• Histopathology Mechanism of Aortic Rupture

The time course of aortic rupture occurs in two distinct

phases owing to the three histologic layers that compose
the vessel wall. Immediately following injury, there is
rupture of the inner intima and media layers of the vessel
wall. Next, after an indeterminate and unpredictable
amount of time, disruption of the outermost adventitial
layer occurs resulting in rapid clinical decline. Studies have
shown the time interval between disruption of the intima-
media and adventitial rupture can vary from seconds to
years.
• Pathophysiology

1. Aorta consists of 3 layers- Intima, Media & Adventitia.

2. Certain diseases causes weakening of the aortic walls ,
reduces its elasticity. When blood is pumped through
these weakened areas, it bulges out, which are called
aneurysms.
3. As the flow and thus the pressure through this area
increases, it causes the rupture of the aneurysm of the
aortic wall.
Depending on its cause, an aortic rupture is
classified into 2 types:
• Traumatic aortic rupture, where the aorta
ruptures due to any trauma or injury to the
chest wall or abdomen, such as could occur in
motor vehicle accidents.
• Aortic rupture occurring secondary to an aortic
aneurysm, which is the commonest cause.
• Physical Examination
1. A patient with a ruptured aneurysm at any level is likely to look pale and
unwell and to be cold and sweaty.
2. The pulse will be rapid, weak and thready. Hypotension is common.
3. With a ruptured AAA there may well be a pulsatile mass in the vicinity of
the bifurcation of the aorta. This is a few centimetres above the umbilicus
and a little to the left.
4. It may be tender and a bruit may be audible. Bleeding causes peritoneal
irritation and it may appear as an acute abdomen.
5. The following findings are listed with approximate frequency:
6. Palpable mass (90%).  Tenderness (80%).  Systolic blood pressure (BP)
below 80 mm Hg (40%).  NB: presentation can be atypical, eg: intestinal
obstruction from haematoma or an apparent irreducible inguinal hernia. 
Rare presentations are:
7. Severe hematemesis from an aorto -duodenal fistula.  A fistula into the
inferior vena cava, producing lower limb oedema and high-output cardiac
failure.
• Evaluation
1. A chest radiograph. Although it lacks reliable
sensitivity, its availability and ease of use make chest
radiography a useful diagnostic tool in patients who are
too unstable to receive computed tomography. A
normal chest x-ray, however, does not exclude rupture,
as studies have shown patients with blunt aortic injury
may present with a normal mediastinum on chest
radiography. For this reason, other imagining modalities
with greater diagnostic sensitivity are commonly used.
2. Computed tomography angiography (CTA) has replaced traditional
angiography and transesophageal echocardiography as the diagnostic test
of choice for blunt thoracic aortic injury. This highly sensitive (86% to
100%) and specific (40% to 100%) imaging modality is widely available as
well as both time and cost effective. CTA findings indicative of an aortic
rupture include active extravasation of intravenous contrast dye from the
aorta, pseudo-aneurysm formation, an intimal flap, luminal filling defects,
periaortic hematoma formation, as well as aortic contour abnormalities.

3. Transesophageal echocardiography is another imaging modality used

to evaluate and diagnose damage to the aorta. This method is most useful
in patients who are hemodynamically unstable since it can be performed
quickly at the bedside in the emergency room or the operating theater by
a skilled operator. Other less frequently used options for the identification
of aortic transection include intravascular ultrasonography and magnetic
resonance imaging.
4. CBC: NB: if there has not been time for
haemodilution then haemoglobin will be normal.
Anaemia is present in less than half of patients. Around
80% have a white cell count of 10 x 109/L or more.
5. Group and rapid cross-match: whilst arranging
surgery.
6. Baseline biochemistry of U&Es: should be performed.
7. ECG: is important In patients presenting with chest
pain.
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aortic rupture: detection with helical CT of the chest. Radiology. 1995
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