Blood Vessels Lecture Flashcards
most common caused of death in untreated HTN
1/2 die of ischemic heart dz or congestive heart failure
-another 1/3 die of stroke second to mult-infarcts in the brain
Common traits of Abdominal Aortic aneurysm (AAA)
-mainly due to atherosclerosis
nevus flammeus vs port wine stain
nevus - “birthmark” vascular ectasia (local dilation of structure) that is flat and usually regresses with time
-port wine stain is a special type of nevus that grows during childhood, thickens, and is permanent (no fading over time)
what is Takotsubo Cardiomyopathy
“broken heart syndrome”
- myocardial vessel vasospasm associated with emotional stress
- can cause sudden cardiac death from ischemia or infarct of the heart
two most important causes of aortic aneurysm is
atherosclerosis and HTN
what factors can cause activation of endothelium to prothrombogenic state? and expression of what is increased in this state?
caused by: HTN , cytokines, lipid products, cig smoke, turbulent flow
expression: procoagulants, adhesion molecules, growth factors , cytokines, chemokines
primary vs secondary Raynauds phenomenon
primary (Raynaud DZ)- induced by cold or emotion
- symmetric
- young women
- benign
secondary - component of arterial dz (SLE, scleroderma, Beurgers)
- asymmetric
- progressive
when to use a synthetic graft vs a graft utilized from elsewhere in the body to treat vascular replacements
- large-bore synthetic graft works for high-flow locations (large arteries) like aorta; but cause thrombosis or intimal hyperplasia in small vessels
- saphenous vein and internal mammary a. used as small-bore grafts for coronary arteries
what is defined by the loss of elastic tissue , scarring, inadequate extracellular matrix synthesis, and increased production of ground substance (proteoglycans) seen bc smooth muscle cell loss of degenerative changes
cystic medial degeneration
“degenerative changes sometimes causes by medial ischemia”
what is thrombophlebitis and its most important risk factor
another name for DVT
-risk: LE prolonged inactivity/immobilization
where are cavernous lymphangiomas common
aka “cystic hygroma”
neck of turners syndrome patients
-responsible for “webbed neck” look
what is a double-barreled aorta
when an aortic dissection reenters through a second intimal tear causing the formation of a false vascular channel that saves the pt from a hemmorhage.
-the new channel can become endothelized and a recognizable chronic dissection
Wegener granulomatosis common features
- polyangitis noninfectious vasculitis of small vessels; T cell mediated hypersensitivity
- necrotizing granulomatous
- nasopharynx, lungs , kidneys
- sx: middle aged men with sinusitis, hemoptysis, hematuria
- focal necrotizing often cresenteric glomerulonephritis
- C-ANCA associated (PR3-ANCA)
- untx= fatal, survivors = chronic relapsing and remitting
- may have lung cavitations like TB
define hemangioma (or angioma)
- neoplasm defined by abnormal BV growth from the dilation or new formation of blood vessels
- common childhood tumors (neoplasms) marked by increased numbers of normal or abnormal vessel filled with blood.
- typically localized to head and neck
- most are congenital, increase initially, then regress spontaneously (“cherry angiomas” )
- malignant transmformation is rare
- if it diffuses proliferation and becomes extensive internally (esp to liver) it is called angiomatosis
Buerger DZ common features
- thromboangitis obliterans
- smoking dz
- necrotizing vasculitis of digits–> ulcers and gangrene
- digit amputation
- Raynauds Phenonmemon seen
what do drug-eluting stents incorporate to decrease risk of restenosis at 1yr compared to regular stents
release anti proliferative drugs targeting the smooth muscle cells
at risk population for aortic dissection
hypertensive males., age 40-60
what is Kawasaki Dz and common features of it
- noninfectious vasculitis of infants and small children
- often of the coronary a.
- can cause aneurysm –> acute MI in 4 yo
- sx: redness of eye, and oral mucosa, and rash on palms and soles , cervical LN enlarged
- tx: IVIg and Aspirin
define telangiectasia
permanent dilation of preexisting small vessels that form a discrete red lesion
*NOT TRUE NEOPLASMS
define bacillary angiomatosis
- vascular (capillary) proliferation in response to gram negative bartonella bacilli
- often in immunocompromised pts.
- form red papule,
- use warthrin-starry stain to identify bacteria
- tx with macrolide abx
define acute plaque change seen as a possible consequence to atherosclerosis
- an acute thrombus that may form over the plaque occluding the artery , or an hemorrhage of the plaque causing volume expansion and arterial occlusion
- can occur following rupture of the plaque or erosion/ulceration of the plaque surface
most common site of atherosclerosis
places with hemodynamic turbulence (opening of exiting vessels, branch points, posterior abdominal aorta)
define arterial dissection
blood entering an arterial defect in the arterial wall and causing a tunnel between its layers
what causes the kidney to release renin from the JG cells in the afferent arteriole
low blood volume, low resistance, renal artery stenosis, decreased GFR
main IL released during atherosclerosis
IL-1
what can result from a rupture of an arterial aneurysm into the adjacent vein ? and how can it be used surgically?
an AVM
-surgical fistula can provide vascular access for chronic hemodialysis
____ causes outer media ischemia of the aortic media from obliterative endarteritis to the vaso vasorum of the thoracic aorta causing aneurysmal dilation and possible aortic valve regurg
tertiary syphilis
classic presentation of aortic dissection
sudden onset of severe chest pain (anterior chest) radiating to the back between the scapulae and moving downward as the dissection progresses
-can be confused with AMI
Define a Berry “saccular” Aneurysm and its most common traits
- an aneursym that bulges from one side of an artery with a neck leading to it
- most commonly found near major branch points in the anterior circulation of the Circle of Willis, also in AD polycystic kidney Dz
- most frequent cause of subarachnoid hemorrhage
primary vs secondary lymphedema
primary- caused by isolated congenital defect of familial Milry Dz (lymphatic agenesis or hypoplasia)
secondary- caused by blockade of previously NL lymphatic , malignant tumor (breast cancer is common), mastectomy with node dissection, post-irradiation fibrosis, filariasis, ; peau d’ orange (orange peel) of skin overlying the breast cancer, where draining lymph is clogged with tumor cells. see chylous liquid from it
Giant cell (temporal) arteritis and aortitis common features
- affects large vessels
- T-cell mediated non-infectious vasculitis
- common site is branches off carotid A.
- sx: temporal HA , visual disturbance, jaw claudication, flu-like arthralgia, myalgia (polymyalgia arteritis), facal pain
- common population: most common vasculitis in older patients
- see giant cells, intimal fibrosis/thickening, medial granulomatous inflammation, elastic lamina fragmentation
- *unique ft = diplopia/ vision loss
- *negative biopsy does not rule out dx
define mycotic aneurysm
- a rare aneurysm caused by infected artery wall due to
1. embolization of septic emboli from infective endocarditis
2. direct infection from circulating organism
3. extension of adjacent suppurative process
define angiosarcoma
malignant endothelial tumor
- can be induced by radiation exposure,
- common sites: skin, soft tissue, breast, liver
- use CD31 or vWF markers for malignancy
plaque stability in atherosclerosis is related to the strength of the
fibrous cap (can be weakened by stress, , BP changes, or vasoconstriction )
common traits of fibromuscular dysplasia
- common in young women
- medial and intimal hyperplasia leads to luminal stenosis
- renovascular HTN can be causes by fibromuscular dysplasia of renal arteries
- “string of beads” on angiography
- can develop an aneurysm that may rupture
- NOT associated with oral contraceptive use
formula for BP and CO is
BP= CO x PVR CO= SV x HR (strongly influenced by BV regulated by sodium excretion)
what is the first response to vascular wall injury
endothelial cell activation and intimal thickening (neointmal response) by smooth muscle cells migration and proliferation in the intimal
- normalizing the injury can return the cells back to non-proliferative state
- ***smooth muscle cells are associated with atherosclerosis
obliterative endarteritis
- characteristic of late-stage (tertiary) syphilis*
- proliferative inflammation with predilection for small vessels of vasa vasorum of the thoracic aorta .
- leads to ischemic injury of aortic outer media and aneurysmal dilation
define pyogenic granuloma
- *NOT PYOGENIC OR A GRANULOMA
- is a capillary hemangioma, that presents as rapidly growing red resin on skin, gums, or oral mucosa
- they bleed easy and often ulcerate
- *granuloma gravidarum (pregnancy tumor) is common type that occurs rarely in gums of pregnant women
what is “cardiac Raynaulds”
myocardial vessel vasospasm - excessive contraction of myocardial arteries or arterioles may cause ischemia or infarct
- can be caused by vasoactive mediators (Epe, pheochromocytoma, or cocaine)
- outcome: sudden cardiac death possible
define epitheliod hemangioendothelioma
vascular tumor of adults, occur in med-large veins
- vascular channels cells begin to resemble epithelial cells,
- variable sx; 20-30% metastasize
define hyperplastic arteriolosclerosis
- occurs in severe malignant HTN
- smooth muscle cells form concentric lamellations (“onion skinning”) leading to luminal narrowing and possible ischemic injury
- can be accompanied by fibrinoid deposits and vessel wall necrosis (necrotizing arteriolitis) in the kidneys
hereditary hemorrhagic telangiectasia (osler-weber-rendu- dz)
AD DO, mutations in genes for TGF-B, congenital capillary and venous dilations (telangiectasias)
- in skin, moucus membranes, GI, and GU tracts
- spontanous rupture can occur causing serious epistaxis, GI bleeding, or hematuria
hepatic angiosarcoma associated with
arsenic, pesticide, throtrastm and PVC exposure (polyvinyl chloride)
microscopic polyangitis common features
- like Wegeners polyangitis
- has P-ANCA (or MPO-ANCA)
- only lungs and kidneys small vessels affected
- sx: hemotpysis , hematuria, proteinuria, palpable purpura
- apoptoic neutrophils seen (vs Churg Straus with esophinphila)
___ measurement can predict cardiovascular risk
C-reactive protein
aneurysms are usually managed surgically if greater than __cm
5cm
pathogenesis of varicose veins
sustained increase intraluminal pressure–>valvular dysfunction–>dilated veins
- complications: poor wound healing, infection, stasis dermatitis (pain and ischemia of overlying skin)
- usually in superficial LE veins therefore embolism is rare
risk of rupture in a saccular aneurysm
if >10mm diameter than it has 50% risk of bleeding per year
>6 mm = 25%
5-6cm = 11%
4-5 cm = 1%
<4 is negligible risk
-1/3 of ruptures associated with acute increases in intracranial pressure (straining at stool or sexual orgasm)
-repeat bleeding common in survivors
most common site of vasculitis
arterioles, venues, capillaries
capillary vs cavernous hemangioma
capillary- most common; occur in skin, sub q tissue, muous membranes of oral cavity, and lips, and maybe spleen, liver, kidneys.
-histologically = thin walled capillaries with scant storm
cavernous- large dilated vascular channels, more infiltrative and often involve deep structures, and do not spontaneously regress
- mass is unencapsultaed,with infiltrative borders
- intravascular thrombosis an and dystrophic calcifications are common
- usually little clinical significance, but cosmetically troublesome and vulnerable to traumatic ulceration/blessing
- part of VHL dz
how does atherosclerosis and HTN lead to an aneurysm
atherosclerosis - ischemia of the inner media due to plaque thickening of intimal increasing the distance of nutrient diffusion leads to weaker vascular wall
HTN- ischemia of outer media due to stenosing of vasa vasorum arterioles leads to weaker vascular wall
-medial ischemia leads to degenerative changes known as cystic medial degeneration
classic triad of Sx seen in Bechet Dz
- noninfectoius vasculitis of small vessels
1. ulcers of oral cavity
2. genital ulcers
3. uveitis - HLA-B51 associated
SVC syndrome vs IVC syndrome
*both are caused by neoplasm invasion/compression
SVC
-bronchogenic carcinoma, mediastinal lymphoma, or aortic aneurysm
-dilation of veins in head, neck, arms with cyanosis
-possible respiratory distress if Pulmonary A. compresses
IVC
- hepatocellular carcinoma, renal cell carcinoma,
- LE edema, distention of superficial collateral veins of lower abdomen
- if renal vein involved- mastic proteinuria
is Kaposi sarcoma malignant or benign
it is intermediate because not sure how it will respond
HTN is a major risk factor for
atherosclerosis, CHF, and renal failure caused by luminal stenosing and cardiac hypertrophy
-can also lead to aortic dissection or cerebrovascular hemmorhage
premenopausal women are somewhat protected by ____due to estrogen levels
atherosclerosis
most common site of aortic dissection
in the ascending aorta within 10cm of aortic valve
type A vs Type B Aortic Dissection
A- involves the ascending aorta and is more associated with morbidity and mortality
What part of the artery is responsible for blood pressure control
the arteriole
Sturge-weber syndrome
-facial port wine stain, ipsilateral venous angiomas in cortical leptomeninges, mental retardation, seizures, hemiplegia, abnormal skull
define glomus tumor
“glomangioma” or “paraganglioma”
- benign but painful tumors
- arise from smooth muscle cells (not endothelial cells like hemangioma)
- commonly found in distal part of digits
complications seen with thoracic aortic aneurysm
compression of respiratory tract, laryngeal nerves, and esophagus causes dyspnea, speech problems, and esophageal dysfunction
point of critical stenosis
70% occlusion, can lead to ischemia of organ system
what is migratory thomboplebitis
- paraneoplastic syndrome associated with mucin-producing adenocarcinomas (lung, ovary, pancreas)
- causes systemic hypercoagablity from mucin and can causes venous thrombi to appear at one site and disappear and reappear at another site
causes of non-infectious vasculitis
- immune system mediated inflammation
- immune complexes
- ANCA
- endothelial Abs
- autoreactivity - indirect infections
- trauma/injury
Common ft of Churg Straus syndrome
- small vessel necrotizing vasculitis, associated with asthma, allergic rhinitis, hyperesophinilia
- also has granulomas
- <1//2 have P-ANCA (MPO-ANCA)
what are malignant vascular tumor markers
CD31 or vWF
define malignant HTN
5% rapid increase in BP following with death in 1-2 years
- > 200/120
- causes renal failure, retinal hemorrhages and exudates with possible papilledema,
- rare
three pathogens most associated with infectious vasculitis
pseudomonas aspergilus mucor *PAM* -can lead to mycotic aneurysms
define lymphangitis and its most common cause
acute inflammation or spread of bacterial infection into lymphatics
- red painful sub-q streaks (inflamed lymph) with painful enlarged LN draining (lymphadenitis)
- cause: Group A strep
define Monckeberg medial sclerosis
in pt >50yo, calcifications of muscular arteries with involvement of internal elastic membrane leads to thinking of artery but not narrowing of the lumen therefore not clinically significant
bopsy finding of numerous plump spindle cells surrounding jagged vascular channels
seen in karposi sarcoma lesions
Takayasu arteritis common features
- “pulseless dz” bc affects aortic arch
- similar to Gaint Cell arteritis except the population affected is Japanese Women
- sx: ocular disturbances and marked weak pulses in UE
- medium and large arteries show granulomatous inflammation
- pulmonary A. may be involved (Pulm HTN –> systemic HTN)
define hyaline arteriolosclerosis
increased in smooth muscle proliferation at the arteriolar level leading to plasma protein leakage across damaged endothelium and possibly leading to ischemic injury
-homogenous pink (hyaline) thickening of the vessel wall leads to luminal narrowing and increased vascular resistance
true vs false aneurysm
true- intact, thinned muscular wall at the site of dilation
false - ruptured muscular walll and a defect through the wall of vessel where intravascular space has communication with an extravascular hematoma (pulsating hematoma)
which vasculitis is seen associated with geographic necrosis
granulomatosis with polyangitis, (wegener dz)
which vasculitis is associated with cardiomyopathy
Churg Straus Syndrome
Polyarteritis Nodosa (PAN) common features
- systemic vasculitis of muscular medium a., immune complex mediated
- most commonly seen in renal vessels and GI tract
- *spares the pulmonary vessels
- population: young adult
- seen with Hep B patients and HBsAG-Ab complexes in vessels
- fibrinoid necrotizing vasculitis, with segmental transmural inflammation causing “string of pearls” image
- sx: young adult with rapid HTN, ab pain, melena, neuro problems, skin lesions, bloody stool
- can be one-sided (non-circumferential)
3 non AIDS associated ways Karposi Sarcoma is seen
- middle eastern/eastern european older men
- endemic in africa, pts < 40
- transplant pt associated
artery to vein shunting without intervening capillary bed causing a tangled worm-like vascular channel with prominent pulsatile, high blood flow
arteriovenous malformation (AVM)
role of endothelial cells in the vascular wall
- mainyain blood in fluid state by nonthrombogenic smooth surface
- influences vascular resistance by controlling medial smooth muscle tone
- metabolizes hormones (angiotensin)
- regulates inflammation
- affect growth of cells (esp. smooth muscle cells)
nephrosclerosis relationship to hyaline arteriosclerosis
nephrosclerosis is due to chronic HTN resulting in renal arteriolar narrowing (by hyaline arteriosclerosis) leading to diffuse impairment of renal blood supply and glomerular scarring
focal or irregular thickening in medium and large muscular arteries (renal, carotids, splanchnic, vertebral)
fibromuscular dysplasia
localized abnormal dilations of blood vessels or the heart that develop over time due to defects in underlying media (usually elastic layer) and connective tissue
aneurysm
HTN secondary to _____ is caused by increased production of renin from the ischemic kidney; a bruit can be heard on auscultation of affected kidney
renal artery stenosis
