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Etiology of aortic dissection

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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.

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References

  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.

    Article  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  5. Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med. 1982;106:175–80.

    CAS  PubMed  Google Scholar 

  6. Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol. 1984;53:849–55.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  11. Nakashima Y, Shiokawa Y, Sueishi K. Alterations of elastic architecture in human aortic dissecting aneurysm. Lab Investig. 1990;62:751–60.

    CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  22. Cripe L, Andelfinger G, Martin LJ, Shooner K, Benson DW. Bicuspid aortic valve is heritable. J Am Coll Cardiol. 2004;44:138–43.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  32. Gao F, Guo Z, Sakamoto M, Matsuzawa T. Fluid-structure interaction within a layered aortic arch model. J Biol Phys. 2006;32:435–54.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  41. Roberts WC. Aortic dissection: anatomy, consequences, and causes. Am Heart J. 1981;101:195–214.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  48. Guidelines for Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. (JCS 2011)—Digest Version—JCS Joint Working Group. https://www.jstage.jst.go.jp/article/circj/77/3/77_CJ-66-0057/_pdf.

  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.

    Article  Google Scholar 

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  1. Division of Vascular Medicine, Department of Cardiovascular Surgery, Kawasaki Aortic Center, Kawasaki Saiwai Hospital, 31-21, Ohmiya-cho, Saiwaiku, Kawasaki, Kanagawa, 212-0014, Japan

    Koichi Akutsu

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Akutsu, K. Etiology of aortic dissection. Gen Thorac Cardiovasc Surg 67, 271–276 (2019). https://doi.org/10.1007/s11748-019-01066-x

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