The disorder of local

circulation
Dr. Philip S.L. Beh
Email:
philipbeh@pathology.hku.hk
 Lecture Outline
Overview and revisit basic concepts
Circulatory system
Structure of blood vessels
Components of blood
Oedema
Generalised
Local
Effects on Brain and Lungs
Hemostasis Normal physiological response
Thrombosis Abnormal pathological response
Other forms of obstruction
Infarction Abnormal pathological outcome
 Overview and Revisit
Circulatory System
Structure of blood vessels
Components of Blood
 Circulatory System
Heart Pump
Blood Vessels Pipes
Artery, Vein, Capillary
Lymphatics Drainage pipes
Properties of circulatory system
Ensure smooth and adequate flow of
blood.
Delivers nutrients and oxygen
Removes waste and carbon dioxide
 Properties of arteries
Aorta
Comes off the heart
Sustains high blood pressures
Elastic but rigid wall
Arteries
Lower blood pressures
Often have muscular wall and can contract
 Structure of artery

Taken from www.sirinet.net/~jgjohnso/ circulation.html

 Properties of veins

Thin wall
Some have valves to prevent back-flow
of blood
Weak ability to contract even if there are
muscle fibers in the wall.
Dependant on pumping action of
surrounding muscles particularly of
the limbs.
 Structure of vein

Taken from www.sirinet.net/~jgjohnso/ circulation.html

 Properties of capillary bed
Very thin wall often only one cell-thick and
can change to allow blood to pass through
into the interstitial space.
Taken from Underwood General and Systemic Pathology
Taken from Guyton & Hall Human
Physiology and Mechanisms of Disease
 Properties of lymphatic
channels
Tube-like
Numerous valves
Drains fluid back to blood-stream passes
through at least one lymph-node.
Present in all tissues except
CNS, Eyeballs, Internal Ear, Epidermis of the
skin, cartilage and bone.
Taken from Guyton & Hall Human Physiology and
Mechanisms of Disease
 Systemic
circulation
vs.
Pulmonary
circulation

Taken from Robbins

Pathologic Basis of
Disease
 Schematic of
lymphatic
channels

Taken from Colour Atlas of

Anatomy Roden, Yokochi and
Lutjen-Drecoll
 Components of Blood
Plasma proteins, electrolytes and water
Cells red blood cells, white blood cells
and platelets.
 Disorders of the Circulatory
System
Congestion
Hemostasis
Thrombosis
Emboli
Other obstruction
Ischaemia and infarction
 Congestion
Distension of blood vessels
May be an active or passive process
Reversible condition
Oedema
 Oedema
Water compartments
Movement of water between the
compartments
Causes of oedema
Pulmonary oedema
Cerebral oedema
Taken from Guyton & Hall Human Physiology and Mechanisms
of Disease
Taken from Underwood General and Systemic Pathology
Taken from
Guyton & Hall
Human Physiology
and Mechanisms
of Disease
Taken from
Guyton & Hall
Human
Physiology
and
Mechanisms
of Disease
Taken from Guyton & Hall Human
Physiology and Mechanisms of Disease
Taken from Guyton & Hall Human Physiology and
Mechanisms of Disease
Taken from Guyton & Hall Human Physiology and
Mechanisms of Disease
Taken from Guyton & Hall Human Physiology and
Mechanisms of Disease
Taken
from
Guyton &
Hall
Human
Physiology
and
Mechanis
ms of
Disease
Taken from Underwood General and Systemic Pathology
Taken from Underwood General and Systemic Pathology
Taken from Underwood General and Systemic Pathology
Taken from Sternberg`s HISTOLOGY for PATHOLOGISTS
Taken from Sternberg`s HISTOLOGY for PATHOLOGISTS
Taken from Colour Atlas of
Anatomy Roden, Yokochi
and Lutjen-Drecoll
Taken from Colour Atlas
of Anatomy Roden,
Yokochi and Lutjen-
Taken from Colour
Atlas of Anatomy
Roden, Yokochi
and Lutjen-Drecoll
Taken from
Colour Atlas of
Anatomy
Roden, Yokochi
and Lutjen-
Drecoll
 Hemostasis

Diagram from Robbins Pathologic Basis of Diseases

 Platelet adhesion to von
Willebrands factor

Diagram from Robbins Pathologic Basis of Diseases

 Hemostasis Adhesion and
Recruitment

Diagram from Robbins Pathologic Basis of Diseases

 Hemostasis Thrombin
activation

Diagram from Robbins Pathologic Basis of Diseases

Diagram from Robbins Pathologic Basis of Diseases
 Hemostasis - Plug

Diagram from Robbins Pathologic Basis of Diseases

 Opposing actions

Diagram from Robbins Pathologic Basis of Diseases

Thrombosis
 Definition
Thrombus a blood clot.
Thrombosis a pathological process
whereby there is formation of a blood clot
in uninjured vasculature or after
relatively minor injury.
 Definition
Embolus A detached intravascular solid,
liquid or gaseous mass that is carried by
the blood to a site distant from its point of
origin.
Virchows Triad

Pathogenesis of a
Thrombus
Endothelial injury
Abnormal blood flow
Hypercoagulability
Primary (genetic)
Secondary (acquired)
 ENDOTHELIAL
INJURY

THROMBOSIS

ABNORMAL
HYPERCOAGULABILITY
BLOOD FLOW
 Endothelial Injury
Dominant factor
Sufficient as the sole factor
Examples include
Myocardial infarction
Ulcerated atheromatous plaques
Hemodynamic injury such as hypertension,
turbulent flow over heart valves
Endotoxins, inflammation, etc
 Abnormal Blood Flow
Turbulence in arterial flow as a result of changes
in the diameter of the vessel leading to non-
laminar flow, resulting in:-.
Platelet coming into contact with endothelium.
Prevent dilution by fresh flowing blood of
activated clotting factors.
Retard inflow of clotting factor inhibitors.
Promote endothelial cell activation predisposing
to local thrombosis.
 Hypercoagulability
Alteration of the coagulation pathway
that predisposes to thrombosis
Higher viscosity of blood changing the
flow dynamics of blood
 Fate of a Thrombus

Diagram from Robbins Pathologic Basis of Diseases

 Fate of a Thrombus
The thrombus may propagate
The thrombus may become organised and
recanalised
The thrombus may become organised and
incorporated into the wall of the vessel
The thrombus may be resolved completely
The thrombus may dislodge and become
an embolus or emboli
Propagation of Thrombus
 Classification of Thrombi
Anatomical Morphological
Cardiac Pale (platelet
Arterial thrombus)
Venous Red (RBC thrombus)
Capillary Mixed (intermittent
layers)
Renal Thrombosis of the
Artery descending aorta
extending from the
origins of the renal
arteries down to the
Thrombus iliac vessels

Iliac
Artery
 A mixed thrombus

Pale thrombus

Red thrombus
 Venous Thrombosis

Two distinct types

Phlebothrombosis predisposes to
thromboemboli to lungs
Thrombophlebitis unusual to have
associated pulmonary thromboemboli
 Effects of Thrombosis
Dependent on location and degree of
vascular occlusion.
Effects also dependent on the
availability of collateral blood supply
and susceptibility of area of supply to
interruption of blood supply.
 Demand
Supply
Taken from www.ecureme.com/atlas/ ata/Renal_Artery_Steno...
Taken from Underwood General and Systemic Pathology
 Other obstruction
Atherosclerosis
Embolism
Others
Congenital
Mechanical
Chemical
Iatrogenic
 Schematic of
atherosclerosis
 Concepts of atherogenesis

Hyperlipideamia, Hypertension,
Smoking, Homocysteine,
Hemodynamic factors, etc

Endothelium (E) Endothelial

Subendothelial space Injury/Dysfunction
Smooth muscle layer (S)
Adventitia

Taken from Robbins Pathologic Basis of Disease

 Concepts of atherogenesis

Circulating platelets
adhere to endothelial
surface

Leukocyte
adhesion

Leukocyte migration

Taken from Robbins Pathologic Basis of Disease

 Concepts of atherogenesis
Endothelial
Permeability
increased

LDL, VLDL
and leukocyte Ingestion of oxidised
accumulation LDL by leukocyte
(Foamy macrophage)

Smooth muscle migration

Taken from Robbins Pathologic Basis of Disease

 Concepts of atherogenesis
Gross appearance of
fatty streaking
Macrophage
and smooth
muscles
engulfing
more and
more LDL

Arrival of
lymphocyte

Taken from Robbins Pathologic Basis of Disease

 Concepts of atherogenesis

Smooth muscle
proliferation
and
accumulating
extracellular
collagen and
fatty deposits
 Effects of atherosclerosis
Hardening of the wall,
Loss of elasticity
Obstruction of lumen
Aneurysm
Rupture
Markedly atheromatous
Advanced
and atheromatous
calcified aorta with
degeneration and
thrombus saddle at the
calcification with thrombus
iliac bifurcation.
at iliac bifurcation
Cerebrovascular Disease

Intracerebral
haemorrhage with rupture
of the haemorrhage into
the lateral ventricle of the
brain. This lesion is likely
to result in hemiplegia
and could also be fatal if
the brain haemorrhage
and swelling cannot be
controlled.
 Types of embolism
Pulmonary
Air
Fat
Amniotic fluid
Septic
Tumour
Others
 Emboli
Pulmonary thromboemboli
Fat emboli
Marrow emboli
Air emboli
Amniotic fluid emboli
Others foreign bodies e.g. glass, metal
fragments (even occasionally bullets), etc.
Phlebothrombosis
Phlebothrombosis
 Pulmonary
Thromboembolism

Probably the most common form of

embolism.
Emboli derived from thrombosis of deep
veins of the lower limbs.
Predisposing factors include prolonged
immobility, dehydration, etc.
 Fat Embolism
Commonly found at autopsies
Often associated with injuries to
adipose tissues, long bones and
stressful states
May be quite asymptomatic
Can however lead to extensive
occlusion of vessels leading to
hemorrhagic infarcts
 Marrow Embolism

Often seen together with fat

embolism in particular
following fractures of long
bones.
Also quite commonly found
after fractures of ribs during
cardiopulmonary resuscitation.
 Air-embolism
Associated with high-pressure
activities or work, e.g.. Scuba diving,
compression chamber workers, etc
Gases are dissolved in the blood at
high pressures, sudden
decompression allows the gases to
form bubbles within the vascular
system, leading to obstruction
 Air-embolism
When large quantities of gases/air
collects in the right heart (usually
more than 100 ml), the pumping
action of the heart together with the
blood plasma and air/gas mixture will
lead to frothing and obstruction to the
blood flow and death.
 Amniotic Fluid Embolism
Associated with high mortality.
Contents of the fetal amniotic sac is
forced into the maternal circulation
often during induced labour.
The squames and other material in the
amniotic fluid is believed to lead to an
anaphylactic type reaction with
resultant disseminated intravascular
coagulopathy and death due to shock.
Embolism other forms
A variety of material may give
rise to emboli, e.g. Foreign
objects such as glass, bullets,
etc.
Tumor and bacteria may give
rise to tumor and septic emboli.
 Effects of embolisation
Identical
to those of thrombosis
and governed by similar factors.
 Effects of embolism
Dependant on extent of disruption to the
local circulation and susceptibility of the
target organ or tissue to such disruption.
 Fate of a Thrombus

Diagram from Robbins Pathologic Basis of Diseases

Tissues supplied by end-arteries
without significant collateral
supplies will be the most
susceptible.
Obstruction of blood supply
leads to ischemia which when
prolonged leads to necrosis and
atrophy.
Where there is reperfusion after
ischemic necrosis the tissues will
show a hemorrhagic necrosis.
Where there is infection by
Clostridia (gram positive bacilli),
gangrene sets in.
 Ischaemia
Transient
Insufficient blood supply
 Infarction
Cell death due to prolonged ischaemia
Irreversible
Mural
thrombus of the
left ventricle
commonly seen
after
transmural
infarction
Occlusive
thrombus or
emboli of cerebral
artery leading to
hemorrhagic
infarct of internal
capsule region
Chronic insufficient blood supply leading to atrophy
Patchy areas of gangrene of left foot
Bilateral gangrene of feet.
Wedged shaped area of infarct of the liver
Hemorrhagic infarcts of small bowels
Coil of thromboemboli of the pulmonary trunk
Saddle thrombus of the pulmonary trunk
Often leads to sudden death.
Pulmonary
thrombus
organised
Hemorrhagic
infarcts of the
lung
Fat emboli stained red
Fat embolism involving
glomeruli of kidney
Marrow emboli
Amniotic fluid emboli (squames)
Tumor embolus
 References
& Hall Human Physiology and
Guyton
Mechanisms of Disease 6th Edition
Section IV Chapters 13
Section V Chapters 20
Robbins Pathologic Basis of Disease
5th Edition
Chapter 1V