OT: Aortic dissection

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https://www.nytimes.com/2026/07/12/science/lindsey-graham-aortic-dissection.html

What Is an Aortic Dissection?

The condition that killed Senator Lindsey Graham is deadly, sudden and difficult to treat — “like a knife to the back,” one expert said.

By Gina Kolata, The New York Times, July 12, 2026, 7:35 p.m. ET

On Saturday night, Senator Lindsey Graham, Republican of South Carolina, died of an aortic dissection — a rip in the aorta, the main artery carrying blood from the heart to the rest of the body.

Such a tear is a medical emergency. Fifty percent of patients make it to the hospital, and about half survive…

The wall of the aorta has three layers, said Dr. Kendra J. Grubb, a heart surgeon formerly at Emory University and now at Medtronic, the medical device company. A dissection occurs in the inner layer, allowing blood to pour in between the layers of the tubelike vessel.

It’s most likely caused by an underlying aortic aneurysm — a bubble in the vessel, similar to what can occur in old bicycle tubes. Aortic aneurysms can be caused by high blood pressure, atherosclerosis or some rare underlying genetic conditions, like bicuspid aortic valves… [end quote]

In 2024, a nurse practitioner found a heart murmur when I visited the clinic for an unrelated issue.

Testing found a bicuspid aortic valve (a birth defect) that was extremely calcified to the point that the open area was only 1 square centimeter to provide all the blood to my body. Due to my decades of aerobic workouts, this small aperture had squirted a garden hose-like stream of blood against my ascending aorta, causing an aneurysm. Fortunately, my blood pressure is generally under 120/75.

My aortic valve and the aortic aneurysm were cut out and replaced in open heart surgery, November 2024. (Age 71, the same as Senator Graham.)

Subsequent ultrasounds found that things are now A-OK. My resting pulse is 65 and I’m doing Zumba again.

After I read the news about Senator Graham I was glad that I had the surgery even though I was extremely weak for almost a year afterwards. My advice is : don’t have open-heart surgery unless your life depends on it. But it’s a good idea to have a PCP listen to your heart from time to time. And maybe an abdominal aortic ultrasound if you have high blood pressure.

Wendy

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This condition also caused the death of John Ritter, back in 2003. He was 54 years old.

_ Pete

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Lindsey should have gotten his free Medicare Abdominal Aortic Aneurysm screening exam.

intercst

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I had a coworker who suffered that while he was getting a heart exam. I don’t recall the details, or maybe he didn’t give me all of them, but he said it was his proximity to the hospital that saved his life. If it had happened at work, or home, he almost certainly wouldn’t have survived.

Scary thing is that those can happen to anyone at anytime. From what I understand, they are very unpredictable. You feel fine until you don’t.

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Not quite (the underlying conditions all have to be lined up)…but it sure feels like that when it does.

The timeline with dh’s was quite sudden. An insurance physical a month before showed him in rude good health. He cleaned out his own stethoscope just over a week before and listened to his own heart…perfectly normal. Annual physical (with auscultation!) …the tell tale heart sounds and “water-hammer pulse” of Aortic Incompetence as an aneurysm developed in the aorta and was expanding. Immediate referral for an cardiac work up…which, knowing what we now know should’ve been an immediate referral to the ER.

Fortunately daughter acted quickly bringing her mobile equipment round and identified the problem and captured a slew of pictures on her cell phone. She was certain she saw …but couldn’t capture an image of…the ascending aorta starting to dissect. Off to hospital (local ER initially with transfer to Univ Colorado Anschutz medical campus) and a new biovalve and ascending aorta. Pathology report on the aorta…daughter had been right, it was starting to dissect.

A rapidly emergent situation like this…which was secondary to a congenital aortopathy (unfortunately inherited by the daughter)…is one of those rare situations that would, in all probability have evaded a routine screening ultrasound of abdominal aorta/carotid artery and quite possibly even ascending aorta in the hands of a less experienced ultrasonographer taking routine shots (the cardiac unit’s ultrasound tech didn’t get images of the dissection)

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@intercst it’s not clear yet, but Lindsey Graham’s aortic aneurysm may have been in the ascending aorta which comes upward from the heart and then arches sharply downward toward the abdomen. (That was the location of mine and also of @VeeEnn’s husband.)

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That area right next to the heart isn’t imaged by the typical free AAA screening exam which is centered over the abdomen. The ascending aorta needs a separate exam that is focused on the heart region.

My aneurysm was in the ascending aorta where the force of the blood from my bicuspid aortic valve was focused. Note how the normal aortic valve has 3 leaves. Due to a mutation, mine only had 2 leaves (called “bicuspid”) so the valve couldn’t open properly and became calcified. That’s what caused the heart murmur which triggered the heart ultrasound that found the aneurysm.

But I might request a AAA screening anyway even though the probability of a problem there is low.

Wendy

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You beat me to it, Wendy. A shortcoming of “diagnostic used as screening” tests such as this…there’s the tendency to assume that the “all clear” in one is a proxy for health throughout the cardiovascular system. Such is not the case.

Additionally, a reminder for us all…the man did not die “after a brief and sudden illness”. According to preliminary reports his ruptured aortic aneurysm was secondary to ASCVD…which we all know by now is a disease process with a long period of progression before the stuff that makes a person take notice happens

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@VeeEnn

@VeeEnn here is a video of an abdominal aorta with atherosclerosis. The atherosclerosis obviously took many years to accumulate.

The video is focused on the physical structure so the lecturer didn’t mention that the healthy aorta is highly elastic and assists the heart in circulating the blood to the lower body by expanding and contracting in response to the pulse.

A highly deposited, stiffened aorta like the one in the video is unable to assist the heart by elastic rebound. Also, the surface is rough and friction inhibits blood flow. That puts even more stress on the heart.

The video mentions that pieces of the deposits can break off and flow downstream toward the legs. This can cause blockage of leg arteries.

@intercst

Having an aneurysm in one part of the body—like a peripheral artery in the leg—significantly increases the likelihood of having one elsewhere, particularly an abdominal aortic aneurysm (AAA).

Here is why these conditions are so closely linked:

The Shared Root Cause: Systemic Vessel Weakness

An aneurysm isn’t just an isolated “accident” in a single blood vessel; it is often a localized manifestation of a systemic issue. The same underlying factors that weaken the arterial wall in your leg are likely at work throughout your entire circulatory system.

  • Atherosclerosis & Wear and Tear: The breakdown of elastin and collagen (the proteins that give arteries their strength and elasticity) happens globally. If high blood pressure, smoking, or aging has degraded the vessels in the legs, the aorta—which handles much higher pressure—is often under similar or greater stress.

The “Popliteal-Aortic” Connection: This link is so well-documented that it has specific statistics tied to it. If a patient is diagnosed with a popliteal artery aneurysm (the main artery behind the knee), there is an estimated 30% to 50% chance that they also have an abdominal aortic aneurysm.

Why the Aorta is Especially Vulnerable

The aorta is the body’s primary highway for blood. It receives the absolute highest pressure directly from the heart. If a person’s genetic makeup or lifestyle has made their arterial walls prone to stretching and bulging, the abdominal aorta is usually the first and most critical place doctors look for a secondary aneurysm.

Wendy

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As others have stated, could’ve been in the ascending or arch part of the aorta. Not going to pic that up on an abdominal screening exam which is what medicare covers.

DW had an attending back in medical school that collapsed while on rounds in the hospital. Dissecting ascending aortic aneurysm on autopsy. So even if it happens right there in a teaching hospital, in an “ideal” situation (trauma room/OR, staff, etc. 24/7) chances of survival quickly approaches zero.

I had one patient that had a known abdominal aneurysm but they decided against surgery. Can’t argue, there are a ton of undesirable complications such as renal failure and paralysis. Then showed up in the ER complaining of abdominal pain. Rush to the OR. By the time prepped, draped, and incision made, aorta dissected all the way up through the arch and to the aortic valve. Next minute, dead.

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Richard Holbrooke died of this same aquired cardiovascular disease. It’s highly likely that Obama would have ended the war in Afghanistan had he survived. Holbrook’s experience in the middle east was extensive as was his ability to negotiate. His sudden death probably cost us an extra decade involved in a useless situation. He was well aware.

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So in other words, it not worth worrying about, since there’s nothing you can do.

intercst

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No. Quite the reverse. Address the issue before it becomes a catastrophic event.

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@intercst this time, pay attention because you are wrong and this could cost you your life.

It is very simple to find and fix an aneurysm before it dissects or, worse, blows out completely.

Since you had an aneurysm in your leg you have a high probability of having an aortic aneurysm, either in your abdomen or above your heart (where I had mine). It should be easy to convince your primary care doctor to order the two separate ultrasounds needed to detect them. You have a pre-existing condition that should make the approval simple.

Ultrasounds are painless and only take a few minutes.

The repairs involve surgery but the techniques and materials have been available for decades.

Take care of this. It could save your life.

Wendy

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CT with contrast (specifically CT angiography) is the gold standard for diagnosing and measuring ascending aortic aneurysms.

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In an emergency situation, survival is low. In a controlled scheduled operation, generally things turn out well but there are several severe risks involved.

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On the contrary, I had the Abdominal Aortic screening exam and everything was fine. The ultrasound tech even remarked to me, “My God, you don’t even have any calcium deposits in your abdominal aorta. That’s very unusual for someone your age.”

I do have an appointment to see a cardiologist in September, just to check on things. Nobody advised me to do that based on my history of a Popliteal Aneurysm. I asked my PCP for the referral, and we’re justifying it on my Bradycardia (slow resting heart rate) It’s usually around 50, but sometimes goes as low as 45 or so. All my doctors to date attribute the bradycardia to the fact that I get a lot of exercise, and the half dozen or so EKGs I’ve had over the years have all been normal.

The CT I had last year before the surgery did show a “mild 2 cm ectatic” in the left femoral artery (i.e., slight dilation along a 2 cm length of the artery). They’re telling me I need to have that checked once every 2 to 3 years.

There is a concern that you don’t want do get a a lot of CT scans because it’s a lot more radiation than an x-ray.

intercst

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Yep. But you get a lot more radiation with a CT scan than an x-ray, so they don’t want to do a lot of them on you.

intercst

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Don’t feel too confident. I was the same way. 8 months and 3 days after the last doctor told me how great my heart function was I had a severe heart attack. And BTW, having an extremely"in shape" heart can actually mask the symptoms of a heart attack, so you’ll ignore it till it gets really really bad. UPSIDE: The heart attack was a plaque rupture in aright side artery… BUT the 2 major ones on the left side were almost entirely blocked. I could have died suddenly or in my sleep at any moment from those. So, the heart attack actually saved my life. DOWNSIDE: The slow heart rate and low BP doctors used to love prevent them from giving me all the medication they usually give someone in my condition that takes load stress off of the heart pumping.

The good news is all my other arteries are nice and clean. Peripheral, head & neck aorta, apparently like a 20 yr old’s.

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@intercst make the decision based on risk. You are more risk-tolerant than I am but in this case the calculation is clear.

For a one-time diagnostic CT in a 68-year-old (that’s you, you kid :wink: ), this is a low-risk, well-tolerated test. It is not risk-free, but it’s the kind of risk hospitals accept routinely for far less consequential diagnostic questions.

From Claude AI:

  • If an ascending aortic aneurysm exists and stays undetected, the danger is dissection or rupture — and these are genuinely catastrophic events. Acute aortic dissection carries pre-hospital mortality of up to 40%, with perioperative mortality (for those who make it to surgery) still ranging 10% to 25%.
  • Critically, aneurysm size does not reliably predict this: up to 60% of dissections occur in aneurysms smaller than the 5.5 cm threshold that guidelines use to recommend elective surgery — meaning “watching and waiting without ever looking” isn’t a safe substitute for imaging, since you can’t manage a risk you haven’t measured.
  • Elective ascending aortic surgery, done proactively for a known, sized aneurysm, is dramatically safer than emergency repair: overall survival was 83.5% in men and 94.3% in women at 36 months, with age being the main mortality risk factor.

Put together:

There is no serious comparison here. A single cardiac/aortic CT is a minor, well-tolerated risk. An ascending aortic aneurysm that ruptures or dissects while undetected is one of the most lethal events in cardiovascular medicine — and elective, planned repair of a known aneurysm has dramatically better odds than emergency surgery after a dissection. In a patient like this one — bilateral popliteal aneurysmal disease, a demographic and disease pattern associated with aortic aneurysm elsewhere — the standard clinical reasoning strongly favors imaging over not imaging.

I’d add: this is exactly the kind of individualized weighing (his actual kidney function, prior contrast reactions, overall frailty after the amputation, etc.) that his vascular surgeon or cardiologist needs to make with his full chart in front of them — I can lay out the general risk magnitudes, but I’m not able to weigh them for his specific case the way his treating physician can. [end Claude]

My ascending aortic aneurysm wasn’t huge but it was definitely there - 4.6 cm which was a few mm larger than usual for a small woman like me. The risk of death from a rupturing aneurysm is very high. That weighed on the decision of whether to get a TAVR (sliding a new heart valve in like a stent, a one-night stay in the hospital) or SAVR (open-heart surgery which was a bear, 9 days in the hospital plus months of recovery).

I bit the bullet, got the surgery and now I’m good to go, hopefully for the next 10 years.

I didn’t take the risk. I think you should get the CT and make a decision based on the data.

Wendy

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@intercst I forgot to mention…

One of the nasty, rotten, no-good things about getting older is that parts of your body that were 100% fine a few years ago can weaken and break suddenly. This has happened to me several times with sports injuries - and I’m not a super-athlete like @VeeEnn or @JLC, just a little old lady trying to stay fit.

So collagen-based tendons, ligaments and arteries can betray us.

If your abdominal aorta scan was a few years ago you might want to have a repeat look. The years after age 60 can be a slippery slope.

By the way, apart from a 40% blocked LAD my heart is fine due to decades of aerobic exercise. Resting pulse 65, can get up to 145 with enough effort like doing step aerobics with hand weights. (Against cardiologist’s instructions.)

Wendy

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