1. Vascular diseases: Varicose veins, DVT and Aneurysms CVS6
Dr Hisham Alkhalidi

2. Lecture 6 Diseases of arteries and veins:
Pathology of varicose veins, thrombophlebitis and deep vein thrombosis.
Definition of aneurysm, types and aetiology of aneurysms.

3. Varicose Veins
Legs, testis,

4. Varicose Veins
Abnormally dilated, tortuous veins produced by prolonged increase in intraluminal pressure and loss of vessel wall support
The superficial veins of the lower leg, venous pressures in these sites can be markedly elevated
10% to 20% of adult males
25% to 33% of adult females
Thrombosis is common but not clinically significant
Valve incompetence rule
Haemorrhoides and esophageal varices

5. Varicose Veins Increased risk: Obesity Hereditary Proximal thrombus
Proximal compression (e.g. tumor)
legs are dependent for long periods
Higher incidence in women (pregnancy)

6. Varicose Veins Complications Stasis dermatitis Delay healing
Stasis, edema, trophic skin
Varicose ulcers

7. Stasis dermatitis
Varicose ulcer

9. DVT
The deep leg veins account for more than 90% of cases of phlebothrombosis
Other sites include:
The periprostatic venous plexus in males
The pelvic venous plexus in females
The large veins in the skull and the dural sinuses (especially in the setting of infection or inflammation)
thrombophlebitis and phelbothrombosis
the two terms are largely interchangeable designations for venous thrombosis and inflammation.
Portal tracts
Popliteal, femoral, and iliac veins
Superficial saphenous vein
Not clinically significant

10. DVT Predisposing factors: Congestive heart failure Neoplasia Pregnancy
Obesity
Postoperative state
Prolonged bed rest
Genetic hypercoagulability syndromes

11. DVT
Trousseau sign:
In patients with cancer, particularly adenocarcinomas, hypercoagulability occurs as a paraneoplastic syndrome related to tumor elaboration of procoagulant factors
In this setting, venous thromboses classically appear in one site, disappear, and then reoccur in other veins, so-called migratory thrombophlebitis (Trousseau sign)
Association with NBTE

12. DVT 50% clinically silent. Local manifestations: Distal edema Cyanosis
Superficial vein dilation
heat, tenderness, redness, swelling and pain
Sometimes, the first manifestation of thrombophlebitis is a pulmonary embolus
Depending on the size and number of emboli, the outcome can range from no symptoms at all to death

14. localized abnormal dilation of a blood vessel or the heart
ANEURYSMS
localized abnormal dilation of a blood vessel or the heart

15. ANEURYSMS

16. Thrombosis

17. ANEURYSMS
The two most important disorders that predispose to aortic aneurysms are:
atherosclerosis (abdominal aorta)
hypertension (ascending aorta)
Other causes of aneurysms:
Trauma
Congenital (berry aneurysms in the circle of Willis)
Infections (mycotic aneurysms, syphilis)
Vasculitides
cystic medial degeneration of the arterial media was from the two most common cause on this slide

18. ANEURYSMS Mycotic aneurysm may originate either from:
embolization and arrest of a septic embolus at some point within a vessel, usually as a complication of infective endocarditis
an extension of an adjacent suppurative process
circulating organisms directly infecting the arterial wall

19. ANEURYSMS Complications Rupture Hemorrhage
Occlusion of proximal vessels
Embolism

20. ANEURYSMS abdominal aortic aneurysm (AAA):
More in men and rarely develops < 50 years
Abdominal aorta is the main location but the common iliac arteries, the arch and descending parts of the thoracic aorta can be involved
Below the renal arteries and above the bifurcation of the aorta
Atherosclerosis, rule of genetics or HTN
Additional reading:
Inflammatory AAAs are characterized by dense periaortic fibrosis containing abundant lymphoplasmacytic infiltrate with many macrophages and often giant cells. Their cause is uncertain. Mycotic AAAs are atherosclerotic lesions infected by lodging of circulating microorganisms in the wall, particularly in the setting of bacteremia from a primary Salmonella gastroenteritis. In such cases, suppuration further destroys the media, potentiating rapid dilation and rupture.

21. ANEURYSMS abdominal aortic aneurysm (AAA): Risk of rupture:
11% per year for aneurysms between 5.0 and 6 cm in diameter
Operative mortality for unruptured aneurysms is approximately 5%, whereas emergency surgery after rupture carries a mortality rate of more than 50%
As a reflection of the systemic nature of ATH and its complications, patients with AAAs are also at significantly increased risk for myocardial infarction and stroke.

22. ANEURYSMS SYPHILITIC (LUETIC) ANEURYSMS:
The obliterative endarteritis of the the vasa vasorum of the thoracic aorta can lead to aneurysmal dilation that can include the aortic annulus
Ascending aorta and arch
May cause aortic valve ring dilation -> valvular insufficiency -> ventricular wall hypertrophy, sometimes to 1000 gm "cor bovinum" (cow's heart)
Tertiary stage of syphilis
Causes ischemic injury of the aortic media, with patchy loss of the medial elastic fibres and muscle cells followed by inflammation and scarring. With destruction of the media, the aorta loses its elastic recoil and may become dilated, producing a syphilitic aneurysm. Contraction of fibrous scars may lead to wrinkling of intervening segments of aortic intima, noted grossly as "tree-barking." 

23. SYPHILITIC (LUETIC) ANEURYSMS
Widening of the commissures between the cusps, and turbulence-induced thickening and rolling of the free margins.
Talk about complications of compression, cough, SOB, Swallowing, bone…, rupture
Most patients with syphilitic aneurysms die of heart failure induced by aortic valvular incompetence

25. Dissecting hematoma
defective fibrillin production in Marfan disease affects elastic tissue synthesis;

30. Dissecting hematoma Causes Hypertension Connective tissue defects
Cannulation or other trauma
Preganancy
Hypertension years
Rarely, for unknown reasons, dissection of the aorta or other branches, including the coronary arteries, occurs during or after pregnancy.
unusual in the presence of substantial atherosclerosis or other causes of medial scarring,

31. Types Type A is associated with serious complications
Type A COMMON and Dangerous
Type B distal to subclavian

32. Dissecting hematoma Clinical picture
sudden onset of excruciating pain:
usually beginning in the anterior chest
radiating to the back between the scapulae
moving downward as the dissection progresses
Previously, aortic dissection was typically fatal, but the prognosis has markedly improved. Rapid diagnosis and institution of intensive antihypertensive therapy, coupled with surgical procedures involving plication of the aorta permits survival of 65% to 75% of patients.

33. Dissecting hematoma Clinical picture
cardiac tamponade
aortic insufficiency
myocardial infarction
extension of the dissection into the great arteries of the neck or into the coronary, renal, mesenteric, or iliac arteries
causing critical vascular obstruction; compression of spinal arteries may cause transverse myelitis