Acute type B aortic dissection with multiple cholesterol embolism: an autopsy case report

Background: Most cases of cholesterol embolism are known to be triggered by cardiac catheterization, cardiovascular surgery, anticoagulation, or fibrinolytic therapy; however, spontaneous cases after aortic dissection are rare. In this report, we describe a case of cholesterol embolism after type B aortic dissection, which rapidly developed into multiple organ failure and death. Case summary: A 65-year-old man with untreated hypertension was admitted to our hospital with sudden back pain and diagnosed with type B aortic dissection. The patient experienced a rapid progression of inflammation and developed respiratory and renal failure, despite computed tomography showing no obvious progression of dissection. We attributed them to a cytokine storm and acute respiratory distress syndrome, but steroid pulse therapy did not alleviate the symptoms. Finally, the patient died on Day 6 after admission, and an autopsy was performed, which revealed cholesterol crystal occlusions in the kidney, spleen, and the left lower leg. The lumen in the aorta is filled with atheroma and thrombus, and we suspect that aortic dissection triggered failure of the aortic plaques and released cholesterol crystals to distal arteries that led to cholesterol embolism. Discussion: We experienced a patient with a type B aortic dissection that led to cholesterol embolism and rapid progression of respiratory and renal failure, resulting in death. The aortic dissection combined with cholesterol embolism was considered to trigger the subsequent severe inflammation, leading to rapid respiratory and renal failure. Our case points to the possibility that cholesterol embolism can extensively escalate inflammation after aortic dissection.