Difference between revisions of "Vascular disease"

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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>
**In one large registry, approximately 15% of acute dissections are associated with prior cardiac surgery.<ref name=pmid24030404>{{cite journal |author=Teman NR, Peterson MD, Russo MJ, ''et al.'' |title=Outcomes of patients presenting with acute type A aortic dissection in the setting of prior cardiac surgery: an analysis from the International Registry of Acute Aortic Dissection |journal=Circulation |volume=128 |issue=11 Suppl 1 |pages=S180–5 |year=2013 |month=September |pmid=24030404 |doi=10.1161/CIRCULATIONAHA.112.000342 |url=}}</ref>
 
Note:
*Diabetes uncommon in thoracic aortic dissection.<ref name=pmid21173794/>
 
May be separated into two groups:<ref>URL: [http://path.upmc.edu/cases/case84/dx.html http://path.upmc.edu/cases/case84/dx.html]. Accessed on: 13 May 2014.</ref>
#Hypertension + atherosclerosis, typically 40-60 years old.
#Connective tissue disorders - "young".
 
====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====
<gallery>
Image:AoDiss_Patho.jpg | Aortic dissection. (WC)
</gallery>
 
www:
*[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===
Features:
*Defect in the tunica media (muscle layer).
*"Abundant" fresh blood in the adventitia.
*+/-Changes of [[cystic medial degeneration]] - a specific histopathologic cause of aortic dissection.
 
DDx:
*[[Cystic medial degeneration]].
 
====Images====
<gallery>
Image:Aortic dissection (1) Victoria blue-HE.jpg | Aortic dissection. Victoria blue-H&E. (WC/KGH)
</gallery>
 
www:
*[http://path.upmc.edu/cases/case84.html Aortic dissection - autopsy (upmc.edu)].
*[http://library.med.utah.edu/WebPath/CVHTML/CV029.html Aortic dissection (utah.edu)].


==Cystic medial degeneration==
==Cystic medial degeneration==

Revision as of 13:06, 13 May 2014

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]

General

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

Note about cystic medial necrosis:

  • Often not cystic and not necrotic.

Microscopic

Features:[4][5]

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

Images

  • Cystic medial degeneration - low mag. (WC/Nephron)

  • Cystic medial degeneration - high mag. (WC/Nephron)

  • Cystic medial degeneration - movat - low mag. (WC/Nephron)

  • Cystic medial degeneration - movat - intermed. mag. (WC/Nephron)

www:

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:[6]

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

Note:

  • Lumen unaffected.

Images

  • MCS. (WC)

www:

Sign out

RIGHT LEG, BELOW KNEE AMPUTATION:
- MINIMAL-TO-MILD LARGE VESSEL ATHEROSCLEROSIS, SEE COMMENT.
- MEDIAL CALCIFIC SCLEROSIS.
- SKIN WITH DERMAL FIBROSIS.

COMMENT:
The sections may not be representative of disease in the distal vascular bed.

Hyperplastic arteriolosclerosis

General

Note:

  • Hyperplasia = proliferation of cells.

Microscopic

Features:[6]

  • 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.[8]

Gross/radiologic

  • Segmental - thinning and thickening.[9]

Classical locations:[9]

Microscopic

Features:[9]

  • 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:[12]

  • 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://emedicine.medscape.com/article/756835-overview. Accessed on: 12 August 2010.
  5. ↑ 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.
  6. ↑ 6.0 6.1 Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 7. ISBN 978-1416002741.
  7. ↑ URL: http://library.med.utah.edu/WebPath/IMMHTML/IMM028.html. Accessed on: 11 May 2011.
  8. ↑ 8.0 8.1 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.
  9. ↑ 9.0 9.1 9.2 Hata, D. (Sep 2001). "Fibromuscular dysplasia.". Intern Med 40 (9): 978-9. PMID 11579971.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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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