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A 68 year old male smoker, who was hypertensive, diabetic, and dyslipidaemic, with renal dysfunction (blood urea nitrogen 19 mg/dl, serum creatinine 1.6 mg/dl) and recent troponin T negative unstable angina, underwent a coronary angiogram. A non-ionic contrast agent (iopamidol) was used. Pre-procedure peripheral pulses were normal with no bruit. The angiogram revealed three vessel disease, and coronary artery bypass graft surgery was advised. Immediately following the angiogram no significant deterioration of renal function was evident. However, the patient presented four weeks later with renal failure (maximum blood urea nitrogen 73 mg/dl, serum creatinine 3.6 mg/dl), livedo reticularis (panel A, arrow), and bilateral persistent lower limb pain with bluish discolouration of toes suggestive of digital gangrene (panels A and B). Peripheral pulses were normal. Doppler of lower limb arteries showed normal flow in major arteries. A diagnosis of cholesterol embolisation syndrome (livedo reticularis and digital gangrene with renal impairment) was made. The patient was managed conservatively.
Cholesterol embolisation syndrome is a systemic disease caused by distal showering of cholesterol crystals after angiography, major vessel surgery, or thrombolysis. The management is supportive. The syndrome may go undetected unless there is monitoring of renal function following invasive procedures.