The blood vessels diseases
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This document summarizes common diseases of the blood vessels. It describes the anatomy of blood vessels and then discusses various vascular diseases including arteriosclerosis, atherosclerosis, vasculitis, aneurysms, and common diseases of veins. Specific conditions that are described in detail include atherosclerosis, syphilitic arteritis, polyarteritis nodosa, Wegener's granulomatosis, Takayasu's arteritis, Kawasaki's disease, Buerger's disease, Raynaud's disease, and types of aneurysms. The clinical manifestations and complications of many of these conditions are also summarized.
The blood vessels diseases
- 1. DISEASES OF THE BLOOD VESSELS • PRESENTER : DR ALLY RASHID (CUHAS/MMED/6000438/T/20) • FACILITATOR : DR EDRICK ELIAS MD, MMED PATHOLOGY
- 2. CONTENT • ANATOMY OF BLOOD VESSELS • ARTERIOSCLEROSIS • ATHEROSCLEROSIS • VASCULITIS • ANUERISMS • COMMON DISEASES OF VEINS
- 3. The Blood Vessels • The blood containing oxygen, nutrients and metabolites is routed through arteries, arterioles, capillaries, venules and veins. • These blood vessels differ from each other in their structure and function.
- 4. ARTERIES • 1. Tunica intima This is the inner coat of the artery. It is composed of the lining endothelium, subendo thelial connective tissue and bounded externally by internal elastic lamina. • 2. Tunica media is the middle coat of the arterial wall, bounded internally by internal elastic lamina and externally by external elastic lamina. This layer is the thickest and consists mainly of smooth muscle cells and elastic fibres. • 3.Tunica adventitia The outer coat of arteries is the tunica adventitia. It consists of loose mesh of connective tissue and some elastic fibres that merge with the adjacent tissues. This layer is rich in lymphatics and autonomic nerve fibres.
- 5. • There are structural variations in three types of arteries: • Large, elastic arteries such as the aorta, common carotid, major pulmonary, and common iliac arteries have very high content of elastic tissue in the media and thick elastic laminae Medium-sized, muscular arteries are the branches of elastic arteries. All the three layers of arterial wall are thinner than in the elastic arteries. The internal elastic lamina appears as a single wavy line while the external elastic lamina is less prominent. The media primarily consists of smooth muscle cells and some elastic fibres
- 8. • Arterioles consist of a layer of endothelial cells in the intima, one or two smooth muscle cells in the media and small amount of collagen and elastic tissue comprising the adventitia. The elastic laminae are virtually lost
- 9. • VEINS • The walls of the veins are thinner, the three tunicae (intima, media and adventitia) are less clearly demarcated, elastic tissue is scanty and not clearly organised into internal and external elastic laminae. The media contains very small amount of smooth muscle cells with abundant collagen. • Capillaries are about the size of an RBC (7-8 µm) and have 1-2 endothelial cells but no media
- 10. ARTERIOSCLEROSIS • Arteriosclerosis is a general term used to include all conditions with thickening and hardening of the arterial walls • The following morphologic entities are included under arteriosclerosis: • I. Senile arteriosclerosis (affects arteries) • II. Hypertensive arteriolosclerosis (affects arterioles) • III. Mönckeberg’s arteriosclerosis (Medial calcific sclerosis) (affects arteries) • IV. Atherosclerosis (affects arteries)
- 11. ATHEROSCLEROSIS • Atherosclerosis is an thickening and hardening of large and medium- sized muscular arteries, primarily due to involvement of tunica intima and is characterised by fibrofatty plaques or atheromas. • Mostly affected are the 1. Aorta, ( aortic aneurysm) 2. Coronaries ( MI) 3. cerebral arterial systems.( Stroke)
- 13. • Dyslipidaemia • chronic dyslipidaemia in itself may initiate endothelial injury and dysfunction by causing increased permeability. In particular, hypercholesterolaemia with increased serum concentration of LDL promotes formation of foam cells, while high serum concentration of HDL has anti-atherogenic effect • Diabetis mellitus • The causes of increased severity of atherosclerosis are complex and numerous which include endothelial dysfunction, increased aggre gation of platelets, increased LDL and decreased HDL
- 15. • Hypetension • It acts probably by mechanical injury to the arterial wall due to increased blood pressure. Elevation of systolic pressure of over 160 mmHg or a diastolic pressure of over 95 mmHg is associated with five times higher risk of developing IHD than in people with blood pressure within normal range (140/90 mmHg or less). • Smoking • The increased risk and severity of atherosclerosis in smokers is due to reduced level of HDL, deranged coagulation system and accumulation of carbon monoxide in the blood that produces carboxy haemoglobin and eventually hypoxia in the arterial wall favouring atherosclerosis.
- 19. • The clinical effects of atherosclerosis depend upon the size and type of arteries affected. In general, the clinical effects result from the following: • 1. Slow luminal narrowing causing ischaemia and atrophy. • 2. Sudden luminal occlusion causing infarction necrosis. • 3. Propagation of plaque by formation of thrombi and emboli. • 4. Formation of aneurysmal dilatation and eventual rupture.
- 21. Common site for Aneurysm
- 22. VASCULITIS • Arteritis, angiitis and vasculitis are the common terms used for inflammatory involvement of an artery, arterioles, venules and capillaries. • It may occur following invasion of the vessel by infectious agents, or may be induced by non-infectious injuries such as chemical, mechanical, immuno logic and radiation injury
- 24. INFECTIOUS ARTERITIS • Direct invasion of the artery by infectious agents, especially bacteria and fungi, causes infectious arteritis. • It may be found in the vicinity of an infected focus like in tuberculosis, pneumonia, abscesses, etc. or less frequently may arise from haematogenous spread of infection such as in infective endocarditis, septicaemia, etc
- 25. ENDARTERITIS OBLITERANS • Endarteritis obliterans is not a disease entity but a pathologic designation used for non-specific inflammatory response of arteries and arterioles to a variety of irritants. • It is commonly seen close to the lesions of peptic ulcers of the stomach and duodenum, tuberculous and chronic abscesses in the lungs, chronic cutaneous ulcers, chronic meningitis, and in postpartum and post-menopausal uterine arteries
- 27. SYPHILITIC ARTERITIS • Syphilitic or luetic vascular involvement occurs in all stages of syphilis but is more prominent in the tertiary stage. • The changes that are found in the syphilitic arteritis are seen within the arterial tissue (syphilitic endarteritis) and in the periarterial tissues (syphilitic peri arteritis). • Manifestations of the disease are particularly prominent at two sites—the aorta and the cerebral arteries
- 28. SYPHILITIC AORTITIS • Syphilitic involvement of the ascending aorta and the aortic arch is the commonest manifestation of cardiovascular syphilis. • It occurs in about 80% cases of tertiary syphilis. • Preferential involvement of the arch of aorta may be due to involvement of mediastinal lymph nodes in secondary syphilis. • The lesions diminish in severity in descending thoracic aorta and disappear completely at the level of the diaphragm.
- 31. COMPLICATIONS OF SYPHILITIC AORTITIS • a) Aortic aneurysm may result from damage to the aortic wall • b) Aortic incompetence results from spread of the syphilitic process to the aortic valve ring. • c) Stenosis of coronary ostia is seen in about 20% cases of syphilitic aortitis and may lead to progressive myocardial fibrosis, angina pectoris and sudden death
- 32. NON-INFECTIOUS ARTERITIS • II. This group consists of most of the important forms of vasculitis, more often affecting arterioles, venules and capillaries, and hence also termed as small vessel vasculitis. • Serum from many of patients with vasculitis of immunologic origin show the presence of following immunologic features: • 1. Anti-neutrophil cytoplasmic antibodies (ANCAs) • Wegener’s granulomatosis, - PAN • 2. Anti-endothelial cell antibodies (AECAs) • SLE, Kawasaki disease and Buerger’s disease.
- 33. POLYARTERITIS NODOSA • Is a necrotising vasculitis involving small and medium-sized muscular arteries of multiple organs and tissues. • More commonly in adult males than females. • Most commonly affected organs, in descending order of frequency of involvement, are the kidneys, heart, liver, gastrointestinal tract, muscle, pancreas, testes, nervous system and skin. • The condition is believed to result from deposition of immune complexes and tumour-related antigens
- 34. • CHARACTARISTICS • fever, • malaise, • weakness, • weight loss, • renal manifestations (albuminuria, haematuria and renal failure), • vascular lesions in the alimentary tract (abdominal pain and melaena), peripheral neuritis and hyper tension.
- 37. WEGENER’S GRANULOMATOSIS • Wegener’s granulomatosis is another form of necrotising vasculitis characterised by a clinicopathologic triad consisting of the following symptom • i) Acute necrotising granulomas of the upper and lower respiratory tracts involving nose, sinuses and lungs; • ii) focal necrotising vasculitis, particularly of the lungs and upper airways; • iii) focal or diffuse necrotising glomerulonephritis.
- 40. TAKAYASU’S ARTERITIS (PULSELESS DISEASE) • This is a form of granulomatous vasculitis affecting chiefly the aorta and its major branches and hence is also referred to as aortic arch syndrome. The disease affects chiefly young women and is typically • CHARACTERISED by 1.absence of pulse in both arms and presence of ocular manifestations. 2.myocardial infarction, 3 .congestive heart failure and 4.neurologic deficits. The etiology of Takayasu’s arteritis is not known but the autoimmune reaction to aortic tissue has been suggested as the possible cause
- 42. KAWASAKI’S DISEASE (mucocutaneous lymph node syndrome’,) • It is an acute and subacute illness affecting mainly young children and infants. • febrile illness with mucocutaneous symptoms like erosions of oral mucosa and conjunctiva, skin rash and lymphadenopathy. • The etiology is unknown; possible causes considered are infectious, genetic, toxic and immunological. • The most characteristic finding is the presence of multiple aneurysms of the coronaries detected by angiography
- 44. BUERGER’S DISEASE (THROMBOANGIITIS OBLITERANS) • Affecting chiefly small and medium-sized arteries and veins of the extremities and characterised by acute and chronic occlusive inflammatory involvement. • The disease affects chiefly men under the age of 35 years who are heavy cigarette smokers • CHARACTARISED by claudication due to ischaemia manifested by intense pain affecting the limbs, more commonly the legs. • Eventually, gangrene of the affected extremities occurs requiring amputation
- 46. RAYNAUD’S DISEASE AND RAYNAUD’S PHENOMENON • Raynaud’s disease is not a vasculitis but is a functional vasospastic disorder affecting chiefly small arteries and arterioles of the extremities, occurring in otherwise young healthy females. • The disease affects most commonly the fingers and hands. • The ischaemic effect is provoked primarily by cold but other stimuli such as emotions, trauma, hormones and drugs also play a role. Clinically, • pallor, • cyanosis, • redness,
- 48. • Raynaud’s phenomenon differs from Raynaud’s disease in having an underlying cause e.g. secondary to artherosclerosis, connective tissue diseases like scleroderma and SLE, Buerger’s disease, multiple myeloma, pulmonary hypertension and ingestion of ergot group of drugs
- 49. ANEURYSMS • An aneurysm is defined as a permanent abnormal dilatation of a blood vessel occurring due to congenital or acquired weakening or destruction of the vessel wall. • Most commonly, aneurysms involve large elastic arteries, especially the aorta and its major branches. • Aneurysms can cause various illeffects such as thrombosis and thromboembolism, alteration in the flow of blood, rupture of the vessel and compression of neighbouring structures.
- 50. CLASSIFICATION OF ANEURYSMS • A. Depending upon the composition of the wall • 1 True aneurysm composed of all the layers of a normal vessel wall. • 2. False aneurysm having fibrous wall and occurring often from trauma to the vessel.
- 51. • B. Depending upon the shape • 1. Saccular having large spherical outpouching. • 2. Fusiform having slow spindle-shaped dilatation. • 3. Cylindrical with a continuous parallel dilatation. • 4. Serpentine or varicose which has tortuous dilatation of the vessel. • 5. Racemose or circoid having mass of inter communicating small arteries and veins
- 53. • Based on pathogenetic mechanisms • 1. Atherosclerotic (arteriosclerotic) aneurysms • 2. Syphilitic (luetic) aneurysms. • 3. Dissecting aneurysms (Dissecting haematoma). • 4. Mycotic aneurysms. • 5. Berry aneurysms • The three common types of aortic aneurysms—atherosclerotic, syphilitic and dissecting,
- 55. The clinical effects of atherosclerotic aneurysms • 1. Rupture of the atherosclerotic aneurysm is the most serious and fatal complication. The risk of rupture depends upon the size and duration of the aneurysm and the blood pressure. • Rupture of abdominal aneurysm may occur either into the peritoneum or into the retroperitoneum resulting in sudden and massive bleeding. • A ruptured aneurysm is more likely to get infected.
- 56. • 2.Compression • The atherosclerotic aneurysm may press upon some adjacent structures such as compression of ureter and erosion on the vertebral bodies.
- 57. • 3. Arterial occlusion • Atherosclerotic aneurysms of the abdominal aorta may occlude the inferior mesenteric artery, or there may be development of occlusive thrombosis. • However, collateral circulation develops slowly and is nearly always sufficient so as not to produce effects of ischaemia. Thromboembolism is rather common in abdominal aneurysms
- 58. The clinical manifestations in syphilitic aneurysms • 1. Rupture Syphilitic aneurysm is likely to rupture causing massive and fatal haemorrhage into the pleural cavity, pericardial sac, trachea and oesophagus. • 2. Compression The aneurysm may press on the adjacent tissues and cause symptoms such as on trachea causing dyspnoea, on oesophagus causing dysphagia, on recurrent laryngeal nerve leading to hoarseness; and erosion of vertebrae, sternum and ribs due to persistent pressure.
- 59. • . 3. Cardiac dysfunction • When the aortic root and valve are involved, syphilitic aneurysm produces aortic incompetence and cardiac failure. Narrowing of the coronary ostia may further aggravate cardiac disease.
- 60. CHEST X RAY SHOWING ANEURYSM
- 61. DISSECTING ANEURYSMS • The term dissecting aneurysm is applied for a dissecting haematoma in which the blood enters the separated (dissected) wall of the vessel and spreads for varying distance longitudinally. • The most common site is the aorta and is an acute catastrophic aortic disease. • The condition occurs most commonly in men in the age range of 50 to 70 years. In women, dissecting aneurysms may occur during pregnancy.
- 62. PATHOGENESIS • i) Hypertensive state • About 90% cases of dissecting aneurysm have hypertension which predisposes such patients to degeneration of the media • ii) Non-hypertensive cases • a) Marfan’s syndrome, • b)Development of cystic medial necrosis of Erdheim, especially in old age. • c) Iatrogenic trauma during cardiac catheterisation or coronary bypass surgery. • d) Pregnancy, for some unknown reasons.
- 66. COMMON DISEASES OF VEINS • VARICOSITIES • Are abnormally dilated and tortuous veins. The veins of lower extremities are involved most frequently, called varicose veins. • The veins of other parts of the body which are affected are the lower oesophagus (oesophageal varices), the anal region (haemorrhoids) and the spermatic cord (varicocele)
- 67. Varicose Veins • Varicose veins are permanently dilated and tortuous superficial veins of the lower extremities, especially the long saphenous vein and its tributaries. • Adult females are affected more commonly than the males, especially during pregnancy. • This is attributed to venous stasis in the lower legs because of compression on the iliac veins by pregnant uterus.
- 68. ETIOPATHOGENESIS • i) Familial weakness of vein walls and valves is the most common cause. • ii) Increased intraluminal pressure due to prolonged upright posture e.g. in nurses, policemen, surgeons etc. • iii) Compression of iliac veins e.g. during pregnancy, intravascular thrombosis, growing tumour etc. • iv) Hormonal effects on smooth muscle. • v) Obesity. • vi) Chronic constipation.
- 69. EFFECTS OF VARICOSE VEINS OF THE LEGS • Venous stasis which is followed by • congestion, • oedema, • thrombosis, • stasis, • dermatitis, • cellulitis and ulceration. • Secondary infection results in chronic varicose ulcers
- 70. PHLEBOTHROMBOSIS AND THROMBOPHLEBITIS • The most common locations for phlebothrombosis and thrombophlebitis are the deep veins of legs accounting for 90% of cases; it is commonly termed as deep vein thrombosis (DVT)
- 71. ETIOPATHOGENESIS • Venous thrombosis that precedes thrombophlebitis is initiated by triad of changes: • endothelial damage, • alteration in the composition of blood and • venous stasis. • The factors that predispose to these changes are cardiac failure, malig nancy, use of oestro gen-containing compounds, postoperative state and immobility due to various reasons
- 72. Special Types of Phlebothrombosis • 1. THROMBOPHLEBITIS MIGRANS • 2. PHLEGMASIA ALBA DOLENS • 3. PHLEGMASIA CERULEA DOLENS • 4. SUPERIOR VENA CAVAL SYNDROME • 5. INFERIOR VENA CAVAL SYNDROME
Editor's Notes
- #18: Foam cells, also called lipid-laden macrophages are a type of cell that contain cholesterol. These can form a plaque that can lead to atherosclerosis and trigger heart attacks and stroke. Foam cells are fat-laden M2 macrophages containing low density lipoproteins (LDL).