CVS lll Flashcards
Epi of Moenckberg Arteriosclerosis
: >50 yrs
loc of Moenckberg arterioscleoris
calcification of media, of small and
medium-sized muscular arterie
*no arterial flow obstruction
Macro-/Microscopic picture:
* Stiff, calcific “pipe-stem” arteries
* Ring-like calcifications in the media
Are the features of what type of Plaque?
Moenckeberg arteriosclerosis (Medial Calcific Sclerosis)
Etiology of Calciphylaxis (Vascualar calcinosis)
–> severe form of the media calcification
–> Association with renal failure & hyper-parathyroidism
patho of Calciphylaxis
1) Elevation of acute phase reactants
2) Marked giant-cell reaction in proximal arteries
3) Extension of calcification into distal vessels
4) Intima fibrosis→ Vessel’s obstruction → Ischaemia symptoms or progressive ischaemic gangrene
5) Frequently, vascular micro-thrombi
6) Occasionally, subcutaneous calcium deposits with panniculitis (inflammation of subcutaneous adipose tissue) and fat necrosis
The 2 forms of Arteriosclerosis
1) Hyaline Arteriosclerosis
2) Hyperplastic Arteriosclerosis
Atiology/association of arteriosclerosis
*Hyaline thickening or proliferative changes of
small arteries and arterioles (e.g. Kidneys)
*Associated w/ –> Hypertension or Diabetes Mellitus
patho of Hyaline arteriosclerosis
- Hyaline thickening of arteriolar walls →
- → Narrowing of the arteriolar lumen →
- → Ischaemia
Histopathological features:
- Tubular atrophy, Interstitial fibrosis,
Glomerular alterations (mild hyalinosis to
sclerosis of glomeruli) and peri-glomerular
fibrosis
- Accumulation of pink, amorphous,
homogeneous material in the wall of small
arteries and arterioles
* “Benign nephrosclerosis” –> Long-standing
Hypertension
Are the features of what type of plaque?
Hyaline arteriosclerosis
Histopathological features:
- Concentric, laminated, “onion-skin”
thickening of the arteriolar walls –> narrowed lumen
- accompanied by necrotising arteriolitis
(intramural deposition of fibrinoid material
in arterioles with vascular necrosis and
inflammation) in malignant hypertension
* Malignant hypertension –> “Malignant
nephrosclerosis”
Are the features of what type of palque?
Hyperplastic plaque
Risk factors of Atherosclerosis
1) Age
2) Gender ( M > F) [increased
incidence in post-menopausal women]
3) Cigarette smoking
4) Hypertension
5) Diabetes Mellitus (Peripheral vascular occlusive
disease → Gangrene of the lower extremities)
6) Obesity, “type A” personality, hyper-uricaemia, hyper-homocysteinaemia
7) Hyper-cholesterolaemia
Atheroscleorsis: the formation of fibrous plaque or atheromas within the intima of the arteries.
At which anatomical site do these atheromas form?
1) Proximal portions of coronary arteries
2) Larger branches of carotid arteries
3) Circle of Willis
4) Large vessels of lower extremities
5) Renal and mesenteric arteries
Atherosclerosis are characterised by the formation of ?
Fatty streaks (Accumulation ofOxidised LDL within macrophages and SMCs, underneath the enothelial cells)
Macroscopic features of Fatty streaks?
Yellow elevations on the
internal surface of the vessel wall
patho of Atherosclerotic plaque
1) Death of foamy macrophages → Release of
intra-cytoplasmic lipid → Formation of lipid
debris
2) Proliferation of smooth muscle cells and
secretion of collagen + ECM proteins
→ Development of a fibrous cap over the
core (composed of oxidised lipid and inflammatory cells)
*fibrous cap –> bodies attempt to repaire the injured vessele wall by scaring
*Core –> plaque (oxidised LDL)
The 3 Hallmarks of Chronic inflammation
-
Persistent injury (endothelial damage from
aforementioned risk factors) -
On-going inflammation (macrophages and
lymphocytes) -
Repair with scarring (formation of a fibrous
cap)
Plaque stability depends on the —————- and ————— in the fibrous cap
1) No. of SM
*smooth muscles –> Protective effect
2) Inflammaotry cells
*have Destablising effect
Plaque stability depends on the numbers of smooth muscle and inflammatory cells in the fibrous cap. Explain
1) Inflammatory cells have destabilising effect,
since:
* Produce MMPs → Digestion of fibrous cap
* Induce smooth muscle cells’ apoptosis
2) Smooth muscle cells have protective effect,
since:
* Produce fibrous cap → Plaque stabilisation
* Produce TIMPs → Inhibition of MMPs’ action
Stable plaques vs Unstable plaques
1) Stable plaques:
- Few inflammatory cells but Many smooth muscle cells
* Thick fibrous cap –> Resistant to rupture
* Slow growth → Gradual Stenosis of the lumen
2) Unstable “vulnerable” plaques:
* Inflammatory cells > Smooth muscle cells
* Thin fibrous cap → Acute rupture →
Thrombosis and/or Embolism
Atherosclerosis Complications related to plaques
1) Myocardial infarction (MI)
2) Ischaemic stroke
3) Rupture of aneurysm –> thrombous formation –> Embolisation
4) Stable Angina
Virchow’s Triade
1. Endothelial Injury
a. Atherosclerosis
b. Vasculitis
c. Trauma
2.Abnormal blood flow:
a. Turbulence
b. Stasis
3.Hypercoagulability:
a. Too many blood cells
b. Coagulation factor defects
Types of Aneurysm
1) Atherosclerotic
2) Aneurysms due to cystic medial necrosis
3) Berry aneurysms
4) Syphilitic (luetic) aneurysm
5) Dissecting aneurysm
6) Arterio-venous fistula
loc of Atherosclerotic aneurysm
Abdominal aorta
Epi of Atherosclerotic Aneurysm
Men and smokers
patho of Atherosclerotic aneuryms
1) Excess ECM degradation by the inflammatory
infiltrates in atherosclerotic arteries and the
destructive proteolytic enzymes at these sites
Impairment of the diffusion of nutrients and
wastes between vascular lumen and wall
* Direct compression on the media
* → Degeneration and necrosis → Wall
thinning
CM of Cystic medial Degeneration
Proximal aortic aneurysm → Aortic dissection
and rupture; Aortic incompetence; Mitral valve
prolapse; Peripheral artery aneurysms
loc of cystic medial degeneration
aortic root
- loss of elastic laminae
- loss of smooth muscle cells, with replacement by pools of proteoglycan matrix
Are the histopatho of what type of aneurysm?
Cystic medial degeneration
loc of Berry Aneurysm
Vessels of Willis’ circle
patho of Berry Aneurysm
: Development at sites of congenital
medial weakness (bifurcation of cerebral arteries)
Assocation of Berry Aneurysm?
adult polycystic kidney disease
Macroscopic picture: Small, saccular lesions
Are the features of what type of Aneurysm?
Berry Aneurysm
complications of Berry Aneurysm?
subarachnoid haemorrhage, after aneurysm’s rupture
Macroscopic picture:
Characteristic “tree-bark” appearance <> Multiple gelatinous plaques, separated by stellate scars and vertical furrows
Are the features of what type of Aneurysm?
Syphilitic (Leutic) Aneurysm
Complications of Syphilitic (leutic) aneyurysm?
1) Obliterative endarteritis of the vasa vasorum
and necrosis of the media
2) Dilatation of the ascending aorta → Widening of the aortic valve commissures → Aortic valve insufficiency
causes of Dissecting Aneurysm
1) Hypertension,
2) cystic medial necrosis
patho of Dissecting Aneurysm
Longitudinal intraluminal tear in the wall of the ascending aorta → Second arterial lumen within the media
Clinical picture of dissecting Aneurysm
Severe, tearing chest pain, radiating through to the back
DD of Dissecting Aneurysm
Myocardial infarction
complications of Dissecting Aneurysm
Aortic rupture → Haemo-pericardium and cardiac tamponade
the Two vasculitic syndromes that affect elastic arteries
1) Takayasu disease
2) Giant-cell arteritis
Two vasculitic syndromes affect muscular arteries?
1) Polyarteritis nodosa
2) Kawasaki disease
complications of Arterio-venous Fistula
1) Ischaemic changes (due to diversion of blood)
2) Ballooning and aneurysm formation (↑ venous
pressure)
3) High-output cardiac failure (hypervolaemia)
risk factors of Varicose veins of Extremities
1) Familial predisposition
2) Prolonged standing
3) Obesity
4) Pregnancy (Compression of the inferior vena cava)
loc of Varicose veins of extremities
Superficial veins of the upper and lower leg
Microscopic Findings:
1) Fibrosis beneath the endothelium and in the wall
2) Secondary elastosis and loss of muscle
3) Possible occurrence of calcificatin
Are the features of what type of aneurysm?
Varicose veins of Extremities
clinical features of Varicose veins of extremities
1) Pain or cramping
2) Tingling or burning sensations
3) Heaviness or tiredness
4) Lower extremity stasis and congestion
5) Thrombosis
6) Oedema
complications of Varicose veins of Exremities
1) Persistent oedema → Secondary ischaemic
changes (such as: stasis dermatitis and
ulcerations)
2) Ulcerations with poor wound healing and superimposed infections → Chronic varicose ulcers
patho of Oesophagaeal varices
Liver Cirrhosis, Portal vein obstruction, Hepatic vein thrombosis –> portal vein hyepertension –> Opening of porto-systemic shunts –> Increased blood flow into veins at:
1) Gastro-Oesoph. Junction –> Oesophageal varices
2) Rectum –> Haemorrhoids
3) Peri-umbilical veins of abdominal wall –> “Caput medusae”
cause of Heamorrhoids
1) Pregnancy
2) Straining during defecation
patho of Haemorrhoids
Prolonged pelvic vascular congestion
venous thrombus is aka?
Phlebo-thrombosis
loc of Venous thrombosis?
Deep veins of the lower extremities
predisposing factors of Venous Thrombosis
- Venous circulatory stasis or partially obstructed venous return (cardiac failure, pregnancy, prolonged bed rest, varicose veins)
- Thrombo-Embolism → Pulmonary infarct
venous Thrombosis associated w/ Inflammation?
Thrombo-Phlebitis
clinical features of Thrombo-Phlebitis
1) Minimal/marked oedema of the extremity
2) Purulent Thrombo-Phlebitis: Marked chills and high temperature
Macroscopic findings:
* Superficial veins (e.g. saphenous vein)
* Acutely inflamed and tender vein
* Redness of the overlying skin
* Thrombosis limited to the superficial veins –> Little oedema
Are the features of what type of Aneurysm
THROMBO-PHLEBITIS
Microscopic findings:
* Oedematous venous wall
* Irregular ulceration of the intima
* Chronic inflammatory infiltrates in the media
* Deposition of fibrous tissue in the adventitia & media
Are the features of what type of aneurysm
Thrombo-phlebitis
Factors favouring intravenous thrombosis → Pulmonary embolism:
1) Neoplasms
2) Cardiac disease
3) Venous stasis from any cause
4) Infection in the immediate area of veins
5) Trauma
6) Vasospasm
7) Intimal injury
8) Increased coagulability
9) Immobilisation of the limbs
Long-term (after several years) complications of Thrombo-Phlebitis
Statis ulcer
Macroscopic features:
* Cutaneous pigmentation
* Brawny (strapping) oedema
* Dermal and subcutaneous fibrosis
* Extensive secondary varicosities
* Ulceration of the skin in the lower 1/3 of the leg
Are the features of what type of Atheroma?
Statis ulcer
Thromangiitis obliterans is aka?
Buerger’s disease
casue of Thrombangiitis obliterans
Rare thrombotic and inflammatory disease
of the arteries and veins of unknown aetiology
epi of Thrombangiitis obliterans
young men (20-35 yrs) , heaving smokerts
clinical features of Thrombangiitis obliterans
painful ischaemic disease
→ Gangrene
Macroscopic findings:
- Inflam. of small- to mediumsized arteries, especially of the lower extremities, with
extension to the adjacent veins and nerves
Microscopic findings:
* Panarteritis, often in association with thrombosis
* Endothelial proliferation and peri-arterial fibrosis
* Extension of the inflammatory process through the
entire vessel wall to the adjacent peri-vascular
tissues and involvement of peri-neurial stroma
* Partial and incomplete recanalisation of thrombi
→ Results in numerous small vascular channels
passing through the remaining fibrous tissue
Are the features of what type of condition?
THROMANGIITIS OBLITERANS
clinical features of Lympahngitis
- Red, painful subcutaneous streaks
- Tender enlargement of draining lymph nodes
(acute lymphadenitis)
cause of Secondary obstructive Lymphoedema
1) Tumours
2) Surgical procedures (e.g. axillary lymph
nodes in radical mastectomy)
3) Post-radiation fibrosis
4) Lymphatic Filariasis (parasite Wuchereria
bancrofti) → Elephantiasis
4) Post-inflammatory thrombosis and scarring
patho of Lymphodema
- Lymphoedema → Increase of the hydrostatic
pressure in the lymph vessels distal to the
obstruction → Oedema - Chronic oedema → Deposition of ECM and fibrosis
→ Brawny induration or a “peau d’orange”
appearance of the overlying skin - Inadequate tissue perfusion → Skin ulceration
- Rupture of dilated lymphatics, after obstruction
by an infiltrating tumour → Milky accumulations of
lymph in various spaces (chylous ascites, chylothorax, chylo-pericardium)
Primary Lymphoedema occurs as?
1) Isolated congenital defect (Simple Congenital Lymphoedema) or
2) Familial Milroy disease (Heredofamilial Congenital Lymphoedema), resulting from agenesis or hypoplasia of lymphatics
causes of secondary hypertension
1) Chronic renal disease (diabetic nephropathy, obstructive uropathy, chronic glomerulonephritis, etc.
▪ Reno-vascular disease (renal artery
stenosis), Adult polycystic kidney disease,Acute glomerulonephritis ,polyarteritis nodosa
2) Coarctation of the aorta
3) Endocrine diseases:
▪ Cushing’s syndrome
▪ Conn’s syndrome
▪ Phaeochromocytoma
▪ Acromegaly
3) Drugs: Steroids, oral contraceptives,
NSAID
4) Pregnancy (pre-eclampsia)
clinical features of Pheochromocytoma
1) random sever hypertension
2) Headache
3) sweating
4) heart palpitation
clinical manifestaions of Acromegaly
cardiovascular problems:
1) hypertension
2) HF
3) Cardiomegaly
4) Edema
5) Dyspnea
clinical features of hypertension
1) Retinopathy
2) Cerebral haemorrhage (“haemorrhagic
stroke”) –>due to rupture of tiny CharcotBouchard aneurysms; the latter develop as a result of weakening of arteriolar wall
3) Atherosclerosis (Cerebral infarct, Ischaemic Heart Disease)
4) Subarachnoid haemorrhage –> due to
rupture of a Berry aneurysm; the latter as
a result of combined hypertension and
atherosclerosis in genetically predisposed
cerebral vessels
5) Aortic dilatation → Aortic dissection
6) Pressure overload → Left Ventricular
Hypertrophy (LVH) → Heart Failure
7) Renal Failure
effect of hypertension on vessles
1) Large and medium-sized arteries:
–> Acceleration of atherosclerosis
2) Small arteries (arterioles):
–> Hyaline Arteriolosclerosis
(Deposition of pink hyaline material in the walls of arterioles → Narrowing of lumen → Decreased blood flow → Ischaemia of the corresponding tissues/organs)
–> Hyperplastic Arteriolosclerosis
(Characteristic, but not limited to malignant /accelerated hypertension
–> Hyperplasia of the intima and internal elastic
layer and hypertrophy of the media → Onionskin appearance with progressive narrowing of the lumen → Ischaemia of the
corresponding tissues/organs
