The death of Sen. Lindsey Graham on Saturday at the age of 71 from an aortic dissection has brought attention to a life-threatening condition. Pending the final death certificate, details about his diagnosis and treatment remain unclear, but experts agree on how serious it is and how suddenly it explodes after a long prelude.
A cardiothoracic surgeon had questions about the South Carolina senator’s treatment.
“Someone of his stature and age would have definitely had very advanced medical care. At some point, he had a chest echocardiogram to check his heart, he had chest imaging, and if he hadn’t had those tests, I wonder why,” Mark Peterson, system director of aortic surgery at New York University Langone Health, told STAT in an interview. “If they had, were there signs of aortic dilatation or aneurysm that were being monitored or missed?”
Patients who come to his aortic clinic often say that an echocardiogram done a few years ago showed a dilated aorta (a sign of dissection) or a bulge in the vessel wall of an aneurysm, but no one took them seriously or told them about it.
“I’d like to know if he’s had advanced chest imaging and if so, what those tests showed, whether there was any enlargement or dilation or any signs of an aneurysm, and what the recommendations were from his medical team,” Peterson said of Graham. “It’s all speculation now.”
Aortic dissection can occur suddenly, but it doesn’t happen suddenly. When the body’s most important blood vessels rupture from the inside, it creates a medical emergency that can take years. It is more likely to develop in people in their 50s and 60s, but it is rare after the age of 80. It occurs twice as often in men as in women.
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What doctors don’t know is which aorta is most likely to rupture and why.
“This is one of the biggest unanswered questions in this field,” Joanna Chikwe, director of cardiac surgery at the Smit Heart Institute at Cedars-Sinai, told STAT in an email interview. “Improving risk prediction by combining genetics, clinical factors, image processing, biomechanics, and potentially AI is likely to be one of the major advances in aortic dissection prevention over the next decade.”
People diagnosed with atherosclerosis suddenly become more susceptible to damage as fat, cholesterol, and calcium harden and narrow blood vessels, while high blood pressure puts pressure on them. This is a warning signal that the weakened artery may dilate and rupture under pressure. Although aortic diameter is an important predictor, it is a poor proxy for the underlying strength of the aortic wall, Chikwe said.
Still, if imaging scans show that the aorta is dilated, patients are warned to limit strain, such as lifting weights, that can compromise the integrity of these vital blood vessel walls, which tear from the inside out.
Cardiologist Eric Topol, director of the Scripps Research Institute’s Translational Research Institute, will never forget the patient who died outside the gym shortly after a workout. Imaging tests showed the man was at risk of aortic dissection and he was warned not to lift weights.
Although there are ways to treat the underlying atherosclerosis long before aortic rupture, such as statins to lower cholesterol and blood pressure drugs to lower high blood pressure, surveillance and surgery remain the options for avoiding aortic dissection.
Echocardiograms and CT scans provide insight into the health of blood vessels and provide guidelines for determining when to begin monitoring based on the width of the blood vessels. Although surgery can correct the problem, it is a major and risky operation that involves replacing a weakened aorta with a graft. Another option is a minimally invasive repair in which a stent is passed through the artery to close the torn blood vessel lining.
The challenge is to determine who will benefit.
That’s where AI could help, and scientists are studying it, Topol said.
“Unfortunately, we’re very bad at predicting who will go on to dissection from an enlarged aorta. Where AI can make a big contribution is in pinpointing people who are at risk, because we waste a lot of imaging and have people go through all these MRIs and CTs and ultrasounds all the time, and only a small percentage of people actually go on to dissection,” he told STAT. “Our discernment abilities are very weak, and we need help.”
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Clinical decisions currently rely heavily on the diameter of the aorta, but many dissections occur below the surgical threshold of about 4.5 to 5 centimeters, Chikwe said. The goal is more individualized risk prediction, rather than relying solely on diameter. She said that while this is an active area of research, it is not yet part of routine clinical practice.
“AI could help identify more subtle risk markers by analyzing CT, MRI, or echocardiographic images, such as aortic shape, wall features, tissue properties, growth patterns, and biomechanical stress, which are difficult to quantify with the human eye,” she said. “AI can be used to identify people at high risk for aortic disease from other routine imaging tests.”
Although family history of heart disease is a well-known risk factor, aortic dissection is not always declared as the cause of death. Aortic dissection is estimated to occur in 20,000 people each year in the United States, and half of these cases are fatal. Experts believe the incidence may be even higher because so many people do not undergo autopsies after sudden death. If in some cases the cause was actually an aortic dissection, a more common heart attack may be blamed.
Graham’s father died of a heart attack at the age of 60.
Chikwe said family history is one of the most important clues to increased risk. Approximately one in five patients with an aortic aneurysm or dissection has a first-degree relative with a similar disease who may have died suddenly.
“Many affected people are asymptomatic before the catastrophe occurs, so early identification can save lives,” she said.
Experts say that if a family member experiences sudden unexplained death, thoracic aneurysm, or autopsy, it is necessary to discuss genetic testing and imaging tests for first-degree relatives.
Genetic syndromes are even rarer. Connective tissue diseases such as Marfan syndrome and Loyce-Dietz syndrome make people vulnerable, while Turner syndrome and other genetic disorders that affect the aorta and aortic valve put people at high risk of developing aortic hypertrophy. It can cause abnormalities in the heart and blood vessels, which can later lead to tearing or dissection of the aorta.
Overall, aortic dissections and related aneurysms (when a weak section of the aorta bulges) will account for 3.5 of every 100,000 deaths in 2023, ranking 10th on the list of cardiovascular death causes in the U.S. and worldwide, said Gregory Ross, a professor of cardiology at the University of Washington and co-author of a study tracking coronary artery disease. Mortality told STAT. The main risk for aortic disease is by far smoking, followed by high blood pressure and high body mass index.
Peterson, of NYU Langone, said the condition is relatively rare and does not require routine surveillance testing. That makes family history all the more important, he said, likening aortic dissection to a “silently ticking time bomb” for people at risk.
If the aorta ruptures, it’s a surgical emergency, and if it happens in the emergency department, there won’t be enough time to get the patient to the operating room, Peterson said. “Unless the surgical team is able to respond and get ready quickly and open the chest quickly and get someone on bypass, that still might not be fast enough.”
Graham’s death gave heart doctors an opportunity to provide information on how to tell if an aortic dissection or other serious heart problem is occurring. If in doubt, call 911.
““Treat it as a medical emergency. In the long term, aortic dissection is a case of no time, and early diagnosis and treatment greatly improves survival rates,” Dr. Chikwe said.
