Atheroembolism to the Breast

Journal Pre-proof Atheroembolism to the Breast Shruti Zaveri, MD MPH, Lucyna Z. Price, MD, Haley Tupper, MPH, Rami O. Tadros, MD PII:

S0890-5096(19)30899-4

DOI:

https://doi.org/10.1016/j.avsg.2019.10.052

Reference:

AVSG 4714

To appear in:

Annals of Vascular Surgery

Received Date: 23 April 2019 Revised Date:

26 September 2019

Accepted Date: 9 October 2019

Please cite this article as: Zaveri S, Price LZ, Tupper H, Tadros RO, Atheroembolism to the Breast, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.10.052. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.

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Title: Atheroembolism to the Breast

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Authors: Shruti Zaveri, MD MPH1, Lucyna Z. Price, MD2, Haley Tupper, MPH3, Rami O.

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Tadros, MD2

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1. Department of Surgery, Division of General Surgery, The Mount Sinai Hospital

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2. Department of Surgery, Division of Vascular Surgery, The Mount Sinai Hospital

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3. Icahn School of Medicine, The Mount Sinai Hospital

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Corresponding Author:

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Rami O. Tadros, MD

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Division of Vascular Surgery, Mount Sinai Hospital

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1425 Madison Avenue, 4th Floor, Box 1273

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New York, NY 10029

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T (212)-241-2087 | F (212)-987-9310

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[email protected]

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Keywords: Atheroembolism, Cholesterol crystal embolization, Breast

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Declaration of Interests: The authors have no competing interests to declare.

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Abstract:

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We report the case of a woman presenting with livedo reticularis of the breast who was found to

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have atheroembolism to the breast following upper extremity percutaneous access.

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Atheroembolism is the embolization of cholesterol crystals off an atherosclerotic plaque that can

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occur spontaneously or as a result of vascular intervention. This is a unique presentation of an

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otherwise well-described complication of vascular catheterization, and we propose that livedo

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reticularis of the breast can be interpreted as a sign of atheroembolism in the appropriate clinical

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context.

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I.

Introduction:

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Atheroembolism is the embolization of cholesterol crystals from an atherosclerotic plaque off a

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proximal large caliber artery to distal small caliber arteries [1]. These embolic events can occur

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spontaneously or as a result of vascular intervention [2]. Atheroembolism is a rare but well-

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described complication of cardiac and vascular catheterization with a reported incidence of

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approximately 2% in prospective studies [3,4]. Atheroembolism not only leads to mechanical

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plugging and end-organ ischemia, but can also incite a systemic inflammatory response [1]. In

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this report, we describe a case of atheroembolism to the breast following upper extremity

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percutaneous access for lower extremity angioplasty. Patient consent for publication has been

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obtained.

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II.

Case Report:

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A 66-year-old woman with an extensive history of peripheral vascular disease and left lower

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extremity claudication underwent a left lower extremity angiogram with external iliac artery and

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common femoral artery angioplasty for focal flow-limiting stenoses of the left external iliac and

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left common femoral arteries. The patient had history of an abdominal aortic aneursym treated

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with aortic stent graft, thus upper extremity access was chosen for intervention in this case.

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Multiple attempts were made to access the left radial artery, however, left radial access could not

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be safely obtained due to diminutive size of the vessel. Ultrasound guided access of the left

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brachial artery was obtained using a standard 4 French micropuncture kit. The micropuncture

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sheath was exchanged for a Terumo 4/5 French Glidesheath Slender introducer sheath. The left

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lower extremity arterial system was catheterized using a 4 French destination sheath and a

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combination of a stiff Glidewire, angled glide catheter, 0.014 inch whisper wire, and 0.014 inch

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grand slam wire. Balloon angioplasty of focal stenoses in the left external iliac and common

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femoral artery was performed. The Terumo 4/5 French glide sheath was the largest sheath

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introduced. 6mm Nanocross and Pacific plus balloons were used through the 4 French Terumo

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glide sheath and did not require upsizing to a larger sheath. Post-intervention angiography

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demonstrated improved flow through the areas of previously identified stenoses. Initial post-

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operative course was unremarkable and the patient was discharged on post-operative day 1. The

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patient subsequently presented for routine scheduled follow-up in the vascular surgery clinic 15

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days following the procedure. She reported purple discoloration of her left breast and left hand.

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Physical examination revealed violaceous skin discoloration in a reticular pattern on the left

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breast (Figure 1) and left hand (Figure 2 and 3), concerning for livedo reticularis due to

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cholesterol embolization. She was started on anticoagulation for treatment of atheroembolism

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with planned 3 month course followed by clinical re-evaluation.

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III.

Discussion:

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Atheroembolism and cholesterol crystal embolism are often used synonymously in the context of

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embolic complications following vascular intervention. Cholesterol embolization syndrome

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refers to showers of microemboli and the associated systemic inflammatory response [5]. This

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should be distinguished from thromboembolic events in which fragments of thrombus atop an

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atheromatous plaque are dislodged, occluding medium to large arteries. In contrast,

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atheroembolic debris lodges in small arterioles with a diameter of 100 to 200µm [1].

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Atheromatous debris has a high rate of release during percutaneous vascular procedures. In a

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case series of 1000 patients undergoing coronary intervention, over 50% had aortic atheromatous

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debris found on the catheter; however, few of these result in clinically recognizable ischemic

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events. The incidence of clinically recognized cholesterol crystal embolism is approximately 1 to

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2% [6-9]. Iatrogenic embolization is more common after arteriography than after surgery [10,

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11].

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Atheroembolism is more common in older patients with an average patient age of 66 years in

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reported cases [12]. Atheroembolism has a multitude of clinical presentations depending

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primarily on the location of the embolic event. Reported locations include renal, ocular, cerebral,

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gastrointestinal, and cutaneous emboli. The presentation of atheroembolism may be subtle,

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depending of the number of embolic events and the degree of occlusion caused by the emboli8.

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In a review of 221 cases, 21% of patients presented with nonspecific systemic symptoms of fever

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and myalgias12. Renal emboli can lead to acute kidney injury [13]; gastrointestinal emboli most

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commonly lead to nonspecific symptoms such as abdominal pain and diarrhea, but can rarely

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result in intestinal infarction, pancreatitis, and hepatic necrosis [14, 15]. As seen in our patient,

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cutaneous findings consist of livedo reticularis, a mottled reticulated discoloration of skin, and

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may develop ulceration depending on the extent of blood flow compromise [12]. Splinter

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hemorrhages, purpura, petechiae, and “blue toe syndrome” have also been reported as skin

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findings of atheroembolism [16, 17]. Given the varied presentation and severity of cases,

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treatment for atheroembolism remains controversial. While anticoagulation may intuitively aid

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with arterial patency, there are no randomized controlled trials that evaluate the role of

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anticoagulation in atheroembolism (Kim, Bashore, Lin). Some studies have shown benefit of oral

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anticoagulation in patients with mobile thrombi in the aortic arch (Lansberg).

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In our case, the patient presented with livedo reticularis of the left breast and left hand after left

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brachial artery micropuncture access and left lower extremity angioplasty. Livedo reticularis

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carries a wide differential diagnosis, including coagulopathic disorders such as disseminated

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intravascular coagulation and thrombotic thrombocytopenic purpura, to embolic disorders,

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vasculitides, and intravascular protein and calcium deposition as seen with calciphylaxis [18].

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Livedo reticularis has also been described as sign of inflammatory carcinoma of the breast [19,

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20]. The finding of violaceous skin discoloration over the breast, as seen in our patient, in

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isolation would have raised suspicion for malignancy; however, in the context of recent

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percutaneous vascular intervention and concomitant ipsilateral hand livedo reticularis,

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atheroembolism to the breast was the most congruent diagnosis. While varied presentations of

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atheroembolism have been described, we propose that livedo reticularis of the breast can be

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interpreted as a sign of atheroembolism in the appropriate clinical context.

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Atheroembolism of the breast in this case likely occurred through branches of the axillary and

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subclavian arteries. The medial aspect of the breast receives arterial supply from the internal

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thoracic artery, a branch of the subclavian artery. The internal thoracic artery supplies six or

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seven perforating branches, and it considered a reliable source of arterial apply to the nipple in

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most patients. The lateral aspect of the breast receives arterial supply from four vessels: the

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lateral thoracic and thoracoacromial arteries from the axillary artery, lateral mammary branches

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from the posterior intercostal arteries, and mammary branches from the anterior intercostal artery

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(van Deventer, Cunningham, Shiffman). Upon review of the preoperative CTA, there were no

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anatomical abnormalities seen that could have increased risk of atheroembolism. Axial CTA did

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not reveal any atheromatous plaque in the patients left brachial, axillary, or subclavian arteries.

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Likewise, the descending thoracic and abdominal aorta were free of calcification as well,

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therefore the anatomic origin of the atheromatous embolization is unclear. The number of sheath

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exchanges should be minimized to the extent possible to decrease the risk of embolism in the

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setting of atheromatous disease, however there was no preoperative suspicion of significant

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atheromatous disease in these vessels in this case.

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IV.

Conclusion:

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Atheroembolism is a known complication of cardiac and vascular catheterization, however

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diagnosis of the complication is often difficult given its varied presentations secondary to emboli

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location. We report a case of a 66-year-old woman with the complication of cholesterol

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embolization following upper extremity percutaneous access causing livedo recticularis of the

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breast. This is the first report to our knowledge describing the occurrence of atheroembolism to

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the breast and is a unique presentation of this otherwise well-described complication.

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References:

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Figure Legend

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Figure 1. Livedo reticularis of the left breast [preferably printed in color]

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Figure 2. Livedo reticularis of the dorsal aspect of the left hand [preferably printed in color]

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Figure 3. Livedo reticularis of the palmar aspect of the left hand [preferably printed in color]

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