Patients with aortic aneurysms are usually asymptomatic. In fact, thoracic aortic aneurysms (TAAs), which account for 10% of all dissections, are discovered incidentally on imaging studies such as chest x rays. Abdominal aortic aneurysms (AAAs) are identified incidentally as well or diagnosed during the physical exam as reflected by a pulsatile abdominal mass.

While a wide range of patients will exhibit hypertension, symptoms may not present until an aneurysm enlarges. When rupture or dissection is impending, the clinical picture is characterized as sudden onset of tearing chest or back pain in many individuals, while others may experience only mild pain. In fact, 10% of patients will be asymptomatic, such as those with Marfan syndrome [10]. These patients may be diagnosed late since the nonspecific features can be clouded by other differentials. The location of the pain can reflect the dissection site. A clinical picture resembling that of myocardial infarction (MI) suggests that the dissection is in the anterior arch or aortic root, which results in diminished blood perfusion to the coronary arteries. Additionally, jaw or neck pain is indicative of dissection in the aortic arch.

Extracardiac manifestations such as neurologic deficits are the initial signs in about 20% of patients. For example, syncope is observed in almost 5% of cases.  Also, cardiovascular symptoms such as orthopnea and dyspnea reflect the development of congestive heart failure (CHF) secondary to aortic regurgitation. Moreover, respiratory signs such as dyspnea and hemoptysis occur if the anatomical airway is obstructed.

Physical exam

Physical exam findings may  include blood pressure asymmetry between the upper extremities, in which a difference of more than 20mm Hg may be demonstrated. Account must be taken that this may be seen in individuals without aortic dissection as well. Severe aortic regurgitation can produce wide pulse pressure and diastolic murmur. The aortic regurgitation causes CHF which results in basilar crackles or increased jugular venous pressure [11]. Other clinical signs include asymmetrical pulses and bruit in the carotid, brachial, and femoral ateries. A life threatening sign, hypotension, is indicative of heavy volume loss, cardiac tamponade, or increased vagal tone. Likewise, a hemothorax can occur in cases with bleeding into the pleura space. 

• Severe Pain

  Typical symptoms include severe pain prior to or during a complete rupture of the blood vessel. If a leak or a rupture occurs, large volumes of blood can be lost over a short period of time and the condition may be fatal. [netdoctor.co.uk]

  […] radiates to back AND Pulse deficit or difference in upper extremity Blood Pressure >20 mmHg AND Mediastinal Widening or aortic knob widening on Chest XRay Timing Sudden onset: 85% Severity Severe pain: 90% Characteristics Pain: 95% Type A: 94% Type B [fpnotebook.com]

  Sudden, severe pain associated with a thoracic aneurysm may be a sign of a life-threatening medical emergency. [urmc.rochester.edu]

• Congestive Heart Failure

  heart failure Pericardial rub 0 5 10 15 20 25 30 35 40 45 50 Sensitivity (%) Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE PROGNOSI Acute Type A dissection is a surgical disease  Previous natural history studios show 80-90% one  Senza [skuola.net]

  Also, cardiovascular symptoms such as orthopnea and dyspnea reflect the development of congestive heart failure (CHF) secondary to aortic regurgitation. [symptoma.com]

  The high risk heart patient can be optimized before surgery with adequate preoperative medical intervention, during surgery with advanced surgery techniques and can then recover postoperatively with expert management of congestive heart failure and low [heartsurgeryinfo.com]

• Fever

  A patient with a dissecting aneurysm of the ascending aorta had fever of unknown origin. [ncbi.nlm.nih.gov]

  Intraoperative and postoperative period was uneventful except for fever. On the 8 th postoperative day, there was complete stitch removal. The patient was followed up 15 days later and was found to be normal. Figure 1: Axial contrast CT. [sjmms.net]

  For example, in the case of an aneurysm caused by vasculitis, or blood vessel inflammation, a person may experience fever, malaise, or weight loss. [medicalnewstoday.com]

  Discussion Non-specific symptoms of inflammatory disease such as fever, night sweats, malaise and weight loss are common early in disease and often precede more specific features [ 2 ]. Arthralgia and myalgia are common. [casesjournal.biomedcentral.com]

• Pallor

  Her gait was normal; pallor was present; clubbing, icterus and cyanosis were absent. Oral hygiene was well-maintained. Neck glands were not palpable, and jugular venous pressure was normal. [sjmms.net]

  Dissection is the tearing of the inner layer of a vessel that allows blood to leak between the inner and outer layers, possibly causing severe back or chest pain, pallor, pulselessness, paresthesiae, and paralysis. [fortherecordmag.com]

  Symptoms are caused by a decrease of blood flowing to the rest of the body, and can include: Anxiety and a feeling of doom Fainting or dizziness Heavy sweating (clammy skin) Nausea and vomiting Pale skin ( pallor ) Rapid, weak pulse Shortness of breath [nlm.nih.gov]

• Orthopnea

  […] flowing to the rest of the body, and can include: Anxiety and a feeling of doom Fainting or dizziness Heavy sweating (clammy skin) Nausea and vomiting Pale skin ( pallor ) Rapid, weak pulse Shortness of breath and trouble breathing when lying flat ( orthopnea [nlm.nih.gov]

  Also, cardiovascular symptoms such as orthopnea and dyspnea reflect the development of congestive heart failure (CHF) secondary to aortic regurgitation. [symptoma.com]

• Painful Cough

  Possible symptoms may include: Pain in the jaw, neck, and upper back Chest or back pain Coughing, hoarseness or difficulty breathing If the aneurysm leads to dissection, there will probably be a severe tearing pain in the chest or back, stroke, cold or [cedars-sinai.edu]

  While only half of those with thoracic aortic aneurysms complain of symptoms, possible warning signs include: Pain in the jaw, neck, and upper back Chest or back pain Coughing, hoarseness, or difficulty breathing [my.clevelandclinic.org]

• Abdominal Pain

  Dissecting aneurysms generally cause radiating back pain, chest pain, or symptoms caused by aortic insufficiency. Presentation solely with abdominal pain is rare. [ncbi.nlm.nih.gov]

  Severe backache, leg pain or a feeling of coldness in the leg (due to an embolus from a clot formed in an abdominal aneurysm), or severe abdominal pain (due to the rupture of an abdominal aneurysm) may indicate a saccular or fusiform aneurysm in the abdominal [healthcommunities.com]

  98% Sharp pain: 64% Tearing/ripping: 50% Type A: 49% Type B: 52% Distribution: Typically involves both above and below the diaphragm Anterior Chest Pain : 61% Type A: 71% Type B: 44% Back pain: 53% Type A: 46% Type B: 64% Abdominal Pain : 35% Type A [fpnotebook.com]

  (Image: JFalcetti/iStock/Getty Images) An iliac aneurysm may cause symptoms such as lower abdominal pain, according to the University of Chicago. You may also feel pain in the lower back or in the groin. This pain may be felt as dull and throbbing. [livestrong.com]

• Severe Abdominal Pain

  Severe backache, leg pain or a feeling of coldness in the leg (due to an embolus from a clot formed in an abdominal aneurysm), or severe abdominal pain (due to the rupture of an abdominal aneurysm) may indicate a saccular or fusiform aneurysm in the abdominal [healthcommunities.com]

• Chest Pain

  Acute dissecting thoracic aortic aneurysm is a rare cause of chest pain in young adults. Patients require prompt surgical treatment to reduce the high risk of early mortality. [ncbi.nlm.nih.gov]

  Chest Pain Accreditation On June 16, 2005, Good Samaritan was given official Chest Pain Center designation by the Society of Chest Pain Centers and recognized for offering state-of-the-art heart care to its patients. [chihealthgoodsamaritan.org]

• Hypertension

  A dissecting aortic aneurysm in a 60-year-old woman resulted in renal artery insufficiency and medically uncontrollable hypertension. [ncbi.nlm.nih.gov]

  This can be severe in patients with hypertension, Marfan syndrome, and bicuspid aortic valves. [symptoma.com]

  1 male to female predominance Over the age of 40 Hemorrhage in the media (at vasa vasorum) leading to either Tear in the weakened intima which breaks into the lumen, or Hemorrhage in the wall (less common) Hemorrhage separate media from adventitia o Hypertension [learningradiology.com]

• Hypotension

  Medical therapy In all patients, intravenous antihypertensives should be initiated immediately if dissection is suspected (unless hypotension is present). [symptoma.com]

  Hypotension indicates a poor prognosis, as it may be due to cardiac tamponade or myocardial infarction. An aortic diastolic murmur occurs in 50% due to aortic regurgitation. Wide pulse pressure may be absent. [patient.info]

  The classical triad of pain, hypotension and pulsatile abdominal mass due to rupture into the retroperitoneum is only seen in 25-50% of patients. [radiopaedia.org]

  […] aortic dilatation / aneurysm wall thinning ‘crack’ cocaine (abrupt catecholamine-induced hypertension) Reduced resistance aortic wall Increasing age pregnancy (debatable) EXAMINATION Features include: aortic regurgitation is common hypertension (if hypotensive [lifeinthefastlane.com]

• Vascular Disease

  The case demonstrates the unique potential of this modality in diagnosis and possible therapy in vascular diseases. [ncbi.nlm.nih.gov]

  Learn more » Vascular Surgery Offering comprehensive care of vascular disease through preventive services, diagnostic expertise, minimally invasive therapies and traditional surgical techniques. [cts.usc.edu]

  EN: The John Ritter Research Program in Aortic and Vascular Disease The JRRP (The John Ritter Research Program) is led by Dr.Dianna M. Milewicz, M.D., Ph.D., a recognized leader in aortic disease research and the President George H.W. [aortadissektion.com]

  One should be particularly alert to the possibility of an aneurysm in persons with a history of cardiovascular disease, hypertension, or peripheral vascular disease. [medical-dictionary.thefreedictionary.com]

  Over time, excess plaque causes the aorta to stiffen and weaken.Your risk for atherosclerosis increases if you: Are a smoker Have high blood pressure Have high cholesterol Are overweight Have a family history of cardiovascular or peripheral vascular disease [my.clevelandclinic.org]

• Chest Pain Radiating to the Back

  CASE REPORT A 55-year-old female patient was transferred from another hospital because of chest pain radiating to her back and thrombocytopenia. [kjim.org]

  His wife took him to a general practitioner in Beverly Hills, Calif., where he complained of swelling and excruciating chest pain that radiated to his back. The pain shooting to his back should have been the first warning sign. [blog.chron.com]

  Case Presentation A 48 year old Irish Caucasian female presented to our Emergency department with a history of central chest pain radiating to her back in an interscapular region. [casesjournal.biomedcentral.com]

• Back Pain

  Dissecting aneurysms generally cause radiating back pain, chest pain, or symptoms caused by aortic insufficiency. Presentation solely with abdominal pain is rare. [ncbi.nlm.nih.gov]

  When rupture or dissection is impending, the clinical picture is characterized as sudden onset of tearing chest or back pain in many individuals, while others may experience only mild pain. [symptoma.com]

  This 65 y/o male presented with chest and upper back pain. A portable chest x-ray and selected early and late phase images from a gadolinium enhanced MR angiogram shown above demonstrate findings of a Type B dissecting thoracic aortic aneurysm. [home.earthlink.net]

  Symptoms of a thoracic aneurysm may include: Pain in the jaw, neck, or upper back Pain in the chest or back Wheezing, coughing, or shortness of breath as a result of pressure on the trachea (windpipe) Hoarseness as a result of pressure on the vocal cords [urmc.rochester.edu]

• Upper Back Pain

  This 65 y/o male presented with chest and upper back pain. A portable chest x-ray and selected early and late phase images from a gadolinium enhanced MR angiogram shown above demonstrate findings of a Type B dissecting thoracic aortic aneurysm. [home.earthlink.net]

  Symptoms of a thoracic aneurysm may include: Pain in the jaw, neck, or upper back Pain in the chest or back Wheezing, coughing, or shortness of breath as a result of pressure on the trachea (windpipe) Hoarseness as a result of pressure on the vocal cords [urmc.rochester.edu]

  […] of aortic dissection usually appear suddenly and may include: Severed, sudden, constant chest pain and/or upper back pain, sometimes described as “ripping” or “tearing” Pain that feels like it is moving from one place to another Unusually pale skin Faint [marfan.org]

  He had severe chest and upper back pain. The EKG and first set of enzymes were normal. The ER physician thought it was gas. Dad was active. He rode his bike 5 miles a day and mowed his yard (a quarter-acre) every five to seven days. A. [articles.chicagotribune.com]

• Stroke

  Stroke 1999;30:477–478. Gerber O, Heyer EJ, Vieux U: Painless dissections of the aorta presenting as acute neurologic syndromes. Stroke 1986;17:644–647. [karger.com]

  In the present study, 4 patients (4.7%) required reexploration for bleeding and 1 patient (1.2%) had a stroke, but none suffered paraplegia. The hospital mortality rate was 1.2% (1 patient), resulting from retrograde type A dissection. [ncbi.nlm.nih.gov]

  This most often results in stroke, heart attack, or death. If a patient has a known enlargement of the ascending aorta, the risk of dissection increases dramatically with size. [uwhealth.org]

  […] symptoms include: Sudden severe chest or upper back pain, often described as a tearing or ripping sensation, that spreads to the neck or down the back Sudden severe stomach pain Loss of consciousness Shortness of breath Symptoms similar to those of a stroke [mayoclinic.org]

• Dizziness

  You might vomit, become sweaty, or feel dizzy. [webmd.com]

  Some people with an AAA have: a pulsing sensation in the tummy (like a heartbeat) tummy pain that doesn't go away lower back pain that doesn't go away If an AAA bursts, it can cause: sudden, severe pain in the tummy or lower back dizziness sweaty, pale [nhs.uk]

  Other signs and symptoms include: breathlessness fainting sweating weakness or paralysis on one side of the body trouble speaking a weaker pulse in one arm than in the other dizziness or confusion Although the exact cause of aortic dissections is unknown [healthline.com]

• Confusion

  […] ok, i'm still confused. [allnurses.com]

  The pain of aortic dissection can be confused with that of heart attack, but can sometimes be distinguished because of its sudden onset, potentially normal electrocardiogram, and abnormal findings on chest X-ray. [medicinenet.com]

  Other signs and symptoms include: breathlessness fainting sweating weakness or paralysis on one side of the body trouble speaking a weaker pulse in one arm than in the other dizziness or confusion Although the exact cause of aortic dissections is unknown [healthline.com]

All patients with chest pain or any clinical picture indicating a cardiac etiology should be evaluated urgently and thoroughly. In addition to a history and physical exam, imaging is crucial for establishing the diagnosis. The choice of imaging depends on the patient's cardiovascular status. 

Hemodynamically stable

The initial test, a chest x ray, may reveal a widened aorta. But the CT with contrast study is commonly used as the test of choice in cases of emergency. Additionally, CT angiography reveals the anatomy of the dissection and identifies plaque development. It offers a sensitivity of 83% to 94% and a specificity of 87% to 100%. The 3D reconstruction, however, is not readily available in all hospitals [12]. Finally, magnetic resonance imaging (MRI) could be an alternative for patients with allergies to dye contrasts. This test demonstrates a sensitivity of 98% and a specificity comparable to CT. 

Hemodynamically unstable

In these individuals, an echocardiogram is a key study.

Laboratory studies

Cardiac markers and biomedical profiles are obtained. Additionally, a complete blood count is important and can show low hemoglobin and hematocrit reflecting a rupture. Leukocytosis can also be revealed, indicating stress. Other findings such as increased blood urea nitrogen and creatinine suggest blood loss or dehydration secondary to conditions such as prerenal azotemia. With regards to coagulation studies, assessment of fibrin degradation products and fibrinogen may point to the diagnosis. Furthermore, another assay tests for smooth muscle myosin heavy-chain, which is typically elevated in the first 24 hours of DAA. 

Other

To differentiate between aortic dissection and MI, the classic electrocardiographic (ECG) findings are not usually found in the former.

• Left Pleural Effusion

  Left pleural effusion (signs of dissecting ruptire) 0 10 20 30 40 50 60 70 80 Sensitivity (%) left pleural effusion mediastinum widening Cattedra di Cardiochirurgia UNIVERSITA’ DEGLI STUDI DI FIRENZE Diagnostica per Immagini (2) CT scan 1. [skuola.net]

  […] paraspinal stripe § Displacement of intimal calcifications § Apical pleural cap § Left pleural effusion § Displacement of endotracheal tube or nasogastric tube o MRI § Intimal flap § Slow flow or clot in false lumen o CT § Intimal flap § Displacement [learningradiology.com]

  Chest radiography showed only an enlargement of the mediastinum and a small, left pleural effusion. [anesthesiology.pubs.asahq.org]

• Electrical Alternans

  alternans (tamponade) Laboratory leukocytosis Cr elevation with renal artery involvement tropnonin elevated if dissection causes myocardial ischaemia D-dimer – if negative dissection is very unlikely, but not sufficient to rule out Cross-match Various [lifeinthefastlane.com]

Medical and surgical treatment options are available. The decision making incolves careful consideration of the patient’s age, comorbidities, the type of dissection, and overall clinical picture.

Medical therapy

In all patients, intravenous antihypertensives should be initiated immediately if dissection is suspected (unless hypotension is present). The goals are to decrease the strength of cardiac contractions and systemic arterial pressure while still maintaining organ perfusion.

Surgical therapy

Surgical interventions aim to reduce complications, prevent rupture and fatality. The procedures include suturing of the layers of the aortic wall. Additionally, a graft is used to replace damaged tissue and reinforce the aorta. The DeBakey classification of aortic dissection guides the treatment strategy. Also, the following signs indicate emergency surgery: dissection, evidence of increased hematoma, impending rupture, hemorrhage into the lung cavity, and persistent pain not responding to treatment. The surgical technique for TAAA repair depends on the type. In Crawford type I TAAAs a Dacron graft is used to replace the aorta from left subclavian artery to visceral organ and renal arteries. In Crawford type II TAAAs the aorta is replaced from left subclavian artery to the aortic bifurcation with a Dacron graft. Finally, Crawford type III or IV TAAAs are repaired with a partial bypass of the left atrium to the femoral artery or renal bypass.

Post-treatment management

Patients will undergo close surveillance. Additionally, they will receive antihypertensive drug therapy and lipid lowering drugs if indicated.

DAA is associated with a high mortality rate, in which a majority of patients die before the arrival at the hospital. Furthermore, mortality in the hospital setting is almost 30%. In fact, those who undergo surgical intervention have a 30% fatality rate while this figure is doubled in individuals treated medically. Of important note, elderly patients and those with coexisting diseases are poor surgical candidates and hence require medical management. Furthermore, almost 60% of treated patients who survive the first 2 weeks will survive 5 weeks and 40% remain alive to the 10 years point.

Historical perepsepctive 

In studies conducted decades ago, a majority of patients with acute dissection died within 3 months [6]. In those that survived, most did not live beyond 5 years due to rupture [6] [7]. However, surgincal intervention has improved survivability [8] [9].

There are risk factors that are heavily associated with DAA. These conditions may be congenital or acquired. Additionally, whether in isolation or conjunction with other factors, they contribute to the development of aortic dissection. 

Congenital causes

The list of congenital disorders associated with aortopathy includes Marfan syndrome, Ehlers Danlos syndrome and other connective tissue disorders such as Turner syndrome, familial aortic dissections, Adult polycystic kidney disease, Osteogenesis imperfecta, coarctation of the aorta, aortic valve anomalies, and metabolic disorders.

Acquired causes

Hypertension, a significant predisposing condition [2], has been demonstrated in 70% of patients with aortic dissection. Furthermore, elevated blood pressure may help  propagate the dissection. Further acquired causes include syphilitic aortitis, blunt chest trauma or injury, and cocaine use.

The incidence of this disease varies according to the risk factors exhibited in different populations [1] [3]. Hence, the annual incidence lies between 5 to 30 individuals per million.

With regards to race, aortic dissection is more frequently observed in black people than in white. Additionally, it is less common in Asians. As for gender, there is a stronger male preference as it is 2 to 3 times more prevalent in males. Finally, the age demographics for this disease reveal that almost 75% of patients with aortic dissection fall in the range of 40 to 70 years of age, especially in the 50 to 65 years group.

The pathogenesis of aortic dissection is characterized by the influence of elevated pulsatile pressure and shear stress on the walls of the aorta. Hence, the large blood vessel becomes vulnerable to damage. In fact, this marked increase in wall tension accounts for the aortic rupture in situations of mechanical trauma or aneurysmal dilatation [4]. This observation is supported by the Laplace law, which explains that an increase in the luminal radius causes greater stress on the wall.

Most cases of thoracic aneurysms are secondary to changes in elastin and collagen in arteriosclerotic disease. These degenerative conditions occur with increased age. Additionally, prior dissections can form pathologic changes making the aorta susceptible to future aneurysms. The aging aorta can develop cystic medial necrosis, which is the breakdown of collagen, elastin and smooth muscle leading to the fragility of the aortic wall. This can be severe in patients with hypertension, Marfan syndrome, and bicuspid aortic valves.

Aortic dissection typically arises from a rupture in the intimal layer of the aortic wall [5] which can lead to the propagation of the dissection into the medial layer. In fact, an intimal flap is characteristically found in aortic dissection. Additionally, hemorrhage or a hematoma in the media can cause intimal perforation [5]. 

In summary, degenerative diseases lead to a weakened aortic wall and aneurysmal dilation especially in patients with hypertension. 

While there are no preventative measures for AD, there are modifiable risk factors. For example, blood pressure maintenance, smoking cessation, and weight control are all very important strategies. Additionally, patients with an aortic aneurysm can undergo surgical repair of the defect. 

Dissecting aortic aneurysm (DAA) is a life-threatening condition, in which a tear in the intimal layer causes blood to enter the intima-media space resulting in the propagation of the dissection. There are numerous predisposing conditions associated with DAA. For example, hypertension, congenital aortic stenosis, bicuspid aortic valve, and connective tissue diseases are all frequently observed in patients with dissection [1]. 

Aortic aneurysms manifest mostly in the abdominal aorta but also occur in the thoracic aorta. Additionally, aneurysms can coexist in both segments, which is referred to as thoracoabdominal aneurysms (TAAA). 

The clinical picture of an aortic aneurysm is variable as many cases are asymptomatic and incidentally discovered through a routine exam or imaging. When an aneurysm expands, patients may experience severe chest or back pain with possible cardiovascular, neurologic, and respiratory signs. Moreover, a potentially fatal complication of an aortic aneurysm is a rupture with hemorrhage. 

Diagnosis is established by history, physical exam, imaging and laboratory tests. In the emergency setting a computed tomography (CT) with contrast is the test of choice. In addition, there are other imaging techniques that can be used depending on the patient's cardiovascular status. 

Therapy includes medical and surgical options. Factors such as patient's age, coexisting morbidities, and stability play a role in the medical management. Prompt diagnosis and treatment are paramount for these patients as these cases are potentially fatal. 

An aortic dissection is a potentially fatal condition in which the walls of the aorta exhibit a tear. The aorta is the large blood vessel carrying blood from the heart to the rest of the body. The tear can cause blood to spill between the layers of the aorta thereby separating the layers.

This disorder is much more common in men than women. It affects people aged between 40 to 70 years old. Also, it is more common in black people than in white. 

In many cases, the wall of the artery becomes weakened because of long-term high blood pressure. Patients with arteriosclerosis are also at risk for developing dissection. In other cases, there are risks such as hereditary diseases in the connective tissue or birth defects such as coarctation of the aorta or abnormalities of the aortic valve.

Patients may either show no symptoms or have severe chest or back pain described as tearing. Exam findings such as diminished or absent pulses can be seen.

Certain tests such as chest x rays and CT scans are helpful to diagnose the disorder. Also, laboratory exams are important to provide the full extent. 

Treatment is usually drug therapy and/or surgical intervention. The doctors will evaluate the patient's age, medical history, stability and other factors to determine the best course of therapy.

All patients will take blood pressure medications and cholesterol-lowering drugs for life. Additionally, they will be closely monitored. 

1. Friedman WF, Silverman N. Congenital Heart Disease in Infancy and Childhood. Braunwald E, Zipes DP, Libby P, eds. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, Pa: WB Saunders; 2001. 1546.
2. Patel PD, Arora RR. Pathophysiology, diagnosis, and management of aortic dissection. Therapeutic Advances in Cardiovascular Disease. 2008; 2(6):439-68.
3. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. Journal of American Medical Association. 2000;283(7):897–903.
4. Eisenberg MJ, Rice SA, Paraschos A, et al. The clinical spectrum of patients with aneurysms of the ascending aorta. America Heart Journal. 1993; 125(5 Pt 1):1380–1385.
5. Wilson SK, Hutchins GM. Aortic dissecting aneurysms: causative factors in 204 subjects. Archives of Pathology and Laboratory Medicine. 1982; 106(4):175–180.
6. Anagnostopoulos CE, Prabhakar MJS, Kittle CF. Aortic dissections and dissecting aneurysms. American Journal of Cardiology.1972; 30(3):263- 273.
7. Crawford ES, DeNatale RW. Thoracoabdominal aortic aneurysm: Observations regarding the natural course of the disease. Journal of Vascular Surgery.1986; 3(4):578-582.
8. DeBakey ME, Cooley DA, Creech 0, Jr. Surgical considerations of dissecting aneurysm of the aorta. Annals of Surgery. 1955;142(4):586-612.
9. Crawford ES, Walker HSJ III, Saleh SA, Normann NA. Graft replacement aneurysm descending thoracic aorta: results without bypass or shunting. Surgery.1981; 89(1):73-85.
10. Spittell PC, Spittell JA Jr, Joyce JW, et al. Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990). Mayo Clinic Proceedings. 1993;  68(7):642-51.
11. Hagiwara A, Shimbo T, Kimira A, Sasaki R, Kobayashi K, Sato T. Using fibrin degradation products level to facilitate diagnostic evaluation of potential acute aortic dissection. Journal of Thrombosis and Thrombolysis.  2013; 35(1):15-22.
12. Niino T, Hata M, Sezai A, et al. Optimal clinical pathway for the patient with type B acute aortic dissection. Circulation Journal. 2009; 73(2):264-8.