Cutaneous Cholesterol Emboli 

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD   more...
 
Updated: May 2, 2011
 

Background

The general term atheromatous emboli describes the embolization of any atheromatous material. Atheroemboli refers to the dislodgment of relatively large portions of atheromatous plaques containing RBCs and fibrin aggregates, which includes cholesterol crystals of sufficient size to occlude a major systemic artery and potentially result in major organ dysfunction. Cholesterol emboli (CE), on the other hand, result from ulceration of plaques and the subsequent release of cholesterol crystals. These emboli are smaller and usually more numerous, often producing multisystem disease.

Chronic leg ulcer due to cutaneous cholesterol embChronic leg ulcer due to cutaneous cholesterol emboli on the leg of a 79-year-old woman.

The term cutaneous CE (CCE) is used when CE result in disease of the skin, as shown in the image below. The terms peripheral emboli, lower extremity atheromatous emboli syndrome, blue toe syndrome, purple toe syndrome, and trash foot refer to special cases of CE to the lower extremities in which cutaneous manifestations are usually present, the latter 3 occurring in association with anticoagulation or vascular surgery.

In 1945, Flory was the first to suggest that CE may produce skin disease.[1] His hypothesis was later validated by Hoye and associates in 1959, who observed arteries occluded with cholesterol crystals in areas of gangrene on the feet and toes.[2]

It is more commonly associated with iatrogenic manipulation via invasive vascular procedures or therapies (anticoagulation or thrombolytics) and, most commonly, affects the kidneys, gastrointestinal system, and skin.[3] Skin findings can facilitate clinical diagnosis, since about 88% of patients with CCE have them, most commonly livedo reticularis and cyanotic changes of the toes.

CCE is a disease primarily of elderly white men with ulcerous atherosclerosis. Atherosclerotic foci release cholesterol crystals spontaneously or after anticoagulation or endovascular manipulation, inducing the obstruction of small arteries. Cholesterol embolization syndrome is a systemic disease due to distal showering of cholesterol crystals after angiography, major vessel surgery, or thrombolysis. Obstruction of cutaneous vasculature most often results in a clinical picture of livedo reticularis (LR). It is more common in patients with atherosclerotic disease, hypertension, a history of smoking, and elevated baseline plasma C-reactive protein levels.

Gangrene, cyanosis, ulcers, nodules, and purpura can also be observed. In cases of multisystem involvement, CCE may masquerade as many different diseases, but the clinical picture most often mimics a vasculitis. Skin or muscle specimens demonstrate the cholesterol crystals characteristic of this disease.

Treatment is based on the identification of the source of emboli through angiography and on the exclusion of that source from the circulation. Medical therapy has largely been unsuccessful. Gangrene necessitating amputation is the major complication of CCE, but complications may occur in practically any organ system. Without surgery, CCE is a recurrent process with a high mortality rate.

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Pathophysiology

The most likely explanation for the cutaneous manifestation of CCE is trapping of cholesterol crystals in blood vessels leading to occlusion and tissue ischemia. Other contributing factors include underlying lowered arterial pressure from proximal atherosclerosis and the ability of emboli to activate the complement system.

The pattern of LR may be the first clinical sign of CCE and is thought to result from incomplete disturbance of circulation and desaturation of blood that initially occurs with subtotal occlusion of vessels.[4, 5, 6, 7, 8] As spasm and complete occlusion occur, the other signs of CCE become evident. In addition to the blockage of small vascular channels, lower arterial pressure from narrowing of larger proximal arteries may be necessary for the cutaneous manifestations of CCE because intact collateral supply should normally avert it. In one study, injections of a cholesterol suspension in the femoral arteries of dogs produced gangrene, but only in cases with associated thrombosis of the femoral artery. This indicates that embolism is a contributing factor in necrosis with a vascular supply already compromised by atherosclerosis or other occlusive disease. Neither thrombosis alone nor CE alone would produce necrosis.

Other evidence suggests that in addition to a purely mechanical effect, crystalline cholesterol may amplify infarctive tissue damage through the activation of plasma complement, which is capable of potently aggregating polymorphonuclear (PMN) leukocytes and provoking them to damage endothelial cells via toxic oxygen radical release. In both experimental and clinical infarction, evidence of plasma complement activation, often with depletion of complement components, is observed. Animals depleted of complement prior to experimental infarction experience smaller infarcts than controls. In one report, a man suspected of having CE with cutaneous lesions, including LR and digital infarcts, reportedly had plasma with PMN leukocyte–aggregating activity that contained a component of molecular weight and antigenicity consistent with C5a.

Cholesterol crystals and lipids from atheromata incubated with plasma or serum activate complement, as evidenced by immunoelectrophoresis that showed conversion of C3 to C5. On the other hand, serum or plasma depleted of complement or from a patient with congenital C5 deficiency resists activation. PMN leukocytes incubated with endothelial cells to which C5a or cholesterol-incubated plasma was added show evidence of endothelial damage via increased superoxide production, while the addition of plasma alone or cholesterol-incubated plasma without PMN leukocytes does not cause any damage beyond that which spontaneously occurs. This damage is partially inhibited by the addition of superoxide dismutase and catalase.

A related eMedicine article is Cutaneous Manifestations of Cholesterol Embolism.

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Epidemiology

Frequency

United States

The incidence of CCE is rising in association with increased use of interventional vascular procedures, angioplasties, and anticoagulant/thrombolytic therapy.[3] The frequency of CCE is difficult to estimate because routine necropsy is often limited and does not include evaluation of the skin; however, because the abdominal aorta is usually the site of the most advanced intimal disease, one would anticipate that the lower extremities and associated skin and musculature would be one of the most frequently involved sites. In one study, skin and muscle biopsy specimens were obtained from the lower extremities of 100 consecutive autopsies and a 4% rate of CCE was observed. In a large review of 223 patients with all types of CE, 78 (35%) had skin involvement.

International

In the Netherlands, cutaneous involvement is observed in approximately 24% of cases of CE.[9]

Mortality/Morbidity

In the most extensive review of CCE cases, the mortality rate was very high. Forty-nine (78%) of 68 patients died.

Race

Of 31 cases of CCE in which race was mentioned, all patients were white.

Sex

In the same study, 64 (82%) of 78 cases of CCE were in men.

Age

Ages of those affected with CCE in the same study ranged from 26-90 years (mean, 63 y).

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Contributor Information and Disclosures
Author

Robert A Schwartz, MD, MPH  Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Jerry Rothenberg, MD  Clinical Associate Professor, Department of Dermatology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; President, Director, New Jersey Dermatopathology Laboratory, Inc

Disclosure: Nothing to disclose.

Specialty Editor Board

James J Nordlund, MD  Professor Emeritus, Department of Dermatology, University of Cincinnati College of Medicine

James J Nordlund, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at San Antonio

Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

References

  1. Flory CM. Arterial occlusions produced by emboli from eroded aortic atheromatous plaques. Am J Path. 1945;21:549-65.

  2. Hoye SJ, Teitelbaum S, Gore I, Warren R. Atheromatous embolization; a factor in peripheral gangrene. N Engl J Med. Jul 16 1959;261(3):128-31. [Medline].

  3. Lane JE, Lane TN, Shams M, Lane CE. Cutaneous cholesterol embolization. J Am Acad Dermatol. Apr 2009;60(4):711-3. [Medline].

  4. Deschamps P, Leroy D, Mandard JC, Heron JF, Lauret P. Livedo reticularis and nodules due to cholesterol embolism in the lower extremities. Br J Dermatol. Jul 1977;97(1):93-7. [Medline].

  5. Kalter DC, Rudolph A, McGavran M. Livedo reticularis due to multiple cholesterol emboli. J Am Acad Dermatol. Aug 1985;13(2 Pt 1):235-42. [Medline].

  6. Kazmier FJ, Sheps SG, Bernatz PE, Sayre GP. Livedo reticularis and digital infarcts: a syndrome due to cholesterol emboli arising from atheromatous abdominal aortic aneurysms. Vasc Dis. Feb 1966;3(1):12-24. [Medline].

  7. Kusaba A, Imayama S, Furue M. Delayed appearance of livedo reticularis in 3 cases with a cholesterol embolism. Arch Dermatol. Jun 1999;135(6):725-6. [Medline].

  8. Sheehan MG, Condemi JJ, Rosenfeld SI. Position dependent livedo reticularis in cholesterol emboli syndrome. J Rheumatol. Nov 1993;20(11):1973-4. [Medline].

  9. Moolenaar W, Lamers CB. Cholesterol crystal embolization in the Netherlands. Arch Intern Med. Mar 25 1996;156(6):653-7. [Medline].

  10. Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol. Jul 16 2003;42(2):211-6. [Medline].

  11. Falanga V, Fine MJ, Kapoor WN. The cutaneous manifestations of cholesterol crystal embolization. Arch Dermatol. Oct 1986;122(10):1194-8. [Medline].

  12. Colt HG, Begg RJ, Saporito JJ, Cooper WM, Shapiro AP. Cholesterol emboli after cardiac catheterization. Eight cases and a review of the literature. Medicine (Baltimore). Nov 1988;67(6):389-400. [Medline].

  13. Freund NS. Cholesterol emboli syndrome following cardiac catheterization. Postgrad Med. Apr 1990;87(5):55-60. [Medline].

  14. Glassock RJ, Ritz E, Bommer J, Andrassy K, Waldherr R. Acute renal failure, hypertension and skin necrosis in a patient with streptokinase therapy. Am J Nephrol. 1984;4(3):193-200. [Medline].

  15. Ridker PM, Michel T. Streptokinase therapy and cholesterol embolization. Am J Med. Sep 1989;87(3):357-8. [Medline].

  16. Schwartz MW, McDonald GB. Cholesterol embolization syndrome. Occurrence after intravenous streptokinase therapy for myocardial infarction. JAMA. Oct 9 1987;258(14):1934-5. [Medline].

  17. Arora RR, Magun AM, Grossman M, Katz J. Cholesterol embolization syndrome after intravenous tissue plasminogen activator for acute myocardial infarction. Am Heart J. Jul 1993;126(1):225-8. [Medline].

  18. Bhardwaj M, Goldweit R, Erlebacher J, Kashani M, Levin D, Leber G. Tissue plasminogen activator and cholesterol crystal embolization. Ann Intern Med. Oct 15 1989;111(8):687-8. [Medline].

  19. Shapiro LS. Cholesterol embolization after treatment with tissue plasminogen activator. N Engl J Med. Nov 2 1989;321(18):1270. [Medline].

  20. Carlson JA, Chen KR. Cutaneous pseudovasculitis. Am J Dermatopathol. Feb 2007;29(1):44-55. [Medline].

  21. Yang YW, Chen CL, Ho WT, Wang KH. Cutaneous reactive angiomatosis associated with cholesterol embolism. J Cutan Pathol. Jun 2010;37(6):692-6. [Medline].

  22. Simon R, Berwert L, Burnier M, Teta D. [Severe renal insufficiency secondary to renal cholesterol emboli: therapeutical options revisited]. Rev Med Suisse. Mar 3 2010;6(238):432-4, 436-7. [Medline].

  23. Filip JR, Dillon RS. Treatment of end-stage "trash feet" with the end-diastolic pneumatic boot. Angiology. Apr-May 2008;59(2):214-9. [Medline].

  24. Acker CG. Cholesterol microembolization and stable renal function with continued anticoagulation. South Med J. Feb 1992;85(2):210-2. [Medline].

  25. Anderson WR. Necrotizing angiitis associated with embolization of cholesterol. Case report, with emphasis on the use of the muscle biopsy as a diagnostic aid. Am J Clin Pathol. Jan 1965;43:65-71. [Medline].

  26. Anderson WR, Richards AM. Evaluation of lower extremity muscle biopsies in the diagnosis of atheroembolism. Arch Pathol. Nov 1968;86(5):535-41. [Medline].

  27. Badawi G, Jebara VA, el Rassi I, Tabet G, el Ayle N, Ashoush R, et al. Spontaneous cholesterol embolization. A rarely reported entity. Tex Heart Inst J. 1994;21(3):228-30. [Medline].

  28. Baumann DS, McGraw D, Rubin BG, Allen BT, Anderson CB, Sicard GA. An institutional experience with arterial atheroembolism. Ann Vasc Surg. May 1994;8(3):258-65. [Medline].

  29. Baxter BT, McGee GS, Flinn WR, McCarthy WJ, Pearce WH, Yao JS. Distal embolization as a presenting symptom of aortic aneurysms. Am J Surg. Aug 1990;160(2):197-201. [Medline].

  30. Becker KA, Schwartz RA, Rothenberg J. Leg ulceration and the cholesterol embolus. J Med. 1997;28(5-6):387-92. [Medline].

  31. Blankenship JC, Butler M, Garbes A. Prospective assessment of cholesterol embolization in patients with acute myocardial infarction treated with thrombolytic vs conservative therapy. Chest. Mar 1995;107(3):662-8. [Medline].

  32. Borrego L, Gil R, Mazuecos A, Ruiz R, Lopez JL, Iglesias L. Cholesterol embolism to the skin. Clin Exp Dermatol. Nov 1992;17(6):424-6. [Medline].

  33. Cabili S, Hochman I, Goor Y. Reversal of gangrenous lesions in the blue toe syndrome with lovastatin--a case report. Angiology. Oct 1993;44(10):821-5. [Medline].

  34. Calhoun P. Proceedings: Cholesterol emboli causing gangrene of the extremities. Arch Dermatol. Oct 1975;111(10):1373. [Medline].

  35. Cappiello RA, Espinoza LR, Adelman H, Aguilar J, Vasey FB, Germain BF. Cholesterol embolism: a pseudovasculitic syndrome. Semin Arthritis Rheum. May 1989;18(4):240-6. [Medline].

  36. Case records of the Massachusetts General Hospital. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 38-1993. Renal failure and a painful toe in a 70-year-old man after an acute myocardial infarct. N Engl J Med. Sep 23 1993;329(13):948-55. [Medline].

  37. Chen GY, Tseng CD, Hsu KL, Chiang FT, Lo HM, Tseng YZ, et al. Atheroembolic occlusion of the left axillary artery after percutaneous transluminal coronary angioplasty. Int J Cardiol. Aug 29 1997;61(1):97-8. [Medline].

  38. Conde-Taboada A, De la Torre C, García-Doval I, Florez A, Cruces M. Intravascular cholesterol clefts as an incidental finding. Am J Dermatopathol. Dec 2004;26(6):518; author reply 518. [Medline].

  39. Crane C. Atherothrombotic embolism of lower extremities in arteriosclerosis. Arch Surg. Jan 1967;94(1):96-101. [Medline].

  40. Dahlberg PJ, Frecentese DF, Cogbill TH. Cholesterol embolism: experience with 22 histologically proven cases. Surgery. Jun 1989;105(6):737-46. [Medline].

  41. Davies DJ, Thurasingham K. Intractable leg ulceration caused by cutaneous cholesterol embolism. Med J Aust. Aug 17 1992;157(4):267-8. [Medline].

  42. Dean SM. Atypical ischemic lower extremity ulcerations: a differential diagnosis. Vasc Med. Feb 2008;13(1):47-54. [Medline].

  43. Debure C, Emmerich J, Thaunier I, Aubertin JM. [Cutaneous cholesterol emboli secondary to acute hepatocellular failure]. Presse Med. Apr 5 1997;26(11):512-3. [Medline].

  44. Deschamps P, Leroy D, Mandard JC. Cutaneous crystal cholesterol emboli. Acta Derm Venereol. 1980;60(3):266-9. [Medline].

  45. Donohue KG, Saap L, Falanga V. Cholesterol crystal embolization: an atherosclerotic disease with frequent and varied cutaneous manifestations. J Eur Acad Dermatol Venereol. Sep 2003;17(5):504-11. [Medline].

  46. Eliot RS, Kanjuh VI, Edwards JE. Atheromatous embolism. Circulation. Oct 1964;30:611-8. [Medline].

  47. Fine MJ, Kapoor W, Falanga V. Cholesterol crystal embolization: a review of 221 cases in the English literature. Angiology. Oct 1987;38(10):769-84. [Medline].

  48. Fisher DF Jr, Clagett GP, Brigham RA, Orecchia PM, Youkey JR, Aronoff RJ, et al. Dilemmas in dealing with the blue toe syndrome: aortic versus peripheral source. Am J Surg. Dec 1984;148(6):836-9. [Medline].

  49. Fisher ER, Hellstrom HR, Myers JD. Disseminated atheromatous emboli. Am J Med. Jul 1960;29:176-80. [Medline].

  50. Franco G, Castelli C, Gatti C. [Postural tenosynovitis caused by misuse of a computer input device (mouse)]. Med Lav. Jul-Aug 1992;83(4):352-5. [Medline].

  51. Friedman SG, Krishnasastry KV. External iliac ligation and axillary-bifemoral bypass for blue toe syndrome. Surgery. Jan 1994;115(1):27-30. [Medline].

  52. Gore I, Collins DP. Spontaneous atheromatous embolization. Review of the literature and a report of 16 additional cases. Am J Clin Pathol. May 1960;33:416-26. [Medline].

  53. Grenader T, Lifschitz M, Shavit L. Iloprost in embolic renal failure. Mt Sinai J Med. Sep 2005;72(5):339-41. [Medline].

  54. Hammerschmidt DE, Greenberg CS, Yamada O, Craddock PR, Jacob HS. Cholesterol and atheroma lipids activate complement and stimulate granulocytes. A possible mechanism for amplification of ischemic injury in atherosclerotic states. J Lab Clin Med. Jul 1981;98(1):68-77. [Medline].

  55. Hawthorn IE, Rochester J, Gaines PA, Morris-Jones W. Severe lower limb ischaemia with pulses: cholesterol embolisation--a little known complication of aortic surgery. Eur J Vasc Surg. Jul 1993;7(4):470-4. [Medline].

  56. Haygood TA, Fessel WJ, Strange DA. Atheromatous microembolism simulating polymyositis. JAMA. Feb 5 1968;203(6):423-5. [Medline].

  57. Hertzer NR. Peripheral atheromatous embolization following blunt abdominal trauma. Surgery. Aug 1977;82(2):244-7. [Medline].

  58. Hyman BT, Landas SK, Ashman RF, Schelper RL, Robinson RA. Warfarin-related purple toes syndrome and cholesterol microembolization. Am J Med. Jun 1987;82(6):1233-7. [Medline].

  59. Jacobson DM. Systemic cholesterol microembolization syndrome masquerading as giant cell arteritis. Surv Ophthalmol. Jul-Aug 1991;36(1):23-7. [Medline].

  60. Jegaden O, Eker A, Mikaeloff P. Should cholesterol embolization be regarded as a contraindication to heart surgery?. J Thorac Cardiovasc Surg. Sep 1994;108(3):593-4. [Medline].

  61. Jenkins DM, Newton WD. Atheroembolism. Am Surg. Sep 1991;57(9):588-90. [Medline].

  62. Jennings WC, Corder CN, Jarolim DR, Blackwell J, Cherian J, Chen D. Atheromatous embolism: varied clinical presentation and prognosis. South Med J. Jul 1989;82(7):849-52. [Medline].

  63. Justrabo E, Faivre JM, Guillermand H, Rifle G, Genin R, Chalopin JM. [Cholesterol embolisms. The anatomical, clinical and pathogenetic aspects. Two case reports, including one case of pseudo periarteritis nodosa (author's transl)]. Sem Hop. Jun 17 1982;58(24):1489-96. [Medline].

  64. Kang K, Botella R, White CR Jr. Subtle clues to the diagnosis of cholesterol embolism. Am J Dermatopathol. Aug 1996;18(4):380-4. [Medline].

  65. Kaplan-Pavlovcic S, Vizjak A, Vene N, Ferluga D. Antineutrophil cytoplasmic autoantibodies in atheroembolic disease. Nephrol Dial Transplant. Apr 1998;13(4):985-7. [Medline].

  66. Karalis DG, Chandrasekaran K, Victor MF, Ross JJ Jr, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol. Jan 1991;17(1):73-8. [Medline].

  67. Kaufman JL, Chang BB, Shah DM, Koslow AR, Leather RP. Acute arterial insufficiency of the male genitalia. Ann Vasc Surg. Jul 1991;5(4):370-4. [Medline].

  68. Kaufman JL, Stark K, Brolin RE. Disseminated atheroembolism from extensive degenerative atherosclerosis of the aorta. Surgery. Jul 1987;102(1):63-70. [Medline].

  69. Kawakami Y, Hirose K, Watanabe Y, Tomioka N, Doyama K, Morikawa M, et al. Management of multiple cholesterol embolization syndrome--a case report. Angiology. Mar 1990;41(3):248-52. [Medline].

  70. Kempczinski RF. Lower-extremity arterial emboli from ulcerating atherosclerotic plaques. JAMA. Feb 23 1979;241(8):807-10. [Medline].

  71. Kwaan JH, Molen RV, Stemmer EA, Connolly JE. Peripheral embolism resulting from unsuspected atheromatous aortic plaques. Surgery. Nov 1975;78(5):583-8. [Medline].

  72. Leal S, Fonseca C, Sarmento P, Marques F, Carvalho D, De Moura ML, et al. Post-percutaneous coronary angioplasty atheroembolization--a feared iatrogenic complication. Rev Port Cardiol. Sep 2007;26(9):857-66. [Medline].

  73. Magee MJ, Landreneau RJ, Keenan RJ, Hazelrigg SR, Posner MC, Ferson PF. Peripheral athero-embolism from the aorta complicating transhiatal esophagectomy. Am Surg. Aug 1994;60(8):634-7. [Medline].

  74. Marty B, Perruchoud C, Wicky S, Guillou L, Von Segesser LK. Atheroembolization: a harmful complication of therapeutic internal iliac artery occlusion. J Vasc Surg. Nov 2002;36(5):1062-5. [Medline].

  75. Maurizi CP, Barker AE, Trueheart RE. Atheromatous emboli. A postmortem study with special reference to the lower extremities. Arch Pathol. Nov 1968;86(5):528-34. [Medline].

  76. McFarland RJ, Taylor RS, Woodyer AB, Eastwood JB. The femoropopliteal segment as a source of peripheral atheroembolism. J Cardiovasc Surg (Torino). Jul-Aug 1989;30(4):597-603. [Medline].

  77. Mehigan JT, Stoney RJ. Arterial microemboli and fibromuscular dysplasia of the external iliac arteries. Surgery. Apr 1977;81(4):484-6. [Medline].

  78. Mendia R, D'Aloya G, Cavaliere G, Palmeri MG, Sparacio F, Sorgato G, et al. Does thrombolysis produce cholesterol embolisation?. Lancet. Feb 29 1992;339(8792):562. [Medline].

  79. Moldveen-Geronimus M, Merriam JC Jr. Cholesterol embolization. From pathological curiosity to clinical entity. Circulation. May 1967;35(5):946-53. [Medline].

  80. Molinos S, Feal C, Gandara A, Morla J, De la Torre C, Roson E. Cholesterol emboli syndrome: significance of the lesional skin biopsies. Acta Derm Venereol. 2005;85(6):527-8. [Medline].

  81. Mondragon P, Descombes E, Bollmann J, Fellay G. Penile necrosis in a haemodialysis patient: a rare manifestation of cholesterol crystal embolism. Nephrol Dial Transplant. Dec 1998;13(12):3233-5. [Medline].

  82. Muretto P, Carnevali A, Ansini AL. Cholesterol embolism of bone marrow clinically masquerading as systemic or metastatic tumor. Haematologica. May-Jun 1991;76(3):248-50. [Medline].

  83. Nakamura S, Misumi I, Koide S. Cholesterol embolism as a complication of aortic dissection. Circulation. Sep 7 1999;100(10):e48-50. [Medline].

  84. Otsubo H, Kaito K, Takahashi H, Yokoi K, Iwano K, Kaida H, et al. Cholesterol emboli following percutaneous transluminal coronary angioplasty as speculated by toe skin biopsy. Intern Med. Feb 1995;34(2):134-7. [Medline].

  85. Paraf F, Jacquot C, Bloch F, de Montpréville V, Bruneval P. Cholesterol crystal embolization demonstrated on GI biopsy. Am J Gastroenterol. Dec 2001;96(12):3301-4. [Medline].

  86. Park S, Schroeter AL, Park YS, Fortson J. Purple toes and livido reticularis in a patient with cardiovascular disease taking coumadin. Cholesterol emboli associated with coumadin therapy. Arch Dermatol. Jun 1993;129(6):777, 780. [Medline].

  87. Peat DS, Mathieson PW. Cholesterol emboli may mimic systemic vasculitis. BMJ. Aug 31 1996;313(7056):546-7. [Medline].

  88. Perdue GD Jr, Smith RB 3rd. Atheromatous microemboli. Ann Surg. Jun 1969;169(6):954-9. [Medline].

  89. Pettelot G, Bracco J, Barrillon D, Baudouy M, Morand P. Images in cardiovascular medicine. Cholesterol embolization: unrecognized complication of thrombolysis. Circulation. Apr 21 1998;97(15):1522. [Medline].

  90. Pierce JR Jr, Wren MV, Cousar JB Jr. Cholesterol embolism: diagnosis antemortem by bone marrow biopsy. Ann Intern Med. Dec 1978;89(6):937-8. [Medline].

  91. Piriou V, Claudel JP, Bastien O, Ross S, Lehot JJ. Severe systemic cholesterol embolization after open heart surgery. Br J Anaesth. Aug 1996;77(2):277-80. [Medline].

  92. Pochmalicki G, Feldman L, Meunier P, Rougeot C, Weschler J, Jan F. Cholesterol embolisation syndrome after thrombolytic therapy for myocardial infarction. Lancet. Jan 4 1992;339(8784):58-9. [Medline].

  93. Quintart C, Treille S, Lefebvre P, Pontus T. Penile necrosis following cholesterol embolism. Br J Urol. Aug 1997;80(2):347-8. [Medline].

  94. Resnik KS. Intravascular cholesterol clefts as an incidental finding: cholesterol embolism or not?. Am J Dermatopathol. Dec 2003;25(6):497-9. [Medline].

  95. Retan JW, Miller RE. Microembolic complications of atherosclerosis. Literature review and report of a patient. Arch Intern Med. Dec 1966;118(6):534-45. [Medline].

  96. Richards AM, Eliot RS, Kanjuh VI, Bloemendaal RD, Edwards JE. Cholesterol embolism: A multiple-system disease masquerading as polyarthritis nodosa. Am J Cardiol. May 1965;15:696-707. [Medline].

  97. Rivera-Manrique E, Castro-Salomo A, Azon-Masoliver A, Marin LM. Cholesterol embolism: a fatal complication after thrombolytic therapy for acute myocardial infarction. Arch Intern Med. Jul 27 1998;158(14):1575. [Medline].

  98. Robicsek F. Prevention of cholesterol embolism (trash foot) during aorto-iliac reconstruction using a blood filtering device. J Cardiovasc Surg (Torino). Jan-Feb 1986;27(1):63-4. [Medline].

  99. Rosansky SJ. Multiple cholesterol emboli syndrome. South Med J. Jun 1982;75(6):677-80. [Medline].

  100. Rosansky SJ, Deschamps EG. Multiple cholesterol emboli syndrome after angiography. Am J Med Sci. Jul-Aug 1984;288(1):45-8. [Medline].

  101. Schechter DC. Atheromatous embolization to lower limbs. N Y State J Med. Jul 1979;79(8):1180-6. [Medline].

  102. Scholten E, Crolla RM, Blomjous FJ, Moll FL. Preputial necrosis as an unusual cutaneous manifestation of cholesterol crystal embolization. J Urol. Mar 1995;153(3 Pt 1):741-2. [Medline].

  103. Shindo S, Okamoto H, Nagai M, Kimura H, Matsumoto J, Yumoto S, et al. Acute ischemia of the lower legs from blunt abdominal trauma: an unusual cause of atheroembolism--case report. J Trauma. Mar 1994;36(3):451-3. [Medline].

  104. Snyder HE, Shapiro JL. A correlative study of atheromatous embolism in human beings and experimental animals. Surgery. Feb 1961;49(2):195-204.

  105. Stewart WM, Lauret P, Testart J, Thomine E, Boullie MC, Leroy D. [Cutaneous cholesterol emboli (author's transl)]. Ann Dermatol Venereol. Jan 1977;104(1):5-8. [Medline].

  106. Tunick PA, Perez JL, Kronzon I. Protruding atheromas in the thoracic aorta and systemic embolization. Ann Intern Med. Sep 15 1991;115(6):423-7. [Medline].

  107. Turakhia AK, Khan MA. Splinter hemorrhages as a possible clinical manifestation of cholesterol crystal embolization. J Rheumatol. Aug 1990;17(8):1083-6. [Medline].

  108. Vanhooteghem O, Papadopoulos T, Sass U, Gheeraert P, Cogan E, Song M. Clinical manifestations of cholesterol crystal embolism with subungual haemorrhages: a possible relationship?. Dermatology. 1996;192(4):395-7. [Medline].

  109. Wagner RB, Martin AS. Peripheral atheroembolism: confirmation of a clinical concept, with a case report and review of the literature. Surgery. Mar 1973;73(3):353-9. [Medline].

  110. Young DK, Burton MF, Herman JH. Multiple cholesterol emboli syndrome simulating systemic necrotizing vasculitis. J Rheumatol. Apr 1986;13(2):423-6. [Medline].

  111. Zaytsev P, Miller K, Pellettiere EV. Cutaneous cholesterol emboli with infarction clinically mimicking heparin necrosis--a case report. Angiology. Jun 1986;37(6):471-6. [Medline].

 
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Chronic leg ulcer due to cutaneous cholesterol emboli on the leg of a 79-year-old woman.
Skin biopsy specimen demonstrating ulceration and an occluded vessel at the right border of the specimen within the fat. Hematoxylin and eosin stain at 22X magnification.
Higher magnification of the same biopsy specimen, demonstrating cholesterol clefts within an occluded arteriole. Hematoxylin and eosin stain at 297X magnification.
 
 
 
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