Myonephropathic Metabolic Syndrome After Bilateral Aortoiliac Bypass: A Pathogenic Role of Cholesterol Microemboli

Abstract

A 72-year-old man was admitted to our hospital for management of intermittent claudication. A preoperative angiogram showed right common iliac artery occlusion with wellmaintained peripheral flow via collaterals and 50% stenosis of the aortic bifurcation through the left common iliac artery. The authors performed bilateral aortoiliac artery bypass surgery. Immediately following the operation, the left lower limb was cyanotic and cold despite a good pulse in the left dorsalis pedis artery. He suffered from severe pain throughout his entire left calf and part of his thigh. Thrombolytic therapy combined with anticoagulation therapy was started in an attempt to reduce limb ischemia. However, swelling of the left calf increased, and clinical and metabolic manifestations consistent with myonephropathic metabolic syndrome (MNMS) developed. Serum creatine kinase and creatinine rose to 21,600 u/L and 2.8 mg/dl, respectively. His toe became necrotic and a transmetatarsal amputation was done. A skin biopsy taken from the edge of the amputation revealed cholesterol crystals within the capillaries. This report suggests that massive cholesterol microemboli are responsible for MNMS in this patient.