What is the best course of action for a patient with a history of Hyperlipidemia (HLD) and Gilbert's syndrome, who was admitted for a Non-ST-Elevation Myocardial Infarction (NSTEMI) and found to have 3-vessel Coronary Artery Disease (CAD), but was not a candidate for Coronary Artery Bypass Grafting (CABG) and had a complex Percutaneous Coronary Intervention (PCI) procedure cancelled due to diarrhea, and now presents with erythematous feet and sensitivity?

Management of Erythematous, Painful Feet in NSTEMI Patient Awaiting Complex PCI

Immediate Recognition: Cholesterol Embolization Syndrome

This patient's presentation of erythematous, painful feet described as "walking on glass" following cardiac catheterization is highly suggestive of cholesterol embolization syndrome (also known as "blue toe syndrome" or "trash foot"), which is a critical complication that requires immediate recognition and supportive management. 1

Clinical Context and Pathophysiology

• The patient underwent left heart catheterization for 3-vessel CAD evaluation, which involves catheter manipulation in atherosclerotic vessels that can dislodge cholesterol crystals 1
• These crystals embolize distally, causing inflammatory occlusion of small arteries in the feet, kidneys, and other organs 1
• The timing (post-catheterization) and characteristic presentation (painful, erythematous feet with extreme sensitivity) are pathognomonic 1
• The concurrent diarrhea may represent gastrointestinal involvement of the same embolic process 1

Immediate Management Steps

1. Confirm the Diagnosis

• Examine feet for livedo reticularis, cyanotic toes, or palpable pulses (typically preserved, distinguishing this from acute arterial occlusion) 1
• Check for systemic involvement: renal function (creatinine, urinalysis for eosinophiluria), eosinophil count, complement levels (C3, C4 may be decreased) 1
• Skin biopsy showing cholesterol clefts is diagnostic but rarely necessary given the clinical context 1

2. Supportive Care (Primary Treatment)

• Discontinue all anticoagulation immediately - heparin, warfarin, and other anticoagulants can worsen cholesterol embolization and are contraindicated 1
• Continue antiplatelet therapy (aspirin) as this does not worsen the condition and is essential for the underlying CAD 1
• Provide aggressive pain management with opioids if needed 1
• Elevate legs and provide wound care to prevent secondary infection 1

3. Optimize Medical Therapy

• Initiate or intensify high-dose statin therapy to stabilize atherosclerotic plaques and prevent further embolization 2, 3
• Continue beta-blockers and ACE inhibitors/ARBs for cardiac protection 1, 2
• Maintain dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) as planned for the upcoming PCI 1, 2

Revascularization Strategy Modification

Critical Decision Point: CABG vs Complex PCI

Given the cholesterol embolization syndrome, the planned complex PCI should be postponed and the patient should be re-evaluated for CABG despite initial assessment that he was "not a candidate." 1

Rationale:

• Further catheter manipulation during complex PCI carries extremely high risk of additional cholesterol embolization 1
• For 3-vessel CAD with diabetes (implied by HLD), CABG provides superior long-term outcomes compared to PCI (reduced mortality, MI, and repeat revascularization) 4, 5
• CABG is the Class I recommendation for 3-vessel disease, particularly with LV dysfunction or diabetes 1, 2

If CABG is truly contraindicated:

• Delay any intervention for 4-6 weeks to allow cholesterol emboli to stabilize 1
• Consider staged PCI of only the culprit vessel with minimal catheter manipulation 1
• Use radial access if possible to minimize aortic manipulation 1
• Avoid aggressive lesion preparation (rotational atherectomy) which increases embolization risk 1

Specific Management Algorithm

1. Week 1-2: Supportive care, discontinue anticoagulation, optimize medical therapy, monitor renal function
2. Week 2-4: Reassess surgical candidacy with cardiac surgery; if CABG possible, proceed when acute inflammation subsides
3. Week 4-6: If CABG definitively contraindicated, consider staged PCI with embolic protection devices if available
4. Ongoing: Continue high-intensity statin, dual antiplatelet therapy, and secondary prevention measures 2, 3

Critical Pitfalls to Avoid

• Do not proceed with the scheduled PCI until cholesterol embolization resolves - this will cause catastrophic worsening 1
• Do not anticoagulate with heparin or warfarin - paradoxically worsens cholesterol embolization 1
• Do not assume peripheral arterial occlusion - pulses are typically preserved in cholesterol embolization, distinguishing it from acute limb ischemia 1
• Do not delay statin therapy - high-dose statins are essential for plaque stabilization 2, 3

Prognosis and Follow-up

• Cholesterol embolization syndrome has variable outcomes; some patients recover completely while others develop chronic kidney disease or tissue loss 1
• The presence of renal involvement (check creatinine) significantly worsens prognosis 1
• Long-term management requires aggressive risk factor modification and careful consideration of any future vascular procedures 2