Dermatopathology
Cutaneous microemboli from hydrophilic polymer after endovascular procedures

https://doi.org/10.1016/j.jaad.2015.07.014Get rights and content

Background

Multiple devices and coatings assist with endovascular insertion of sheaths, catheters, and guide wires. Hydrophilic polymer coatings, a common component of endovascular surgical devices, reportedly cause microvascular obstruction and embolization, with various sequelae in organs and soft tissue.

Objective

We sought to describe clinical and histopathologic features of cutaneous manifestations of hydrophilic polymer gel emboli.

Methods

We evaluated the clinical and histopathologic characteristics of 8 patients with cutaneous complications of hydrophilic polymer gel emboli who presented in May 2013 through February 2015.

Results

Sudden onset of lower extremity livedo racemosa, purpuric patches, or both, occurred hours to days after endovascular procedures involving the aorta. Histopathologic evaluation showed basophilic lamellated material, consistent with hydrophilic polymer gel emboli, within small dermal vessels.

Limitations

This was a retrospective study with small sample size and not controlled for all similar procedures in this population.

Conclusion

Hydrophilic polymer gel coatings in endovascular devices can embolize to skin and cause microvascular occlusion, presenting as livedo racemosa, purpura, or both. Given the number of patients observed over a short period, this phenomenon may be underappreciated. Hydrophilic polymer gel emboli should be considered in differential diagnosis of livedo racemosa and purpura after endovascular procedure.

Section snippets

Methods

We performed retrospective analysis of 8 patients identified between May 2013 and February 2015 at Mayo Clinic's campus in Rochester, MN. Our institutional review board waived the need for formal approval of this case series. Hematoxylin-eosin–stained sections of punch biopsy specimens obtained from the purpuric lesions during the course of patient care (Fig 1) were reviewed. X-ray probe microanalysis was performed on 1 specimen (patient 6) and colloidal iron staining on biopsy specimen from 2

Results

The clinical features, endovascular procedures, and clinical course of each patient are summarized in Table I. Patient age ranged from 58 to 81 years; 7 of the 8 patients were men. All patients had multiple medical comorbidities, and 5 patients had previous endovascular procedures, including aortic graft repair, endarterectomy, and coronary bypass. Patients 2 and 4 underwent repair of the thoracic aorta in addition to repair of the aortic valve. Patient 6 had only aortic valve insertion.

Discussion

Endovascular procedures enable temporary insertion of catheters and sheaths, and permanent placement of grafts and stents.1 The benefits of hydrophilic polymer coatings include decreased coefficient of friction; improved maneuverability in the vascular space, particularly in tortuous vasculature; prevention of vasospasm; and decreased thrombogenicity.1, 6, 7 However, the introduction of this foreign material into the vasculature brings risk of the clinical consequences of embolization.

In vitro

References (12)

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    The FDA is developing testing strategies to evaluate coating performance and to improve device standards.2 Polymer coating emboli in the dermal vasculature can appear clinically as nonpalpable petechiae and purpura, reticulate purpura, acute and chronic ulcerations, hyperkeratotic and lichenified nodules, and hemorrhagic panniculitis.3,5,7-9,19 Similar findings can also be seen in conditions such as vasculitis, venous stasis ulcers, cholesterol emboli, and calciphylaxis.

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Dr Griffin is now with Departments of Internal Medicine and of Laboratory Medicine and Pathology, Texas A&M University Health Science Center, Dallas.

Funding sources: None.

Conflicts of interest: None declared.

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