Difference between revisions of "Vascular disease"

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The article covers '''vascular disease''', i.e. diseases of blood vessels.  Vasculitides are covered in a separate article called ''[[vasculitides]]''.
The article covers '''vascular disease''', i.e. diseases of [[blood vessel]]s. These keep vascular surgeons and cardiac surgeon busy.   
 
Vasculitides are covered in a separate article called ''[[vasculitides]]''.


==Normal blood vessels==
==Normal blood vessels==
Comparing arteries and veins:<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/corepages/vascular/vascular.htm http://www.lab.anhb.uwa.edu.au/mb140/corepages/vascular/vascular.htm]. Accessed on: 13 January 2011.</ref>
Comparing arteries and veins:<ref>URL: [http://www.lab.anhb.uwa.edu.au/mb140/corepages/vascular/vascular.htm http://www.lab.anhb.uwa.edu.au/mb140/corepages/vascular/vascular.htm]. Accessed on: 13 January 2011.</ref>
<center>
{| class="wikitable sortable"
{| class="wikitable sortable"
! Feature
! Feature
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! Vein
! Vein
|-
|-
| Internal elastic lamina
| Internal elastic lamina (IEL)
| prominent/thick, usu. complete
| prominent/thick, usu. complete
| thin & incomplete
| thin & incomplete
|-
|-
| External elastic lamina
| External elastic lamina (EEL)
| present, thick
| present, thick
| absent
| absent
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| thin
| thin
|}
|}
</center>
[[Image:2102 Comparison of Artery and Vein.jpg|thumb|400px|center|Artery and vein. (WC)]]


==Great vessels==
==Great vessels==
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Clinical risk factors:
Clinical risk factors:
*Age.
*Age.
*Blood pressure - modifiable (antihypertensives).
*[[Hypertension|Blood pressure (high)]] - modifiable (antihypertensives).
*Cholesterol - modifiable (statins, diet).
*Cholesterol - modifiable (statins, diet).
*[[Diabetes mellitus]] - modifiable (hypoglycemic medications, diet, lifestyle).
*[[Diabetes mellitus]] - modifiable (hypoglycemic medications, diet, lifestyle).
Line 56: Line 61:
*Luminal narrowing.
*Luminal narrowing.


Image:
*[http://commons.wikimedia.org/wiki/File:RCA_atherosclerosis.jpg RCA with atherosclerosis (WC)].


Notes:
Notes:
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**Haemorrhage.
**Haemorrhage.


====Image====
<gallery>
Image:RCA_atherosclerosis.jpg |Right coronary artery with atherosclerosis. (WC/Nephron)
</gallery>
===Stains===
===Stains===
*[[Elastic trichrome stain]] or [[Movat stain]] - highlights duplication of internal elastic lamina, allows on to identify with ease intimal thickening.
*[[Elastic trichrome stain]] or [[Movat stain]] - highlights duplication of internal elastic lamina, allows on to identify with ease intimal thickening.
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==Aortic dissection==
==Aortic dissection==
*Abbreviated ''AoD''.
*Abbreviated ''AoD''.
===General===
{{Main|Aortic dissection}}
Risk factors:
*[[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>
**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>
 
Note:
*Diabetes uncommon in AoD.<ref name=pmid21173794/>
 
====Associations====
Heritable:<ref name=pmid16253833>{{cite journal |author=Gleason TG |title=Heritable disorders predisposing to aortic dissection |journal=Semin. Thorac. Cardiovasc. Surg. |volume=17 |issue=3 |pages=274-81 |year=2005 |pmid=16253833 |doi=10.1053/j.semtcvs.2005.06.001 |url=}}</ref>
*[[Marfan's syndrome]].
*Loeys-Dietz syndrome - a Marfan-like syndrome<ref name=pmid16928994>{{cite journal |author=Loeys BL, Schwarze U, Holm T, ''et al'' |title=Aneurysm syndromes caused by mutations in the TGF-beta receptor |journal=N. Engl. J. Med. |volume=355 |issue=8 |pages=788-98 |year=2006 |month=August |pmid=16928994 |doi=10.1056/NEJMoa055695 |url=http://content.nejm.org/cgi/content/full/355/8/788}}</ref>
*[[Ehlers-Danlos syndrome]].
*[[Bicuspid aortic valve]].<ref name=pmid21173794/>
 
Others:
*Tertiary [[syphilis]].<ref name=pmid20864080>{{Cite journal  | last1 = Cruz | first1 = RP. | last2 = Marrone | first2 = LC. | last3 = Marrone | first3 = AC. | title = Chronic syphilitic aortic aneurysm complicated with chronic aortic dissection. | journal = Am J Surg | volume = 200 | issue = 5 | pages = e64-6 | month = Nov | year = 2010 | doi = 10.1016/j.amjsurg.2010.02.017 | PMID = 20864080 }}</ref>
*[[Turner syndrome]].<ref name=pmid21731587>{{Cite journal  | last1 = Carlson | first1 = M. | last2 = Silberbach | first2 = M. | title = Dissection of the aorta in Turner syndrome: two cases and review of 85 cases in the literature. | journal = BMJ Case Rep | volume = 2009 | issue =  | pages = bcr0620091998 | month =  | year = 2009 | doi = 10.1136/bcr.06.2009.1998 | PMID = 21731587 }}</ref>
 
====Classification====
Two classification exist:
*''DeBakey''.
*''Stanford''.
 
Stanford dissection classification:<ref name=pmid9362838>{{cite journal |author=Finkelmeier BA |title=Dissection of the aorta: a clinical update |journal=J Vasc Nurs |volume=15 |issue=3 |pages=88-93 |year=1997 |month=September |pmid=9362838 |doi= |url=}}</ref>
*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:
*[http://library.med.utah.edu/WebPath/CVHTML/CV031.html Aortic dissection (utah.edu)].
*[http://www.brown.edu/Courses/Digital_Path/systemic_path/cardio/ad-gross.html Aortic dissection (brown.edu)].
 
===Microscopic===
:See: ''[[cystic medial degeneration]]''.
 
Images:
*[http://path.upmc.edu/cases/case84.html Aortic dissection - autopsy (upmc.edu)].


==Cystic medial degeneration==
==Cystic medial degeneration==
*[[AKA]] ''cystic medial necrosis''.<ref>URL: [http://emedicine.medscape.com/article/756835-overview http://emedicine.medscape.com/article/756835-overview]. Accessed on: 12 August 2010.</ref>
*[[AKA]] ''cystic medial necrosis''.<ref>URL: [http://emedicine.medscape.com/article/756835-overview http://emedicine.medscape.com/article/756835-overview]. Accessed on: 12 August 2010.</ref>
===General===
{{Main|Cystic medial degeneration}}
*Nonspecific finding - may be seen in a number of conditions.
 
Note about ''cystic medial necrosis'':
*Often ''not'' cystic and ''not'' necrotic.
 
===Microscopic===
Features:<ref>URL: [http://emedicine.medscape.com/article/756835-overview http://emedicine.medscape.com/article/756835-overview]. Accessed on: 12 August 2010.</ref><ref name=pmid17620463>{{cite journal |author=Ha HI, Seo JB, Lee SH, ''et al.'' |title=Imaging of Marfan syndrome: multisystemic manifestations |journal=Radiographics |volume=27 |issue=4 |pages=989–1004 |year=2007 |pmid=17620463 |doi=10.1148/rg.274065171 |url=http://radiographics.rsna.org/content/27/4/989.full}}</ref>
*Basophilic ground substance in the media (seen on Movat's [[stain]]).
*Disruption of the elastic lamina (seen on elastic trichrome stain).
*+/-Focal necrosis.
 
Images:
*www:
**[http://radiographics.rsna.org/content/27/4/989.full Marfan's syndrome (radiographics.rsna.org)].
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Cystic_medial_degeneration_-_low_mag.jpg Cystic medial degeneration - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Cystic_medial_degeneration_-_high_mag.jpg Cystic medial degeneration - high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Cystic_medial_degeneration_-_movat_-_low_mag.jpg Cystic medial degeneration - movat - low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Cystic_medial_degeneration_-_movat_-_intermed_mag.jpg Cystic medial degeneration - movat - intermed. mag. (WC)].
 
===Stains===
*Elastin stains (e.g. [[elastic trichrome stain]]) - disruption of the elastic lamina.
*[[Movat's stain]] - basophilic ground substance in the media.


==Medial calcific sclerosis==
==Medial calcific sclerosis==
*[[AKA]] ''Moenckeberg medial calcific sclerosis'', ''calcific medial sclerosis of Monckeberg'', and ''Monckeberg's arteriosclerosis''.
[[AKA]] ''Moenckeberg medial calcific sclerosis'', ''calcific medial sclerosis of Monckeberg'', and ''Monckeberg's arteriosclerosis''.
===General===
{{Main|Medial calcific sclerosis}}
*Usually of no clinical consequence.
 
===Microscopic===
Features:<ref name=Ref_Klatt7>{{Ref Klatt|7}}</ref>
*Medial calcification (purple irregular stuff -- calcium phosphate).
 
Note:
*Lumen unaffected.
 
Images:
*[http://library.med.utah.edu/WebPath/COW/COW086.html Moenckeberg medial calcific sclerosis (med.utah.edu)].
*[http://commons.wikimedia.org/wiki/File:Calcificatio_atherosclerotica.jpg MCS (WC)].


==Hyperplastic arteriolosclerosis==
==Hyperplastic arteriolosclerosis==
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==Thromboangiitis obliterans==
==Thromboangiitis obliterans==
*[[AKA]] ''Buerger disease''.
{{Main|Thromboangiitis obliterans}}
**Should '''not''' be confused with ''Berger disease'' ([[IgA nephropathy]]).
 
===General===
*Strong association with smoking.<ref>{{Cite journal  | last1 = Highlander | first1 = P. | last2 = Southerland | first2 = CC. | last3 = VonHerbulis | first3 = E. | last4 = Gonzalez | first4 = A. | title = Buerger disease (thromboangiitis obliterans): a clinical diagnosis. | journal = Adv Skin Wound Care | volume = 24 | issue = 1 | pages = 15-7 | month = Jan | year = 2011 | doi = 10.1097/01.ASW.0000392923.37852.43 | PMID = 21173586 }}</ref>
*Small and medium-sized vessels of the extremities.
 
Diagnosis - clinical:
*Corkscrew vessels on angiography.<ref>{{Cite journal  | last1 = Fujii | first1 = Y. | last2 = Soga | first2 = J. | last3 = Nakamura | first3 = S. | last4 = Hidaka | first4 = T. | last5 = Hata | first5 = T. | last6 = Idei | first6 = N. | last7 = Fujimura | first7 = N. | last8 = Nishioka | first8 = K. | last9 = Chayama | first9 = K. | title = Classification of corkscrew collaterals in thromboangiitis obliterans (Buerger's disease): relationship between corkscrew type and prevalence of ischemic ulcers. | journal = Circ J | volume = 74 | issue = 8 | pages = 1684-8 | month = Aug | year = 2010 | doi =  | PMID = 20534945 }}</ref>
 
Treatment:
*Stop smoking.
===Microscopic===
Features:<ref name=pmid16892557>{{Cite journal  | last1 = Kurata | first1 = A. | last2 = Schulz | first2 = A. | last3 = Franke | first3 = FE. | title = Reappraisal of thromboangiitis obliterans--a pathological contribution. | journal = Verh Dtsch Ges Pathol | volume = 88 | issue =  | pages = 231-6 | month =  | year = 2004 | doi =  | PMID = 16892557 }}</ref>
*Acute inflammation:
** Endarteritis - inner layers of blood vessels.
** Periarteritis.


==Thrombosis==
==Thrombosis==
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*Fibrin - pink acellular stuff on a [[H&E stain]].
*Fibrin - pink acellular stuff on a [[H&E stain]].


Image:
====Image====
*[http://commons.wikimedia.org/wiki/File:Fetal_thrombotic_vasculopathy_-_high_mag.jpg Intravascular fibrin - high mag. (WC)].
<gallery>
 
Image:Fetal_thrombotic_vasculopathy_-_high_mag.jpg | Intravascular fibrin - high mag. (WC/Nephron)
</gallery>
==Cholesterol embolism==
==Cholesterol embolism==
*Abbreviated ''CE''.
*Abbreviated ''CE''.
 
{{Main|Cholesterol embolism}}
===General===
*Strong association with [[atherosclerosis]] - found in ~3% of individuals in an [[autopsy]] series of 267 older individuals (mean age ~65 years).<ref name=pmid19970827>{{cite journal | author=Flory CM | title=Arterial occlusions produced by emboli from eroded aortic atheromatous plaques | journal=Am J Pathol | year= 1945 | volume=21 | pages=549–565 | pmid=19970827 | issue=3 | pmc=1934118}}</ref>
*Significant CEs are often iatrogenic.
**Known complication of coronary catherization (incidence ~ 1%).<ref name=pmid12875753>{{cite journal |author=Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A |title=The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study |journal=J. Am. Coll. Cardiol. |volume=42 |issue=2 |pages=211–6 |year=2003 |month=July |pmid=12875753 |doi=10.1016/S0735-1097(03)00579-5 | url=http://linkinghub.elsevier.com/retrieve/pii/S0735109703005795}}</ref>
**May complicate any vascular surgery, CABG.
 
===Microscopic===
Features:<ref name=Ref_Sternberg5_1735-6>{{Ref Sternberg5|1735-6}}</ref>
*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:
*[http://commons.wikimedia.org/wiki/File:Cholesterol_embolus_-_intermed_mag.jpg Cholesterol embolus - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Cholesterol_embolus_-_high_mag.jpg Cholesterol embolus - high mag. (WC)].


==Coarctation of the aorta==
==Coarctation of the aorta==
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*Narrowing (stenosis) of the aorta proximal or distal to the ductus arteriosis.
*Narrowing (stenosis) of the aorta proximal or distal to the ductus arteriosis.


Image:
====Image====
*[http://commons.wikimedia.org/wiki/File:Coarctation_and_PDA.png Pre- and postductal coarctation of the aorta - schematic (WC)].
<gallery>
 
Image:Coarctation_and_PDA.png | Pre- and postductal coarctation of the aorta - schematic (WC)
</gallery>
==Intracranial berry aneurysm==
==Intracranial berry aneurysm==
{{Main|Berry aneurysm}}
{{Main|Berry aneurysm}}

Latest revision as of 03:39, 7 March 2016

The article covers vascular disease, i.e. diseases of blood vessels. These keep vascular surgeons and cardiac surgeon busy.

Vasculitides are covered in a separate article called vasculitides.

Normal blood vessels

Comparing arteries and veins:[1]

Feature Artery Vein
Internal elastic lamina (IEL) prominent/thick, usu. complete thin & incomplete
External elastic lamina (EEL) present, thick absent
Shape circular / lumen wide open collapsed
Wall thickness thick thin
Artery and vein. (WC)

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.


Notes:

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

Image

  • Right coronary artery with atherosclerosis. (WC/Nephron)

Stains

Aortic dissection

  • Abbreviated AoD.
Main article: Aortic dissection

Cystic medial degeneration

  • AKA cystic medial necrosis.[3]
Main article: Cystic medial degeneration

Medial calcific sclerosis

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

Main article: Medial calcific sclerosis

Hyperplastic arteriolosclerosis

General

Note:

  • Hyperplasia = proliferation of cells.

Microscopic

Features:[5]

  • 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.[6]

Gross/radiologic

  • Segmental - thinning and thickening.[7]

Classical locations:[7]

Microscopic

Features:[7]

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

Images:

Stains

Thromboangiitis obliterans

Main article: Thromboangiitis obliterans

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

  • Intravascular fibrin - high mag. (WC/Nephron)

Cholesterol embolism

  • Abbreviated CE.
Main article: Cholesterol embolism

Coarctation of the aorta

  • AKA aortic coarctation.

General

  • Uncommon.

Classification:

  • Preductal.
  • Postductal.

Associations:

Clinical

Presentation:[10]

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

Gross

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

Image

  • Pre- and postductal coarctation of the aorta - schematic (WC)

Intracranial berry aneurysm

Main article: 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. ↑ URL: http://emedicine.medscape.com/article/756835-overview. Accessed on: 12 August 2010.
  4. ↑ URL: http://library.med.utah.edu/WebPath/IMMHTML/IMM028.html. Accessed on: 11 May 2011.
  5. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 7. ISBN 978-1416002741.
  6. ↑ 6.0 6.1 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.
  7. ↑ 7.0 7.1 7.2 Hata, D. (Sep 2001). "Fibromuscular dysplasia.". Intern Med 40 (9): 978-9. PMID 11579971.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
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