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We report a case of systemic cholesterol embolisms (CE) with rare localization to the level of the face from a tight carotid stenosis. The case history is that of a 75 year old patient who presented with cholesterol embolisms in the territory of the external carotid artery. The patient underwent successful carotid endarterectomy with no postoperative neurological event.

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A 47-year-old man was admitted for progressively worsening calf cramp in the right leg while walking. No risk factors for vascular disease were identified, apart from some degree of hypercholesterolemia. He had no history of trauma in the right leg, and he participated in regular physical activity. The ankle-brachial index was 0.6 on the right side and 1.0 on the left side. On examination, no popliteal and distal arterial pulses were present in the right leg, whereas this arterial pulses were present in the left leg. Duplex ultrasound examination and computed tomography scans performed 3 months after the onset of symptoms revealed a multilocular cystic formation within the right popliteal artery wall, determining a severe luminal stenosis. Therefore, a diagnosis of cystic adventitial disease was confirmed (A). In this case, a subsequent conventional angiography revealed a concentric compression of the popliteal artery by the cyst, with the characteristic hour glass sign (B). The therapeutic approach was surgical first. The patient was placed in a supine position and the great saphenous vein was removed from the right leg via internal access. Second, the patient was placed prone, and a posterior approach was realized through an incision in the popliteal fossa. A multilocular cyst was identified (C) and resected, followed by a popliteal bypass reconstruction with autologous great saphenous vein. Clinical follow-up was free of symptoms. He remains asymptomatic with normal peripheral pulses 0.3 years after surgery, with an ankle-brachial index of 0.9. Histopathology showed a multilocular cystic adventitial disease interesting the popliteal artery wall (D). This cyst was located between the media and adventitia of the artery. and contained gelatinous material. The patient (Mr M.B) agree to publish his case details and images, in all editions of the Journal of Vascular Surgery Publications and in any other publication, as well as in any advertising or promotional material for such product or publications. DISCUSSION Cystic adventitial disease is encountered predominantly in men, with an average male:female ratio of 15:1 and an incidence of 1:1200 in patients with claudication. 1 The etiology of cystic adventitial disease remains controversial. Four theories are proposed: degenerative, traumatic, synovial, and developmental. The adventitial cyst becomes incorporated into the vascular wall and its growth causes compression of the lumen. These cysts contain myxoid material rich in hyaluronic acid. 2 In our case, the diagnosis was confirmed using Doppler ultrasound examination and computed tomography imaging; other pathologies were excluded, such as popliteal aneurysms and extrinsic compression from Baker's cysts, 3,4 false aneurysms, and