cardiovascular pathology
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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CARDIOVASCULAR PATHOLOGY
Tutorial I
William H. Luer M.D.
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TOPICS
• Aneurysms• Embolism• Vasculitides• Myocardial Infarction• Diseases of Veins & Lymphatics
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ANEURYSM
• An abnormal dilatation of an artery or vein• Caused by weakened vessel wall from:
Congenital defectSystemic diseaseAtherosclerosisInfectionTrauma
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SHAPES OF ANEURYSMS
• Saccular• Fusiform• Cylindroid• Berry
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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
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Atherosclerotic Abdominal Aortic Aneurysm
Aneurysm withthrombus
Kidney Kidney
Aorta
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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
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Syphilitic Aneurysm – Ascending Arch of Aorta
Aneurysm
Aortic Valve
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MYCOTIC ANEURYSM
• Bacterial infection weakens vessel wall• Associated with sepsis, bacterial endocarditis• May involve aorta or cerebral, renal, mesenteric, and splenic
arteries
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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
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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
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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
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Ascending Aorta – Dissecting Aneurysm
Dissection
Aortic Valve
Aorta
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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
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Axilla –Pseudoaneurysm, stab wound severed brachial artery
Brachial artery
Pseudoaneurysm withblood clotAxillary fat
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EMBOLISM
• The occlusion of a vessel by an object, the embolus, that has been transported to the site of occlusion, through the cardiovascular system.
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TYPES OF EMBOLI
• Thromboemboli• Bone marrow emboli• Fat emboli• Air emboli• Amniotic fluid emboli• Foreign body emboli
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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
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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
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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
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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
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Coiled Embolus in Pulmonary Artery
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Pulmonary Emboli removed from Pulmonary Artery
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CASE OF PULMONARY INFARCT
• Next photograph is from an elderly male in congestive heart failure
• He experienced sudden pleuritic chest pain followed by hemoptysis
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Lung – Pulmonary Infarct
Lung
Pulmonary infarct with hemorrhage
Embolus
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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
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Greenfield Filter in Inferior Vena Cava with Trapped Emboli
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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
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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
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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
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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
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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
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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
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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
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HV: PATHOLOGY
• Leukocytoclastic vasculitis, features are:fibrinoid necrosis of vascular wallextravasation of red blood cells
nuclear dust from PMN breakdown• Vascular lesions all about same stage• Can resolve, recur, or become chronic
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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
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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
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GCA: CLINICAL
• Weakness, malaise, fever, weight loss, headache• Can become chronic, usually resolves• Can affect sight if involves ocular vessels
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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
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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
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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
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“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
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CHARACTERISTIC
• Affects post capillary venules in skin producing a palpable purpura
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ANSWER
• Hypersensitivity (Leukocytoclastic) Vasculitis
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CHARACTERISTIC
• Facial pain, headache, fever, fatigue, weight loss, in an elderly female
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ANSWER
• Giant Cell (Temporal) Arteritis
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CHARACTERISTIC
• Gastrointestinal bleeding• Renal failure• Fever• + p-ANCA (perinuclear antineutrophil cytoplasmic
antibody)• Vessel biopsy: transmural necrotizing acute
inflammation of vessel wall
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ANSWER
• Polyarteritis Nodosa
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CHARACTERISTICS
• Necrotizing granulomas in respiratory tract• Necrotizing granulomatous vasculitis in lungs• Necrotizing cresentric glomerulonephritis• + c-ANCA (cytoplasmic diffuse anti-neutrophil
cytoplasmic antibody)
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ANSWER
• Wegener’s Granulomatosis
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MYOCARDIAL INFARCTION
• Topic covered in lecture• Case study discussed in tutorial
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DISEASES OF VEINS
• Varicose Veins• Thrombophlebitis
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VARICOSE VEINS
• Legs: associated with pregnancy, increasing age, and can be familial
• Hemorrhoids: associated with pregnancy and cirrhosis
• Esophageal varices: associated with cirrhosis
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COMPLICATIONS OF VARICSOSE VEINS
• Pain• Stasis• Thrombosis• Bleeding
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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)
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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
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CARDIOVASCULAR PATHOLOGY
Tutorial I
The End