Catastrophic cholesterol crystal embolization after endovascular stent placement for peripheral vascular disease

A 55-year-old man was hospitalized for endovascular stent placement in both right common iliac and femoral arteries for relief of claudication symptoms due to peripheral vascular disease. Angiography demonstrated diffuse atherosclerosis of the infrarenal aorta and severe stenosis of the right common iliac and right femoral arteries. Physical examination showed diminished but palpable peripheral pulses. Uncomplicated stent placement was done in the right common iliac and right femoral arteries via a left femoral artery approach resulting in improved pedal pulses. Over the next 36 hours, the patient developed severe bilateral lower extremity pain followed by extensive livedo reticularis over lower extremities, elevated creatine kinase levels, myoglobinuria, and a rise in serum creatinine to 1.5 mg/dL (133 micromol/L). Pedal pulses continued to be palpable. This was followed by bilateral lower extremity compartment syndrome, requiring fasciotomies. Myoglobinuria cleared with hydration and creatinine kinase levels returned to normal; however, the patient ultimately developed gangrene of both lower extremities. Bilateral below the knee amputations were performed and histopathology showed wide spread cholesterol crystals in arterioles and small and medium sized arteries in skin and muscle of both lower extremities. This case emphasizes the potential for major complications of cholesterol embolism associated with even uncomplicated vascular procedures performed for treatment of peripheral vascular disease.