2026 Clinician Corner - Perilous polymers: a case of hydrophilic gel polymer embolism

Abstract 

Hydrophilic polymer embolism (HPE) is a rare complication of endovascular procedures caused by embolization of polymer coatings from vascular devices. We report a 72-year-old man with peripheral artery disease, diabetes, and chronic kidney disease who developed painful, nonhealing lower-extremity ulcers presenting shortly after vascular stenting. Initial biopsies and an extensive infectious and autoimmune workup were nondiagnostic, and the patient failed treatment for presumed pyoderma gangrenosum. Repeat biopsies later revealed amorphous blue material in dermal vessels, highlighted by Alcian blue staining, confirming HPE. Despite treatment with pentoxifylline and wound care, disease progression led to bilateral below-the-knee amputations. This case highlights the diagnostic challenge of HPE, which can present months after endovascular intervention and mimic other ulcerative disorders. Histologic findings are subtle, and early coordination with dermatopathology is key. Clinicians should maintain high suspicion for HPE in patients with unexplained ulcers and vascular procedure history, as early recognition may reduce morbidity.     

Keywords:  comorbidities; dermatopathology; endovascular complications; HPE; hydrophilic gel polymer embolism; lower-extremity wounds; peripheral artery disease; polymer; ulcers

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Faculty credentials/disclosure 

The planners and faculty for this activity have no relevant financial relationships to disclose. The patient consented to the publication of this report.

Process

Click the "add to cart/begin" button, pay any relevant fee, take the quiz, complete the evaluation, and claim your CME credit.  You must achieve 100% on the quiz with unlimited attempts available.

  • By completing this process, you are attesting that you have read the journal article.

Expiration date:

Credit eligibility for this article is set to expire on March 1, 2027.

Learning Objectives

After completing the article, the learner should be able to:

  • Recognize the clinical presentation and diagnostic challenges of hydrophilic polymer embolism (HPE) following endovascular procedures, including its ability to mimic other ulcerative conditions such as pyoderma gangrenosum.  

  • Identify the histopathologic hallmark of HPE, amorphous material within dermal vessels, and understand the importance of repeat biopsy and special staining in cases of nonhealing ulcers with inconclusive initial workup.  

  • Be able to apply a high index of suspicion for HPE in patients with unexplained lower extremity ulcerations and a history of vascular intervention and understand the role of early multidisciplinary collaboration in improving diagnostic accuracy and patient outcomes. 

Key Points 

  • A temporal association between endovascular procedures and rapid onset of nonhealing ulcerations should raise suspicion for iatrogenic embolic phenomena. Early recognition of hydrophilic polymer embolism (HPE) is essential to avoid inappropriate treatment and reduce the risk of severe outcomes such as limb loss. 

  • The histopathologic hallmark of HPE is amorphous Alcian blue-positive material within dermal vessels. 

  • HPE can mimic neutrophilic dermatoses both clinically and histologically, highlighting the need for repeat biopsy and special stains when ulcers do not respond to standard treatments. 

  • Initial misdiagnosis of pyoderma gangrenosum led to prolonged, ineffective immunosuppressive therapy. 

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Course summary
Available credit: 
  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2
    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
  • 1.00 American Board of Surgery (ABS) Accredited CME
    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.
  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance
Course opens: 
03/01/2026
Course expires: 
03/01/2027
Cost:
$25.00

Allison Roecker, BS¹, Sovan Ven, BS², Sonali Batta, MD³, Annika Silfvast-Kaiser, MD3, Kirstin Altman, MD3, and Madeeha Drissi, MD3 

 

¹Texas A&M University College of Medicine, College Station, Texas, USA 

² Baylor College of Medicine, Houston, Texas, USA 

³ Department of Dermatology, Baylor Scott & White Medical Center –Temple, Temple, Texas, USA 

 

Corresponding author: Allison Roecker, BS, A&M University College of Medicine, College Station, Texas (e-mail: [email protected])

 The planners and faculty for this activity have no relevant financial relationships to disclose. The authors report no funding. The patient consented to publication of this case report. 

Accreditation

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation

AMA PRA Category 1 Credit™

The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABS CC

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

ABIM MOC

 Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Available Credit

  • 1.00 American Board of Internal Medicine (ABIM) MOC Part 2
    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.00 MOC points in the American Board of Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.
  • 1.00 American Board of Surgery (ABS) Accredited CME
    Successful completion of this CME activity enables the learner to earn credit toward the CME requirement of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.
  • 1.00 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 1.00 Attendance

Price

Cost:
$25.00
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