What is the role of surgery in the treatment of cutaneous cholesterol emboli (CCE)?

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

Removal of the source of the emboli using thromboendarterectomy or excision and replacement of the prosthesis has resulted in resolution of CCE. Because gangrene is more likely to occur in persons whose circulation is already compromised, reconstruction of the stenotic proximal artery, which may or may not be the source of emboli, is also advised. Other forms of surgical treatment include embolectomy, sympathectomy, and primary excision of necrotic tissue, possibly involving amputation.

Thoracoabdominal repair is the criterion standard of treatment. Bypass without vessel ligation is contraindicated because it does not remove the source of emboli. Improvement and healing of cutaneous lesions was observed in 2 of 3 patients after resection of abdominal aortic aneurysms. Another group reported that 4 of 5 patients with ischemic lesions from toe gangrene or necrosis benefited from arterial reconstruction. For multilevel occlusive disease, proximal reconstructions are performed prior to distal ones, but the reverse may be appropriate for blue toe syndrome.

If the entire aorta is diffusely ulcerative, the source of emboli is inaccessible, or the patient is a poor surgical candidate, then thoracoabdominal repair may not be possible. Palliative treatment for such patients is axillobifemoral bypass with external iliac ligation. Four patients with peripheral emboli who underwent this procedure had cessation of new lesions, healing, and pain relief. Embolization to the pelvic circulation may be controlled by iliac ligation at the aortic bifurcation or by individual interruption of the internal iliac arteries. Another group had similar success with this technique and was able to salvage 12 limbs in 6 patients, apart from the loss of a fifth toe.

Embolectomy may be effective in cases of the larger atheroemboli.

Peripheral nerve blockade or lumbar sympathectomy has been used to deter cutaneous breakdown and promote healing. They are advocated for patients with persistent areas of pain, cyanosis, or cutaneous gangrene in the involved limb. Sympathetic blockade influences the microcirculation of the skin through a direct effect on arteriovenous communications that are almost entirely made of smooth muscle.

If peripheral circulation is intact, hard eschars from infarcted skin and/or muscle on the legs should be excised primarily.

If circulation is inadequate, amputation may be the only way to stop the advance of ascending gangrene.


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