Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
General Thoracic and Cardiovascular Surgery
Published in: General Thoracic and Cardiovascular Surgery 3/2019

01-03-2019 | Aortic Aneurysm | Current Topics Review Article

Etiology of aortic dissection

Author: Koichi Akutsu

Published in: General Thoracic and Cardiovascular Surgery | Issue 3/2019

Login to get access

Abstract

We discuss the etiology of aortic dissection (AD) from various points of view. The development of AD requires two pathological conditions: medial degeneration and mechanical wall stress. First, histopathological findings of medial degeneration are hypothesized to be due to a loss of elastic fibers and interconnecting elastic fibers. Damage to the vasa vasorum plays a key role in creating an entry site. The clinical causes of medial degeneration include hypertension, aortic aneurysms, obstructive sleep apnea, and connective tissue disorders. Second, mechanical wall stress is supposedly induced by shear stress caused by blood flow, together with hypertension and aortic root movement. Further investigation is necessary in the search for mechanisms responsible for medial degeneration prior to AD development.
Literature
1.
Hirst AE Jr, Johns VJ Jr, KIime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore). 1958;37:217–79.CrossRef
2.
Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The international registry of acute aortic dissection (IRAD): new insights into an old disease. JAMA. 2000;283:897–903.CrossRefPubMed
3.
Nienaber CA, Fattori R, Mehta RH, Richartz BM, Evangelista A, Petzsch M, et al. International registry of acute aortic dissection. Gender-related differences in acute aortic dissection. Circulation. 2004;109:3014–21.CrossRefPubMed
4.
Halushka MK, Angelini A, Bartoloni G, Basso C, Batoroeva L, Bruneval P, et al. Consensus statement on surgical pathology of the aorta from the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology: II. Noninflammatory degenerative diseases—nomenclature and diagnostic criteria. Cardiovasc Pathol. 2016;25:247–57.CrossRefPubMed
5.
Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med. 1982;106:175–80.PubMed
6.
Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol. 1984;53:849–55.CrossRefPubMed
7.
Nakashima Y, Kurozumi T, Sueishi K, Tanaka K. Dissecting aneurysm: a clinicopathologic and histopathologic study of 111 autopsied cases. Hum Pathol. 1990;21:291–6.CrossRefPubMed
8.
Carlson RG, Lillehei CW, Edwards JE. Cystic medial necrosis of the ascending aorta in relation to age and hypertension. Am J Cardiol. 1970;25:411–5.CrossRefPubMed
9.
Kageyama N, Ro A, Tanifuji T, Kumagai T, Murai T, Fukunaga T. The histopathologic study of elastic laminar and interconnecting elastic fiber in aortic media: Implications for aortic dissection (Japanese). J Jpn Coll Angiol. 2005;45:1003–9.
10.
Roberts WC, Vowels TJ, Kitchens BL, Ko JM, Filardo G, Henry AC, et al. Aortic medial elastic fiber loss in acute ascending aortic dissection. Am J Cardiol. 2011;108:1639–44.CrossRefPubMed
11.
Nakashima Y, Shiokawa Y, Sueishi K. Alterations of elastic architecture in human aortic dissecting aneurysm. Lab Investig. 1990;62:751–60.PubMed
12.
Loeys BL, Schwarze U, Holm T, Callewaert BL, Thomas GH, Pannu H, et al. Aneurysm syndromes caused by mutations in the TGF-beta receptor. N Engl J Med. 2006;355:788–98.CrossRefPubMed
13.
Morisaki H, Akutsu K, Ogino H, Kondo N, Yamanaka I, Tsutsumi Y, et al. Mutation of ACTA2 gene as an important cause of familial and non-familial non-syndromatic thoracic aortic aneurysm and/or dissection. Hum Mutat. 2009;30:1406–11.CrossRefPubMed
14.
van de Laar IM, van der Linde D, Oei EH, Bos PK, Bessems JH, Bierma-Zeinstra SM, et al. Phenotypic spectrum of the SMAD3-related aneurysms-osteoarthritis syndrome. J Med Genet. 2012;49:47–57.CrossRefPubMed
15.
Boileau C, Guo DC, Hanna N, Regalado ES, Detaint D, Gong L, et al. TGFB2 mutations cause familial thoracic aortic aneurysms and dissections associated with mild systemic features of Marfan syndrome. Nat Genet. 2012;44:916–21.CrossRefPubMedPubMedCentral
16.
Détaint D, Faivre L, Collod-Beroud G, Child AH, Loeys BL, Binquet C, et al. Cardiovascular manifestations in men and women carrying a FBN1 mutation. Eur Heart J. 2010;31:2223–9.CrossRefPubMed
17.
Akutsu K, Morisaki H, Takeshita S, Sakamoto S, Tamori Y, Yoshimuta T, et al. Phenotypic heterogeneity of Marfan-like connective tissue disorders associated with mutations of the transforming growth factor-β receptor gene. Circ J. 2007;71:1305–9.CrossRefPubMed
18.
Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35:2873–926.CrossRefPubMed
19.
Oderich GS, Panneton JM, Bower TC, Lindor NM, Cherry KJ, Noel AA, et al. The spectrum, management and clinical outcome of Ehlers-Danlos syndrome type IV: a 30-year experience. J Vasc Surg. 2005;42:98–106.CrossRefPubMed
20.
Januzzi JL, Isselbacher EM, Fattori R, Cooper JV, Smith DE, Fang J, et al. Characterizing the young patient with aortic dissection: results from the international registry of aortic dissection (IRAD). Am Coll Cardiol. 2004;43:665–9.CrossRef
21.
Hahn RT, Roman MJ, Mogtader AH, Devereux RB. Association of aortic dilation with regurgitant, stenotic and functionally normal bicuspid aortic valves. J Am Coll Cardiol. 1992;19:283–8.CrossRefPubMed
22.
Cripe L, Andelfinger G, Martin LJ, Shooner K, Benson DW. Bicuspid aortic valve is heritable. J Am Coll Cardiol. 2004;44:138–43.CrossRefPubMed
23.
Bonderman D, Gharehbaghi-Schnell E, Wollenek G, Maurer G, Baumgartner H, Lang IM. Mechanisms underlying aortic dilatation in congenital aortic valve malformation. Circulation. 1999;99:2138–43.CrossRefPubMed
24.
Padang R, Bagnall RD, Richmond DR, Bannon PG, Semsarian C. Rare non-synonymous variations in the transcriptional activation domains of GATA5 in bicuspid aortic valve disease. J Mol Cell Cardiol. 2012;53:277–81.CrossRefPubMed
25.
Garg V, Muth AN, Ransom JF, Schluterman MK, Barnes R, King IN, et al. Mutations in NOTCH1 cause aortic valve disease. Nature. 2005;437:270–4.CrossRefPubMed
26.
Akutsu K, Morisaki H, Okajima T, Yoshimuta T, Tsusumi Y, Takeshita S, et al. Genetic analysis of young adult patients with aortic disease not fulfilling the diagnostic criteria for Marfan syndrome. Circ J. 2010;74:990–7.CrossRefPubMed
27.
Suzuki T, Isselbacher EM, Nienaber CA, Pyeritz RE, Eagle KA, Tsai TT, et al. Type-selective benefits of medications in treatment of acute aortic dissection (from the international registry of acute aortic dissection [IRAD]). Am J Cardiol. 2012;109:122–7.CrossRefPubMed
28.
Li Y, Yang N, Duan W, Liu S, Yu S, Yi D. Acute aortic dissection in China. Am J Cardiol. 2012;110:1056–61.CrossRefPubMed
29.
Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM, et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013;127:2031–7.CrossRefPubMedPubMedCentral
30.
Pape LA, Awais M, Woznic.ki EM, Suzuki T, Trimarchi S, Evangelista A, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol. 2015;66:350–8.CrossRefPubMed
31.
Angouras D, Sokolis DP, Dosios T, Kostomitsopoulos N, Boudoulas H, Skalkeas G, et al. Effect of impaired vasa vasorum flow on the structure and mechanics of the thoracic aorta: implications for the pathogenesis of aortic dissection. Eur J Cardiothorac Surg. 2000;17:468–73.CrossRefPubMed
32.
33.
Sampol G, Romero O, Salas A, Tovar JL, Lloberes P, Sagales T, et al. Obstructive sleep apnea and thoracic aorta dissection. Am J Respir Crit Care Med. 2003;168:1528–31.CrossRefPubMed
34.
Yanagi H, Imoto K, Suzuki SI, Uchida K, Masuda M, Miyashita A. Acute aortic dissection associated with sleep apnea syndrome. Ann Thorac Cardiovasc Surg. 2013;19:456–60.CrossRefPubMed
35.
Teng HI, Huang CC, Chiang CH, Huang PH, Chung CM, Lin SJ, et al. Sleep apnea and risk of aortic dissection: a nonrandomized, pair-matched cohort study. J Chin Med Assoc. 2016;79:422–7.CrossRefPubMed
36.
Tamori Y, Akutsu K, Kasai S, Sakamoto S, Okajima T, Yoshimuta T, et al. Coexistent true aortic aneurysm as a cause of acute aortic dissection. Circ J. 2009;73:822–5.CrossRefPubMed
37.
Miller DV, Isotalo PA, Weyand CM, Edwards WD, Aubry MC, Tazelaar HD. Surgical pathology of noninfectious ascending aortitis: a study of 45 cases with emphasis on an isolated variant. Am J Surg Pathol. 2006;30:1150–8.CrossRefPubMed
38.
Nasiell J, Lindqvist PG. Aortic dissection in pregnancy: the incidence of a life-threatening disease. Eur J Obstet Gynecol Reprod Biol. 2010;149:120–1.CrossRefPubMed
39.
Oskoui R, Lindsay J Jr. Aortic dissection in women < 40 years of age and the unimportance of pregnancy. Am J Cardiol. 1994;73:821–3.CrossRefPubMed
40.
Reilly JM, Savage EB, Brophy CM, Tilson MD. Hydrocortisone rapidly induces aortic rupture in a genetically susceptible mouse. Arch Surg. 1990;125:707–9.CrossRefPubMed
41.
42.
Creager MA, Jones DW, Easton JD, Halperin JL, Hirsch AT, Matsumoto AH, et al. American Heart Association. Atherosclerotic Vascular Disease Conference. Writing Group V: Medical decision making and therapy. Circulation. 2004;109:2634–42.CrossRefPubMed
43.
Heistad DD, Marcus ML, Law EG, Armstrong ML, Ehrhardt JC, Abboud FM. Regulation of blood flow to the aortic media in dogs. J Clin Investig. 1978;62:133–40.CrossRefPubMed
44.
Osada H, Kyogoku M, Ishidou M, Morishima M, Nakajima H. Aortic dissection in the outer third of the media: what is the role of the vasa vasorum in the triggering process? Eur J Cardiothorac Surg. 2013;43:e82-8.CrossRefPubMed
45.
Beller CJ, Labrosse MR, Thubrikar MJ, Robicsek F. Role of aortic root motion in the pathogenesis of aortic dissection. Circulation. 2004;109:763–9.CrossRefPubMed
46.
Beller CJ, Labrosse MR, Thubrikar MJ, Robicsek F. Finite element modeling of the thoracic aorta: including aortic root motion to evaluate the risk of aortic dissection. J Med Eng Technol. 2008;32:167–70.CrossRefPubMed
47.
Mitsui H, Uchida H, Teramoto S. Correlation between the layer of an intimal tear and the progression of aortic dissection. Acta Med Okayama. 1994;48:93–9.PubMed
48.
49.
Harris KM, Braverman AC, Eagle KA, Woznicki EM, Pyeritz RE, Myrmel T, et al. Acute aortic intramural hematoma: an analysis from the international registry of acute aortic dissection. Circulation. 2012;126(11 Suppl 1):91–6.CrossRef
Metadata
Title
Etiology of aortic dissection
Author
Koichi Akutsu
Publication date
01-03-2019
Publisher
Springer Singapore
Published in
General Thoracic and Cardiovascular Surgery / Issue 3/2019
Print ISSN: 1863-6705
Electronic ISSN: 1863-6713
DOI
https://doi.org/10.1007/s11748-019-01066-x

Other articles of this Issue 3/2019

General Thoracic and Cardiovascular Surgery 3/2019 Go to the issue

How to Do It

Three-step method for transesophageal echocardiography-guided implantation of the frozen elephant trunk: how to prevent spinal cord injury

Case Report

Pulmonary capillary hemangiomatosis diagnosed by pathology of explanted lungs: a unique etiology serves as a key of clinical diagnosis

Case Report

Successful surgical treatment with tracheal resection for a symptomatic vascular ring in an adult

Case Report

Transcatheter aortic valve implantation: a safe and efficient procedure to treat an aortic valve stenosis before lung cancer resection

Case Report

Arterial inflow line equipped with a side arm for circulatory support and catheter insertion during transcatheter aortic valve implantation for limited vascular access

Original Article

Updated meta-analysis of survival after extrapleural pneumonectomy versus pleurectomy/decortication in mesothelioma