diseases of bloodvessels
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Diseases of BLOOD VESSELS
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COMPONENTS• Intima, Media, Adventitia, M>A or A>M• ENDOTHELIUM• INTERNAL ELASTIC LAMINA• ECM: Elastin (~aging), collagen,
mucopolysaccharides• Smooth Muscle• Connective Tissue• Fat
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1) Blockage
(preceded by narrowing)
2) Rupture
Preceded by weakening)
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TOPICS• Vascular wall
responses
• Congenital Anomalies
• Atherosclerosis
• Arteriosclerosis
• Hypertension
• Aneurysms
• Vasculitides
• Raynaud “phenomenon”
• Veins
• Lymphatics
• Tumors
• Interventions
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DEFINITIONS• ARTERIO-sclerosis• ATHERO-sclerosis• Aneurysm• Dissection• Thrombus• Hypertension• Vasculitis/Vasculitides, infectious/NON-infectious (often-
autoimmune)• Varicosity• DVT/Thrombo-phlebitis/Phlebo-thrombosis
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DEFINITIONS• Lymphangitis
• Lymphedema
• Angioma/Hemangioma (generic)
• Lymphangioma
• Angiosarcoma (generic)
• Lymphangiosarcoma
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NON-Specific Vascular WallResponse to Injury
• Endothelial “activation”
• Smooth Muscle cell roles
• Development, Growth, Remodeling
• Intimal “thickening”
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ENDOTHELIAL CELLS• Recall Jeckyl/Hyde concept: maintain hemostasis/cause
thrombosis• Maintenance of Permeability Barrier • Elaboration of Anticoagulant, Antithrombotic,
Fibrinolytic Regulators• Elaboration of Prothrombotic Molecules • Extracellular Matrix Production (collagen,
proteoglycans) • Modulation of Blood Flow and Vascular Reactivity • Regulation of Inflammation and Immunity • Regulation of Cell Growth • Oxidation of LDL
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ENDOTHELIAL CELL“ACTIVATORS” (Δ?)
• Cytokines• Bacterial Products• Hemodynamic Forces• Lipid Products• Viruses• Complement• Hypoxia
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VASCULAR SMOOTH MUSCLE
• Vasoconstriction• Vasodilatation• Make ECM:
– Collagen– Elastin– Proteoglycans
• Regulated by:– PROMOTORS: PDGF, endothelin, thrombin, etc.– INHIBITORS: Heparan SO4, NO, TGF-β
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Vessel Growth & Remodeling
• The sum total of all the factors and processes involved in tissue injury and the body’s ability to grow vessels, develop new pathways, and re-perfuse areas in response to tissue and/or blood vessel injury.
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Intimal thickening is a NON-specific response to vascular (chiefly arterial) injury, and is they KEY feature in atherosclerosis as well.
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CONGENITAL ANOMALIES
• Arteriovenous fistulas • Also called ArterioVenous Malformation (AVM)• Common factor is abnormal communication between high
pressure arteries and low pressure veins• Usually congenital, but can be acquired by trauma or
inflammation• Most often described in the brain as an AVM• Asymptomatic or with hemorrhage or pressure effects
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CT Angiogram
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ARTERIO-SCLEROSIS
• GENERIC term for ANYTHING which HARDENS arteries– Atherosclerosis (99%)– Mönckeberg medial calcific sclerosis (1%)– Arteriolosclerosis, involving small arteries
and arterioles, generally regarded as NOT strictly being part of atherosclerosis, but more related to hypertension and/or diabetes
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ATHEROSCLEROSIS(classical)
• Etiology/Risk Factors
• Pathogenesis
• Morphology
• Clinical Expression
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ATHEROSCLEROSIS
• *Natural History• *Epidemiology• *Risk Factors• *Pathogenesis• *Other Factors• *Effects• *Prevention
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*NATURAL HISTORY
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1) FATTY STREAK (non-palpable)
2) ATHEROMA
(plaque) (palpable)
3) THROMBUS (non-functional,
symptomatic)
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MORPHOLOGIC CONCEPTS• Intimal Thickening• Lipid Accumulation• Streak• Atheroma• Smooth Muscle Hyperplasia and Migration• Fibrosis• Calcification• Aneurysm• Thrombosis
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FATTYSTREAKS
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PLAQUEwww.freelivedoctor.com
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MILD ADVANCEDwww.freelivedoctor.com
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ADVANCED FEATURES
• RUPTURE
• ULCERATION
• EROSION
• ATHEROEMBOLI
• HEMORRHAGE
• THROMBOSIS
• ANEURYSMwww.freelivedoctor.com
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FUN THINGS TO FIND:
Lumen, Fibrous cap (fibrous plaque), Lipid core, External Elastic Membrane thinning/destruction, Calcification, Neovascularization
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*EPIDEMIOLOGY & RISK FACTORS
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Epid./RiskFactors
• Related to “development” of nation• US highest• 50-70% DECREASE 19632000. Why?• AGE• SEX, M>F until menopause, estrogen
“protection”• GENETICS
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MAJOR factors
• Hyperlipidemia
• Hypertension
• Cigarette Smoking
• Diabetes Milletus
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Risk Factors for AtherosclerosisMajor Minor
NON-modifiable Modifiable
Increasing age Obesity
Male gender Physical inactivity
Family history Stress ("type A" personality)
Genetic abnormalities Postmenopausal estrogen deficiency
High carbohydrate intake
Modifiable
Hyperlipidemia Alcohol
Hypertension Lipoprotein Lp(a)
Cigarette smoking Hardened (trans)unsaturated fat intake
Diabetes Chlamydia pneumoniae
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MAJOR factors
• Hyperlipidemia
• Hypertension
• Cigarette Smoking
• Diabetes Milletus
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HYPERLIPIDEMIA• Chiefly CHOLESTEROL, LDL>>>>HDL• HDL mobilizes cholesterol FROM atheromas to liver• LOW CHOLESTEROL diet is GOOD• UNSATURATED fatty acids GOOD• Omega-3 fatty acids GOOD• Exercise GOOD
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CHOLESTEROL CLEFTS
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Needle shaped washed out spaces in arteries, are cholesterol clefts, and can be nothing else, and like all other fat,
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HYPERTENSION
• HYPERTENSION causes ATHEROSCLEROSIS. Why?
• ATHEROSCLEROSIS causes HYPERTENSION. Why?
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•
• MAJOR RISKFACTORS
Smoking
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diabetes
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NON major factors• Homocysteinuria/homocysteinemia, related
to low B6 and folate intake
• Coagulation defects
• Lipoprotein Lp(a), independent of cholesterol. Lp(a) is an altered form of LDL
• Inadequate exercise, Type “A” personality, obesity (independent of diabetes)
• Protective effect of moderate alcohol? LIE!
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PATHOGENESIS
• “atherosclerosis is a chronic inflammatory response of the arterial wall initiated by injury to the endothelium”
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PATHOGENESIS SAGA• Chronic endothelial injury• LDL, Cholesterol in arterial WALL• OXIDATION of lipoproteins• Monocytes migrate endothelium*• Platelet adhesion and activation• Migration of SMOOTH MUSCLE from media to
intima to activate macrophages (foam cells)• Proliferation of SMOOTH MUSCLE and ECM• Accumulation of lipids in cells and ECM
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A very well constructed graphic understanding of the pathogenesis of atherosclerosis. Please be expected to not only KNOW these five items, but their correct ORDER too.
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Main FOUR STARS of PATHOGENESIS SAGA
• 1) Endothelial Injury
• 2) Inflammation
• 3) Lipids
• 4) Smooth Muscle Cells, SMCs
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atherosclerosis
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Other Pathogenesis Considerations
• Oligoclonality of cells in plaque
• Chlamydia, CMV as endothelial injurers
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PREVENTION PRINCIPLES
• Know what is preventable• Know what is MAJOR (vs. minor)• Know PRIMARY vs. SECONDARY principles• Understand atherosclerosis begins in
CHILDHOOD• Risk factors in CHILDREN predict the ADULT
profile• Understand SEX, ETHNIC differences
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NON ATHEROSCLEROSISVASCULAR DISEASES
• HYPERTENSION• ANEURYSMS• VASCULITIDES• VEIN DISORDERS• NEOPLASMS
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HYPERTENSION
• “ESSENTIAL” 95%• “SECONDARY” 5%
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SECONDARY• Renal • Acute glomerulonephritis • Chronic renal disease • Polycystic disease • Renal artery stenosis • Renal artery fibromuscular dysplasia• Renal vasculitis • Renin-producing tumors • Endocrine • Adrenocortical hyperfunction • (Cushing syndrome, primary aldosteronism, congenital adrenal hyperplasia, licorice ingestion)• Exogenous hormones (glucocorticoids, estrogen [including pregnancy-induced and oral
contraceptives], sympathomimetics and tyramine-containing foods, monoamine oxidase inhibitors)
• Pheochromocytoma, Acromegaly, Hypothyroidism (myxedema), Hyperthyroidism• Pregnancy-induced • Cardiovascular: Coarctation of aorta, Polyarteritis nodosa (or other vasculitis)• Increased intravascular volume• MISC: Increased cardiac output, Rigidity of the aorta, Neurologic, Psychogenic, Increased
intracranial pressure, Sleep apnea, Acute stress, including, surgery
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DEFINITION
• 140/90
• SUSTAINED diastolic >90
• SUSTAINED systolic >140
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BP = CO x PR
ALL Hypertension
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hypertension can be understood best by remembering the simple BP=COxPR equation.
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ReninAngiotensinAldosteroneAXIS
• If the perfusion of the juxtaglomerular apparatus in the kidneys decreases, then the juxtaglomerular cells release the enzyme renin.
• Renin cleaves an inactive peptide called angiotensinogen, converting it into angiotensin I.
• Angiotensin I is then converted to angiotensin II by angiotensin-converting enzyme (ACE), which is found mainly in lung capillaries.
• Angiotensin II is the major bioactive product of the renin-angiotensin system. Angiotensin II acts as an endocrine, autocrine/ paracrine, and intracrine hormone.
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GENETIC
ACQUIRED
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HISTOPATHOLOGY ofESSENTIAL HYPERTENSION
“HYALINE” = BENIGN HTN. “HYPERPLASTIC” = MALIGNANT HTN. SYS>200 1) ONION SKIN 2) “FIBRINOID” NECR.
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GENETICvs.ENVIRONMENTAL
• ENVIRONMENTAL CONTROLABLE– GENETIC UN-CONTROLABLE– STRESS– OBESITY– SMOKING– PHYSICAL ACTIVITY– NaCl INTAKE
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ANEURYSMS• TRUE vs. FALSE• ATHEROSCLEROTIC• NON-ATHEROSCLEROTIC
– CONGENITAL– LUETIC (SYPHILITIC)– TRAUMATIC– “MYCOTIC” (MIS-leading term)– 2° to VASCULITIS
• SACCULAR (i.e., “Berry”) vs. FUSIFORM• DISSECTION vs.NON-DISSECTION
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ANEURYSMS• 2 CAUSES:
– 1) ATHEROSCLEROSIS– 2) CYSTIC MEDIAL DEGENERATION
NORMAL elastic fibers DISRUPTED, FRAGMENTED elastic fibers
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Most abdominal aortic aneurysms (AAA) occur between the renal arteries and the bifurcation of the aorta
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ANEURYSMS(sequelae)
– RUPTURE– OBSTRUCTION– EMBOLISM– COMPRESSION
• URETER• SPINE
– MASS EFFECT
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THORACIC ANEURYSMS
– Encroachment– Respiratory difficulties– Dysphagia– Cough– Pain– Aortic valve dilatation– Rupture
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DISSECTION
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ANEURYSMS(luetic)
–Chiefly thoracic–Follows an AORTITIS
• PLASMA CELLS predominate
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VASCULITIDES
• TEMPORAL “GIANT CELL” ARTERITIS• TAKAYASU ARTERITIS• POLY (PERI) ARTERITIS NODOSA• KAWASAKI DISEASE• WEGENER’s GRANULOMATOSIS• THROMBOANGI(i)TIS OBLITERANS (BUERGER DISEASE)• OTHER• INFECTIOUS
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VASCULITIDES• Chiefly arterial• Infectious (5%) vs. Non-infectious (95%)• NON-infectious are generally “AUTO”-
IMMUNE. Why?• Persistent findings:
– Immune complexes– ANTI-NEUTROPHIL AB’s (Wegener’s, “Temporal”)– ANTI-ENDOTHELIAL CELL AB’s (Kawasaki)
• Often DRUG related (Hypersensitivity, e.g.)
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“TEMPORAL” ARTERITISaka, Giant Cell Arteritis, GCA
• ADULTS• Mainly arteries of the head and temporal
arteries are the most visibly, palpably, and surgically accessible
• BLINDNESS most feared sequelae• GRANULOMATOUS WALL inflammation
diagnostic• OFTEN associated with marked ESR
elevation to be then known as POLYMYALGIA RHEUMATICA
• Anti-NEUTROPHIL AB’s often POSITIVE
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TEMPORAL ARTERITIShttp://www.path.uiowa.edu/cgi-bin-pub/vs/fpx_gen.cgi?slide=623&viewer=java&view=0&lay=iowa
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TAKAYASU ARTERITIS
• Involves aortic arch and other heavilly elastic arteries, i.e., chief thoracic aorta branches, most commonly young Asian women
• FEMALES <40
• “PULSELESS” disease
• NECROSIS, Giant Cells also
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POLY-(Peri-) ARTERITIS NODOSA (PAN)
• ANY MEDIUM or SMALL artery
• OFTEN visceral arteries
• Infarcts, aneurysms, ischemia
• CLASSICAL AUTOIMMUNE disease
• SEGMENTAL, TRANSMURAL, NECROTIZING (fibrinoid) inflammation
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KAWASAKI DISEASE
• CHILDREN <4
• CORONARY ARTERIES
• LEADING cause of ACQUIRED heart disease in children
• USA and JAPAN
• Fatal in only 1%
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MICROSCOPIC POLYANGIITISHYPERSENSITIVITY VASCULITIS
LEUKOCYTOCLASTIC VASCULITIS
• SMALL VESSELS OF ALL TYPES, e.g., capillaries and veins too• FRAGMENTED NEUTROPHILS• aka, LEUKOCYTOCLASIA• aka, NUCLEAR “DUST”• Most are ALLERGIC reactions to allergens like penicillin or strep• DERMATOLOGIST’s DISEASE
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WEGENER GRANULOMATOSIS
• M>F, often in 40’s• ACUTE NECROTIZING GRANULOMAS OF UPPER an
LOWER respiratory tract• NECROTIZING GRANULOMATOUS VASCULITIS of
SMALL vessels of ALL types• Often renal involvement, “crescentic”
glomerulonephritis• ANTI-NEUTROPHIL-CYTOPLASMIC-AB’s usually
present
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necrosis granulomasnecrosisgranulomasnecrosisgranulomasnecrosisgranulomas
necrosis granulomasnecrosisgranulomasnecrosisgranulomasnecrosisgranulomas
necrosis granulomasnecrosisgranulomasnecrosisgranulomasnecrosisgranulomas
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THROMBOANGIITIS OBLITERANSBUERGER(‘s) Disease
• 100% caused by cigarette smoking
• MEN>>>F, 30’s, 40’s
• Often arteries are 100% obliterated, hence the name “obliterans”
• EXTREMITIES most often involved
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OTHER VASCULITIDES
• SLE
• RHEUMATOID ARTHRITIS
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INFECTIOUS ARTERITIDES
• ASPERGILLIS
• MUCORMYCOSIS
• “MYCOTIC” ANEURYSMS
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NON ATHEROSCLEROSISVASCULAR DISEASES
• HYPERTENSION• ANEURYSMS• VASCULITIDES• VEIN DISORDERS• NEOPLASMS
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FINAL TOPICS
• Raynaud Phenomenon• Veins and Lymphatics
– Varicosities– Thrombophlebitis/Phlebothrombosis– SVC/IVC syndromes– Lymphangitis– Lymphedema
• Tumors: Benign, Intermediate (Borderline), Malignant• Vascular Interventions: Angioplasty, Stents, Grafts
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Raynaud “Phenomenon”• PRIMARY: (formerly Raynaud “DISEASE”)
– Digital PALLORCYANOSISHYPEREMIA– (WHITE)(WHITE) (BLUE)(BLUE) (RED)(RED)– Vasoconstriction usually triggered by COLD, emotion– Can be tip of nose, not only digits– Self Limited, Gangrene UN-common
• SECONDARY: (formerly Raynaud “Phenomen.”)– Atherosclerosos– SLE– Buerger Disease
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WHITE
BLUE
RED
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Varicose Veins
• 20% of population, F>M• Related to increased venous pressure, age, valve
dysfunction• Superficial veins of lower extremities most common• PATH: 1) DILATED, 2) TORTUOUS, 3)
ELONGATED, 4) SCARRED (phlebosclerosis), 5) CALCIFICATIONS, 6) NON-UNIFORM SMOOTH MUSCLE
• Conceptually like varices or hemorrhoids
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THROMBOPHLEBITIS
• 90% DEEP veins of the legs• IDENTICAL to PHLEBOTHROMBOSIS• Factors: CHF, Neoplasia (esp. GI, panc. Lung
adenocarcinomas “migratory” thrombophlebitis), pregnancy, obesity, post-op, immobilization, or any of the parts of Virchow’s triangle
• Sequelae: PE most feared• Symptoms: edema, cyanosis, heat, pain,
tenderness, but usually……..NONE!!!
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SVC SYNDROME
• Usually from bronchogenic CA or mediastinal lymphoma
• DUSKY CYANOSIS of:– Head– Neck– Arms
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IVC SYNDROME• Secondary to:
– NEOPLASMS (external compression)– ASCENDING THROMBOSIS from
FEMORALS, ILIACS– AAA, Gravid uterus
• Bilateral leg edema
• Massive proteinuria if renal veins involved (like nephrotic syndrome)
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LYMPHANGITIS• From regional infections• Group-A beta-hemolytic strep most common• Lymphatics dilated, filled with WBCs• Cellulitis usually present too• Lymphadenitis also usually follows• If lymph nodes cannot filter (process)
antigens enough septicemia
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LYMPHEDEMA
• Lymphatic channels blocked or scarred or absent:– Post surgical– Post radiation– Filaria– Congenital– Tumoral (peau d’orange)
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CHYLE
• CHYLOUS ASCITES
• CHYLOTHORAX
• CHYLOPERICARDIUM
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Vascular TUMORS
• BENIGN (NEVER metastasize, in fact some are not even TRUE neoplasms, but hamartomas)
• INTERMEDIATE (rarely metastasize)• MALIGNANT (FREQUENT and EARLY
metastases, like any other sarcoma lung)
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BENIGN---------------------------------------MALIGNANT
Rare mitosis--------------------------Common mitosis
Mild, rare atypia------------Frequent, severe atypia
NO mets----------------------------Early, frequent mets
via BLOODSTREAM
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HEMANGIOMA
• Often a generic term for ANY benign blood vessel tumor
• CAPILLARY (small vascular spaces)– Also called “juvenile”, often called “birth marks”– Usually regress with age
• CAVERNOUS (LARGE vascular spaces)– Also called “adult”– Usually do NOT regress
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PYOGENIC GRANULOMA
• ORAL CAVITY MOST COMMON• Histology like capillary hemangioma• Regress• Indistinguishable from normal granulation
tissue
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LYMPHANGIOMA
• Small 1-2 mm• Head and neck region• Generally……RARE• When large size and/or spaces present often
called “CYSTIC HYGROMA”
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GLOMUS TUMORGLOMANGIOMA
• 1 cm• Most commonly under nail• Painful
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MISC. “BENIGN” TUMORS• -ectasias, telangiectasias
• Nevus Flammeus, aka, port wine stain• Spiders (spider telangiectasias), ass. W. pregnancy,
cirrhosis• Osler-Weber-Rendu Disease (Hereditary Hemorrhagic
Telangiectasia)• Bacillary Angiomatosis, in HIV patients, caused by bacilli
of Bartinella species
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INTERMEDIATE (BORDERLINE)VASCULAR NEOPLASMS
• Kaposi Sarcoma, KS– 1) Classic European, described 1872, NON-HIV– 2) African, pre-HIV, now HIV- and HIV+– 3) Transplant associated, HIV-– 4) AIDS KS, caused by HHV-8, aka KSHV
– PATCH PLAQUENODULE• HEMANGIOENDOTHELIOMA (HETEROGENEOUS GROUP
OF NEOPLASMS)
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Diagnosis of vascular neoplasms may require the use of endothelial cell markers such as Factor VIII or CD-31, especially if clear cut
vascular spaces are difficult to see, especially if the tumor is UNDIFFERENTIATED enough to the degree that endothelial lined
spaces are NOT clearly seen.
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MALIGNANT VASCULAR TUMORS
• ANGIOSARCOMA– May not look “vascular” at all– Severe atypia– Frequent and often bizarre mitoses– Behave as any sarcoma might, i.e., early pulmonary
metastases• HEMANGIOPERICYTOMA
– HETEROGENOUS group of disorders– Most commonly arising in pelvic retroperitoneum
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VASCULAR INTERVENTIONS
• ANGIOPLASTY• STENTS• GRAFTS
– Autologous (saphenous v., internal mammary a.)– Synthetic (Teflon)
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ANGIOPLASTIES
• Dissection• Arterial dilatation initially• Restenosis ~ 6 months
• Plaque fracture (crackling sound)
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STENTS• Metallic mesh• Permanently placed• Stays patent longer than
angioplasty• OFTEN DRUG COATED• Goals:
– Prevent thrombosis– Prevent spasm– Delay RE-stenosis
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GRAFTS• 400,000 CABG grafts per year in USA• Saphenous v. vs. Internal mammary a. (internal
thoracic a.)• 50% patent after 10 years, for saphenous v.• 90% patent after 10 years, for mammary a.
• Endothelial and smooth muscle migration and proliferation key factors for success
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