The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study

J Am Coll Cardiol. 2003 Jul 16;42(2):211-6. doi: 10.1016/s0735-1097(03)00579-5.


Background: Cholesterol embolization syndrome is a systemic disease caused by distal showering of cholesterol crystals after angiography, major vessel surgery, or thrombolysis.

Methods: We prospectively evaluated a total of 1,786 consecutive patients 40 years of age and older, who underwent left-heart catheterization at 11 participating hospitals. The diagnosis of CES was made when patients had peripheral cutaneous involvement (livedo reticularis, blue toe syndrome, and digital gangrene) or renal dysfunction.

Results: Twenty-five patients (1.4%) were diagnosed as having CES. Twelve patients (48%) had cutaneous signs, and 16 patients (64%) had renal insufficiency. Eosinophil counts were significantly higher in CES patients than in non-CES patients before and after cardiac catheterization. The in-hospital mortality rate was 16.0% (4 patients), which was significantly higher than that without CES (0.5%, p < 0.01). All four patients with CES who died after cardiac catheterization had progressive renal dysfunction. The incidence of CES increased in patients with atherosclerotic disease, hypertension, a history of smoking, and the elevation of baseline plasma C-reactive protein (CRP) by univariate analysis. The femoral approach did not increase the incidence, suggesting a possibility that the ascending aorta may be a potential embolic source. As an independent predictor of CES, multivariate regression analysis identified only the elevation of pre-procedural CRP levels (odds ratio 4.6, P = 0.01).

Conclusions: Cholesterol embolization syndrome is a relatively rare but serious complication after cardiac catheterization. Elevated plasma levels of pre-procedural CRP are associated with subsequent CES in patients who undergo vascular procedures.

MeSH terms

  • Acute Kidney Injury / etiology
  • Adult
  • Aged
  • Aged, 80 and over
  • Analysis of Variance
  • Arteriosclerosis / complications
  • Blue Toe Syndrome / etiology
  • C-Reactive Protein / metabolism
  • Cardiac Catheterization / adverse effects*
  • Creatinine / blood
  • Embolism, Cholesterol / blood
  • Embolism, Cholesterol / diagnosis
  • Embolism, Cholesterol / epidemiology
  • Embolism, Cholesterol / etiology*
  • Eosinophils
  • Hospital Mortality
  • Humans
  • Hypertension / complications
  • Incidence
  • Leukocyte Count
  • Middle Aged
  • Predictive Value of Tests
  • Prospective Studies
  • Regression Analysis
  • Risk Factors
  • Skin Diseases, Vascular / etiology
  • Smoking / adverse effects
  • Syndrome


  • C-Reactive Protein
  • Creatinine