A 42-year-old man with a history of Marfan syndrome presents to the emergency room with severe, sudden, tearing chest pain radiating to the abdomen and back. Over the past several hours, the pain has progressively shifted downward. He admits to recent cocaine use and has a history of hypertension, previously treated with hydrochlorothiazide, which he stopped due to thunderclap headaches. He also smokes one pack of cigarettes daily. Vital signs: Temperature: 99.8 °F Heart rate: 108 beats/min (right arm); 94 beats/min (left arm) Blood pressure: 198/105 mm Hg (right arm); 170/94 mm Hg (left arm) Respiratory rate: 19 breaths/min Oxygen saturation: 94% on room air Physical examination reveals: Asymmetric pulses Signs of intravenous drug use (track marks, scarring). Investigations: ECG: Wide QRS complexes Chest X-ray: Widened mediastinum Laboratory findings: Normal troponin and D-dimer levels Most aortic dissections are due to which of the following?
