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Atheromatous emboli

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= cholesterol emboli


  • atheroma a pre-requisite
  • may be spontaneous but usually iatrogenic
  • surgical manipulation of atheromatous aorta
  • intra-arterial catheterization
  • warfarin
  • thrombolysis


  • proximal aortic aneurysm or ulcerated plaque
  • microemboli of cholesterol crystals and other atherosclerotic debris occludes arterioles of 50-900 m m diameter. Often in more than one organ
  • abdominal viscera, kidneys and lower extremities most commonly affected

Clinical features

  • clinical presentation fairly consistent
  • cyanotic and severely painful toes often with bluish patches and haemorrhagic areas resulting from occlusion of digital arterioles
  • livedo reticularis
  • hypertension, renal impairment, haematuria, WBCs in urine and proteinuria without red cell casts result from renal involvement. Kidneys are most commonly affected visceral organs. Renal failure due to atheromatous emboli usually develops over 1-4 weeks after angiographic procedure whereas contrast induced renal failure typically appears soon after the study and reaches maximum severity within 7-10 days

Laboratory features

Differential diagnosis

  • other causes of systemic emboli
  • hyperviscosity syndromes
  • hypercoagulable states: malignancy, antiphospholipid syndrome, DM, essential thrombocytopaenia, DIC, erythromelalgia
  • vasculitis


  • symptomatic
  • local vasodilatation with topical GTN
  • use of heparin controversial as some claim that it may prevent the formation of organized clot over the ulcerated plaques and thus allow continued embolization


  • increased awareness of problem
  • minimization of intra-arterial procedures in atherosclerotic aortas and femoral arteries
  • use of brachial approach in patients with atheromatous disease of aorta and iliac arteries
  • minimizing catheter manipulation
  • use of softer and more flexible catheters

Further reading

Rohrer MJ, Giansiracusa DF. Arterial disease of the extremities. In Rippe 3rd ed. 1996, pp1804



©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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