On Friday, Lindsey Graham made what would be his last public appearance.
Standing outside the golden-domed monastery in Kyiv, Ukraine, after meeting with the country’s president, he declared: ‘I’ve never been more optimistic than I am today.’
Just a day later, he was dead.
After returning to Washington, DC, ambulances were called to his home at around 8.30pm. The 71-year-old was rushed to hospital after suffering what was initially described as a cardiac arrest.
On Sunday, it was revealed he had died from an aortic dissection – a life-threatening condition in which the inner wall of the body’s largest artery tears.
This can cause severe internal bleeding and deprive the vital organs of blood. Without immediate treatment, it is frequently fatal.
‘Aortic dissection isn’t one of those things that happens slowly over time,’ Dr Barbara Hamilton, a cardiac surgeon at the University of Michigan’s leading aorta clinic, told the Daily Mail.
‘When it happens, it happens very quickly and often without warning.
‘At least half of patients don’t make it to the hospital in time to be saved. And even among those who do get there often don’t survive.’
Lindsey Graham is pictured above on Friday in Kyiv, Ukraine, after a meeting with the country’s president Volodymyr Zelensky. He also visited a drone factory during the visit
So what exactly is an aortic dissection, why does it occur and who is most at risk?
The aorta is the largest artery in the human body, carrying oxygenated blood from the heart. It is shaped like a cane, rising upward from the heart, curving over and then travelling down through the chest into the abdomen.
Every organ in the body depends on the blood delivered by it or one of its branches.
The aorta is under the higher blood pressure in the body. Its walls have to withstand the full force of every heartbeat, about 100,000 times a day. And because of this, problems that affect it can be catastrophic.
There are two major emergencies involving the aorta. The first, aortic dissection, which Lindsey Graham reportedly died from, occurs when a tear develops in the inner lining of the vessel.
Blood then forces its way between the layers of the aortic wall, separating them from one another. This can block blood flow to vital organs, including the brain, heart, kidneys and spinal cord, or cause the aorta to rupture – a medical emergency that is often fatal.
The condition has been described by some heart surgeons as an ‘exploding heart’ because of how suddenly and catastrophically it strikes – although the structure that actually tears is the aorta, the body’s main artery, rather than the heart itself.
Dr John Trahanas, a cardiac surgeon and co-director of the Aortic Center at Vanderbilt University Medical Center, previously described an aortic dissection as ‘basically like your heart exploding.’
The above shows the scene outside Graham’s house in Washington DC on Saturday evening
There are two main types of aortic dissection. Type A occurs when the tear affects the ascending aorta, the section closest to the heart. Type B occurs further down, in the descending aorta.
Type A dissections are generally considered the more dangerous of the two because they can interfere with blood flow from the heart itself and are more likely to rupture. Both types, however, are life-threatening emergencies that require urgent medical treatment.
Aortic dissections are rare, affecting about 30 in every million people in the US each year. Hamilton, an internationally recognized expert in treating the condition, said that she sees about as few as 70 to 90 cases every year.
The other emergency involving this vessel is an aortic aneurism. Instead of tearing, part of the wall of the aorta weakens and balloons outward – often likened to a blow out in car tire. This is often symptomless, until it ruptures, and like a dissection is rapidly fatal.
The walls of the aorta are made up of several layers of strong, elastic muscle, allowing the artery to stretch with each heartbeat before springing back into shape.
Over time, however, these layers can weaken, making them more vulnerable to tearing.
‘By far the biggest risk factor is uncontrolled high blood pressure, which places extra force on the artery wall every second of the day, accelerating wear and tear,’ said Hamilton.
In Lindsey Graham’s case, the medical examiner said he also had atherosclerosis – a build-up of fatty plaques inside the arteries. As well as narrowing blood vessels, atherosclerosis can damage and stiffen the artery wall, making it less able to withstand the stress of blood flowing through it.
The above shows an aortic dissection (top right). Blood is shown flowing into the space between the inner and two outer layers of the aorta’s wall
Aging also increases the risk because the aorta naturally loses some of its elasticity over time. Smoking has a similar effect, damaging the blood vessel lining, promoting inflammation and accelerating the breakdown of the proteins that give the artery its strength.
‘Many patients with high blood pressure and heart disease are not aware they are at risk,’ Dr Manesh Patel, an interventional cardiologist and volunteer president of the American Heart Association, said.
‘It’s often not felt until they have an acute event, when they suffer from chest pain and a heart attack, or when they have an aortic dissection, or a stroke.’
Certain inherited connective tissue disorders, including Marfan syndrome and vascular Ehlers-Danlos syndrome, can also leave the aortic wall unusually fragile, making tears more likely even at a younger age.
But not every patient has an identifiable cause.
‘In some cases, an aortic dissection occurs seemingly without warning in people with no obvious underlying risk factors,’ said Hamilton.
Those who are 50 to 70 years old, male and have a family history of the disease are most at risk, they said.
In some cases, patients may appear otherwise healthy before the condition strikes, doctors said.
After Trump took office, Graham began what was perhaps the most famous and notable phase of his career: ultimate Trump loyalist, frequent golf partner, adviser and advocate for the Maven of Mar-a-Lago, both on television and in the Senate
So how do you know if you’re suffering aortic dissection? Dr Matthew Henn, a cardiac surgeon at Ohio State University, said: ‘It’s a very sudden onset.
‘Patients often describe a sudden tearing chest pain that starts in the front of the chest and tears through to their back. There’s not a lot of warning before this happens.’
The tearing pain has been described by some as similar to a stabbing sensation.
Other symptoms include pain in the neck or jaw. Patients may also start to feel faint, weak or short of breath if the blood supply to other organs, such as the brain, is reduced.
‘Once an aortic dissection happens, the best chance for survival is to get the patient to the operating room as soon as possible,’ Henn added.
‘As soon as someone feels that chest pain, they should call 911. Minutes and hours really count in these cases.’
In the operating room, doctors carry out surgery to repair the aorta to fix the tear and restore proper blood flow. They will also work to control blood pressure.
High blood pressure – the biggest risk factor for aortic dissection – affects nearly half of US adults, yet around 11 million Americans are thought to have the condition without knowing it because it rarely causes symptoms and is often only picked up during a routine medical check or screening.
Graham had no publicly reported health conditions.
The 71-year-old had travelled extensively in the days leading up to his death, flying to Turkey for the NATO summit before traveling to Ukraine and then returning to the US.
Long-haul travel itself is not known to trigger an aortic dissection. However, the physical and emotional stress of travel can cause temporary spikes in blood pressure, which may place additional strain on an already weakened aorta, experts told the Daily Mail.
Despite this, doctors stressed there is no evidence this played a role in Graham’s case.
President Donald Trump told NBC’s ‘Meet the Press’ that he spoke with Graham Saturday evening, saying ‘other than being tired he was fine.’
After the call, Graham said he felt unwell, a staffer told Axios. He was urged to get medical attention, but said he would wait until Sunday morning.
‘I can’t die now,’ he is reported to have said, ‘I still need to do the Russian sanctions, get Iran sorted out and do Israel-Saudi normalization.’
He has no partner or children.