and physical examination. TEE is an invasive pro-
cedure, and not usually performed before angiography.
If CT is arranged before angiography, the risk of CES
could be predicted by the finding of severe athero-
sclerotic aortic debris.
Insufficient blood supply caused by mesenteric ar-
tery occlusion will result in inflammation or injury of the
intestine. Clinical presentations include sepsis, bowel
perforation, or intestinal gangrene and require more
aggressive interventions such as surgery and intensive
care. No observational studies about mesenteric artery
occlusion related to CES have been documented, only
63 Acta Cardiol Sin 2011;27:60�4
Subacute Superior Mesenteric Artery Embolization
case reports are available.6,7 In 2008, Miklik reported on
an acute superior mesenteric artery occlusion that was
caused by CES and successfully solved by immediate
local thrombolysis with recombinant t-PA (alteplase).6 In
addition, another author reported successful local throm-
bolysis treatment and reperfusion of the superior me-
senteric artery with streptokinase four hours after injec-
tion; however, the patient died four days later due to sep-
tic shock with metabolic acidosis.7 The major selection
criteria for fibrinolysis include pain with less than 12
hours of evolution, partial mesenteric artery occlusion,
absence of peritoneal signs, severe acidosis, or organ
failure. In our case, the patient had no acute onset of
symptoms such as abdominal pain or peritoneal signs
after angiography. All the symptoms occurred 18 hours
after procedure, presenting as nausea, abdominal disten-
tion and gastrointestinal bleeding, the latter being a con-
traindication for thrombolytic therapy. In this situation,
the best treatment choice was starting surgical treatment
as soon as possible after the definite diagnosis.
In conclusion, CES should be considered in elderly
patients with peripheral arterial disease who are plan-
ning to undergo catheterized angiography. Transbrachial
or transradial approaches may be better choices to avoid
dislodgement of atheromatous material when the cathe-
ter is manipulated across areas of detected aortic choles-
terol debris within the abdominal aorta. Although the
incidence is very rare, subacute CES with mesentery ar-
tery occlusion should be kept in mind in elderly patients
with multiple risk factors who underwent transfemoral
angiography and demonstrate a non-specific clinical pre-
sentation. Early diagnosis with emergent operation is the
only way to successfully treat such patients.
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