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CLINICAL RESEARCH: INVASIVE AND INTERVENTIONAL CARDIOLOGY

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

^* Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Manuscript received December 9, 2002; revised manuscript received January 6, 2003, accepted January 30, 2003.

^* Reprint requests and correspondence: Dr. Hiroyuki Tsutsui, Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
prehiro{at}cardiol.med.kyushu-u.ac.jp

OBJECTIVES: We sought to determine the incidence of cholesterol embolization syndrome (CES) as a complication of cardiac catheterization and to identify risk factors associated with this disease.

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.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CES = cholesterol embolization syndrome   CRP = C-reactive protein

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