Cholesterol Embolization Syndrome after Carotid-Artery Stenting
Wei Wang, Jifu Cai
N Engl J Med 2022; 386:1265
DOI: 10.1056/NEJMicm2114022
A 63-year-old man had purplish discoloration of the face develop after he underwent stenting and balloon dilation of the left common carotid artery. Shivering, sweating, and confusion developed immediately after artery dilation, along with a left gaze preference, dysarthria, and hemiparesis on the right side of his body. Over the next 20 minutes, livedo reticularis developed on the left side of his face. An embolic protection device had been used during the procedure. Digital subtraction angiography showed a patent left internal carotid artery and an occluded distal left facial artery. No intracranial hemorrhage was seen on computed tomography of the head. He was transferred to the intensive care unit (ICU), where magnetic resonance imaging and angiography of the brain revealed infarctions in the territory of the left middle cerebral artery with patent vasculature. An acute embolic stroke and cholesterol embolization syndrome of the face were diagnosed. In cholesterol embolization syndrome, atherosclerotic plaque contents from large-caliber arteries embolize to smaller arteries and lead to vascular occlusion, inflammation, and end-organ damage. Livedo reticularis is one of the most common skin manifestations of the syndrome. The patient received supportive care in the ICU. The livedo reticularis resolved 1 week after the event, but the neurologic deficits persisted at the time of his discharge from the hospital 2 months later.
