Aortic dissection pathophysiology
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Aortic dissection Microchapters |
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Diagnosis |
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Treatment |
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Special Scenarios |
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Case Studies |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Pathophysiology
As with all other arteries, the aorta is made up of three layers. The layer that is in direct contact with the flow of blood is the tunica intima, commonly called the intima. This layer is made up of mainly endothelial cells. Just deep to this layer is the tunica media, known as the media. This "middle layer" is made up of smooth muscle cells and elastic tissue. The outermost layer (furthest from the flow of blood) is known as the tunica adventitia or the adventitia. This layer is composed of connective tissue.
In an aortic dissection, blood penetrates the intima and enters the media layer. The high pressure rips the tissue of the media apart, allowing more blood to enter. This can propagate along the length of the aorta for a variable distance, dissecting either towards or away from the heart or both. The initial tear is usually within 100 mm of the aortic valve.
The risk in aortic dissection is that the aorta may rupture, leading to massive blood loss resulting in death.
The initiating event in an aortic dissection is a tear in the intimal lining of the aorta. Due to the high pressures in the aorta, blood enters the media at the point of the tear. The force of the blood entering the media causes the tear to extend. It may extend proximally (closer to the heart) or distally (away from the heart) or both. The blood will travel through the media, creating a false lumen (the true lumen is the normal conduit of blood in the aorta). Separating the false lumen from the true lumen is a layer of intimal tissue. This tissue is known as the intimal flap.
The vast majority of aortic dissections originate with an intimal tear in either the ascending aorta (65%), the aortic arch (10%), or just distal to the ligamentum arteriosum in the descending thoracic aorta (20%).
As blood flows down the false lumen, it may cause secondary tears in the intima. Through these secondary tears, the blood can re-enter the true lumen.
While it is not always clear why an intimal tear may occur, quite often it involves degeneration of the collagen and elastin that make up the media. This is known as cystic medial necrosis and is most commonly associated with Marfan syndrome and is also associated with Ehlers-Danlos syndrome.
In about 13% of aortic dissections, there is no evidence of an intimal tear. It is believed that in these cases the inciting event is an intramural hematoma (caused by hemorrhage within the media). Since there is no direct connection between the true lumen and the false lumen in these cases, it is difficult to diagnose an aortic dissection by aortography if the etiology is an intramural hematoma. An aortic dissection secondary to an intramural hematoma should be treated the same as one caused by an intimal tear.
- Aortic dissection begins as a tear in the aortic wall in > 95% of patients. It is usually transverse, extends through the intima and halfway through the media and involves ~50% of the aortic circumference.
- Location of dissections:
- 65% of dissections originate in the ascending aorta, distal to the aortic valve and coronary ostia.
- 10% arise in the transverse aortic arch
- 20% in the proximal descending aorta
- 5% in the more distal descending aorta.
Once a tear develops, blood then passes into the media, and a false leumen is dissected distally in the outer layer of aortic media involving ~50% of the aortic circumference. This false leumen can enlarge, and compress the true leumen, as well as extend proximally or distally and occlude aortic branches. For some unknown reason, the right lateral wall of the ascending aorta is the most common site for dissection.
- An aortic intramural hematoma can form when the vaso vasorum ruptures into the aortic wall. This is distinguished from dissection by the lack of an intimal tear. This disorder parallels aortic dissection in terms of prognosis when the ascending aorta or aortic arch is involved, and rapid surgical intervention is indicated. Involvement of the descending aorta, however, carries a better prognosis than dissection, and outcome tends to be similar with medical or surgical therapy.
References
Acknowledgements
The content on this page was first contributed by: David Feller-Kopman, MD and C. Michael Gibson M.S., M.D.