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Flashcards in Vascular Path Deck (79):
1

causes of 2* HTN

any cardio, renal, and endocrine dx
=inc cardiac output +inc vasoconstriction= inc BP

a. Renal disease:polycystic disease, renal cell carcinoma (RCC), chronic renal failure, glomerulonephritis, renal artery
stenosis and fibromuscular dysplasia
b. Adrenocortical hyperfunction:congenital adrenal hyperplasia, adrenal tumors
c. Adrenal medullary hyperfunction: pheochromocytoma
d. Thyroid dysfunction: myxedema)
e. Pituitary dysfunction: acromegaly
f. Cardiovascular disease: coarctation of the aorta, polyarteritis nodosa
g. Pregnancy: eclampsia and pre-eclampsia
h. Neurologic disease:↑ intracranial pressure
i. Medications and drugs: glucocorticoids, cyclosporine, sympathomimetics, cocaine

2

describe hypertnsion (HTN)

sustained BP >139 systolic or > 89 diastolic
M>F, Afro-Am, smokers, obesity
90% primary (essential HTN/ unknown cause- linked to calories, salt or alcohol)
10% secondary (adrenal/renal cause)

3

HTN: increased risk for

eye (blindness), heart (LVH, IHD/MI, CHF, aortic dissection),
renal (ESRD), & brain (stroke)
INCREASE RISK OF ATHEROSCLEROSIS

4

(2) hitso pathologic features of HTN

Hyaline arteriolosclerosis- protein leaks
hyperplastic arteriolosclerosis- onion-skin
INCREASE RISK OF ATHEROSCLEROSIS

5

describe iodiopathic/primary/essential HTN

genetic + environmental causes ( linked to calories, salt or alcohol)
90% HTN cases
defects in renal homeostasis + vasoconstriction + defects in smooth muscle= inc cardiac output and inc peripheral resistance= HTN

6

(4) hormones maintaining BP homeostasis

renin- renal (increases BP)
angiotensinogen- hepatic (increases BP)
aldosterone- adrenal (increases BP)
ANP- cardiac (decreases BP)

7

Aortic Dissection: types

bad= proximal aorta=risk of rupture into the pericardial sac with cardiac tamponade and harm to coronary or cerebral vessels
Type A (DI/DII): med/surgical
emergency (poor prognosis);
Type B (DIII): distal dissections= better prognosis

8

high risk for aortic dissection

-Connective tissue diseases (Marfan, Ehlers-Danlos= cystic medial degeneration)
-hypertension (Hypertrophy of the vasa vasorum)
-complication of arterial cannulation ( loss of smooth muscle)
-pregnancy

9

Aortic Dissection

Intimal tear, dissection into media (middle/outer
third), thru adventitia HMG into chest, abdominal,
or pericardial sac (poor prognosis);
false channel (better prognosis)

10

Hyaline Arteriolosclerosis

Hyaline protein deposits, narrowed
endothelial cell damage:
DM, HTN (decades), elderly
• endothelial cell dysfunction: plasma protein leakage/inc. SM cell & ECM synthesis
• a/w Nephrosclerosis  Renal Failure

11

Hyperplastic Arteriolosclerosis

Laminated “onion-skin” lesions
smooth muscle proliferation) obliterates lumen
Causes: fibrinoid nectosis, "flea bitten" kidney
• Life-threatening organ damage: brain, kidneys, heart medical emergency

12

Atherosclerosis

Affects elastic and muscular arteries
• Progressive accumulation of
lipid/lipid debris, smooth muscle cells, extracellular matrix, T-lymphocytes, macrophages/foam
cells in the intima
• Encroaches on the media &
adventitia (Atheroma) narrowing of the lumen (e.g., IHD, thrombus)
**chronic inflammation**

13

Atherosclerosis: modifiable risk factors

-Hypercholesterolemia(HC)/ Hyperlipidemia(HL) (Most important cause)
– HTN (major risk factor)
– DM (inc. HC/HL)
– Cigarette Smoking (inc. CRP)

14

steps in Pathogenesis of Atherosclerosis

1. endothelial cell injury/dysfunction
2. increase permeablility
3. cytokine release and leukocyte/monocyte/macrophage emigration
4. smooth muscle proliferation
5. engulf lipid
6. fatty streak
7. ECM deposition
8. fibrofatty atheroma
9. plaque
10. intimal ischemia

15

Elevated serum levels of CRP

Inflammation marker
Risk Factor:
- Atherosclerosis
- Acute Myocardial Infarction
- Stroke
- Peripheral arterial disease
- Sudden cardiac death

16

Atheromas: Thick vs Thin Fibrous Cap

Thin Fibrous Cap: Increase Risk of
Acute Coronary Thrombosis (AMI)

17

saccular aneurysms

1. Saccular- spherical outpouchings

18

fusiform aneurysms

2. Fusiform- diffuse, long, circumferential dilation

19

What are the two most important causes of aortic aneurysms?

HTN+atherosclerosis

other Risk: CT dx: Marfan (fibrillin), Scurvy, Ehler-Danlos; Matrix Metalloprotease (MMP)

20

What are the two most common locations for aortic aneurysms?

Below the renal arteries and above the bifurcation of the aorta. They may be fusiform or saccular, up to 15 cm in diameter and up to 25 cm in length. They are often accompanied by smaller aneurysms of the iliac arteries.

21

describe inflammatory aneurysms

Fibrosis; lymphocytes, marcophages, giant cells

Microbes infect plaque

22

describe mycotic aneurysms

invades Vasa vasorum= ischemia
Obliterative endarteritis

23

endarteritis

inflammation of the inner lining of an artery

24

Obliterative endarteritis

Obliterative endarteritis- severe proliferating inflammation of the inner lining of an artery that results in an occlusion of the lumen of the artery

25

Dissections:

Intimal tear within the wall of a blood vessel, which allows blood to separate the wall layers
Massive hemorrhage

26

Aortic dissection: Types A/B

Type A: Debakey 1- ascending + descending aorta
Type A: Debakey 2- ascending aorta
Type B: Debakey 3- descending aorta
(*worst= closest to aortic valve)

27

Non-infectious Vasculitis:

Inflammation of vessel walls
Thick, nodular
Distrupts elastic lamina
1) Positive for immune
complex deposition,
2) Antineutrophil
cytoplasmic antibodies
(ANCA),
3) Antiendothelial cell
antibodiess

28

what Non-infectious Vasculitis
affect Large vessels: aorta, extremities, head, neck (2)

Giant cell (temporal) arteritis
Takayasu arteritis

29

what Non-infectious Vasculitis affect Medium vessels: visceral (2)

Polyarteritis nodosa
Kawasaki disease

30

what Non-infectious Vasculitis affect Small vessels: arterioles, venules capillaries (4)

Microscopic polyangiitis
Wegner granulomatosis
Churg-Strauss syndrome
Henoch-Schonlein Purpura

31

what Non-infectious Vasculitis affect Small/med a, extremity veins, nerves (1)

Thromboangiitis obliterans (Buerger disease)

32

what Non-infectious Vasculitis: Segmental, thrombosing inflammation of small and medium sized arteries, esp. the tibial and radial arteries

Thromboangiitis obliterans (buerger disease)

33

what Non-infectious Vasculitis: Systemic vasculitis of small and med sized arteries, esp the renal and visceral vessels, spares pulmonary vessels

Polyarteritis nodosa

34

what Non-infectious Vasculitis: Necrotizing or granulomatous vasculitis of small to medium vessels, esp. in the lungs and upper airway

Wegner granulomatosis

35

what Non-infectious Vasculitis: Granulomatous vasculitis of medium and large arteries with ocular problems and weakening of the pulses in the upper extremities (2)

Takayasu arteritis (female50yo)

36

what Non-infectious Vasculitis: Arteritis of large to medium vessels, predilection for coronary arteries

Kasasaki disease

37

what Non-infectious Vasculitis: Small vessel vasculitis mediated by IgA immune complexes

Henoch Schonlein purpura

38

what Non-infectious Vasculitis: Necrotizing vasculitis of capillaries, arterioles and venules

Microscopic polyangiitis

39

describe Giant cell (temporal) arteritis

Large vessels: aorta, extremities, head, neck

Granulomatous inflamm.
Intimal fibrosis
Tcells, multinucl. Giant cells

Temporal artery
Ophthalmic artery
>50yo
Polymyalgia rheumatica

40

describe Takayasu arteritis

Large vessels: aorta, extremities, head, neck

Granulomatous inflamm.
Reduced BP, weak pulse

<50yo
Aorta arch (transmural)
Japanese women

41

describe Polyarteritis nodosa

Medium vessels: visceral

Necrotizing inflamm
Histo: Fibrinoid necrosis, lesions at varying stages, "string of pearls" healing
Multiple organs

Renal arteries, mesenteric, spares pulmonary vessels
Chronic HBV

42

describe Kawasaki disease

Medium vessels: visceral

Arteritis, mucocutaneous lymph node sx
Erythema/Desquamative rash (Conjunctiva, oral cavity, Hands/feet)
Tx: Aspirin and gamma globulin
Causes: coronary artery aneurysm, heart/lung block
Histo: inflammatory cell infiltrates

Asian children
Coronary artery

43

Microscopic polyangiitis

Small vessels: arterioles, venules capillaries

Necrotizing vasculitis, p-ANCAs (MPO-ANCA)
Histo: All lesions are of same age; Fragmented, apoptotic neut
Tx: Immunosuppression

glomerulonephritis and pulmonary capillaries

44

Wegner granulomatosis

Small vessels: arterioles, venules capillaries

Granulomatous inflamm., Necrotizing vasculitis,
c-ANCAs

Respiratory tract (lungs+nasal+pharynx), glomerulonephritis

45

Churg-Strauss syndrome

Small vessels: arterioles, venules capillaries

Eosinophil-rich,
Granulomatous inflamm., Necrotizing vasculitis
p-ANCAs

Respiratory tract
Asthma
Blood eosinophil

46

Henoch-Schonlein Purpura

Small vessels: arterioles, venules capillaries

IgA immune complex deposition
Palpable purpura, hematuria

Children, follows URI

47

Thromboangiitis obliterans (Buerger disease)

Small/med a, extremity veins, nerves

Segmental, thrombosing inflamm., fibrous tissue,
Leads to vascular insufficency
Histo: Occluding thrombus & microabscesses
Ulceration & gangrene
Autoamputation of digits

Cigarettes
Arteries in extremities
(UE/radial; LE tibial)
digits

48

Infectious vasculitis

1) Bacterial
(pseudomonas),
2) Fungal (mucor;
aspergillus)
by vascular/hemato spread

49

Raynaud phenomenon

recurrent vasospasm of the fingers and toes and usually occurs in response to stress or cold exposure
reduced blood= white/blue

50

Hemangioma

benign vascular tumor
vessels filled with blood
3 types (capillary, cavernous, pyogenic)
Histo: organized, lobular architecture. Each lobule consists of small vessels

51

Bacillary angiomatosis (bartonella)

benign
vascular proliferation involving the skin, bone, brain, and other organs
Gross: Red papules or nodules
Histo: PMN inflammation & capillary proliferation
-gram negative bacilli Bartonella on Warthin-Starry stain
Risk: immunocompromised patients,
also causes: cat-scratch fever & trench fever
-Tx w/ Abx’s

52

Kaposi sarcoma

Intermediate grade malignant tumors:
Locally invasive

Risk: AIDS (herpesvirus type 8), east. European males, transplants
Gross: - Red-purple patches, macules, papules, plaques or nodules
Morph: - nodular, Sheets of plump, proliferating spindle cells
Dilated irregular endothelial cell-lined vascular spaces with interspersed lymphocytes, plasma cells, and macrophages
Tx: excision,radiation,chemo Rx (good prognosis)

53

Angiosarcoma

malignant: aggressive tumor
Proliferation of endothelial cells (cell marker CD31)
breast, skin, liver
Gross: Aggressive, poorly demarcated, variegated, fleshy masses
Histo: dense clumps of Atypical cells lining vascular lumen
Risk: older adults, PVC, arsenic
(5 yr survival= 30%)

54

Syphilitic Aneurysm

Untreated 3* syphilis, treponema pallidum
Histo: "tree bark" intima
Enlarged heart
Causes thoracic aortic aneurysm
Obliterative endarteritis of vasa vasorum

55

HOW IS VASCULITIS DIAGNOSED?

Biopsy—surgical removal of a small piece of tissue for inspection under a microscope
Angiography—a type of X-ray to look for abnormalities of blood vessels
Blood tests (+ANCA)

56

effects of Antineutrophil cytoplasmic antibodies (ANCA):

Leads to vascular injury
Autoantibodies cause autoimmune swelling and inflammation of blood vessels

57

C-ANCA (anti-proteinase-3/PR3-ANCA)

Attacks in cytoplasm
Neutrophil azurophillic granules
Increase PMN activity
Intracellular components

Microbial peptides (polyangiitis)

58

P-ANCA (anti-myeloperoxidase/MPO-ANCA)

Attacks near nucleus
Lysosomal granules
Forms Oxygen free radials

Microbial antigens
Infection
Endotoxins
autoantibodies

59

Proliferative restenosis

Proliferative restenosis- metabolic syndrome = inc risk for coronary atherosclerosis
Tx: angioplasty: place stent with paclitaxel to limit smooth muscle hyperplasia

60

Risk factors for atherosclerosis in pulmonary vasculature: (*different than systemic risk factors*)

emphysema and fibrosis (obstructive and restrictive dx's)

61

Raynaud phenomenon

recurrent vasospasm of the fingers and toes and usually occurs in response to stress or cold exposure
reduced blood= white/blue

62

varices

abnormally dilated vessel with a tortuous path
Caused by blocked venous drainage

63

phlebothrombosis vs Thrombophlebitis

phlebothrombosis= blood clot in a vein without inflammation.
Thrombophlebitis = inflammation of a vein with a clot

64

Lymphangitis

inflammation or an infection of the lymphatic channels that occurs as a result of infection at a site distal to the channel.
Caused by acute streptococcal infection of the skin

65

lymphedema

lymphatic obstruction
localized fluid retention and tissue swelling caused by a compromised lymphatic system
Develops over time
Causes: infection, cellulitis

66

define angiitis & vasculitis

inflammation of blood vessel walls
Thick, nodular
Disrupts elastic lamina

67

What are the complications of hypertension?

Heart – concentric LV hypertrophy → LV dilatation → congestive heart failure, arrhythmias
• Blood vessels – arteriosclerosis → myocardial infarction, peripheral vascular disease, Aortic dissection
• Kidneys – ↓ GFR → chronic renal failure
• Brain – stroke (due to atherosclerosis) and intracerebral hemorrhage (due to Charcot-Bouchard microaneurysms)
• Retina - retinopathy → blindness

68

What are the risk factors for atherosclerotic cardiovascular disease?

Age, Sex (Male), Family history and genetic abnormalities, Post-menopausal females (decreased estrogen)
Hyperlipidemia, Hypertension, Diabetes
Smoking, Obesity, Inactivity, Stress, Alcohol
Genetic: rare single gene defects of aldosterone or Na+ channels. Polymorphisms at multiple sites are much more common,
but not well defined.

69

“Response to Injury” Hypothesis: pathogenesis of atherosclerosis

atherosclerosis is an aberrant chronic inflammatory response:
All five cell types in an atherosclerotic plaque are capable of liberating mediators that have a role in the disease progression.
These interact with the ECM and induce the formation of the thick fibrous cap with the lipid core.

70

What are complications of atherosclerotic disease?

myocardial infarction/ischemic heart disease, strokes, aortic aneurysms, and peripheral
vascular disease (distal lower extremity gangrene). In addition, rupture of an atherosclerotic plaque may cause thrombus
formation and occlusion of a vessel.

71

Which inflammatory marker in the serum correlates with the risk of ischemic heart disease and is important in the
overall risk stratification of patients?

Serum C-reactive protein (CRP)

72

What population is most at risk for the development of an abdominal aortic aneurysm?

Male, smokers, > 50 years of age, atherosclerosis, HTN

73

What is the incidence of abdominal aortic aneurysms?

<5% in males over 60 even with close to 100% aortic atherosclerosis in that population

74

What determines the risk of rupture of an abdominal aortic aneurysm?

The risk of rupture is directly related to the size of the aneurysm.
negligible risk if < 4cm,
1% per year if between 4-5cm,
11% per year if between 5-6 cm,
and 25% per year if > 6 cm.
Surgical treatment (prosthetic grafts) are usually recommended if the AAA is 5cm or greater in diameter

75

What is the mortality of abdominal aortic aneurysm surgery with and without rupture?

Operative mortality for un-ruptured aneurysms is approximately 5% and emergency surgery after rupture has a mortality rate
>50%

76

What is the mortality of a ruptured abdominal aortic aneurysm?

Mortality is about 50% for emergency surgery to repair a ruptured AAA, whereas it is only 5% operative mortality for
unruptured AAA

77

Describe the clinical features (sx) of temporal arteritis?

fever, fatigue, weight loss; facial pain and headache, especially along the course of
the superficial temporal artery, which is often painful to palpation. Ocular symptoms, associated with involvement of the ophthalmic artery, appear abruptly in 50% of patients, and include diplopia to complete vision loss.

78

What are (3) TYPES OF Hemangiomas (common benign vascular tumors) and what are their histologic features?

1. Capillary hemangiomas of of skin, subcutaneous tissues, mucosa, liver, spleen or kidneys, which are un-encapsulated
aggregates of closely packed thin walled capillaries. These lesions frequently regress spontaneously to variable
degrees.
2. Cavernous hemangiomas with infiltrative growth of large, dilated vascular channels into deeper structures; they do
not tend to regress. and
3. Pyogenic granulomas which are pedunculated skin nodules of proliferating capillaries with extensive edema and
inflammation.

79

What are the diagnostic criteria of Kawasaki disease

1. Bilateral non-exudativet conjunctival injection
2. Changes of the mucosa of the oropharynx, including infected pharynx, infected and/or dry fissured lips, strawberry tongue
3. Changes of the peripheral extremities, such as edema and/or erythema of the hands or feet, desquamation, usually
beginning periungually
4. Rash, primarily truncal, polymorphous but nonvesicular
5. Cervical adenopathy