How is cutaneous cholesterol emboli (CCE) treated?

Updated: Apr 12, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Answer

Medical treatment of CCE has largely been unsuccessful, with the exception of a few anecdotal reports. The early goals of treatment are to augment the circulation and to try to prevent occlusion. Some believe this can be achieved with drugs that inhibit coagulation, platelet aggregation, and RBC sludging. Vasodilators and corticosteroids have also been used. Variable results have been reported with the use of heparin, streptokinase, urokinase, tissue plasminogen activator, warfarin, bishydroxycoumarin, aspirin, pentoxifylline, dipyridamole, prostaglandins, prostacyclin, intra-arterial papaverine, sulfinpyrazone, low–molecular-weight dextran, nifedipine, prednisone, and methylprednisolone. Some have also recently reported success with hemostatic and lipid-lowering agents (eg, vitamin K, carbazochrome, tranexamic acid, reptilase, lovastatin, cholestyramine, probucol).

Although anticoagulants have been observed to cause CCE and many reports indicate the cessation of symptoms upon discontinuation, in 2 patients, heparin resulted in resolution of their myalgias, tenderness, and pregangrene. Furthermore, they did not have any recurrence of symptoms or signs. Another group reported clinical and radiographic improvement following therapy with intra-arterial streptokinase, heparin, and prostacyclin. Iloprost, a prostacyclin analog, has also been reported to improve renal function and peripheral symptoms in patients with CE. Subcutaneous heparin, which is intermittently administered through the tissue to provide trough periods, may allow more effective healing of plaques than the intravenous form.

Some recommend a trial of corticosteroids for their anti-inflammatory effect to limit arteritis and the subsequent fibrotic occlusion of vessels; however, in 9 patients with CCE thought to have vasculitis who were treated with corticosteroids, 7 died.

Lovastatin may effect healing by inducing the regression of atherosclerosis and by decreasing plaque cholesterol content, which is linked to an increased incidence of emboli.

One group used the combination of hemostatic (ie, vitamin K, carbazochrome, tranexamic acid, reptilase) and antihyperlipidemic (ie, cholestyramine, probucol) drugs and had positive results.

The clinical effect of circulator boot therapy in patients with cholesterol embolization syndrome of the lower extremities in patients following cardiac or vascular procedures may be an effective noninvasive therapeutic option. [37]


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