Cholesterol Embolization after Transcatheter Aortic-Valve Replacement
An 88-year-old man with a history of myocardial infarction for which he had required quadruple coronary-artery bypass grafting presented with mottled-appearing purple discoloration of the skin on his toes. One month earlier, he had undergone transapical transcatheter aortic-valve replacement (TAVR). The discoloration of the skin on his toes (Panels A and B) was consistent with livedo reticularis. Laboratory findings were notable for a serum creatinine level of 2.8 mg per deciliter (248 μmol per liter), which had increased from a baseline level of 1.4 mg per deciliter (124 μmol per liter), and a white-cell count of 10,200 per microliter with 13% eosinophils (absolute eosinophil count, 1170 per microliter). A skin-biopsy sample revealed obstructive cholesterol crystals in midsized arteries, which confirmed the diagnosis of the cholesterol embolization syndrome (Panels C and D). This syndrome is caused by distal showering of cholesterol crystals and can involve many organ systems, including the peripheral vasculature, kidneys, and brain. It is a well-described complication of angiography, vascular surgery, thrombolytic therapy, and more recently, TAVR. The patient was treated with oral prednisone and statins. The skin lesions resolved within 3 weeks, but the patient did not recover normal renal function.