dr. Budiana Tanurahardja.,SpPA

DEPARTMENT of ANATOMIC PATHOLOGYDEPARTMENT of ANATOMIC PATHOLOGYFACULTY of MEDICINE UNIVERSITY of INDONESIAFACULTY of MEDICINE UNIVERSITY of INDONESIA

Center of Anatomic Pathology Studies

Vascular pathology

Vascular Pathology

• Normal blood vessels.• Aneurysms.• Hypertension.• Vasculitis.• Varices.• Neoplasms.

Normal blood vessels

• Arteries : - large/elastic• - medium size/muscular/distribute• - small arteries ( < 2 mm ).• Arterioles : 20 - 100 u .• Capillaries: 7 - 8 u.• Postcapillary venules.• Collecting venule.

Normal blood vessels

• Veins : - small.• - medium.• - large.• Lymphatic.• The main components : - endothelial cells.• - smooth muscles.• Tn. intima, tn.media, tn.adventitia.

Normal blood vessels

Normal blood vessels

Normal blood vessels• Main cellular components : endothelial

cells, smooth muscle cells• Endothel : - Weibel- Palade bodies 0,1x0,3u • storage organelle for vWF.• - IHC : antibody to vWF (factor VIII related

Ag) ; CD31• Vascular abnormalities caused by 2 mecha : • - narrowing/complete obstruction• - weakening of the walls : dilatation/rupture

Aneurysm• Aneurysm is localized abnormal dilatation of

blood vessel.• True and false.• Saccular and fusiform.• Etiology: atherosclerosis, cystic medial

degeneration, congenital, infection (mycotic aneurysm), syphilis, trauma,systemic dis., immunologic.

• Dissecting aneurysm: blood enters the wall of the artery, dissecting the layers.

Berry aneurysm

• Occurrence among patient with heritable systemic disorders ( autosomal dominant polycystic kidney, Ehlers-Danlos syndrome type IV,neurofibromatosis type I, Marfan syndrome), and fibromuscular dysplasia of arteries and coarctation of aorta.

• Cigarette smoking and hypertension ( 54 % of the patient)

Berry aneurysm• Saccular aneurysm.• The most frequent cause of subarachnoid

haemorrhage --> circle of Willis.• The 4th most common CVA after:

atherosclerotic thrombosis, embolism and hypertensive haemorrhage.

• 2 % in autopsy.• Pathogenesis: unknown.• Genetic factor may be important.

Berry aneurysm

Berry aneurysm

Aneurysm

Dissecting aneurysm

Hypertensive vascular disease

• Hypertension : elevated blood pressure diastole : > 90 mm Hg.

• Systole : > 140 mm Hg.• 90%-95%: idiopathic (essential hypertension}• 5%-10 : secondary : renal ,endocrine,

cardiovascular, neurologic.

Classification of blood pressure in adults

Category systolic diastolicNormalHigh normalHypertension:Stage 1 (mild)Stage 2 (moderate)Stage 3 (severe )Stage 4 (very severe)

< 130130-139

140-159160-179180-209> 210

< 8585-89

90-99100-109110-119> 120

Morphology

• Hyaline arteriolosclerosis: - in elderly patients normotensive or hypertensive, but more generalized and severe in hypertensive.

• - common in diabetes.• Hyperplastic arteriolosclerosis: - related to

severe acute elevation of blood pressure (diastole > 110 mmHg). – laminated thickening of the walls of arteriole that consist of smooth muscle cells and reduplicated basement membrane.

Arteriolosclerosis• Elderly patient:

normal/hypertensive.• Diabetes.• Leakage plasma

component ,matrix production by smooth muscle cells -> hyaline deposition.

• benign nephrosclerosis.

Arteriolosclerosis

• Acute /severe hypertension.

• Onion skin• often : accompanied by

deposits of fibrinoid and acute necrosis --> necrotizing arteriolitis(kidney)

Vasculitis• Inflammation of the walls of the vessels.• Classification :-direct infection: bacterial,

rickettsial, spirochaetal, fungal, viral.• Immunologic:-immunecomplex mediated:SLE,

RA• -ANCA(antineutrophil cytoplasmic autoAb

mediated: Wegener granlms,microscopic polyangiitis, Churg-Strauss syndr.

• -direct antibody attack mediated: Goodpasture, Kawasaki (antiendothelial)

Vasculitis

• -cell mediated: allograft organ rejection, IBD, paraneoplastic vasculitis.

• -unknown: giant cell temporal arteritis, Takayasu arteritis, PAN.

• Other classification: large vessel vasculitis(giant cell,Takayasu) , medium-sized vessel vasculitis (PAN, Kawasaki), small cell vasculitis(Wegener ).

Vasculitis

Thromboangiitis obliterans

Vein and lymphatics• Varicose veins (varices): abnormally dilated,

tortuous veins produced by prolonged, increased intraluminal pressure.

• Thrombophlebitis and phlebothrombosis.• Lymphangitis and lymphedema :

lymphangitis caused by bacterial infection group A beta hemolytic streptococcus.

• Lymphedema caused by occlusion of lymphatic drainage.

Varicose veins• Pathogenesis: obese persons have greater

tendency poor tissue support. • The most important factor is posture long

periods of standing . Even in normal person simple orthostatic edema.

• Other conditions : pregnancy, intravascular thrombosis, tumor mass.

• Micros : variation in thickness dilation and hypertrophy of smooth muscle and subintimal fibrosis, degeneration of elastic tissue, and spotty calcification in the media (phlebosclerosis).

Varices

• Statis dermatitis.• Varicose ulcers.

Neoplasm• Benign : -hemangioma: capillary,cavernous.• -lymphangioma: capillary,cavernous.• -pyogenic granuloma(lobular capillary)• -glomus tumor.• Intermediate grade neoplasms.• - Kaposi sarcoma.• - Hemangioendothelioma• - hemangiopericytoma.• Malignant neoplasm.• - angiosarcoma.

Congenital cavernous hemangioma

Haemangioma

Angiosarcoma