[A patient under hemodialysis with acute distal ischaemia: cholesterol crystal embolism]

A 61-year old man was admitted in our hospital for distal ischaemic lesions of the right foot with necrosis of the fifth toe. The lesions appeared a few days before admission. He was known for severe atheromatous disease and multiple aortic and femoro-popliteous aneurysms. He presented also numerous cardiovascular risk factors and a terminal chronic kidney disease was found 18 months earlier. The etiology of the kidney disease was not clear. The patient received hemodialysis since one month. We suspected a severe peripheral arterial disease but the investigations showed preserved distal arterial blood flow what made us think about a thromboembolic disease. We ruled out a potential embolic cardiopathy and, after finding eosinophilia and a previous consultation report of livedo, we suggested the diagnosis of cholesterol crystal embolisation. It was confirmed by the macroscopic examination of the necrotic toe. It's a rare and under-diagnosed pathology with a variable presentation. Though, it's important to detect this affection early as possible to prevent the frequent recurrences. The acute mortality is about 15%. There is no specific treatment, but an an aggressive control of the atheromatous disease is important. We must also avoid the known potential triggering factors: vascular surgery, angiography and anticoagulant or thrombolytic medications.