Difference between revisions of "Vascular disease"

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*[[Hypertension]].<ref name=pmid21968475>{{Cite journal  | last1 = Braverman | first1 = AC. | title = Aortic dissection: prompt diagnosis and emergency treatment are critical. | journal = Cleve Clin J Med | volume = 78 | issue = 10 | pages = 685-96 | month = Oct | year = 2011 | doi = 10.3949/ccjm.78a.11053 | PMID = 21968475 | URL = http://www.ccjm.org/content/78/10/685.long }}</ref>
*[[Hypertension]].<ref name=pmid21968475>{{Cite journal  | last1 = Braverman | first1 = AC. | title = Aortic dissection: prompt diagnosis and emergency treatment are critical. | journal = Cleve Clin J Med | volume = 78 | issue = 10 | pages = 685-96 | month = Oct | year = 2011 | doi = 10.3949/ccjm.78a.11053 | PMID = 21968475 | URL = http://www.ccjm.org/content/78/10/685.long }}</ref>
*[[Atherosclerosis]].<ref name=pmid21173794>{{Cite journal  | last1 = LeMaire | first1 = SA. | last2 = Russell | first2 = L. | title = Epidemiology of thoracic aortic dissection. | journal = Nat Rev Cardiol | volume = 8 | issue = 2 | pages = 103-13 | month = Feb | year = 2011 | doi = 10.1038/nrcardio.2010.187 | PMID = 21173794 }}</ref>
*[[Atherosclerosis]].<ref name=pmid21173794>{{Cite journal  | last1 = LeMaire | first1 = SA. | last2 = Russell | first2 = L. | title = Epidemiology of thoracic aortic dissection. | journal = Nat Rev Cardiol | volume = 8 | issue = 2 | pages = 103-13 | month = Feb | year = 2011 | doi = 10.1038/nrcardio.2010.187 | PMID = 21173794 }}</ref>
**Smoking.
**[[Smoking]].
*Cardiac surgery - rare, well-known complication.<ref name=pmid22345184>{{Cite journal  | last1 = Leontyev | first1 = S. | last2 = Borger | first2 = MA. | last3 = Legare | first3 = JF. | last4 = Merk | first4 = D. | last5 = Hahn | first5 = J. | last6 = Seeburger | first6 = J. | last7 = Lehmann | first7 = S. | last8 = Mohr | first8 = FW. | title = Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients. | journal = Eur J Cardiothorac Surg | volume = 41 | issue = 3 | pages = 641-6 | month = Mar | year = 2012 | doi = 10.1093/ejcts/ezr070 | PMID = 22345184 }}</ref>
*Cardiac surgery - rare, well-known complication.<ref name=pmid22345184>{{Cite journal  | last1 = Leontyev | first1 = S. | last2 = Borger | first2 = MA. | last3 = Legare | first3 = JF. | last4 = Merk | first4 = D. | last5 = Hahn | first5 = J. | last6 = Seeburger | first6 = J. | last7 = Lehmann | first7 = S. | last8 = Mohr | first8 = FW. | title = Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients. | journal = Eur J Cardiothorac Surg | volume = 41 | issue = 3 | pages = 641-6 | month = Mar | year = 2012 | doi = 10.1093/ejcts/ezr070 | PMID = 22345184 }}</ref>



Revision as of 18:35, 2 May 2013

The article covers vascular disease, i.e. diseases of blood vessels. Vasculitides are covered in a separate article called vasculitides.

Normal blood vessels

Comparing arteries and veins:[1]

Feature Artery Vein
Internal elastic lamina prominent/thick, usu. complete thin & incomplete
External elastic lamina present, thick absent
Shape circular / lumen wide open collapsed
Wall thickness thick thin

Great vessels

When things go wrong here, you see a cardiac surgeon.

Atherosclerosis

General

  • A leading cause of death, esp. in the Western world.
  • May have multi-system manifestations.

Location and associated pathology:

Clinical risk factors:

  • Age.
  • Blood pressure (high) - modifiable (antihypertensives).
  • Cholesterol - modifiable (statins, diet).
  • Diabetes mellitus - modifiable (hypoglycemic medications, diet, lifestyle).
  • Smoking - modifiable (cessation).
  • Family history.

Microscopic

Features:

  • Intimal hyperplasia.
  • Lipid deposition.
  • Foamy macrophages within intima & media.
  • Cholesterol clefts
  • Luminal narrowing.

Image:

Notes:

  • Considered "complex" if any of the following are present:[2]
    • Calcifications.
    • Thrombosis.
    • Haemorrhage.

Stains

Aortic dissection

  • Abbreviated AoD.

General

Risk factors:

Note:

  • Diabetes uncommon in AoD.[4]

Associations

Heritable:[6]

Others:

Classification

Two classification exist:

  • DeBakey.
  • Stanford.

Stanford dissection classification:[10]

  • Type A - aortic root to the left subclavian artery.
    • Considered a surgical emergency.
  • Type B - distal to (left) subclavian artery.
    • Generally, treated conservatively.

Gross

  • Entry intimal tear +/- exit intimal tear.
    • Blood between layers of the vessel wall.

Images:

Microscopic

See: cystic medial degeneration.

Images:

Cystic medial degeneration

General

  • Nonspecific finding - may be seen in a number of conditions.

Note about cystic medial necrosis:

  • Often not cystic and not necrotic.

Microscopic

Features:[12][13]

  • Basophilic ground substance in the media (seen on Movat's stain).
  • Disruption of the elastic lamina (seen on elastic trichrome stain).
  • +/-Focal necrosis.

Images:

Stains

Medial calcific sclerosis

  • AKA Moenckeberg medial calcific sclerosis, calcific medial sclerosis of Monckeberg, and Monckeberg's arteriosclerosis.

General

  • Usually of no clinical consequence.

Microscopic

Features:[14]

  • Medial calcification (purple irregular stuff on H&E -- calcium phosphate).

Note:

  • Lumen unaffected.

Images:

Hyperplastic arteriolosclerosis

General

Note:

  • Hyperplasia = proliferation of cells.

Microscopic

Features:[14]

  • Onion-skin appearance of intima & media due to:
    • Intimal hyperplasia.
    • Smooth muscle hyperplasia.

Image: Hyperplastic arteriolosclerosis (utah.edu).

Fibromuscular dysplasia

  • Abbreviated FMD.

General

Etiology:

  • Unknown, possibly genetic.

Gender:

  • Women > men.
  • May be seen in virtually any artery.
  • Reported as a cause of sudden death with involvement of the artery supplying the AV node.[16]

Gross/radiologic

  • Segmental - thinning and thickening.[17]

Classical locations:[17]

Microscopic

Features:[17]

  • Smooth muscle hyperplasia - key feature.
  • Elastic fibre fragmentation.
  • Luminal narrowing.

Images:

Stains

Thromboangiitis obliterans

General

  • Strong association with smoking.[18]
  • Small and medium-sized vessels of the extremities.

Diagnosis - clinical:

  • Corkscrew vessels on angiography.[19]

Treatment:

  • Stop smoking.

Microscopic

Features:[20]

  • Acute inflammation:
    • Endarteritis - inner layers of blood vessels.
    • Periarteritis.

Thrombosis

See also: Cerebral venous thrombosis.

General

Definition:

  • Blood clot formation within a vessel.

Complications:

Risk factors:

  • The classic pimping question is what "Virchow's triad?"
    • Stasis, hypercoagulability, endothelial injury.
  • A long list is found in: risk factors for VTE.

Gross

See: Pulmonary embolism - gross features.

Microscopic

Features:

  • Lines of Zahn.
  • Fibrin - pink acellular stuff on a H&E stain.

Image:

Cholesterol embolism

  • Abbreviated CE.

General

  • Strong association with atherosclerosis - found in ~3% of individuals in an autopsy series of 267 older individuals (mean age ~65 years).[21]
  • Significant CEs are often iatrogenic.
    • Known complication of coronary catherization (incidence ~ 1%).[22]
    • May complicate any vascular surgery, CABG.

Microscopic

Features:[23]

  • Intravascular cholesterol clefts (biconvex white spaces) - key feature.
    • Typically ~ 100-500 micrometers (long axis) x 50-100 micrometers (short axis). (?)
  • +/-Macrophages and giant cells.
  • +/-Eosinophils.

Note:

  • May be associated with ischemic changes and necrosis.
  • Usually in the context of severe atherosclerosis.

Note (trivia):

  • Cholesterol crystals dissolve with routine processing (paraffin embedding); this is why one talks of "cholesterol clefts".

Images:

Coarctation of the aorta

  • AKA aortic coarctation.

General

  • Uncommon.

Classification:

  • Preductal.
  • Postductal.

Associations:

Clinical

Presentation:[26]

  • Heart failure.
  • Hypertension - esp. upper extremity vs. lower extremity.

Gross

  • Narrowing (stenosis) of the aorta proximal or distal to the ductus arteriosis.

Image:

Intracranial berry aneurysm

See also

References

  1. URL: http://www.lab.anhb.uwa.edu.au/mb140/corepages/vascular/vascular.htm. Accessed on: 13 January 2011.
  2. Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 4. ISBN 978-1416002741.
  3. Braverman, AC. (Oct 2011). "Aortic dissection: prompt diagnosis and emergency treatment are critical.". Cleve Clin J Med 78 (10): 685-96. doi:10.3949/ccjm.78a.11053. PMID 21968475.
  4. 4.0 4.1 4.2 LeMaire, SA.; Russell, L. (Feb 2011). "Epidemiology of thoracic aortic dissection.". Nat Rev Cardiol 8 (2): 103-13. doi:10.1038/nrcardio.2010.187. PMID 21173794.
  5. Leontyev, S.; Borger, MA.; Legare, JF.; Merk, D.; Hahn, J.; Seeburger, J.; Lehmann, S.; Mohr, FW. (Mar 2012). "Iatrogenic type A aortic dissection during cardiac procedures: early and late outcome in 48 patients.". Eur J Cardiothorac Surg 41 (3): 641-6. doi:10.1093/ejcts/ezr070. PMID 22345184.
  6. Gleason TG (2005). "Heritable disorders predisposing to aortic dissection". Semin. Thorac. Cardiovasc. Surg. 17 (3): 274-81. doi:10.1053/j.semtcvs.2005.06.001. PMID 16253833.
  7. Loeys BL, Schwarze U, Holm T, et al (August 2006). "Aneurysm syndromes caused by mutations in the TGF-beta receptor". N. Engl. J. Med. 355 (8): 788-98. doi:10.1056/NEJMoa055695. PMID 16928994. http://content.nejm.org/cgi/content/full/355/8/788.
  8. Cruz, RP.; Marrone, LC.; Marrone, AC. (Nov 2010). "Chronic syphilitic aortic aneurysm complicated with chronic aortic dissection.". Am J Surg 200 (5): e64-6. doi:10.1016/j.amjsurg.2010.02.017. PMID 20864080.
  9. Carlson, M.; Silberbach, M. (2009). "Dissection of the aorta in Turner syndrome: two cases and review of 85 cases in the literature.". BMJ Case Rep 2009: bcr0620091998. doi:10.1136/bcr.06.2009.1998. PMID 21731587.
  10. Finkelmeier BA (September 1997). "Dissection of the aorta: a clinical update". J Vasc Nurs 15 (3): 88-93. PMID 9362838.
  11. URL: http://emedicine.medscape.com/article/756835-overview. Accessed on: 12 August 2010.
  12. URL: http://emedicine.medscape.com/article/756835-overview. Accessed on: 12 August 2010.
  13. Ha HI, Seo JB, Lee SH, et al. (2007). "Imaging of Marfan syndrome: multisystemic manifestations". Radiographics 27 (4): 989–1004. doi:10.1148/rg.274065171. PMID 17620463. http://radiographics.rsna.org/content/27/4/989.full.
  14. 14.0 14.1 Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 7. ISBN 978-1416002741.
  15. URL: http://library.med.utah.edu/WebPath/IMMHTML/IMM028.html. Accessed on: 11 May 2011.
  16. 16.0 16.1 Lee, S.; Chae, J.; Cho, Y. (Dec 2006). "Causes of sudden death related to sexual activity: results of a medicolegal postmortem study from 2001 to 2005.". J Korean Med Sci 21 (6): 995-9. PMID 17179675.
  17. 17.0 17.1 17.2 Hata, D. (Sep 2001). "Fibromuscular dysplasia.". Intern Med 40 (9): 978-9. PMID 11579971.
  18. Highlander, P.; Southerland, CC.; VonHerbulis, E.; Gonzalez, A. (Jan 2011). "Buerger disease (thromboangiitis obliterans): a clinical diagnosis.". Adv Skin Wound Care 24 (1): 15-7. doi:10.1097/01.ASW.0000392923.37852.43. PMID 21173586.
  19. Fujii, Y.; Soga, J.; Nakamura, S.; Hidaka, T.; Hata, T.; Idei, N.; Fujimura, N.; Nishioka, K. et al. (Aug 2010). "Classification of corkscrew collaterals in thromboangiitis obliterans (Buerger's disease): relationship between corkscrew type and prevalence of ischemic ulcers.". Circ J 74 (8): 1684-8. PMID 20534945.
  20. Kurata, A.; Schulz, A.; Franke, FE. (2004). "Reappraisal of thromboangiitis obliterans--a pathological contribution.". Verh Dtsch Ges Pathol 88: 231-6. PMID 16892557.
  21. Flory CM (1945). "Arterial occlusions produced by emboli from eroded aortic atheromatous plaques". Am J Pathol 21 (3): 549–565. PMC 1934118. PMID 19970827. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934118/.
  22. Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A (July 2003). "The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study". J. Am. Coll. Cardiol. 42 (2): 211–6. doi:10.1016/S0735-1097(03)00579-5. PMID 12875753. http://linkinghub.elsevier.com/retrieve/pii/S0735109703005795.
  23. Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 1735-6. ISBN 978-0781779425.
  24. Braverman, AC.; Güven, H.; Beardslee, MA.; Makan, M.; Kates, AM.; Moon, MR. (Sep 2005). "The bicuspid aortic valve.". Curr Probl Cardiol 30 (9): 470-522. doi:10.1016/j.cpcardiol.2005.06.002. PMID 16129122.
  25. Hjerrild, BE.; Mortensen, KH.; Sørensen, KE.; Pedersen, EM.; Andersen, NH.; Lundorf, E.; Hansen, KW.; Hørlyck, A. et al. (2010). "Thoracic aortopathy in Turner syndrome and the influence of bicuspid aortic valves and blood pressure: a CMR study.". J Cardiovasc Magn Reson 12: 12. doi:10.1186/1532-429X-12-12. PMID 20222980.
  26. Peres, A.; Martins, JD.; Paramés, F.; Gil, R.; Matias, C.; Franco, J.; Freitas, I.; Trigo, C. et al. (Jan 2010). "Isolated aortic coarctation: experience in 100 consecutive patients.". Rev Port Cardiol 29 (1): 23-35. PMID 20391897.