Cardiovascular system:

Atherosclerosis, aneurysm and

syphilis
II MBBS

Dr. Maitrayee Roy MD FRCPath

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The thicker smooth muscle layer in the arteries allow
them to be resistance vessels and control blood pressure
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Layers in the wall of an artery: Schematic representation

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There are three main
types of arteries:
•Elastic arteries
•Muscular arteries
•Arterioles

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Elastic arteries: E.g. Aorta and pulmonary artery.
The walls of elastic arteries are exposed to high pressures; hence contain
a large number of elastic fibers that allow them to withstand pressure
during systole and recoil back in diastole

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Muscular arteries: E.g. Most visceral arteries like coronary artery,
renal artery, etc.
Less elastic fibers because it is no longer exposed to very high
pressures. The tunica media has more smooth muscle, allowing the
muscular arteries to constrict and dilate in response to environmental
signals such as, hormones or temperature, and thus control the
distribution of blood between organs.
The elastic fiber layer is much reduced, and found at the border
between the tunica intima and tunica media in a layer called
the internal elastic layer and a less well defined external elastic
layer between the tunica media and tunica adventitia

Internal elastic
Tunica intima lamina

Tunica media
External elastic
lamina
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Adventitia
Arteriole: Arterioles are small arteries that deliver blood to
capillaries.
Tunica intima is very thin containing a layer of flattened endothelium.
The internal elastic lamina layer is still present.
Tunica media layer has no more than six concentric rings of smooth
muscle.
Tunica adventitia layer is approximately the same size as the tunica
media.

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Heart: epicardium

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Heart: epicardium

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Atherosclerosis

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 Atherosclerosis
• Disease of cardiovascular system affecting vessel wall.

• Atherosclerosis is an intima-based lesion

• Atherosclerotic plaque → fibrous cap and an

atheromatous core (necrotic center).

• Constituents of the plaque include smooth muscle cells,

extracellular matrices, inflammatory cells, lipids, and
necrotic debris.
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Atherosclerotic
plaque:
Schematic
representation

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Atherosclerotic plaque: cross section of artery, H&E

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Risk factors for atherosclerosis

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 Etiopathogenesis of atherosclerosis

• The key event is damage to the endothelium.

• Hemodynamic disturbance with platelet

adhesion to endothelium.

• Endothelium also becomes more permeable to

lipoproteins and inflammatory cells.

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 Types of plaques
• Atherosclerotic plaques develop and grow slowly over
decades.

• Stable plaques: causes narrowing of vessel lumens →

symptoms of ischemia

• Unstable/ vulnerable plaques: can cause potentially

fatal ischemic complications due to acute plaque
rupture, thrombosis, or embolization

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Fate of atherosclerosis

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 What is arteriolosclerosis?

• Arteriolosclerosis means ‘hardening of small arteries

& arterioles’

• 2 types: Hyaline arteriolosclerosis & hyperplastic

arteriolosclerosis.

• Risk factor: Most typically associated with

hypertension and diabetes mellitus.

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 Arteriolosclerosis: Types
• Hyaline arteriolosclerosis: thickening
of the arteriolar wall due to the
accumulation of homogeneous pink
material; typically found in the kidneys
of patients who have diabetes mellitus
or benign arterial hypertension.
• Hyperplastic arteriolosclerosis:
Thickening of the arteriolar wall due to
the concentric proliferation of smooth
muscle cells in tunica media, giving
the arterioles an “onion skin”
appearance; often seen in patients with
severe (“malignant”) hypertension. 25
Aneurysm: A ticking time bomb!

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 Aneurysm
• An aneurysm is a localized abnormal dilation
of a blood vessel or the heart due to
weakening of the wall of a blood vessel or
ventricular wall of heart.

• Congenital or acquired

• Most common site of vessel wall aneurysm:

aorta, vessels of brain, legs etc
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 True vs. False Aneurysm
True aneurysm False aneurysm
• Aneurysm involves an • aka pseudo aneurysm
attenuated but intact • Defect in the vascular
arterial wall or thinned wall that freely
ventricular wall of the communicates with the
heart. intravascular space
• e.g. Atherosclerotic • e.g. ventricular rupture
aneurysm, syphilitic after myocardial
aneurysm, congenital infarction (MI)
vascular aneurysms, contained by a
ventricular wall pericardial adhesion
aneurysm following MI
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 True vs. False Aneurysm

Arterial dissection: blood enters a defect in the arterial

wall and tunnels between its layers; often but not always
result in aneurysm
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 Etiology of aneurysm
• Congenital aneurysm: Inherited defects in
connective tissues (collagen, elastic tissue) resulting
in weakening of blood vessel wall
e.g. Marfan syndrome (cerebral vessel Berry
aneurysm), vascular forms of Ehlers-Danlos
syndrome

• Acquired aneurysm: Atherosclerosis, hypertension,

trauma, septic emboli from subacute endocarditis,
syphilis.
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 Clinical features
• Brain aneurysm: Headache, dilated pupil,
sensitivity to light, blurred vision, nausea,
vomiting, seizure, loss of consciousness

• Aortic aneurysm: Pulsing sensation in the

abdomen, abdominal/ back pain, shortness of
breath
Dreaded sequel → Rupture and internal bleeding.

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 Diagnosis
• Ultrasonography for screening
• CT scan/ CT angiography
• MRI/ MR angiography
• Trans-esophageal Echocardiogram

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 VDRL +

Diagnosis ?

Syphilis
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 Cardiovascular syphilis
• Late onset tertiary syphilis; latent period is 15-30 years

• Gumma (localized granulomatous inflammation) →

interventricular septum (bundle branch block),
myocardium, valves, pericardium

• Diffuse myocarditis

• Syphilitic aortitis → Aneurysm

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➢Affects proximal aorta
Syphilitic aortitis
➢Dilated aorta, thickened
intima with depressed scars and
white, shiny plaques

➢Tree bark like appearance

➢Peri-vascular inflammation
around vasa vasorum in
adventitia of aorta →
transmural inflammation
obliterative endarteritis →
localized ischemia &
weakening of wall → aneurysm 37
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Thank you

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