1. CARDIOVASCULAR PATHOLOGY
Tutorial I
William H. Luer M.D.

2. TOPICS Aneurysms Embolism Vasculitides Myocardial Infarction
Diseases of Veins & Lymphatics

3. ANEURYSM An abnormal dilatation of an artery or vein
Caused by weakened vessel wall from:
Congenital defect
Systemic disease
Atherosclerosis
Infection
Trauma

4. SHAPES OF ANEURYSMS
Saccular
Fusiform
Cylindroid
Berry

5. 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

6. Aorta
Aneurysm with
thrombus
Kidney
Kidney
Atherosclerotic Abdominal Aortic Aneurysm

7. 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

8. Aortic Valve
Aneurysm
Syphilitic Aneurysm – Ascending Arch of Aorta

9. MYCOTIC ANEURYSM Bacterial infection weakens vessel wall
Associated with sepsis, bacterial endocarditis
May involve aorta or cerebral, renal, mesenteric, and splenic arteries

10. 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

11. 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

12. 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 Marfan’s syndrome

13. Dissection
Aorta
Aortic Valve
Ascending Aorta – Dissecting Aneurysm

14. 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

15. Brachial artery
Pseudoaneurysm with
blood clot
Axillary fat
Axilla –Pseudoaneurysm, stab wound severed brachial artery

16. EMBOLISM
The occlusion of a vessel by an object, the embolus, that has been transported to the site of occlusion, through the cardiovascular system.

17. TYPES OF EMBOLI Thromboemboli Bone marrow emboli Fat emboli Air emboli
Amniotic fluid emboli
Foreign body emboli

18. 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

19. 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

20. 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

21. 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

22. Coiled Embolus in Pulmonary Artery

23. Pulmonary Emboli removed from Pulmonary Artery

24. CASE OF PULMONARY INFARCT
Next photograph is from an elderly male in congestive heart failure
He experienced sudden pleuritic chest pain followed by hemoptysis

25. Pulmonary
infarct with
hemorrhage
Embolus
Lung
Lung – Pulmonary Infarct

26. 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

27. Greenfield Filter in Inferior Vena Cava with Trapped Emboli

28. 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

29. VASCULITIDES Polyarteritis nodosa
Allergic granulomatosis of Churg & Strauss
Kawasaki’s disease
Hypersensitivity vasculitis
Giant cell arteritis (Temporal arteritis)
Takayasu’s arteritis
Buerger’s disease
Wegener’s granulomatosis

30. 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

31. 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

32. 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

33. KAWASAKI’S DISEASE Most have heart involvement
See necrotizing vasculitis of coronary arteries (lesions resemble PN)
May see thrombosis, aneurysm, and myocardial infarction
Possible viral etiology

34. 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

35. 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

36. GIANT CELL ARTERITIS (GCA)
Also called temporal arteritis
Female>Male, 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

37. 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

38. GCA: CLINICAL Weakness, malaise, fever, weight loss, headache
Can become chronic, usually resolves
Can affect sight if involves ocular vessels

39. TAKAYASU’S ARTERITIS Female>Male, 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

40. BUERGER’S DISEASE Also called thromboangitis obliterans
Related to cigarette smoking, 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

41. WEGENER’S 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

42. “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

43. CHARACTERISTIC
Affects post capillary venules in skin producing a palpable purpura

44. ANSWER
Hypersensitivity (Leukocytoclastic) Vasculitis

45. CHARACTERISTIC
Facial pain, headache, fever, fatigue, weight loss, in an elderly female

46. ANSWER
Giant Cell (Temporal) Arteritis

47. CHARACTERISTIC Gastrointestinal bleeding Renal failure Fever
+ p-ANCA (perinuclear antineutrophil cytoplasmic antibody)
Vessel biopsy: transmural necrotizing acute inflammation of vessel wall

48. ANSWER
Polyarteritis Nodosa

49. CHARACTERISTICS Necrotizing granulomas in respiratory tract
Necrotizing granulomatous vasculitis in lungs
Necrotizing cresentric glomerulonephritis
+ c-ANCA (cytoplasmic diffuse anti-neutrophil cytoplasmic antibody)

50. ANSWER
Wegener’s Granulomatosis

51. MYOCARDIAL INFARCTION
Topic covered in lecture
Case study discussed in tutorial

52. DISEASES OF VEINS
Varicose Veins
Thrombophlebitis

53. VARICOSE VEINS
Legs: associated with pregnancy, increasing age, and can be familial
Hemorrhoids: associated with pregnancy and cirrhosis
Esophageal varices: associated with cirrhosis

54. COMPLICATIONS OF VARICSOSE VEINS
Pain
Stasis
Thrombosis
Bleeding

55. 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-Trousseau’s sign)

56. 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

57. CARDIOVASCULAR PATHOLOGY
Tutorial I
The End