BLOOD VESSELS Flashcards
- What is the risk of rupture of abdominal aortic aneurysm if it is more than 6cms
a. 1%
b. 10%
c. 20%
d. 25%
Rationale: [d] 25%- larger than 6cm . Risk of rupture is directly related to the size of aneurysm (size is directly proportional to degree of rupture): 1%- 4-5cm; 11%- 5-6cm; 25%- larger than 6cm; 20%- expands rapidly (0.2-0.3cm/yr.)
- All vessels have a three-layered architecture, consisting of an intima, tunica media and adventitia, except:
a. veins
b. aorta
c. arterioles
d. capillaries
[d] capillaries. They have an endothelial lining but without tunica media and with variable number of pericytes
- Which form of Kaposi Sarcoma is associated with HHV8?
a. Classic KS
b. Endemic KS
c. Epidemic KC
d. Transplant associated KS
A. Chronic, Classic or European KS: Associated with a second malignant tumor or altered immune state but NOT associated with HIV.
B. Lymphadenopathic, African or Endemic KS: Localized or generalized lymphadenopathy and disorder occasionally involves the viscera.
C. AIDS associated (epidemic) KS: HHV 8.
D. Transplant Associated KS: Post op in solid organ transplant recipients who receive high doses of immunosuppressive therapy.
- A 23 years old man presents with fever, weight loss,
malaise, abdominal pain, and myalgias. Work up reveals that the patient has polyarteritis nodosa (PAN) . Which of
the following is associated with this form of vasculitis?
a. Chlamydia
b. Hepatitis B
c. HHV8
d. HIV
[b] Hepatitis B. Vasculitis secondary to infections. Antibodies to microbial constituents can form immune complexes that circulate and deposit in vascular lesions. In up to 30% of patients
with polyarteritis nodosa, the vasculitis is attributable to immune complexes composed of hepatitis B surface antigens (HBsAg) and anti-HBsAg antibody.
- 19 years old women presents with fever, malaise, myalgias and arthritis and “coldness” in her upper extremities. She has a weak radial pulse. Angiography shows stenosis of the aorta. Which among the following rheumatic condition does
the patient have?
a. Buerger Disease
b. kawasaki Disease
c. Reynaud disease
d. Takayasu disease
[d] Takayasu disease/arteritis characterized by ocular disturbances and marked weakening of pulses in the upper extremities (pulseless disease) classically involves the aortic arch with pulmonary, coronary and renal artery involvement.
This condition is the result from exaggerated vasoconstriction of digital arteries and arteriole and there paroxysmal pallor of the hands and feet.
a. Buerger Disease
b. kawasaki Disease
c. Reynaud Phenomenon
d. Takayasu disease
[c] Reynaud phenomenon is an exaggerated vasoconstriction resulting in red, white and blue discoloration proximal to distal. Buerger disease or Thromboangitis obliterans is a segmental thrombosing acute and chronic inflammation of tibial and radial artery almost exclusively to heavy smoker less than 35 y.o. Kawasaki disease is the leading cause of acquired heart disease in children with anti-endothelial antibody. While Takayasu disease also known as pulseless disease is a granulomatous vasculitis with ocular disturbance and marked weakening of pulse in upper extremities.
- This vasculitis is almost exclusive to heavy smokers less than 35 y/o
a. Buerger Disease
b. kawasaki Disease
c. Reynaud Phenomenon d. Takayasu disease
[a] Buerger disease or Thromboangitis obliterans is a segmental thrombosing acute and chronic inflammation of tibial and radial artery almost exclusively to heavy smoker less than 35 y.o. Reynaud phenomenon is an exaggerated vasoconstriction resulting in red, white and blue discoloration proximal to distal. Kawasaki disease is the leading cause of acquired heart disease in children with anti-endothelial antibody. While Takayasu disease also known as pulseless disease is a granulomatous vasculitis with ocular disturbance and marked
weakening of pulse in upper extremities.
- What are the antibodies present in the following vasculitis?
Churg-strauss
a. MPO ANCA
b. PR3 ANCA
c. Anti-endothelial antibodies
a. MPO ANCA
- What are the antibodies present in the following vasculitis?
Kawasaki Disease
a. MPO ANCA
b. PR3 ANCA
c. Anti-endothelial antibodies
c. Anti-endothelial antibodies
- What are the antibodies present in the following vasculitis?
Granulomatosis with Polyangitis
a. MPO ANCA
b. PR3 ANCA
c. Anti-endothelial antibodies
b. PR3 ANCA
- This type of vessels provides conduit to return interstitial tissue fluid and inflammatory cells to the bloodstream.
a. Post capillary venules
b. lympathics
c. arterioles
d. small artery
b. LYMPHATICS
are Thin-walled channels lined by
specialized endothelium. Returns interstitial tissue fluid and inflammatory cells to the blood stream. Can also transport microbes and tumor cells, thus constituting an important potential pathway for disease dissemination.
- This vasculitis is almost exclusive to heavy smokers less than 35%
a. Buerger disease
b. Kawasaki disease
c. Reynaud phenomenon
d. Takuyasu dise
Buerger’s disease (also known as thromboangiitis obliterans) affects blood vessels in the body, most commonly in the arms and legs. Blood vessels swell, which can prevent blood flow, causing clots to form. This can lead to pain, tissue damage, and even gangrene (the death or decay of body tissues). The exact cause of Buerger’s disease is unknown, however tobacco use is strongly linked to its development. Researchers believe that chemicals in tobacco may irritate the lining of the blood vessels, causing them to swell. Almost everyone diagnosed with Buerger’s disease smokes cigarettes or uses other forms of tobacco, such as cigars and chewing tobacco.
dislodge thrombosis which may lead to stroke when lodge to the blood vessels of the brain
Embolism
mainly elastic and muscular arteries
ATHEROSCLEROSIS
small muscle arteries and arterioles
HYPERTENSION
- derived from mesoderm which will differentiate to single layer epithelium to allow diffusion of oxygen and nutrients
TUNICA INTIMA
- Innermost layer of the vessel
TUNICA INTIMA
- Normally consists of a single layer of endothelial cells - These cells sit in basement membrane
TUNICA INTIMA
- is distinct from the media by internal elastic
lamina
TUNICA INTIMA
- thick layer
- Concentric layers of smooth muscle cells
TUNICA MEDIA
- Veins - arranged haphazardly
- Media of elastic arteries (e.g., Aorta) - has high
elastin content allowing these vessels to expand during systole and recoil during diastole, a property that serves to propel the blood towards the tissues - Media of muscular arteries- predominantly circumferentially arranged smooth muscle cells
TUNICA MEDIA
are the principal point of physiologic resistance to blood flow
Arterioles
- Outermost layer of vessel
- External to the media and is separated by external elastic
lamina - Loose connective tissue containing nerve fibers and the
vasa vasorum
TUNICA ADVENTITIA
literally “vessels of the vessels”
VASA VASORUM
Approximately the diameter of an RBC (7-8um) – capillaries are smaller than this about 5um
They have an endothelial lining but without tunica media and with variable number of pericytes
CAPILLARIES
Have large diameter, large lumen, thin wall
Has the capacity to contain about 2/3 of the circulating blood
Reverse flow (due to gravity) is prevented in the extremities
by venous valves.
VEIN
Thin-walled channels lined by specialized endothelium
Returns interstitial tissue fluid and inflammatory cells to the blood stream
Can also transport microbes and tumor cells, thus constituting an important potential pathway for disease dissemination
LYMPHATIC
Developmental or berry aneurysm
- Occur in 2 cerebral vessels namely:
- ACOM - ANTERIOR COMMUNICATING ARTERY
- ACA - ANTERIOR CEREBRAL ARTERY
- Direct connections between an artery and vein
- can shunt blood from arterial to venous side
AV FISTULA
ARTERIOVENOUS FISTULA
- Focal irregular thickening in medium and large
muscular arteries, including renal, carotid,
splanchnic and vertebral vessels
FIBROMUSCULAR DYSPLASIA
- Segments of the vessel wall are focally thickened by a combination of intimal and medial hyperplasia and fibrosis resulting in stenosis
FIBROMUSCULAR DYSPLASIA
It is a medical procedure which gives a contrast media or a dye and by utilizing radiologic imaging it yields a rosary like appearance or string of beads appearance.
ANGIOGRAPHY
-FIBROMUSCULAR DYSPLASIA
- Specialized lining of blood vessels (found in tunica intima)
- Fenestrated and impermeable
- They have several constitutive activities that are critical for vessel homeostasis and circulatory function
ENDOTHELIAL CELLS
- Endothelial cells can respond to various stimuli by adjusting their steady-state (constitutive) functions and by expressing newly acquired (inducible) properties
ENDOTHELIAL ACTIVATION
- Regulated predominantly at the level of the arterioles
by neural and hormonal inputs.
PERIPHERAL RESISTANCE
- Have the ability to proliferate (to prevent any further
damage of the injury but narrowing the lumen of the
blood vessel) - Synthesizes collagen, elastin, proteoglycans and elaborate growth factors and cytokines
- Responsible for vasoconstriction and vasodilation
VASCULAR SMOOTH MUSCLES
VASCULAR PATHOGENESIS OF HYPERTENSION
It is associated with 2 forms of blood vessel disease:
It is associated with 2 forms of blood vessel disease:
1. HYALINE ARTERIOSCLEROSIS
2. HYPERPLASTIC ARTERIOSCLEROSIS
- Arterioles show homogenous pink hyaline thickening
associated with luminal narrowing - Reflect both plasma protein leakage across the injured
endothelial cell and increased matrix synthesis of smooth
muscle
HYALINE ARTERIOSCLEROSIS
- A common feature of diabetic microangiography AND neprosclerosis
HYALINE ARTERIOSCLEROSIS
- In severe hypertension, exhibits concentric laminated
thickening of the walls with luminal narrowing - Laminations consist of smooth muscle with thickened,
reduplicated basement membrane.
HYPERPLASTIC ARTERIOSCLEROSIS
necrotizing arteriolitis and onion skinning
HYPERPLASTIC ARTERIOSCLEROSIS
- is the most insignificant form of arteriosclerosis (atherosclerosis and arteriosclerosis are significant because of arterial luminal narrowing).
- It is more common in the elderly.
MOCKENBERG MEDIAL SCLEROSIS
[M-M-S]
you have these purplish calcifications and the lumen appears unaffected. Incidental finding. The process would be, if there are risk factors as in the Virchow’s triad, other areas like the neck and the lymph will be involved.
MOCKENBERG MEDIAL SCLEROSIS
Accumulation of lipid in the vascular wall
ATHEROSCLEROSIS
ATHEROSCLEROSIS
Constitutional Risk Factors (Non-modifiable)
- GENETICS
- AGE(40 ABOVE)
- GENDER (premenopausal women are protected
ATHEROSCLEROSIS
Modifiable Risk Factors
**HYPERLIPIDEMIA
o Hypertension
o Cigarette smoking
o Inflammation
o Hyperhomocystenemia
o Metabolic Syndrome
o Lipoprotein A- an altered form of LDL. Associated
with MI and CVD
PATHOGENESIS OF ATHEROSCLEROSIS
- ENDOTHELIAL INJURY AND DYSFUNCTION
- LIPOPROTEINS ACCUMULATION
- MONOCYTE ADHESION TO THE EPITHELIUM
- PLATELET ADHESION
- FACTOR RELEASE FROM ACTIVATED PLATELETS
- SMOOTH MUSCLE PROLIFERATION, ECM PRODUCTION
- FURTHER LIPID ACCUMULATION
In a nutshell, endothelium is good, media, intima adventitia but if you have hypertension,
endothelium will be damaged that would trigger the recruitment of your macrophage plus the addition of your platelet, secretion of your inflammatory cytokines
In a nutshell, endothelium is good, media, intima adventitia but if your patient is hyperlipidemic, smoker,
it will lead to atherosclerosis.
Principal point of physiologic resistance to blood flow
ARTERIOLES
They have an endothelial lining but without tunica media
and with variable number of pericytes
CAPILLARY
Focal irregular thickening in medium and large muscular
arteries, including renal, carotid, splanchnic and vertebral vessels
FIBROMUSCULAR DYSPLASIA
BP of greater than or equal to 200/120 mmHg
MALIGNANT HYPERTENSION
Arterioles show homogenous pink hyaline thickening
associated with luminal narrowing
HYALINE ARTERIOSCLEROSIS
A localized abnormal dilatation of blood vessel or the heart that may be congenital or acquired.
ANEURYSM
Occurs when blood separates the laminar planes of the
media to form a blood-filled channel within the aortic walls
AORTIC DISSECTION
Vessel wall inflammation
VASCULITIS
Granulomatous vasculitis of medium and larger arteries
characterized principally by ocular disturbances and marked
weakening of pulses in upper extremities, hence, the name
pulseless disease.
TAKAYASU ARTERITIS
A small to medium sized vessel neutrophilic vasculitis that
classically presents as a clinical triad of recurrent oral aphthous
ulcers, genital ulcers and uveitis
BEHCET DISEASE
Tumors have a preference to travel through
Veins
Favorite transport route of metastatic cancers.
LYMPHATIC
For example a person had a wound caused by an abrasion:
● The endothelium would start to bleed then produce cytokines.
● The cytokines would then cause:
○ Inflammation
○ Hypotension
○ Hemorrhagic Shock
● Stereotyped response to vascular injury.
● Formation of neointima
INTIMAL THICKENING
● Stereotyped response to vascular injury.
○ Smooth muscle recruitment.
○ Smooth muscle proliferation
○ Matrix synthesis
Most Important Determinant of Stroke Volume
FILLING PRESSURE
○ Heart rate and myocardial contractility: Regulated by:
ɑ- and β- adrenergic systems.
Dilators
- Prostaglandin
- Kinins
- NO (Nitric Oxide)
Examples of hypertensive drugs are
ACE INHIBITORS
RELATIONSHIP OF PERIPHERAL RESISTANCE AND BP
Increased Peripheral Resistance = Increased BP
● Neural Factors: (what is constrictor/dilator?)
○ ɑ- androgenic -
○ β- adrenergic -
○ ɑ- androgenic (constriction)
○ β- adrenergic (dilator)
● Local Factors:
○ Autoregulation
○ pH
○ Hypoxia
WHERE IS Angiotensinogen
LIVER
WHERE IS Angiotensin Converting Enzyme
LUNGS
If a patient has High Blood, a non-pharmacologic solution to treat them would be
decreasing the salty food intake
○ Inadequate organ perfusion.
○ Can lead to tissue dysfunction or death.
Low Blood Pressure (hypotension)
○ Can cause end-organ damage.
○ Can damage capillaries like in kidneys.
High Blood Pressure (hypertension)
Fibrinoid deposits and
vessel wall necrosis (necrotizing arteriolitis).
MALIGNANT HYPERTENSION
● From the greek root words: “gruel” and “hardening”
● Most frequent and clinically important pattern.
ATHEROSCLEROSIS
consists of a raised lesion with a soft grumous core of lipid (mainly cholesterol and cholesterol esters) covered by a fibrous cap.
ATHEROMATOUS PLAQUE
smooth muscle cells, macrophages, foam cells, lymphocytes, collagen, elastin, proteoglycans, neovascularization and there will be new blood vessel formation).
FIBROUS CAP
cell debris, cholesterol crystals, foam cells, calcium - too thick so the vasa vasorum cannot meet their metabolic demands so they will eventually die, so it will be forming cholesterol crystal, debris, and foam cells
NECROTIC CENTER
● Composed of lipid-filled foamy macrophages.
● Begins as multiple minute flat yellow spots.
● Eventually coalesce into elongated streaks 1 cm
long or longer.
● These lesions are not sufficiently raised to cause any
significant flow disturbances.
● Can evolve into plaques.
● not all are destined to become advanced lesions.
FATTY STREAKS
● Key processes: intimal thickening and lipid
accumulation .
● White-yellow
● Encroach (protrude) on the lumen of the artery.
ATHEROSCLEROTIC PLAQUE
it’s a stage wherein the
occlusion is around 70%; with this degree of stenosis, chest pain may develop with exertion (so-called stable angina).
CRITICAL STENOSIS
can lead to aneurysm and rupture.
Mural thrombosis
embolization
wall weakening
Most important causes of aortic aneurysms:
1.ATHEROSCLEROSIS (AAA)
2.HYPERTENSION (TAA)
Attenuated but intact arterial wall or thinned ventricular wall of the heart.
TRUE ANEURYSM
Spherical outpouchings involving
only a portion of the vessel wall.
SACCULAR
Diffuse, circumferential dilations of a long vascular segment.
FUSIFORM
Defect in the vascular wall leading to an extravascular hematoma that freely communicates with the intravascular
space (pulsating hematoma”).
FALSE ANEURYSM
Most common sites of atherosclerotic aneurysms:
ABDOMINAL AORTA
COMMON ILIAC ARTERIES
ABDOMINAL AORTIC ANEURYSM usuallylocated:
below the renal arteries
above the bifurcation of the aorta
in aortic dissection whatare more common and are more dangerous.
PROXIMAL LESIONS
● Giant cell arteritis
● Takayasu arteritis
● Kawasaki disease
● Granulomatosis with polyangiitis
Autoreactive T-cells
● Systemic lupus erythematosus (SLE)
● Drug Hypersensitivity
● Polyarteritis nodosa (PAN)
Immune complex deposition
LARGE VESSEL
● Giant Cell Arteritis
● Takayasu Arteritis
LARGE - GT
MEDIUM VESSEL
● Polyarteritis Nodosa (PAN)
● Kawasaki Disease
MEDIUM - PK
NEUTROPHILIA
BEHCET DISEASE
Most common form of vasculitis among older individuals.
GIANT CELL ARTERITIS
- Segmental transmural necrotizing inflammation.
- Mixed infiltrate of neutrophils, eosinophils, and mononuclear cells.
- Fibrinoid necrosis.
Polyarteritis Nodosa (PAN)
- Necrotizing glomerulonephritis
(90% of patients will have a
problem in the kidneys) - As well as the pulmonary capillaritis
Associated with MPO-ANCA.
Microscopic Polyangiitis
TRIAD
Necrotizing granuloma
Necrotizing or granulomatous vasculitis (most prominent in the lungs)
Focal necrotizing, glomerulonephritis - often crescentic.
○ (+) PR3-ANCA also known as CANCA previously.
Granulomatosis with Polyangiitis
Wegener granulomatosis.
HYPEREOSINOPHILIA
MPO-ANCA
Churg-Strauss Syndrome
○ Small- to medium-vessel neutrophilic
vasculitis, this one needs to haveneutrophil
○ TRIAD:
- Recurrent oral aphthous ulcers
- Genital ulcers (presence of“butlig”)
- Uveitis
○ Associated with certain HLA haplotypes
(HLA-B51).
○ TH17 cells recruit neutrophils which
infiltrate the vessel walls.
BEHCET DISEASE
- Focal acute and chronic vasculitis of small- and medium-sized arteries, predominantly of the extremities.
- Luminal thrombosis with small microabscesses
BUERGER DISEASE
● Direct invasion of infectious agents.
○ Positive agent like usually bacteria
(Pseudomonas) or fungi (Aspergillus and Mucor)
● Part of a localized tissue infection.
○ Bacterial pneumonia or adjacent to
abscesses.
INFECTIOUS VASCULITIS
coronary arteries and myocardial arterioles
Myocardial Vessel Vasospasm
-Exaggerated central and local vasomotor responses to cold or emotion
-Symmetric involvement of the extremities
-Extent and severity: static
Primary Raynaud Phenomenon
-Due to arterial disease caused by other entities: SLE, scleroderma, Buerger disease, atherosclerosis
-Asymmetric involvement of the extremities
-Extent and severity: progressively worsen
Secondary Raynaud Phenomenon
● Vasospasm of cardiac arterial or arteriolar beds has been called cardiac Raynaud and in a subset of cases leads to Prinzmetal angina (angina due to vasospasm).
● Intrinsic hyper-reactivity of medial smooth muscle cells.
● Vasoactive mediators can also precipitate prolonged myocardial vessel contraction.
MYOCARDIALVESSELVASOSPASM
pain elicited on forced dorsiflexion of the foot.
HOMAN SIGN
Most common serious clinical complication of DVT
PULMONARY EMBOLISM
○ Venous thrombosis appears in one location, disappears, and then occurs in another site.
○ Hypercoagulability occurs as a paraneoplastic syndrome related to elaboration of procoagulant factors by
tumor cells (adenocarcinomas).
Migratory thrombophlebitis (Trousseau sign)
● Acute inflammation elicited by bacterial infection into lymphatics
● Most common cause
○ Group A B-hemolytic streptococci
LYMPHANGITIS
Peau d’orange (orange peel) appearance due to persistent edema and subsequent deposition of interstitial connective tissue.
LYMPHEDEMA
○ Most common form of vascular ectasia.
○ Most ultimately regress spontaneously.
Nevus flammeus (birthmark)
○ Radial arrays of dilated subcutaneous arteries about a central core.
○ Most frequently associated with hyperestrogenic states.
Spider telangiectasia
Port wine stain
Sturge-Weber syndrome
Hereditary hemorrhagic telangiectasia
Osler-Weber-Rendu disease
Cavernous hemangioma
Von Hippel-Lindau disease
Cystic hygroma
Turner disease
● Tumors arising from modified smooth muscle cells
of the glomus bodies (arteriovenous structures
involved in thermoregulation).
● Benign but exquisitely painful.
GLOMUS TUMOR
- A necrotizing granulomatous disorder of lymph nodes) in immunocompetent hosts like those who have HIV.
- Bartonella henselae
Cat-scratch disease
Trench fever” in World War I.
Bartonella quintana
● Not associated with HIV.
● Multiple red-purple skin plaques or nodules, usually
in the distal lower extremities;
CLASSIC Kaposi sarcoma
● HIV-seronegative.
● A particularly severe form, with prominent lymph
nodes and visceral involvement, occurs in prepubertal children; prognosis is poor, with an almost 100% mortality within 3 years.
ENDEMIC AFRICAN Kaposi sarcoma
Solid organ transplant recipients in the setting of
T-cell immunosuppression
TRANSPLANT-ASSOCIATED Kaposi sarcoma
● AIDS defining illness.
● Most common HIV-related malignancy
● Involves lymph nodes and disseminates widely to
viscera early in its course.
AIDS-ASSOCIATED Kaposi sarcoma (epidemic)
● Intermediate gray tumor.
● Spectrum of vascular neoplasms with clinical
T-cell immunosuppression.
behaviors intermediate between well-differentiated hemangiomas and anaplastic angiosarcomas.
HEMANGIOENDOTHELIOMA
● Malignant endothelial neoplasm that primarily affects older adults.
● Most commonly involves skin, soft tissue, breast, and liver.
ANGIOSARCOMA
marker for blood vessels
CD31
● Considered as tumors that arise from pericytes, the
myofibroblast-like cells associated with capillaries
and venules.
● Recent studies suggest that tumors of pericytes are
very rare.
HEMANGIOPERICYTOMA
