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Thrombosis
Thrombosis
MYOCARDIAL INFARCTION
Causes endothelial injury
Non contractile myocardium brings an element of
stasis.
MITRAL Valve stenis eg 2 Rbeumatic heart
disease
Causes left anterial dilation
Profound stasis favors thrombosis.
HYPERCOAGULABILITY
Less frequent cause of thrombosis but
important
Defined as alteration in coagulation pathway
predisposing to thrombosis
Can be Primary (genetic) or Secondary
(acquired) disorder.
Most common inherited causes are;
Mutation of factor v gene
Mutation of Prothrombin gene.
Acquired disorders leading to thrombosis
occurs in common clinical settings:
Examples
Cardiac failure or trauma;
Due to stasis
Vascular injury
Oral Contraceptives and Hyperoestrogenic
state of Pregnancy
Disseminated cancer(Release of
Procoagulant factors)
Hypercoagulabily of advance age may be due
to;
Susceptibility to platelets aggregation
Smoking and obesity – promotes
hypercoagulability – reason unknown.
MORPHOLOGY
Thrombi May develop anywhere in
cardiovascular system.
Are of Variable size and shape depending on
Size
Circumstances leaving to Development
Arterial or Cardiac Thrombi usually begins at
site of endothelial injury or;
At area of turbulence e.g. vessel bifurcation.
Venous thrombi characteristically occur at site
of stasis.
Arterial thrombi tends to grow in retrograde
direction.
Venous thrombi- Direction of Blood flow.
Propagating fail may not be well attached
(especially venous)
May detach causing embolus.
When arterial thrombi arise in Heart
Chambers of aortic Lumen are termed Mural
thrombi.
Common causes of Thrombi in Heart;
Abnormal myocardial contraction (arrythmias)
Dilated Myocardiapathy.
Myocaridal infarction.
Aortic thrombus
Ulcerated atherosclerotic plaque
Aneurysms
Venous Thrombosis
Almost always oculusive
Creates a long cast along vein lumen.
Because occurs in areas of stasis, there is
more emeshed erythrocytes therefore red.
Venous Thrombosis Commonly affects veins of
Lower extremites(90% of cases)
Less Community in upper limbs.
In special cases: Dura sinuses, portal vein or
hepatic veins.
Under special condations thrombi may form in
heart valves.
FATE OF THROMBUS
If Patient survives initial effects of occlusion
thrombus may undergo the following;
PROPAGATION
Thrombus may accumulate more platelets
and fibrin( Propagate) – eventual Vessel
obstruction.
Embolization
Disloge and travel to other sites of Vasculature.
Dissolution
Thrombi removed by fibronolytic activity.
Organization and recanalization.
Thrombi may induce inflammation and fibrosis
( Organization) and;
Eventually because recanalized and establish
vascular flow.
Clinic significance
Both Arterial and venous thrombus may
cause vessel occlusion.
Venousthrombus may cause Oedema and
Congestion in various bed distal to
obstruction.
Most dramatic (grave)Conquence is
embonzation to lung – death.
Venous thrombosis
Most occurs in superficial or deep veins of legs
Superficial thrombosis
Usually in salphenus vein(vericosity)
Thrombi usually causes local congestion and
tenderness in affected vein.
Rarely embolizes
Impaired drainage predisposes to infection of
overlying skin from slight trauma – Vericose ulcer.
Deep vein thrombosis- grave due to embolism
Deep vein obstruction may also cause local pain
oedema and congestion
Because of collateral circualtion 50% of affected
patients may be assymptomatic.
Deep vein thrombosis may occur with stasis or
hyrercoagulabilty states
Candiac failure a common cause of venous
stasis.
Trauma, surgery, burns – reduced physical
actibity, injury to vessels, release of
procoagnatants by tissues.
Arterial thrombosis
Atherosclerosis is major contributor.
Cardiac Mural thrombus may occur in setting
to myocardial infarction.
Rheumatic heart diseases may results into
artrial mural thrombus( Mitral valve stenosis)
In addation to consequences of obstruction
may embolise Virtually to any tissue.
Primciple targets, brain, kidney, spleen (Large
volume of flow).
EMBOLISM
Defn: Detached intravascular solid, fluid or
gaseous mass that is carried by blood to distant
site from origin.
Almost all emboli represent some disloged
thrombus hence;
THROMBOEMBOLISM
Unless otherwise stated embolism reffers to
thromboembolism.
Emboa lodges in a vessel to small to allow
further passage.
May lead to partial or complete vascular
occlusion.
Consequence of occlusion is ischaemic
necrosis of distal tissue ( infarction)
Depending on site of origin may lodge
anyway in vascular tree.
Clinical consequence depends whether emboi
hodges in pulmonary or systemic circulation.
Pulmonary thromboembolism
Common in hospitalized patient.
In 95% of pulmonary embolism the origin is
thrombus in deep vein of leg.
Carried through right side of heart to
pumonary vasculature.
Depending on size;
May occlude Main Pulmonary artery.
Impact across bifurcation(saddle embolus)
Pass into smaller branches.
Frequently there may be multiple smaller
emboli( shower from a single large mass)
In general a person with one pulmonary
embolus is at risk of having more.
Rarely embolus may pass through interatrial or
interventricular defect.
When if this happen it enters systemic
circulation( paradoxical embolism)
CLINICAL CONQUENCES.
Most pulmonary emboli(60-80%) are clinically silent
because they are small
Sudden death, right heart failure or cardivascular collapse
may occur:
When more than 60% of pulmmory circulation is
obstructed.
Embolic obstruction of medium sized arteries may result it
no pumornary haemornhage without infart.
This due to dual blood flow from bronchial
circulation.
Obstruction of small end- artery infarction of
area distal to obstruction.
Multiple emboli. Over time may cause
pumonary hypertension with right heart failure.
SYSTEMIC EMBOLISM
Emboli travelling in arterial circualtion .
Most (80%) arise from intracardiac mural
thrombi
Two third of these associated with left
ventriculary wall infarcts.
Another one quarter dilated fibrilaring left
arteria.
Remainder from;
Aortic oneurysms
Thrombi on ulceraled atheroscleerotic plaque
Valvular vegetations.
About 10-15& systemic embolism are
unknown origin.
Arterial emboli can travel wide to a variety of
sites
Major site of artterialar embolism;
Lower extremites( 75%)
Brain 10%
Lesser exlent, intestines, Spleen, upper extremities.