BLOOD VESSELS
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

I am active in HealthTap, which provides free medical guidance from your cell phone. There is also a fee site at www.afraidtoask.com.


If you have a Second Life account, please visit my teammates and me at the Medical Examiner's office.

Freely have you received, give freely With one of four large boxes of "Pathguy" replies.

I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:

Also:

pathology.org -- my cyberfriends, great for current news and browsing for the general public

EnjoyPath -- a great resource for everyone, from beginning medical students to pathologists with years of experience
Medmark Pathology -- massive listing of pathology sites
Estimating the Time of Death -- computer program right on a webpage
Pathology Field Guide -- recognizing anatomic lesions, no pictures


Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

I've spent time there and they are good. Write "Thanks Ed" on your check.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!

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Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

I [Allah] am nearer to you than the vein in your neck. --Koran

KCUMB Students
"Big Robbins" -- Blood Vessels
Lectures follow Textbook

QUIZBANK: Hemodynamic #'s 1-30, Vessels (all)

LEARN FIRST

The term "arteriosclerosis" (literally, "hardening of the arteries") should be avoided by physicians. It includes (1) atherosclerosis; (2) Monckeberg's medial calcific sclerosis; and (3) arteriolar sclerosis (hyaline, hyperplastic, intimal fibrosis). Unqualified, the term usually means "atherosclerosis".

The vascular intima looks simple but isn't. Endothelial cells must maintain their no-stick inner surfaces, help constrict and dilate vessels, and heal damaged vessels. Myointimal cells and macrophages, located between the endothelium and the internal elastic membrane, are the principal actors in atherosclerosis.

Atherosclerosis is a stereotyped response of the inner surfaces of large arteries to a variety of insults. In this disease, the cells between the endothelium and the internal elastic membrane take up cholesterol-rich lipid, which then causes harm. Lesions progress from FATTY STREAKS to FIBROUS PLAQUES to COMPLICATED FIBROUS PLAQUES; they can also regress.

Atherosclerosis may calcify, but the problem in atherosclerosis is not the dystrophic calcification. Monckeberg's medial calcific sclerosis just means dystrophic calcification of the media of an artery, but it is almost never a real problem.

Atherosclerosis is an ancient disease, present in some Egyptian mummies (JAMA 302: 2091, 2009 -- the lesions are real but look quite mild by today's standards).

Atherosclerosis was THE great killer of 20th century North Americans. The epidemic peaked in 1968, and since then the decline has been spectacular, due more than anything else to healthier lifestyles (JAMA 277: 535, 1997; it's been steady since the mid-1980's: NEJM 339: 861, 1998). We are beginning to understand how the common risk factors relate to its pathogenesis. Americans are taking steps to protect themselves, and lifestyle changes can almost certainly reverse much of the damage in all but the most advanced lesions.

Hyaline arteriolar sclerosis results from damage to arterioles usually from increased pressure or increased blood glucose. Hyperplastic arteriolar sclerosis involves hyperplasia of the intimal cells; it results from processes that do severe, acute damage to the endothelium. Fibrosis of the intima results from high blood pressure or "just getting older."

Blood Vessels and Heart
Taiwanese pathology site
Good place to go to practice

Cardiovascular
Surgical Pathology Atlas
Nice photos, hard-core

Cardiovascular
Utah cases for path students
Juliana Szakacs MD

Vascular
Iowa Virtual Microscopy
Have fun

Cardiovascular Diseases
First Section
Chaing Mi, Thailand

Cardiovascular Diseases
Second Section
Chaing Mi, Thailand

Cardiovascular Diseases
Third Section
Chaing Mi, Thailand

Cardiovascular Pathology
Photo Library of Pathology
U. of Tokushima

Cardiovascular
Brown Digital Pathology
Some nice cases

Aorta Exhibit
Virtual Pathology Museum
University of Connecticut

Cardovascular Pathology
Sampurna Roy, MD
Lots of photos and good text

Heart and Vessel Pathology
Photomicrograph collection
In Portuguese

Harvey
William Harvey

OBJECTIVES: This is mastery material.

aortogramNORMAL ANATOMY

Pete Maravich BIRTH DEFECTS INVOLVING VESSELS

ATHEROSCLEROSIS (best recent update J. Am. Coll. Card. 46: 937, 2005; DeBakey tries to sort out what puts you at risk for what Am. J. Card. 85: 1045, 2000)

{03476} coronary artery atherosclerosis
{06485} coronary artery atherosclerosis, mild
{06491} coronary artery atherosclerosis, severe
{06497} coronary artery atherosclerosis, total
{09446} êtat cribilé from multiple atheroemboli

Aortic Atherosclerosis, longstanding
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Occlusive Atherosclerosis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Mild, moderate & severe atherosclerosis
WebPath Photo

Cholesterol emboli

KU Collection

Atherosclerosis of the Aorta
CDC
Wikimedia Commons

Carotid atherosclerosis
Severe disease
Wikimedia Commons

{06737} atherosclerosis of coronaries
{09443} atherosclerosis of middle cerebral artery
{10889} atheroembolus

Kidney
ERF/KCUMB

Severe atherosclerosis of a coronary artery
WebPath Photo

Atheroembolus
WebPath Photo

{03473} atherosclerosis, in a vein graft
{06581} atherosclerosis after radiation

{11057} fatty streak
{25024} fatty streak
{41533} foam cells

Fatty streaks
WebPath Photo

Fatty streaks
WebPath Photo

{11054} fibrous plaques

Fatty streaks
WebPath Photo

Severe atherosclerosis
WebPath Photo

Atherosclerotic plaque with needles and clot
WebPath Photo

Needles & foam cells
WebPath Photo

Fibrofatty plaque
Great labels
Romanian Pathology Atlas

Coronary graft vascular disease
Pittsburgh Pathology Cases

Calcified plaque
Great labels
Romanian Pathology Atlas

{11060} the nasty stuff
{14216} the nasty stuff
{25461} the nasty stuff
{53265} the nasty stuff

Atherosclerosis
Prosthesis in place
Urbana Atlas of Pathology

{06524} lethal hemorrhage into a plaque in a coronary artery

Hemorrhage into a plaque
Caused death
ERF/KCUMB

MONCKEBERG'S MEDIAL CALCIFIC SCLEROSIS

Medial Calcification
From Chile
In Spanish

Monckeberg's
UHS Case
Photo by Ed

Monckeberg's
WebPath Photo

ARTERIOLAR SCLEROSIS ("arteriolosclerosis")

Arterial Sclerosis I
From Chile
In Spanish

Arterial Sclerosis II
From Chile
In Spanish

{11777} hyaline arteriolar sclerosis
{40267} hyaline arteriolar sclerosis
{40347} hyaline arteriolar sclerosis

Hyalinized intramyocardial artery (diabetes)
Slide from Andrea McCollum MD
Cuyahoga County Coroner's Office

Hyaline arteriolar sclerosis
Tom Demark's Site

Hyaline arteriolar sclerosis
Tom Demark's Site

Hyalinized arteriole
WebPath Photo

Arteriolar sclerosis
Thick intima, hyaline media

{39559} hyperplastic arteriolar sclerosis in pulmonary hypertension
{24854} hyperplastic arteriolar sclerosis, scleroderma kidney

Hyperplastic arteriolar sclerosis
WebPath Photo

Hyperplastic arteriolar sclerosis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

THE VASCULITIS FAMILY (update Am. J. Clin. Path. 124(S): S-84, 2005)

Angiitis I
From Chile
In Spanish

Angiitis II
From Chile
In Spanish

{14284} leukocytoclastic vasculitis
{14286} leukocytoclastic vasculitis
{14287} leukocytoclastic vasculitis
{14289} leukocytoclastic vasculitis
{14290} leukocytoclastic vasculitis
{14292} leukocytoclastic vasculitis
{14293} leukocytoclastic vasculitis
{14294} leukocytoclastic vasculitis
{14295} leukocytoclastic vasculitis
{14296} leukocytoclastic vasculitis
{14298} leukocytoclastic vasculitis

{38497} old burned-out Wegener's, without good granulomas

{22095} temporal arteritis
{22096} temporal arteritis
{22098} temporal arteritis
{24777} temporal arteritis
{28019} temporal arteritis

Temporal arteritis
WebPath Photo

Temporal arteritis
WebPath Photo

{48983} Takayasu's

{24503} Raynaud's
{25459} Raynaud's
{39657} Raynaud's
{39654} Kawasaki's?
{39655} Kawasaki's?
{48983} Takayasu's

ATHEROSCLEROTIC AORTIC ANEURYSMS

Aneurysms I
From Chile
In Spanish

Aneurysms II
From Chile
In Spanish

{03665} atherosclerotic aortic aneurysm
{11042} atherosclerotic aortic aneurysm
{11048} atherosclerotic aortic aneurysm, repaired
{11642} atherosclerotic aortic aneurysm
{11645} atherosclerotic aortic aneurysm
{18717} atherosclerotic aortic aneurysm
{20305} atherosclerotic aortic aneurysm
{24780} atherosclerotic aortic aneurysm
{25742} atherosclerotic aortic aneurysm
{04589} atherosclerotic basilar artery aneurysm
{24836} atherosclerotic aneurysm, brain

Thoracic aortic aneurysm
Atherosclerotic
Ed Lulo's Pathology Gallery

Aortic aneurysm
Autopsy finding
KU Collection

Abdominal aortic aneurysm
Urbana Atlas of Pathology

Aortic aneurysm
WebPath Photo

Coronary Artery Aneurysm
Classic drawing
Adami & McCrae, 1914

{10224} syphilitic aneurysm
{18716} syphilitic aneurysm

Syphilitic aneurysm
Classic patient photo
Adami & McCrae, 1914

Syphilitic aortitis

Yutaka Tsutsumi MD

Syphilitic aortitis
Disrupted elastica
KU Collection

AORTIC DISSECTION

{17467} dissecting aneurysm
{18718} dissecting aneurysm
{20222} dissecting aneurysm
{25747} dissecting aneurysm

Aortic dissection
Pittsburgh Pathology Cases

Aortic Dissection
Pittsburgh Illustrated Case

Aortic dissection
WebPath Photo

Aortic dissection
WebPath Photo

Double-barrel dissection
WebPath Photo

Aortic dissection
WebPath Photo

Dissection up carotid
WebPath Photo

Aortic dissection
WebPath Photo

Dissection tear
WebPath Photo

Dissection tear
WebPath Photo

Hemopericardium
This was secondary to aortic dissection
WebPath Photo

VEINS

LYMPHATICS

Lymphedema
Patient education site
By a cyberfriend

TUMORS OF BLOOD VESSELS

{05888} hemangioma
{12235} hemangioma
{13041} hemangioma
{13042} hemangioma
{13044} hemangioma
{13045} hemangioma
{13047} hemangioma
{13048} hemangioma
{13050} hemangioma
{13051} hemangioma
{13141} hemangioma
{17507} hemangioma in liver
{21832} hemangioma
{21834} hemangioma
{21835} hemangioma
{22116} hemangioma
{22118} hemangioma
{22119} hemangioma

Cavernous hemangioma
Great labels
Romanian Pathology Atlas

Cavernous Hemangioma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Hemangioma
WebPath Photo

Cavernous hemangioma
Microscopic
KU Collection

{53705} Sturge-Weber

{13141} "pyogenic granuloma"
{12786} "pyogenic granuloma"
{12789} "pyogenic granuloma"
{12225} pyogenic granuloma

{12237} Kasabach-Merritt giant hemangioma

{09017} glomus tumor

{10863} hemangiosarcoma
{21065} angiosarcoma, breast
{40635} angiosarcoma

{09484}* hemangiopericytoma. This is subtle.
{09486}*  hemangiopericytoma
{09489} hemangiopericytoma, reticulin stain
{09490} hemangiopericytoma, reticulin stain

Bacillary Angiomatosis
E-medicine
Great photos

{23443} lymphangioma
{13392} cystic hygroma

Lymphangioma circumscripta
Great example of this
uncommon, benign lesion

Lymphangioma circumscripta
Great example of this
uncommon, benign lesion

Benign lymphangioendothelioma
Pittsburgh Pathology Cases

Lymphangioma
WebPath Photo


HIGH TECHNOLOGY

* After thirty years of "study" in the U.S., evidence that acupuncture actually works for ANY disease of the cardiovascular system remains conspicuous by its absence. The best available is that some hypertensives' blood pressure drops some while they are actually in the mellow, comforting acupuncturist's office, only to return to their usual levels when the treatments are over (Circulation 103: 2038, 2001). A major recent study at and near Harvard (SHARP -- Stop Hypertension with the Acupuncture Research Program) has been undertaken, using sham acupuncture for controls (Cont. Clin. Tri. 25: 76, 2004); I predicted in 2004 that it would not publish positive results, and judging on the data (Hypertension 48: 838, 2006) it was a total failure in every category. It's to the great credit of the New England School of Acupuncture, which did a lot of the work, that they were up-front about the whole thing.

* "How many miles of blood vessels are there in a pound of fat?" People write me about this every once in a while. Let's figure it out. Assume an adipocyte is 50 microns across; it'll vary from 10-100 depending on how fat the person is. The fatter you are, the less vascular is your fat, which is one more reason that this whole inquiry is silly. In a section of body fat, which I examine often enough under the microscope, the capillary (there has to be at least one) that supplies each fat cell is not usually visible, so I'll assume one per adipocyte, and all going in the same direction. Put a single capillary between each pair of fat cells and that's about 20 capillaries per millimeter, or about 500 capillaries per inch, or 250,000 capillaries per square inch. Assume a pound of fat is a cube 4" on a side, which is good enough for junk science, or 16 square inches, and that is 4,000,000 capillaries running through the cube, 16,000,000 inches. There are 12 inches in a foot and 5280 feet in a mile, so if you get 500 miles you did the arithmetic the same way that I did. If you prefer 100 miles as in other estimates, simply assume that there's a capillary between every other pair of adipocytes, rather than every pair. That this question is fundamentally wrong-headed can be understood by anyone who considers whether moving a certain total number of cars through Kansas City would be easier with more highways or fewer highways. Further, the vast majority of these capillaries are completely closed at any moment during your life, and not carrying any blood. At autopsy, blood usually dribbles from other organs but not from fat. At surgery, other organs bleed plenty but fat barely bleeds. The real question isn't, "How many extra miles of blood vessels?", but "How much rougher is it on my heart to be fat?" Think about walking around carrying 100 lb of weights everywhere you go. The truth is that "education" and moral exhortation do not cause people to lose weight; overeating is programmed just like scratching when you itch.

* SLICE OF LIFE REVIEW: VESSELS AND HEART

{03184} tricuspid valve, normal
{03187} tricuspid valve, normal
{03329} atrium, normal
{03344} hypertrophy & normal, (l) vent.
{03347} hypertrophy & normal, (l) vent.
{03401} comparison of atria, normal ra & la free walls
{03467} heart, normal histology
{03575} ventricular slice method of dissection normal heart
{03581} cardiac base method of dissection, normal heart
{03599} short axis dissection, normal heart
{03605} four chamber dissection, normal heart
{03611} long axis dissection, normal heart
{03629} cardiomyopathy, dilated; normal
{03683} pericardium intact opened, normal
{03686} pericardium opened removed, normal
{03689} pericardial sac, normal with and without heart removed
{03692} pericardium, normal with anterior portion removed
{03698} heart anterior, normal
{03716} heart, normal (r) (l) ant. oblique
{03719} heart anterior, normal
{03734} heart, normal (r)
{03749} heart, normal
{03758} tricuspid valve, normal
{03764} tricuspid valve (r) ventricle view, normal
{03767} mitral valve opened, normal
{03776} mitral chordae, normal
{03779} mitral valve, normal viewed from LA and LV aspects
{03785} aortic-mitral valvular continuity, normal
{03788} tricuspid mitral valves, normal comparison of shapes
{03791} tricuspid mitral valves, normal
{03794} heart, normal
{03797} heart, normal right ventricle
{03800} heart, normal left ventricle
{03803} heart, normal compare ventricle thick.
{03806} heart, normal
{03809} heart, normal
{03812} heart, normal
{03815} heart, normal: how to cut
{03818} heart, normal: how to cut
{03821} heart, normal: how to cut
{03851} myocardial cell, normal left ventricle
{03854} membranous septum (l) ventricle, normal
{03857} membranous septum (r) ventricle, normal
{03863} pulmonary valve, normal
{03866} aortic valve, normal
{03869} aortic valve closed opened, normal
{03872} aortic valve cusp in elderly, normal
{03881} aortic valve from above, normal
{03884} cardiac valves (all four), normal
{03899} coronary ostia, normal
{03902} aortic valve coronary ostia, normal
{03905} aortic valve coronary ostia, normal
{03908} coronary arteries, normal
{03911} coronary arteries sup. inf., normal
{03914} coronary artery dominance, normal
{03920} septum perforators of (l) ant. desc., normal
{03923} septum coronary arteries, normal
{03926} coronary arteries, normal
{03929} coronary arteries, normal
{04472} hear, normal
{04475} aorta, normal
{06218} superior vena cava aorta pulm. artery, normal
{06224} aortic arch, normal longitudinal section
{06233} vein, normal
{06539} coronary angiogram, normal
{09464} artery, normal
{09828} artery, normal
{11036} artery, normal
{11402} vertebral basilar artery, normal
{11405} vertebral basilar artery, normal
{11408} vertebral basilar artery, normal
{11738} heart, normal ventricle myocardium
{11799} heart, normal
{11800} heart, normal
{11809} aorta, intimal surface
{12889} venogram, normal
{12892} venogram, abnormal
{12894} venogram, abnormal
{14627} Purkinje fibers cross section
{14628} Purkinje fibers long.
{14687} capillary, normal
{14689} arteriole-venule, normal
{14692} artery, muscular
{14693} artery, muscular; shows internal elastic membrane
{14694} artery, small muscular
{14695} artery, small muscular
{14696} artery, muscular
{14697} artery, muscular; b=media, c=external elastic, d=adventitia, e=nerve
{14698} artery, vein
{14699} artery, vein
{14700} aorta, normal
{14701} aorta, normal (elastic stain)
{15047} adrenal medulla (central vein), normal
{15180} stomach, cardia
{15181} stomach, cardia
{15209} Purkinje fibers, heart
{15210} epicardium, #17
{15211} endocardium, #17
{15212} epicardium, #17
{15213} endocardium, #17
{15214} atrium, endocardium
{15215} atrium, endocardium
{15217} artery and vein, elastic stain
{15218} artery, #29
{15219} vein, #29
{15220} aorta, #22, elastic stain
{17466} artery, normal
{20234} ecg, normal
{20255} chest, normal x-ray
{20567} insufficiency, aortic with normal on r
{20798} vein
{20816} Purkinje fiber, heart
{20817} myocardium in cross section
{20818} epicardium with fat and blood vessel
{20819} myocardium with epicardium too
{20820} endocardium
{20821} atrium of heart, endocardial surface
{20822} atrium of heart, endocardial surface
{20823} atrium of heart, epicardial surface
{20824} artery and vein, longitudinal section
{20825} artery and vein, cross section
{20826} artery, elastic
{20839} artery
{31412} internal carotid artery, normal
{31442} straight sinus nerve vein of Galen, normal venous anatomy
{37643} heart, normal
{38015} artery, normal

BIBLIOGRAPHY / FURTHER READING

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