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CARDIOVASCULAR PATHOLOGY

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Myocardial Infarction. Diseases of Veins & Lymphatics. ANEURYSM ... May see thrombosis, aneurysm, and myocardial infarction. Possible viral etiology ... – PowerPoint PPT presentation

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Title: CARDIOVASCULAR PATHOLOGY


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 Marfans 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
  • Kawasakis disease
  • Hypersensitivity vasculitis
  • Giant cell arteritis (Temporal arteritis)
  • Takayasus arteritis
  • Buergers disease
  • Wegeners 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
KAWASAKIS 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
  • FemaleMale, 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
TAKAYASUS ARTERITIS
  • FemaleMale, 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
BUERGERS DISEASE
  • Also called thromboangitis obliterans
  • Related to cigarette smoking, 25-50 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
WEGENERS 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
  • Wegeners 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-Trousseaus 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
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