SUMMARY Cholesterol embolism after left heart catheterisation by the femoral approach was diagnosed in seven men (mean age 59*6 years) out of a total of 4587 catheterisations. Diabetes was present in four patients, systemic hypertension in three, and signs of extensive atherosclerosis in six; five patients were taking anticoagulant drugs. Acute pain in the legs or abdomen occurred in six patients, two of whom had abdominal angina; renal failure was present in six patients, cutaneous manifestations in five, and a cholesterol embolus was seen in the retina in one. Six out' of six patients had an appreciable increase in the erythrocyte sedimentation rate and five out of five had eosinophilia within a week of catheterisation. Renal failure was progressive in five patients, one of whom required haemodialysis. Three patients required amputation of the toes because of gangrene. Four patients died within four and a half months of catheterisation from causes not directly related to cholesterol embolism. At necropsy cholesterol emboli were found in all four patients. Cholesterol embolism is a rare but serious complication of left heart catheterisation.Cholesterol embolism is not widely recognised as a complication of cardiac catheterisation' -and may be difficult to diagnose.69 We report the main findings in seven patients who suffered cholesterol embolism after left heart catheterisation. Patients and methodsBetween January 1978 and April 1982 cholesterol embolism after left heart catheterisation was diagnosed in seven men out of a total of 4587 cardiac catheterisations. Diagnosis was based on the typical clinical features of cholesterol embolism after exclusion of other causes, and in four patients was confirmed at necropsy. was used with polyurethane highflow Judkins catheters (Cordis) and safety guide wires (Cook) with a straight tip. In three patients (cases 2, 5, and 6) a J shaped tip was also used because of difficulties in advancing the guide wire. In six patients metrizoate (Isopaque Coronar, Nyegaard) was used as contrast medium and in one ioxaglate (Hexabrix, Guerbet). In accordance with our protocol for left heart catheterisation all patients received 7500 IU of heparin intraarterially just before the procedure. At

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313IMAGING IN CARDIOLOGY Combination of imaging modalities in a coronary artery fistula A 35-year-old woman was referred for diagnostic evaluation of stitching pain under her left breast. The pain was not related to exercise. There were no cardiovascular risk factors. Physical examination, routine blood testing and chest X-ray were normal. Her ECG showed abnormal ST segments in III and aVF, and down-sloping ST segments with negative T waves in V 3 to V 4 .