The Cholesterol Embolism Syndrome

This 75-year-old man complained of unbearable pain in both feet, at rest, of two months’ duration. Physical examination revealed blue toes, fissures, petechial hemorrhages, and ulcerating gangrene of the ankles. There was no physical or laboratory evidence of endocarditis, peripheral arterial occlusive disease, vasculitis, or infection. The patient had neither cancer nor diabetes and thus did not have either a paraneoplastic syndrome or a diabetic foot. Three months before, he had been found to have coronary heart disease and had undergone the insertion of coronary stents in two separate cardiac catheterization procedures. These interventions gave rise to cholesterol emboli, which led to persistent, severely painful ischemic disturbances in both feet. A skin biopsy revealed the emboli, with characteristic whetstone-like cholesterol deposits (cholesterol clefts). There is no causally directed treatment for the cholesterol embolism syndrome, also known as the “trash foot” syndrome. Often, it can be definitively treated only by amputation(frequency after aortic procedures, 0.6–0.9%). Interventions such as catheter-based studies and procedures, aortic surgery, and aortic stenting can cause cholesterol embolism not only to the feet, but alsoin the eyes, internal organs, and brain.

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