Vascular disease

Question 1

Learning objectives

Answer 1

 Classify vascular diseases
 Describe the characteristics of atheroma and its complications
 Define, classify and describe the types of aneurysm
 Define varicose veins
 Define vasculitis
 Classify vascular tumours

Question 2

Discuss vascular disease in different vessels

Answer 2

Arteries
Arteriosclerosis

Veins
Thrombosis
-Phlebothrombosis vs Thrombophlebitis
Formation of varicosities

All vessels
• Vasculitis (inflammation)
• Radiation damage

Tumours

Question 3

Discuss age-related vascular changes

Answer 3

 Fibrosis of intima and media
 Accumulation of ground substance
 Fragmentation of elastic lamellae

Question 4

Discuss Atherosclerosis

Answer 4

 Also known as atheroma
 Affects large and medium-sized elastic and muscular arteries
 Characterised by lipid deposition, fibrosis and chronic inflammation

Question 5

What are the risk factors for atherosclerosis?

Answer 5

 Age
 Sex
 Hypertension
 Hyperlipidaemia (particularlyLDL) 
 Diabetes
 Smoking
 Obesity
 Sedentary lifestyle
 Low socio-economic status 
 Low birth-weight

Question 6

What is the morphology of atherosclerosis

Answer 6

• Atheromatous (fibro-fatty, fibro-lipid) plaque

• – Patchy and raised white to yellow 0.3-1.5cm
• – Core of lipid
• – Fibrous cap

Question 7

What are some complications of atherosclerosis?

Answer 7

Cerebral infarction

Carotid atheroma - emboli causing transient ischaemic attacks/cerebral infarcts

Myocardial infarction, cardiac failure

Aortic aneurysms (rupture causes sudden death)

Peripheral vascular disease with intermittent claudication

Gangrene

Question 8

Discuss peripheral vascular disease

Answer 8

Atheroma of distal aorta/iliac/femoral arteries
Causes ischaemia of lower limbs

Effects

• Intermittent claudication
• Pain
• Ulcers
• Gangrene

Question 9

Discuss aneurysms

Answer 9

Localised, permanent, abnormal dilatation of
•blood vessel or the heart

 Types:
•– Atherosclerotic
•– Dissecting
•– Berry
•– Micro-aneurysms 
•– Syphilitic
•– Mycotic

Question 10

Discuss atherosclerotic aneurysms

Answer 10

Usually abdominal aorta, distal to renal arteries
Women 50%
frequently contains mural thrombus

 The clinical consequences
     Thrombosis
     Embolism
     Rupture
     Obstruction of a branch vessel
         ischemic injury
     Impingement on an adjacent structure
 Presentation as an abdominal pulsating mass
 Can be repaired

Question 11

Discuss the occurrence of aortic aneurysms

Answer 11

Men x3 more than women aged 40 to 60 with hypertension

Younger patients with systemic or localized abnormalities of connective tissue

Morphology:
usually initiates with an intimal tear
1-2 cm from aortic valve
dissection can extend along the aorta retrograde toward the heart or
distally, sometimes into the iliac and femoral arteries

Question 12

What are the clinical symptoms of aortic aneurysms?

Answer 12

• The sudden onset of excruciating pain,
beginning in the anterior chest, radiating to the back
•between the scapulae, and moving downward as the
•dissection progresses; the pain can be confused with
•that of myocardial infarction.

• The most common cause of death is rupture of
• the dissection outward into the pericardial,
• pleural, or peritoneal cavities.

Question 13

What are Berry aneurysms

Answer 13

 Aneurysms of the circle of Willis
 Young people
 Often hypertensive
 Associated with
sub-arachnoid haemorrhage

Question 14

Discuss capillary micro-aneurysms

Answer 14

Associated with
• Hypertension
• Diabetes mellitus

Small aneurysms of branches of middle cerebral artery

Associated with intra-cerebral haemorrhage

Question 15

Discuss syphilitic and mycotic aneurysms

Answer 15

 Syphilitic
• Usually affects thoracic aorta

 Mycotic
• Wall of artery weakened by infection
• Bacteria or fungi
• Often in brain, secondary to embolism

Question 16

Discuss varicose veins

Answer 16

Definition:
Abnormally dilated, tortuous veins produced by prolonged, increased intraluminal pressure and loss of vessel wall support

Risk factors: Age, sex, heredity, posture, obesity
•Venous valves incompetent and leads to stasis, congestion, oedema, pain, and thrombosis
• Lower limbs usually saphenous system
• Oesophageal varices
• Haemorrhoids
• Varicocele

Question 17

What are the consequences of varicose veins?

Answer 17

• Cosmetic problems
• Aching in legs
• Stasis dermatitis
• Skin ulceration and bleeding

Question 18

Discuss vasculitis

Answer 18

Inflammation and necrosis of blood vessels

Pathogenesis:
•Cell immune-mediated inflammation
•Deposition of immune complexes
•Direct attack by circulating antibodies

•Direct invasion of vascular walls by infectious pathogens •Often part of multi-system disease

Question 19

What are the different types of vasculitis?

Answer 19

Giant-cell (temporal) arteritis
• > age 50, average onset age 70, women > men
• granulomatous inflammation of large to small-sized arteries
(temporal, vertebral and ophthalmic)
• Cord like nodular thickening

Takayasu arteritis (pulseless disease)
• granulomatous vasculitis of medium and larger arteries of upper limbs (+arch of aorta) women age <30

Polyarteritis nodosa (PAN)
• Medium small size muscular arteries of the kidneys, heart, liver, and gastrointestinal tract are involved
• Fibrinoid necrosis could be fatal without steroid treatment

Kawasaki disease (children < age 4)
•High fever, conjunctival and oral lesions. Self-limited

Question 20

Discuss giant-cell (temporal) arteritis

Answer 20

• 6-12 months
• Could be self-limited
• Patchy lesion
• Throbbing temporal pain
• Malaise
• Fever

Question 21

Discuss Takayasu arteritis

Answer 21

• Dizziness
• Visual disturbances
• Dyspnoea
• Intermittent claudication upper limbs
• Asymmetric BP
• Steroid treatment

Question 22

Discuss Vascular Tumours

Answer 22

BENIGN
Angioma
Haemangioma
• Juvenile (strawberry) Skin
• Capillary (rubyspots) Skin, spleen, kidneys
• Cavernous (portwinestains) Skin, spleen, liver, pancreas
Lymphangioma
• Capillary and Cavernous

MALIGNANT
Angiosarcoma
• Skin, soft tissue, breast, bone, liver and spleen
• Kaposi’s sarcoma: associated with HIV / AIDS
Angioproliferative tumour derived from endothelial cells