Hemostasis, Thrombosis, and

Hemorrhage

Blood clot showing

fibrin network
 Normal hemostasis
• The circulatory system must be self-healing to prevent
life-threatening injury

• Bleeding is rapidly stopped by a process called hemostasis

– Complex interaction of endothelium, platelets, and the
coagulation cascade
– These processes maintain blood in a fluid, clot-free state in
normal blood vessels
– They can also induce a rapid and localized “hemostatic plug” at
the site of vascular injury
– Anticoagulant activities also occur to limit the extent of the
“plug”…process of fibrinolysis
 Pathogenic hemostasis
• The pathologic correlate to hemostasis is
thrombosis
– Considered to be an inappropriate activation of normal
hemostatic processes
• Formation of a blood clot (thrombus) in uninjured
vasculature
• Thrombotic occlusion of a vessel after relatively minor injury
 Sequence of events with vascular injury
1. Vasoconstriction
2. Primary hemostasis
3. Secondary hemostasis
4. Reorganization and formation of a permanent
“plug”
 Vasoconstriction
• Transient arteriolar
vasoconstriction after initial
endothelial injury that exposes
collagen of the subendothelial
matrix (ECM)

• Vasoconstriction due to local

nerve reflex and release of
endothelin by endothelial cells

• Vasoconstriction helps limit

escape of RBCs and proteins
from damaged areas
 Primary hemostasis
• Platelets adhere to exposed
ECM via von Willebrand
factor
• Platelets undergo activation
(change shape)
• Platelets release secretory
granules
– ADP and thromboxaneA2
– Cause vasoconstriction and
promote further platelet vWF is released immediately from
aggregation adjacent endothelial cells → aids
platelet binding to collagen
• Form primary hemostatic
plug
 Secondary hemostasis
• Local activation of the
coagulation cascade
– Tissue factor
(thromboplastin) is secreted
by adjacent endothelilal
cells
– Thromboplastin initiates the
clotting cascade
• Results in fibrin
polymerization and
“cementing” platelets into
a definitive secondary plug
 Counter-regulatory mechanisms
• Release of compounds
that limit the hemostatic
process to the site of the
injury
– tissue type plasminogen
activator (t-PA)
(fibrinolytic)
– thrombomodulin
(interferes with the
clottting cascade)
 Thrombosis
• Formation of a blood clot (hemostatic plug) due to either
inappropriate activation of normal hemostasis or
formation of a clot in a vessel after injury

• Can also be due to other abnormal processes that can

block a blood vessel and lead to death

• Fibrinolysis is the process of limiting the hemostatic

process at the site of injury
– Includes the release of tissue plasminogen activator (t-PA) and
thrombomodulin by adjacent endotheliam
 Properties of endothelium
• Endothelium = cells that line blood vessels

• Antithrombotic properties
– Normally acts as a barrier between blood and subendothelial
collagen
• Block platelet aggregation
• Interfere with coagulation cascade
• Actively lyse clots

• Prothrombotic properties
– Injury or activation of endothelial cells can result in
procoagulant phenotypes that augment local clot formation
 Properties of endothelium
(Anti-thrombotic)
(Pro-thrombotic)

PGI2 – prostacyclin; NO – nitric oxide; t-PA – tissue plasminogen activator;

Antithrombotic properties of endothelium
• Antiplatelet effects

• Anticoagulant effects

• Fibrinolytic effects
Antithrombotic properties of endothelium
• Antiplatelet properties (inhibit platelet aggregation)

– Intact endothelium prevents platelets and coagulation factors

from meeting the highly thrombogenic subendothelial ECM

• Non-active platelets do not adhere to the uninjured endothelium

• Activated platelets are inhibited from adhering to surrounding uninjured

endothelium by endothelial prostacyclin (PGI2) and NO
– Potent vasodilators and inhibitors of platelet aggregation

• Endothelial cells also express ADPases (ADP is needed for platelet

aggregation)
Antithrombotic properties of endothelium
• Anticoagulant properties (inhibit blood coagulation)

– Heparin-like molecules (cofactors) from endothelium act

indirectly with and inactivate several coagulation factors
(thrombin, factors IXa, Xa, XIa, and XIIa)

– Thrombomodulin from endothelium also acts indirectly, binding

to thrombin and converting it from a procoagulant to an
anticoagulant

– Major source for tissue factor pathway inhibitor – a cell surface

protein that complexes with and inhibits several proteins of he
clotting cascade (tissue factors VIIa and Xa)
Antithrombotic properties of endothelium
• Fibrinolytic effects of endothelium

– Endothelial cells synthesize tissue-type plasminogen

activator (t-PA)
• Promotes fibrinolytic activity
• Clears fibrin deposits from endothelial surfaces
 Properties of platelets
• Play a central role in normal hemostasis

• Smallest components of mammalian blood (diameter 2-4 µm)

• They are not cells; Membrane-bound smooth discs with no nucleus

(when non-activated)

• Originate from bone marrow megakaryocytes as the end products of

cytoplasmic and membrane protrusions

• Their surface has several glycoprotein receptors called integrins

that bind to exposed collagen
– vWF acts as a bridge between integrins and exposed collagen → process
called adhesion
 Properties of platelets
• After vascular injury, platelets encounter ECM
constituents that are normally sequestered beneath an
intact endothelium
– Collagen (most important)
– Proteoglycans
– Fibronectin
– Other adhesive glycoproteins

• On contact with ECM, platelets undergo 3 general

reactions:
– Adhesion and shape change
– Secretion (release reaction)
– Aggregation
 Properties of platelets
• Contain two types of granules
– Alpha granules
• Express the adhesion molecule P-selectin
• contain fibrinogen, fibronectin, factor V, factor VIII, vWF,
PDGF, TGF-β
– Dense bodies
• A.k.a. delta (δ) granules
• contain ADP, ATP, ionized Ca, histamine, serotonin,
epinephrine
 Properties of platelets
• Activated platelets have spiny processes that protrude
from cell membranes

Resting platelets Activated platelets

 Platelet activation
• Activated platelets undergo change in shape (exact process remains
unknown)

• Secrete granule contents (release reaction) and express surface

phospholipid complex

• Aggregate (with help of thromboxane A2) and form reversible

primary hemostatic plug
– Thrombin (from coagulation cascade) binds to surface receptors and binds
fibrinogen to integrins on surface

• Contract irreversibly to form secondary hemostatic plug,

– Thrombin converts fibrinogen to fibrin
– Fibrin “mortars” in place
 Thrombocytopenia
• Thrombo = platelet
• Penia = deficiency of

• Thrombocytopenia = lack of platelets

 Coagulation cascade
• Secondary hemostasis

• A blood clot (thrombus) forms through the action

of a cascade of proteolytic reactions involving
nearly 20 different substances

• Most are liver-synthesized plasma glycoproteins

 Coagulation cascade
• Third component of the hemostatic process

• Major contributor to thrombosis

• Cascade of enzymatic conversions that turn inactive

proenzymes into activated enzymes

• Culminates in the formation of thrombin

• Thrombin then converts the soluble plasma protein

fibrinogen precursor into the insoluble fibrous protein
fibrin
 Coagulation cascade
• Each reaction in the pathway results from the assembly of
a complex composed of:
– An enzyme (activated coagulation factor)
– A substrate (proenzyme from of coagulation factor)
– A cofactor (reaction accelerator)

• These components are assembled on a phospholipid

complex and help together by Ca ions
– Clotting tends to remain localized to sites where such assembly
can occur
– e.g. on the surface of activated platelets or endothelium
 High molecular
weight kininogen

Activation of
fibrinolysis
 Clotting cascade
• Intrinsic – initiated in vitro by
activation of the Hageman factor
(factor XII)

• Extrinsic – initiated by tissue

factor (a cellular lipoprotein
exposed at site of tissue injury)

• Artificial in vitro divisions

• Note the common link between the

pathways at the level of factor IX
activation
 Fibrinolysis
• Besides inducing coagulation, activation of the
clotting cascade also initiate the fibrinolytic
cascade that limits the final size of the clot
 Fibrinolysis
• Plasminogen is in circulation and is cleaved to
plasmin by tissue plasminogen activator (t-PA)
– Tissue type-PA is synthesized by endothelial cels
• Most active when attached to fibrin meshcwork
• Activity is blocked by PA inhibitor (PAI)

• Plasmin breaks down fibrin and interferes with its

polymerization
 Fibrinolysis
• The resultant fibrin split products (fibrin degradation
products) can also act as weak anticoagulants
– Elevated levels of these products are measured in clinical labs as
fibrin d-dimers
– Helpful in diagnosis of DIC (disseminated intravascular
coagulopathy)

• Can also degrade fibrinogen

• Any free plasmin in circulation is rapidly bound and

neutralized by α-2-antiplasmin
**Important process in the regulation of hemostasis**
Hemorrhage
 Hemorrhage
• Extravasation: escape of blood from blood vessels
• Always antemortem

Rapid (massive) flow of blood through Oozing of blood through holes in vessel
breaks in vessel wall wall
 Hemorrhage
• Hematoma: enclosed accumulation of blood in a
tissue (bulging, rounded area of hemorrhage)
– Can be insignificant (bruise)
– Can cause death (intracranial hematoma)

• Petechiae: 1-2 mm hemorrhage in the skin,

mucous membranes, or serosal surface of an organ
– Associated with locally increased intravascular
pressure, thrombocytopenia, defective platelet function,
of clotting factor deficits
 Hemorrhage
• Ecchymoses: 2mm-1cm SQ hemorrhage
– Associated with same as above, esp. trauma

• Purpura: >1cm hemorrhage in the skin, mucous

membrane, or serosal surface
– Associated with same as petechiation
– Also trauma, local vasculitis, increased vascular fragility

• Paintbrush hemorrhage

• Suffusive: hemorrhage along a natural plane

 Hemorrhage
• Hemorrhage: a large accumulation of blood in a
body cavity
– Hemothorax – blood in thorax
– Hemopericardium – perocardial sac
– Hemoperitoneum – peritoneal cavity
– Hemarthrosis – joint or synovial cavity
 Fate of hemorrhage
• RBCs are phagocytized and enzymatically
degraded by mφ
• Porphyrin release from hemoglobin produces color

Hemoglobin (red-blue)
↓
Bilirubin (blue-green)
↓
Hemosiderin (gold-brown)
 Fate of hemorrhage
• Clot – contracts which causes separation of serum
from coagulum
– Coagulum
• Lysed and removed (if small)
• Can become organized by connective tissue

– Serum
• Resorbed and removed
• Form seroma (large area of fluid in a tissue)
• Seromas can be excellent growth media for bacteria
 Significance/Outcome/Effect
• Depends on amount, rate, location
– Rate and amount
• If > 1/3 blood volume lost quickly (minutes to hours) →
hypovolemic shock → exsanguination
• If < 1/3 blood volume lost quickly → possible compensation
and survival
• Slow blood loss → compensatory changes

– Location of hemorrhage
• Brain, pericardium, lungs → interference with organ normal
function
 Significance/Outcome/Effect
• If blood lost slowly, as much as ½ blood volume
can be lost over weeks to months and animal is
able to compensate
– RR may increase to help oxygenate better
– Hematopoiesis in bone marrow
– Extramedullary hematopoiesis
– Animals will limit exercise to keep O2 consumption
low
– May die acutely if over exerted
Gross appearance of hemorrhage

Describe this lesion

Multifocal to coalescing petechial to ecchymotic hemorrhages on the
epicardial surface of the heart.
 Gross appearance of hemorrhage
• Diffuse hemorrhage
throughout an organ

• Adrenal glands from a 50

hour old foal

• Bilateral hemorrhage
throughout both cortices
and medullas

• Due to Klebsiella spp.

 Gross and microscopic appearance of
hemorrhage
• Urinary bladder from a male cat with
urethral blockage
• Blood is being aspirated from the
bladder
• This is hematuria 2° to hemorrhagic
cystitis
 Thrombosis

Endothelial injury

Thrombosi
s

Abnormal Blood Flow Hypercoagulability

 Thrombosis
• Pathological formation of a clot (thrombus) within
the cv system

• May lead to interference with blood flow

– Turbulence Also causes of thrombosis, along with
endothelial injury and
– Stasis hypercoagulability

• May result in infarction, passive congestion, or

embolism (fragment of thrombus that breaks off
and lodges somewhere distal)
 Causes
• Change in blood flow (slow down)
• Change in blood viscosity
• Loss of vascular endothelial smoothness
• Endothelial injury
• Hyper reactive states of platelets
– Parturition, sepsis, surgery, massive trauma
• Proteinuria (renal dz)
 Causes
• Endothelial injury
– Primary etiology
– Endothelial cell damage and
exposure of subendothelial
collagen
– Vasoconstriction follows →
then platelet adhesion,
aggregation, and activation of
the clotting cascade
– A platelet plug is formed,
which is often held together
by polymerized fibrin
 Causes
• Stasis or turbulence of blood flow

– Turbulence contributes to arterial and cardiac thrombosis by

causing endothelial injury and by forming countercurrent and
local areas of stasis

– Stasis is a major factor in the development of venous thrombi

– Stasis and turbulence disrupt laminar flow and bring platelets

into contact with endothelium
• Prevents dilution of clotting factors by fresh flowing blood
• Retards inflow of clotting factor inhibitors
 Causes
• Blood hypercoagulability (least common)
– In human medicine, defined as any alteration in coagulation
pathways that predisposes to thrombosis
– Primary not described in vetmed, but 2° seen in all spp

– 1° (genetic): mutation in factor V gene

• Affects 2-15% of Caucasian population as recurrent deep venous
thrombosis
– 2° (acquired):
• DIC
• Disseminated cancers – release of procoagulant tumor products
• Certain glomerular diseases (loss of anti-thrombin III)
 PM clot vs. Thrombus
• PM clot – when an animal • Thrombus –
dies, blood clots in vessels – Rough surface and attached
and forms a mold in the to vessel wall
shape of the vessel (or the – Difficult to remove
heart chamber) – Usually pale color
– Shiny and gelatinous • Due to protein and fibrin
– Fills entire chamber – Early thrombi may be red
– Removes easily
– Usually red, but may have
yellow plasma near the
surface and be red at the
base (as RBCs settle before
clotting)
 PM clot vs. Thrombus
PM Clot Thrombi

Smooth, shiny, molded to Dull, rough, stringy on

Surface vessel surface, may not fit vessel

Homogenous, uniform, Granular, layered,

Cut surface shiny, smooth laminations

Consistency Resilient, elastic Britttle, firable, crumbly

Current jelly clot – Stippled, irregular color,

homogenous red yellow to gray to red,
Color Chicken fat clot – layered, with each part
homogenous yellow (plasma) different colors

Not attached to vessel, Attached somewhere b/c

Attachment although may form around originate from a platelet
valves sticking to vessel wall
PM clot vs. Thrombus
 Microscopic thrombus
• Attached to wall

• Laminations –
alternating pale layers
of platelets admixed
with some fibrin and
darker layers containing
more RBCs
 Venous thrombus
• Located in jugular vein
of a horse that had
received repeated
injections in the jugular
vein

• Usually occurs at sites

with blood stasis,
extending in the
direction of blood flow
(toward the heart)
 Arterial thrombus
• Saddle thrombus in a cat
with cardiomyopathy
• Iliac arteries blocked →
lead to lameness in rear
legs; cold to touch
• Tend to grow in retrograde
direction from the point of
attachment
In this case, HCM or dilated L
• Begin at site of endothelial ventricle creates tubulence →
injury or turbulence (i.e. produces microthrombi → cause
vessel bifurcation) saddle thrombi at vessel
bifurcation site
 Vegetative thrombus
• Most common on
mitral (left AV) valve
– Tend to travel in
general circulation
(kidneys)

• Also occur on
semilumar and R AV
valves Mitral vegetative valvular
– Tend to travel to lungs endocarditis in a nursey pig with
Streptococcus suis bacteremia
or general circulation
 Verminous thrombus
• Caused by parasites

• Strongylus vulgaris in
the anterior mesenteric
artery of a horse
– Leads to loss of blood
supply to large intestine
(colic)
– Decrease in occurance
doe to inermectin
administration
 Other types of thrombi
• Mural thrombus: attached to the endocardium

• Septic thrombus: bacterial colonization of a

thrombus; causes or is a result of bacteremia
Outcomes of thrombosis
 Outcomes of thrombosis
• Propagation:
– thrombus may accumulate more platelets and fibrin
leading to vessel obstruction
• Embolization:
– thrombus may dislodge and travel to other sites,
forming thromboemboli
• Dissolution/resolution:
– thrombi may be removed by fibrinolytic activity (drugs
available for this)
• Organization and recanalization:
 Outcomes of thrombosis
• Organization and recanalization:
– May induce inflammation and fibrosis (organization) and
eventually become recanalized (re-establish blood flow or
be incorporated into a thickened vascular wall)
• Possible formation of collateral circulation
• Recanalization
– Thrombus converted to fibrous connective tissue (scar tissue)
– May contract over time