CARDIOVASCULAR PATHOLOGY

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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 defect
• Systemic disease
• Atherosclerosis
• Infection
• Trauma

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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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Aorta
Aneurysm with thrombus
Kidney
Kidney
Atherosclerotic Abdominal Aortic Aneurysm
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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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Aortic Valve
Aneurysm
Syphilitic Aneurysm Ascending Arch of Aorta
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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 Marfans syndrome

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Dissection
Aorta
Aortic Valve
Ascending Aorta Dissecting Aneurysm
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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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Brachial artery
Pseudoaneurysm with blood clot
Axillary fat
Axilla Pseudoaneurysm, stab wound severed
brachial artery
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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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Pulmonary infarct with hemorrhage
Embolus
Lung
Lung Pulmonary Infarct
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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
• Kawasakis disease
• Hypersensitivity vasculitis
• Giant cell arteritis (Temporal arteritis)
• Takayasus arteritis
• Buergers disease
• Wegeners 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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KAWASAKIS 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 wall
• extravasation 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
• FemaleMale, 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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TAKAYASUS ARTERITIS

• FemaleMale, 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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BUERGERS 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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WEGENERS 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

• Wegeners 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-Trousseaus 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