PART I:

Review the following images

Image 1:

Normal coronary artery. Note the uniform muscular wall and lack of intimal thickening.

Image 2:

Coronary artery with narrowed lumen from atherosclerosis.

Image 3:

Coronary atheroma, high power. Note the intimal thickening inside the elastic lamina.

Image 4:

Coronary atheroma, with calcification.

Image 5:

Coronary artery with atherosclerosis and recent thrombus filling the lumen.

Image 6:

Coronary artery with recent thrombosis. Note the cholesterol clefts in the plaque.

Image 7:

Coronary artery atheroma. Note the lipophages in the plaque.

Image 8:

Coronary atheroma. There is intimal proliferation with calcification. A remote thrombus has organized, leaving marked stenosis with only two small recanalized channels.

Image 9:

Coronary stenosis, gross, with a markedly narrowed lumen. The most severe changes in the coronary arteries are usually proximal (which is why coronary artery bypass grafting [CABG] can be done).

Image 10:

Pelvic vein thrombus. Note the thin muscular wall of this vessel, typical of a vein. The thrombus displays varying degrees of organization, reflecting its propagation over time.

Image 11:

Pelvic vein thrombus with area of more recent thrombus formation. Note the layering of the red blood cells and fibrin (which form the lines of Zahn seen grossly).

Image 12:

Pelvic vein thrombus with organization. Note the granulation tissue with capillary proliferation and the attachment of the thrombus to the vessel wall.

Image 13:

Pulmonary embolus, gross, filling the main pulmonary arteries at the bifurcation (saddle embolus). This can be a cause of death.

Image 14:

Pulmonary embolus within a branch of pulmonary artery, microscopic.

Image 15:

Pulmonary infarction, gross, with hemorrhagic lesion based on the pleural surface.

Image 16:

Spleen with recent infarct, microscopic, low power.

Image 17:

Spleen with recent infarct, microscopic, high power. Note the embolus in the small artery in the center of the field.

Image 18:

Left ventricular aneurysm, gross. An old myocardial infarction has healed with replacement of the myocardium with fibrous scar that bulges out, forming an aneurysm.

Image 19:

Left ventricular aneurysm, microscopic, low power. There is mural thrombus overlying the collagenous scar, with some remaining myocardium beneath this.

Image 20:

Aortas, atherosclerosis, gross, with varying degrees of severity with lipid plaques and areas of ulceration.

Image 21:

Aorta, with intimal atheroma, microscopic appearance.

Image 22:

Aorta, intimal atheroma with overlying hemorrhage and early mural thrombus formation, micro.

Image 23:

Aorta, atherosclerosis, microscopic, atheroma with lipophages and cholesterol clefts.

Image 24:

Lower leg, gangrenous necrosis from severe peripheral atherosclerotic vascular disease.

CASE 1:

History:

A 66-year-old man had been in fairly good health throughout most of his life, though he had increasing exercise-induced angina for the past 5 years. His total serum cholesterol was 257 mg/dl with an HDL component of 30 mg/dL. His blood pressure was 145/95 mm Hg. The cross sections of coronary artery show occlusive atherosclerosis with thickening of the intima and calcification. Identify the remaining lumen.

Image 2

Image 3

Image 4

Questions:

1. What are the consequences for the myocardium from coronary atherosclerosis?
2. Name risk factors for coronary atherosclerosis.
3. Is the incidence of coronary artery disease increasing or decreasing in the U.S.?

CASE 2:

History:

A 59-year-old obese man with a history of smoking 2 packs of cigarettes per day developed sudden onset of substernal chest pain. He became diaphoretic and short of breath. Paramedics were called, but upon arrival he was in cardiac arrest and could not be revived. The sections of coronary artery seen here were taken at autopsy.

Image 5

Image 6

Questions:

1. What do you see in the lumen of the coronaries?
2. How does this pathologic appearance correlate with the clinical history?

CASE 3:

History:

An 85-year-old woman fell and broke her hip. She was not a good candidate for surgery, so she was confined to bed in a nursing home. Several weeks later, she was being moved to another room and soon afterwards became short of breath. She died soon after. At autopsy, a large pulmonary embolus was found.

Image 10

Image 11

Image 12

Image 13

Image 14

Questions:

1. What are risk factors for venous thrombosis?
2. Where do most pulmonary emboli originate?
3. How do you distinguish a premortem thrombus from postmortem blood clot?

CASE 4:

History:

Several months following a myocardial infarction, a 30-year-old man with familial hypercholesterolemia (total serum cholesterol 550 mg/dL) noted left upper quadrant pain. He had recovered from the MI, but subsequently had markedly decreased exercise tolerance.

Images 16 and 17 illustrate what the lesion that caused the left upper quadrant pain in such a case would look like. Note that the organ is spleen.

Image 16

Image 17

Image 18:

Image 19

Questions:

1. Describe and name the lesion present in the spleen.
2. What would cause such a lesion?
3. How does this relate to the myocardial infarction with subsequent aneurysm?
4. What are potential complications?

CASE 5:

History:

A 73-year-old man had a long history of diabetes mellitus. He had a history of having ulcers on his left foot that healed slowly. However, over several weeks, his entire left foot began to show progressive black discoloration, eventually extending to involve much of the left lower extremity. Popliteal and dorsalis pedis pulses could not be palpated. An above the knee amputation was performed. The left femoral artery has marked intimal atherosclerosis and focal calcification. The lumen is occluded by recent and remote thrombus.

Image 24:

Questions:

1. What is the name for the process involving the lower extremity?
2. What would be the potential consequences of an arterial thrombus in the carotid artery? In the renal artery? In the inferior mesenteric artery? In the hepatic artery?
3. What therapies are available for diabetes mellitus?

CASE 6:

History:

This 65-year-old man died from a large cerebral infarction several months after retiring from an accounting firm. For many years his only exercise consisted of daily trips to the office soft drink dispenser. At autopsy, the aorta showed 100% atherosclerosis with lipid plaques, ulcerations, mural thrombus, and calcifications. These images all show the aorta.

Image 20

Image 21

Image 22

Image 23

Questions:

1. How often does the aorta become occluded by thrombus?
2. How often do atheromatous emboli occur?
3. What factors accelerate atherosclerosis?