By Gary M. White, MD
In cholesterol emboli, particles from the inner wall of larger blood vessels embolize to extremities causing impaired blood supply to the skin. Often patients have a history of a prior arteriography, although arteriography may help localize a source. Usually the onset is within hours or days of the procedure, although 3 cases with onset of symptoms 5-16 weeks after undergoing a vascular procedure have been reported [AD 1999;135;725]. Embolization may affect internal organs as well, e.g. the kidney (hematuria, acute renal failure), brain (stroke), eyes (acute loss of vision) and gastrointestinal tract (abdominal pain, diarrhea, and gastrointestinal blood loss). For a related entity, see Hydrophilic Polymer Emboli.livedo racemosa
Common cutaneous manifestations include livedo racemosa (49%), blue toes, gangrene (35%), cyanosis (28%), ulceration (17%), nodules (10%), and purpura (9%) [AD 1999;135;725].
The history is usually quite suggestive. Diagnosis is made by finding cholesterol crystal clefts in the dermal blood vessels.
For the skin, if minor, supportive treatment may be all that is needed. Otherwise, surgery may be indicated. Because this disorder is a manifestation of atherosclerosis, avoidance of traditional risk factors for atherosclerosis such as smoking, hypertension and hypercholesterolemia is strongly advised. Anticoagulant therapy should be discontinued if possible if it seemed to have precipitated the event. Therapies that have been reported helpful include iloprost, a prostacyclin analogue, hyperbaric oxygen and pentoxifylline.
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