CARDIOVASCULAR PATHOLOGY
Tutorial I
William H. Luer M.D.
TOPICS
•
•
•
•
•
Aneurysms
Embolism
Vasculitides
Myocardial Infarction
Diseases of Veins & Lymphatics
ANEURYSM
• An abnormal dilatation of an artery or vein
• Caused by weakened vessel wall from:
Congenital defect
Systemic disease
Atherosclerosis
Infection
Trauma
SHAPES OF ANEURYSMS
•
•
•
•
Saccular
Fusiform
Cylindroid
Berry
ATHEROSCLEROTIC ANEURYSM
•
•
•
•
Atherosclerosis is the most common cause of aortic aneurysm
Most frequently occur in males, >50 years of age
Most occur in abdominal aorta, below the renal arteries
Complications include thrombosis, embolism, and rupture
Aorta
Aneurysm with
thrombus
Kidney
Kidney
Atherosclerotic Abdominal Aortic Aneurysm
SYPHILITIC ANEURYSM
• Seen in tertiary stage of syphilis with obliterative endarteritis of
vasa vasorum and aortitis
• Roughening of intima: “Tree barking”
• Involves the thoracic aorta
• Complications include rupture, aortic insufficiency, and
narrowing of coronary ostia
Aortic Valve
Aneurysm
Syphilitic Aneurysm – Ascending Arch of Aorta
MYCOTIC ANEURYSM
• Bacterial infection weakens vessel wall
• Associated with sepsis, bacterial endocarditis
• May involve aorta or cerebral, renal, mesenteric, and splenic
arteries
BERRY ANEURYSM
•
•
•
•
Involve cerebral arteries at bifurcations
Probably arise at congenital points of weakness in wall
Can rupture and result in subarachnoid hemorrhage
Clinically may see headache, stiff neck (meningeal irritation) and
death
DISSECTING ANEURYSM
• Entry of blood into substance of wall & extension
along the length of the vessel
• Actually a form of hematoma, hence also called
dissecting hematoma
• Male > female
• Associated with hypertension
DISSECTING ANEURYSM (CONT.)
• Usually have tear in media where blood enters the
wall & blood can reenter lumen through a second
tear
• Blood dissects in media as outer third & inner third
of media separates
• May be associated with cystic medial necrosis with
loss of elastic and smooth muscle fibers
• Can be seen in Marfan’s syndrome
Dissection
Aorta
Aortic Valve
Ascending Aorta – Dissecting Aneurysm
PSEUDOANEURYSM
• Injury to wall of vessel allows blood to escape from
vessel into adjacent tissue
• Extravasated blood coagulates and becomes a
mass along side the vessel
• This mass of blood (hematoma) gives the
impression that there is an aneurysm
Brachial artery
Axillary fat
Pseudoaneurysm with
blood clot
Axilla –Pseudoaneurysm, stab wound severed brachial artery
EMBOLISM
• The occlusion of a vessel by an object, the
embolus, that has been transported to the site of
occlusion, through the cardiovascular system.
TYPES OF EMBOLI
•
•
•
•
•
•
Thromboemboli
Bone marrow emboli
Fat emboli
Air emboli
Amniotic fluid emboli
Foreign body emboli
PULMONARY EMBOLISM (PE)
• Cause of death in about 100,000 people per year in
USA
• Number 3 killer in USA, behind heart disease and
cancer
• Emboli travel to lungs and lodge in pulmonary
arteries
• Emboli usually from thrombi in deep veins of legs
• Leg thrombosis common, found in 10-65% of
autopsies on hospitalized patients
VENOUS THROMBOSIS & PE
ESPECIALLY COMMON IN:
•
•
•
•
•
•
Prolonged bed rest
Immobilization of extremity
Congestive heart failure (CHF)
Following trauma, burns, fractures, surgery
During & after parturition
Disseminated cancer
PE
•
•
•
•
PE often unsuspected
Death may follow a large embolic event in seconds
If not fatal, PE may or may not cause an infarct
Consequences depend on size & number of
emboli & the state of the circulation
CASE OF FATAL PE
• The following two photographs are from an autopsy
performed on a 66 year old female who died
suddenly on the second day after an open lung
biopsy
• She died as she was being moved from her bed
(where she had been since surgery) to a chair
• The cause of death was PE
• The predisposing causes include surgery and
immobilization during bed rest
Coiled Embolus in Pulmonary Artery
Pulmonary Emboli removed from Pulmonary Artery
CASE OF PULMONARY INFARCT
• Next photograph is from an elderly male in
congestive heart failure
• He experienced sudden pleuritic chest pain
followed by hemoptysis
Pulmonary
infarct with
hemorrhage
Embolus
Lung
Lung – Pulmonary Infarct
CASE OF RECURRENT PE
• The next photograph is from an 86 year old male
with chronic renal failure and bilateral deep vein
thrombosis
• He was experiencing recurrent pulmonary emboli
• A filter was placed in the inferior vena cava to catch
the emboli before they reached the lungs
Greenfield Filter in Inferior Vena Cava with Trapped Emboli
VASCULITIS
• Inflammation & often necrosis of blood vessels
• May be the predominant or sole manifestation of a
disease or only on component of a disease
• May induce tissue ischemia
VASCULITIDES
•
•
•
•
•
•
•
•
Polyarteritis nodosa
Allergic granulomatosis of Churg & Strauss
Kawasaki’s disease
Hypersensitivity vasculitis
Giant cell arteritis (Temporal arteritis)
Takayasu’s arteritis
Buerger’s disease
Wegener’s granulomatosis
POLYARTERITIS NODOSA (PN)
• Systemic necrotizing vasculitis
• Segmental involvement of small & medium sized
muscular arteries
• Often leads to microaneurysms
• Widespread ischemic damage
• Vascular lesions at different stages of evolution
• Probably due to immunologic disorder since see Ig
& C in lesions & about 30% of cases have Hepatitis
B antigenemia and have + p-ANCA: perinuclear
antineutrophil cytoplasmic antibodies
PN CLINICAL
• Male > Female
• Erratic multisystem involvement, may see tender
muscles, skin lesions, subcutaneous nodules,
malaise, fever, weight loss, high blood pressure,
hematuria, abdominal pain, diarrhea, melena
• May be acute or chronic with recurrences
• Renal involvement may be prominent & often
cause of death with hematuria, albuminuria, and
hypertension
• Treat with immunosuppression
ALLERGIC GRANULOMATOSIS OF
CHURG &STAUSS
• Vascular lesions resemble PN but involve vessels
in lung (in contrast to PN)
• Related to allergy, esp. asthma
• See peripheral eosinophilia & eosinophils in
vascular lesions
• Probably a hypersensitivity disorder
KAWASAKI’S DISEASE
• Most have heart involvement
• See necrotizing vasculitis of coronary arteries
(lesions resemble PN)
• May see thrombosis, aneurysm, and myocardial
infarction
• Possible viral etiology
HYPERSENSITIVITY VASCULITIS (HV)
• Involves post-capillary venules, mostly in skin to
produce palpable purpura, can affect internal
organs and tissues
• Mediated by immune complex deposition, Type III
hypersensitivity
• Causes include
drugs: penicillin, sulfonamides
bacterial: beta hemolytic Streptococcus
endogenous antigen
Hepatitis B antigen
HV: PATHOLOGY
• Leukocytoclastic vasculitis, features are:
fibrinoid necrosis of vascular wall
extravasation of red blood cells
nuclear dust from PMN breakdown
• Vascular lesions all about same stage
• Can resolve, recur, or become chronic
GIANT CELL ARTERITIS (GCA)
• Also called temporal arteritis
• Female>Male, usually >50 years of age
• Typically involves temporal artery, but may involve
other medium to large sized arteries, but rarely
renal (in contrast to PN)
• Possible autoimmune reaction to elastic fibers in
vessel wall
GCA: PATHOLOGY
• Full thickness granulomatous inflammation of
vessel wall
• Destruction of elastic lamina
• Thrombosis & fibrosis
• Can have “skip areas” in affected vessel, where
inflammation is lacking
GCA: CLINICAL
• Weakness, malaise, fever, weight loss, headache
• Can become chronic, usually resolves
• Can affect sight if involves ocular vessels
TAKAYASU’S ARTERITIS
• Female>Male, young
• Decreased pulses in upper extremities, ischemia of
upper body
• Etiology unknown
• Adventitial inflammation, that moves inward to
involve full thickness of vessel, may see
thrombosis & scarring
• Aortic arch may show irregular thickening and
stenosis
BUERGER’S DISEASE
• Also called thromboangitis obliterans
• Related to cigarette smoking, 25-50 year olds
• Involves radial & tibial arteries and adjacent nerves
and veins
• See thrombosis, organization, recanalization,
microabscess, granulomas, & fibrosis of vascular
bundle
• In extremities get pain, ischemia, ulcers, &
gangrene
WEGENER’S GRANULOMATOSIS
• Necrotizing vasculitis, esp. in lung, kidney, and
spleen
• Acute necrotizing granulomatous lesions in lung,
and in nasal & oral cavities
• Proliferative glomerulonephritis
• See cytoplasmic diffuse antineutrophil cytoplasmic
antibody (c-ANCA)
• 90% remission with cytotoxic treatment
“NAME THAT VASCULITIS”
• Test your vasculitis knowledge
• The next slide will give a characteristic(s) of one of
the vasculitides
• Name the vasculitis from the information given
• The slide after will name the vasculitis
• Good Luck
CHARACTERISTIC
• Affects post capillary venules in skin producing a
palpable purpura
ANSWER
• Hypersensitivity (Leukocytoclastic) Vasculitis
CHARACTERISTIC
• Facial pain, headache, fever, fatigue, weight loss,
in an elderly female
ANSWER
• Giant Cell (Temporal) Arteritis
CHARACTERISTIC
•
•
•
•
Gastrointestinal bleeding
Renal failure
Fever
+ p-ANCA (perinuclear antineutrophil cytoplasmic
antibody)
• Vessel biopsy: transmural necrotizing acute
inflammation of vessel wall
ANSWER
• Polyarteritis Nodosa
CHARACTERISTICS
•
•
•
•
Necrotizing granulomas in respiratory tract
Necrotizing granulomatous vasculitis in lungs
Necrotizing cresentric glomerulonephritis
+ c-ANCA (cytoplasmic diffuse anti-neutrophil
cytoplasmic antibody)
ANSWER
• Wegener’s Granulomatosis
MYOCARDIAL INFARCTION
• Topic covered in lecture
• Case study discussed in tutorial
DISEASES OF VEINS
• Varicose Veins
• Thrombophlebitis
VARICOSE VEINS
• Legs: associated with pregnancy, increasing age,
and can be familial
• Hemorrhoids: associated with pregnancy and
cirrhosis
• Esophageal varices: associated with cirrhosis
COMPLICATIONS OF VARICSOSE VEINS
•
•
•
•
Pain
Stasis
Thrombosis
Bleeding
THROMBOPHLEBITIS
•
•
•
•
Deep vein thrombosis, usually in lower extremities
Pain
Risk of pulmonary embolism
Associated with: congestive heart failure,
prolonged bed rest, post operative & post partal
states, trauma, & neoplasm (esp. pancreatic
cancer-Trousseau’s sign)
Diseases of Lymphatics
• Lymphangitis – inflamed lymphatics
• Secondary Lymphedema from inflammatory
scarring, metastatic carcinoma, surgical resection
(eg. arm edema post mastectomy), radiation
therapy induced fibrosis, & filariasis
CARDIOVASCULAR PATHOLOGY
Tutorial I
The End