Peripheral Embolism from an Aortic-Arch Atheroma

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     To the Editor: In Images in Clinical Medicine (Dec. 11 issue),1 Lee and Chandraratna provide evidence of dry gangrene in the right foot of a 62-year-old man and evidence of a mobile arch atheroma. They suggest that thromboembolism from atheroma is an important cause of stroke and peripheral embolism. We agree. However, we would suggest that this is not a case of "thromboembolism," as it is characterized in the second paragraph. The presence of both the dorsalis pedis and posterior tibial pulses in the affected foot suggests that there has not been a fibroplatelet embolic event. Indeed, this constellation is more suggestive of cholesterol crystal embolization — how else to explain the preserved pulses? Also, single-vessel infrapopliteal occlusion typically does not cause intermittent claudication, much less gangrene. We suggest that the transesophageal echocardiogram reveals a ruptured plaque and substrate for cholesterol emboli, not thromboembolism.

    Joshua A. Beckman, M.D.

    Marie Gerhard-Herman, M.D.

    Brigham and Women's Hospital

    Boston, MA 02115

    jbeckman@partners.org

    References

    Lee JS, Chandraratna PAN. Peripheral embolism from an aortic-arch atheroma. N Engl J Med 2003;349:e23-e23.

    http://www.100md.com/html/DirDu/2006/11/29/30/75/37.htm