Aortic dissections and aneurysms: Pathology review

Ronda is a 55 year old with a history of hypertension, diabetes and coronary artery disease who came to the emergency department with a 1 hour history of sudden chest pain that’s described as “something’s tearing inside my chest!” She says this pain is different from the occasional chest pain she gets when she exercises. She was given nitroglycerin in the ER but the pain did not improve. Her blood pressure is 175/95 in the right arm, but 130/80 in the left arm. An ECG shows left axis deviation, but no ST segment changes. Her troponin levels are normal. This is what her chest x-ray looked like. After seeing this x-ray, a CT of the chest was performed, and this is what it looked like.

Okay, so the aorta is subject to a lot of stress, so a lot can go wrong. First let’s look at aortic aneurysms which is an outpouching that occurs due to weakening of the aortic wall. A true aneurysm involves all three vessel layers; the tunica intima, media and adventitia. A dissection occurs when there is a tear in the tunica intima, allowing blood to literally “dissect” into the vessel wall. This may create the appearance of an aneurysm, but because it doesn’t involve all three layers, it’s a false, or pseudoaneurysm.

Now, that we got the basic terminology down, let’s take a closer look at aortic aneurysms. These usually occur in the abdominal aorta, but can also occur in the thoracic aorta. The most high yield and most important risk factor for abdominal aortic aneurysms is atherosclerosis. In atherosclerosis, chronic inflammation results in the release of enzymes called matrix metalloproteinases, or MMPs, which degrade the extracellular matrix in the tunica media, weakening the aortic wall.

Abdominal aortic aneurysms, or AAAs, are most common below the origin of the renal arteries, which corresponds to the L2 vertebral level. This is because below this level, the abdominal aorta lacks “vasa vasorum”, which sounds like a graduation title, but are in fact small blood vessels in the adventitial layer that provide nutrients to the aorta itself. Therefore, the absence of vasa vasorum in this part of the aorta makes the tunica media particularly susceptible to ischemia. That’s because in atherosclerosis, thickening of the intima makes it harder for oxygen to diffuse to the tunica media. Other important risk factors include age greater than 65, male sex, smoking, and family history of abdominal aortic aneurysm.