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Blood Vessels

Blood Vessels
There are 100,000 miles of blood vessels. Thats enough to circle the world 4 times! 1/5 of the blood is in the lungs. The brain receives 1.5 pints of blood every minute. With the exception of cartilage (which is avascular), no cell is more than a few cell diameters away from a blood vessel, so they can get oxygen, nutrients, remove waste.
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Blood Vessels
Arteries get smaller and thinner and are then called arterioles. Arterioles get smaller and thinner until their lumen is just one red blood cell in diameter. At this point, they are called capillaries, and this is where the oxygen exchange takes place. Capillaries then get larger as they take waste products away from the cells in the capillary bed and head back to the heart; now they are called venules. As venules get bigger, they are called veins until they return to the heart.
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Blood Vessels
From the heart the blood is pumped to the lungs to get more oxygen. During this trip, they get smaller again until they are capillaries, then they get the oxygen from the lungs and drop off the waste products (carbon dioxide). Then they get larger until the blood returns to the heart to get pumped out to the body again. All blood vessels (except the smallest) look similar.
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Tunica intima Endothelium Subendothelium Tunica media Smooth muscles Elastic fibers Tunica adventitia Vasa vasorum

Structure of Blood Vessels


Composed of three layers (tunics)
Tunica intima
ENDOTHELIUM: simple squamous epithelium. Allows for smooth flow of blood. Similar to endocardium. SUBENDOTHELIUM: loose connective tissue.

Structure of Blood Vessels


Composed of three layers (tunics)
Tunica media
SMOOTH MUSCLE: allows vasoconstriction. Allows blood to be directed to parts of body. ELASTIC FIBERS: within smooth muscles. Allows for forced vasodilation during heart contraction.

Structure of Blood Vessels


Composed of three layers (tunics)
TUNICA ADVENTITIA (TUNICA EXTERNA): dense fibrous connective tissue which thins out to loose connective tissue.
Protects the blood vessel (strong) Gives vessel strength for shape Anchors vessel to surrounding tissue; loosens with age.

Lumen central blood-filled space of a vessel


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These layers are thick, so they need their own vascular supply: VASA VASORUM (blood vessel for a blood vessel) to supply the oxygen. The endothelium layer does not need this because its in direct contact with the blood, but the subendothelium needs it.
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Tunica intima Endothelium Subendothelium Tunica media Smooth muscles Elastic fibers Tunica adventitia Vaso vasorum

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Structure of Arteries, Veins, and Capillaries

Figure 19.1a 11

Types of Blood Vessels


Arteries carry blood away from the heart
It does not matter if it is oxygenated or deoxy blood. If it is leaving the heart, it is an artery.

Veins carry blood toward the heart


It does not matter if it is oxygenated or deoxy blood. If it is entering the heart, it is a vein.

Capillaries smallest blood vessels


The site of exchange of molecules between blood and tissue fluid
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Arteries
ARTERIES carry blood away from the heart. Arteries have a smaller lumen than veins of similar size. Arterial walls are thicker than venous walls. Arteries have more elastin than veins. Arteries have no valves because the blood pressure in arteries is high enough that there is no backflow of blood.
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Arteries
Two types of large arteries:

Elastic
Muscular

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Types of Arteries
Elastic arteries the largest arteries
Diameters range from 1 - 2.5 cm Includes the aorta and its major branches High elastin content dampens surge of blood pressure
Figure 19.2a 15

ELASTIC ARTERIES
a. Largest, closest to heart. b. Has to take the full force of the systolic contraction; compensates by expanding a lot. c. There of lots of elastic fibers in the tunica intima as well. d. Does blood flow during diastole? Yes; elastic arteries return to original size, pumps blood. e. This is another pump besides the heart.
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Muscular Arteries
Muscular (distributing) arteries
Distal to elastic arteries From 0.3 mm- 1 cm Includes most of the named arteries Tunica media is thick

Figure 19.2b 17

MUSCULAR ARTERIES
a. Function is to distribute blood, and help control which regions of the body get blood. b. When you are exercising, you want the blood from the GI system to go to muscles. c. When your hands are cold, your body is using its blood for something more important. Therefore, the vessels will constrict in the hands. d. Dilation is just lack of constriction.
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ARTERIOLES
These are microscopic; they are the smallest type of artery. Large ones look like muscular arteries. Small ones only have two layers: endothelium and tunica media. One of the characteristics of an arteriole is that when it contracts, the lumen closes completely.
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Types of Arteries
Arterioles
Smallest arteries Diameters range from 10 m to 0.3 mm

Figure 19.2c 20

A sac-like outpouching of an artery Can rupture at any time; in aorta or brain can cause death within a few seconds. Symptoms: Swelling or throbbing (asymptomatic in brain) Some common locations for aneurysms include: Aorta Brain Leg Intestine (mesenteric artery aneurysm) Splenic artery aneurysm (can form during pregnancy)

Aneurysm

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Aneurysm
Causes of an aneurysm:
Defect in part of the artery wall High blood pressure (abdominal aortic aneurysms) Congenital (present at birth)

Usually not detected except by an angiogram or ultrasound. Treatment: surgical repair


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MRI for Blood Vessels

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Stroke

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Aneurysm

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The Ovation Abdominal Stent Graft System


Aneurysms can be repaired through open surgery or less invasively with endograft repair using a stent graft otherwise known as an endograft. Endografts feature a tube typically made of plastic material that is supported by a metal frame or stent. They are compressed into a delivery catheter, inserted into the femoral artery of the leg and then threaded into position in the weakened portion of the artery where they are released. Once released, the endograft expands against the wall of the aorta to redirect blood flow away from the aneurysm.
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How to Recognize a Stroke (STROKE)


S * Ask the individual to SMILE. T * Ask the person to TALK and SPEAK A SIMPLE SENTENCE (Coherently; i.e. It is sunny out today) R * Ask him or her to RAISE BOTH ARMS. O * Open the mouth and stick out the tongue K * Keep them comfortable and still E * Get EMERGENCY help (911) If one side of the body responds differently than the other side, or if they have trouble with the task, call 911.

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Important:
You dont have enough blood to go around; you only have 5 liters for 100,000 miles of blood vessels. At any given time, most blood vessels will be closed (except at lungs). Are you using your legs now? When your legs run low on oxygen, the vessels there will open up again. Are you using your brain now? I hope so! The vessels there will be open. When your leg falls asleep, there is pressure on an artery which stops the blood flow. When the nerves are deprived of oxygen, they tingle.
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Some clinically significant arteries

Femoral artery: easy to find pulse, but susceptible to injury. Circle of Willis: loop of arteries around pituitary and optic chiasma. Common area for stroke to cause blindness.

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Circle of Willis

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Capillaries
Smallest blood vessels; they are found everywhere These are the only sites of nutrient, gas exchange, and waste exchange in the cardiovascular system.
Diameter from 810 m
Diameter is similar to an erythrocyte Red blood cells pass through single file They only have an endothelium.

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Capillaries
Site-specific functions of capillaries
In the lungs oxygen enters blood, carbon dioxide leaves In the small intestines receive digested nutrients In endocrine glands pick up hormones In the kidneys removal of nitrogenous wastes

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Capillary Permeability
Intercellular clefts gaps of unjoined membrane
Small molecules can enter and exit

Three types of capillaries


Continuous most common Fenestrated (window) have pores Discontinuous (Sinusoids) have very large gaps
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Types of Capillaries
CONTINUOUS CAPILLARIES FENESTRATED CAPILLARIES DISCONTINUOUS CAPILLARIES

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CONTINUOUS CAPILLARIES
All capillaries are made of simple squamous epithelium. Continuous capillaries are most common, found in all organs of body. They have intracellular clefts, the function of which is essential for plasma to leak out and bathe each cell with extracellular fluid, which is rich in oxygen and nutrients. Erythrocytes and platelets dont fit through, but leukocytes can squeeze through so they can enter and leave the blood vessels as needed.
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Continuous Capillary

Figure 19.4a 36

FENESTRATED CAPILLARIES
These have a lot more leakage because there are more pores (holes). Found in areas where lots of fluids need to be moved back and forth (synovial membrane, small intestine).

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Fenestrated Capillary

Figure 19.4b 38

DISCONTINUOUS CAPILLARIES (sinusoidal capillaries)


These have very large gaps in the capillary. Anything can go in and out here, including erythrocytes. These are found in red bone marrow, where RBCs are made, and they need to enter the circulation by way of the sinusoidal capillaries. These capillaries are also in the liver and spleen, where red blood cells are destroyed.

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Sinusoids

Figure 19.4c 40

Capillary Beds

Figure 19.3a 41

PRE-CAPILLARY SPHINCTER
A small muscle in front of each capillary, controls the flow of blood to individual capillaries. ARTERIOLES direct the blood flow to the specific tissue. PRE-CAPILLARY SPHINCTERS direct the blood flow to specific cells. If one cell is starving, the capillary next to it will open. The sphincter opens and closes depending on the needs of individual cells.
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Capillary Beds

Figure 19.3b 43

PRE-CAPILLARY SPHINCTER
There is not enough blood to go around, so blood always flows only to those cells and tissues that need it. They drop off nutrients, pick up CO2 and other wastes.

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Veins
Veins take blood TO the heart. Two types:
Venuole: from the capillary to the vein Vein: takes blood to the heart.
Thinner walls (less pressure here) Larger lumen (blood moves more slowly) Skeletal muscle pushes on the vein to move the blood uphill. Need valves in veins

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Valves in Veins
How does blood get uphill back to the heart? Veins need valves. Veins are the only BLOOD vessels that have valves (although LYMPH vessels also have valves). Valves in veins allow blood to move in only one direction. What pushes the blood? The muscles of the body constrict, squeezing the vessels. This is a type of blood pump.
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Veins

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BLOOD PUMPS

The heart Elastic arteries Muscles constricting the veins

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Clinically Significant Veins

Greater Saphenous vein: used for coronary bypass; most likely becomes varicose. Facial vein: Danger triangle infection spreads to meninges in brain. Renal vein: oxygen poor, and contains the lowest concentration of nitrogen waste.
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Veins that are rich in oxygen and nutrients


Pulmonary vein Umbilical vein Hepatic Portal vein

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Fun Fact

Shivering increases your body heat by 18 fold. Moderate walking only increases it by 3 fold.

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Varicose Veins
The valves become incompetent: They cant close all the way because too much fluid has built up in them and the lumen has stretched too wide. They might be asymptomatic or they may be painful (phlebitis).

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Varicose Veins

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Telangiectasias
(Spider veins) Small dilated blood vessels (varicose veins) near the surface of the skin or mucous membranes that blanch (turn colorless) with direct pressure. They can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin. They can also develop on the legs, specifically on the upper thigh, below the knee joint, and around the ankles.

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Telangiectasias
Telangiectasia in the legs is often related to the presence of venous hypertension within underlying varicose veins. Age: The development of spider veins may occur at any age but usually occurs between 18 and 35 years, and peaks between 50 and 60 years. Females are affected approximately four to one to males.
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Telangiectasias
Pregnancy is a key factor contributing to the formation of varicose and spider veins. The most important factor is circulating hormones that weaken vein walls. There's also a significant increase in the blood volume during pregnancy. Varicose veins that form during pregnancy may spontaneously improve or even disappear a few months after delivery.
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Telangiectasias
Those who are involved with prolonged sitting or standing in their daily activities have an increased risk of developing varicose veins. The weight of the blood continuously pressing against the closed valves causes them to fail, leading to vein distention.

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Other causes of spider veins


Acne rosacea Sun or cold exposure Trauma to skin such as contusions or surgical incisions. Radiation exposure for the treatment of cancer Chemotherapy Chronic treatment with topical corticosteroids

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Spider Veins
Cause an unsightly appearance but are not dangerous. Injections of alcohol or saline into the vein will sclerose them (scar them shut). A laser can also be used to do the same. After treatment, macrophages will eventually phagocytize them and they will disappear.
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Spider Veins

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Varicose Vein Treatment


Laser can be used to seal off the distal end of the vein. It will close off. Sclerosing agents (alcohol or saline) injected around the vein can be used to do the same thing. Large painful veins can be surgically removed (vein stripping)

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Polidocanol
A sclerosant, an irritant injected to treat varicose veins. It causes fibrosis inside varicose veins, occluding the lumen of the vessel, and reducing the appearance of the varicosity. The FDA has approved it for veins up to 3 mm in diameter. It works by damaging the cell lining of blood vessels, causing them to close and eventually be replaced by other types of tissue.
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Edema
If the veins are varicose for a long time, plasma may leak out into the tissues, causing edema. Edema means swelling anywhere in the body (including from an injury or from hanging your legs down too long like when on an airplane), but it frequently occurs from incompetent veins in the legs.

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Edema
There are two types of edema:
Pitting Non-pitting

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Pitting Edema
Pitting edema is when you can push your finger into the skin and it leaves behind your print when you remove it. This type is less serious; it tends to be better in the morning since the legs have been horizontal all night. It will improve if a pressure bandage is applied.

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Pitting Edema in the Foot

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Treatment for Pitting Edema


Ace wrap
In the foot or leg always wrap from base of toes all the way to below the knee. Dont leave a hole at the heel! In the hand, always wrap from the base of the fingers to right before the bend of the elbow

Support hose (dont use the kind with the open heel; edema will push out of that area) Jobst Intermittent Compression A machine is used to inflate air in a bag around the leg. The air pressure is increased and decreased every few minutes to milk the edema out. Patient goes in for therapy several 67 times a week.

Jobst Intermittent Compression

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Non-Pitting Edema
Non-pitting edema is hardened tissue that does not leave your fingerprint. It is just as bad in the morning as it is at the end of the day. This is more severe because it does not go away easily.

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Tip For Everyone!


Buy your shoes at the end of the day when your feet are the most swollen. Wear new shoes around the house for two hours to make sure they dont hurt. Diabetic people need to have someone else examine their feet after wearing a new pair of shoes for two hours. Check for redness and blisters that they might not see or feel.
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Venous Stasis Ulcers


Might occur after the formation of varicose veins, when plasma has leaked out into the tissues, causing edema. Acid products from the blood plasma (carbon dioxide, etc) can eventually erode all the way to the skin. Common in diabetics. Treatment must address sugar levels, vein problem, and the open wound.
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Venous Stasis Ulcers

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PHLEBITIS
Inflammation of a vein Usually in the legs. When phlebitis is associated with the formation of blood clots (thrombosis), usually in the deep veins of the legs, the condition is called Deep Vein Thrombophlebitis (DVT).

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DEEP VEIN THROMBOPHLEBITIS


Signs and Symptoms Redness (erythema) and warmth with a temperature elevation of a degree or more above the baseline Pain or burning along the length of the vein Swelling (edema) Vein being hard, and cordlike Need ER if all symptoms are present
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DVT

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Severe DVT

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Tissue Necrosis (gangrene)


Necrosis = dead Caused by infection, toxins, or trauma Almost always detrimental and can be fatal

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Gangrene
Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies (necrosis). This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood supply to the affected tissues, which results in cell death. Diabetes and long-term smoking increase the risk of suffering from gangrene

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Types of Gangrene
Dry gangrene Wet gangrene Gas gangrene Necrotising fasciitis

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Dry Gangrene
Dry gangrene begins at the distal part of the limb due to ischemia, and often occurs in the toes and feet of elderly patients due to arteriosclerosis. Dry gangrene is mainly due to arterial occlusion. There is limited putrefaction and bacteria fail to survive. Dry gangrene spreads slowly until it reaches the point where the blood supply is adequate to keep tissue viable.
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Dry Gangrene
The affected part is dry, shrunken and dark reddishblack, resembling mummified flesh. The dark coloration is due to liberation of hemoglobin from hemolyzed red blood cells, which is acted upon by hydrogen sulfide (H2S) produced by the bacteria, resulting in formation of black iron sulfide that remains in the tissues. The line of separation usually brings about complete separation, with eventual falling off of the gangrenous tissue if it is not removed surgically, also called autoamputation.
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Dry Gangrene

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Wet Gangrene
Wet gangrene occurs in naturally moist tissue and organs such as the mouth, bowel, lungs, cervix, and vulva. Bedsores occurring on body parts such as the sacrum, buttocks, and heels are also categorized as wet gangrene infections. It is characterized by numerous bacteria and has a poor prognosis (compared to dry gangrene) due to septicemia (bacterial infection of the bloodstream).
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Wet Gangrene

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Wet Gangrene
In wet gangrene, the tissue is infected by saprogenic microorganisms (those that eat dead organic matter) such as Clostridium perfringens or Bacillus fusiformis, which cause tissue to swell and emit a fetid smell. Wet gangrene usually develops rapidly due to blockage of venous (mainly) and/or arterial blood flow. The affected part is saturated with stagnant blood, which promotes the rapid growth of bacteria. The toxic products formed by bacteria are absorbed, causing systemic manifestation of septicemia and finally death.
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Wet Gangrene
The affected part is edematous, soft, putrid, rotten and dark. The darkness in wet gangrene occurs due to the same mechanism as in dry gangrene. Wet gangrene is coagulative necrosis progressing to liquefactive necrosis (transformation of dead tissue into a liquid).
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Gas Gangrene
This is a bacterial infection that produces gas within tissues. It is a deadly form of gangrene usually caused by Clostridium perfringens bacteria. Infection spreads rapidly as the gases produced by bacteria expand and infiltrate healthy tissue in the vicinity. Because of its ability to quickly spread to surrounding tissues, gas gangrene should be treated as a medical emergency.
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Gas Gangrene

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Gas Gangrene
These bacteria are mostly found in soil and enter the muscle through a wound and subsequently proliferate in necrotic tissue and secrete powerful toxins. These toxins destroy nearby tissue, generating gas at the same time. Gas gangrene can cause necrosis, gas production, and sepsis. Progression to toxemia and shock is often very rapid.
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Necrotizing Fasciitis (flesh-eating disease)


This is a rare infection of the deeper layers of skin and subcutaneous tissues, easily spreading across the fascial plane within the subcutaneous tissue.

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Gangrene Treatment
Debridement (laser or mechanical) Amputation Antibiotics Vascular surgery Maggot therapy Hyperbaric oxygen therapy

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Peripheral Vascular Disease (PVD)


Refers to the obstruction of large arteries, frequently in the lower extremity. Usually caused from atherosclerosis (fatty plaques). Symptoms Claudication: pain, weakness, numbness, or cramping in muscles due to decreased blood flow Sores, wounds, or ulcers that heal slowly or not at all Change in color (blueness or paleness) or temperature (coolness) when compared to the other limb Diminished hair and nail growth on affected limb and digits (shiny, hairless skin)
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Migraines
Migraines are severe headaches that cause vomiting and photosensitivity (the person cannot tolerate any light). They can be caused by several things, including muscle spasms in the blood vessels. Caffeine can cause them, and so can caffeine withdrawal. Treatments may include medicines, botox injections, and magnesium infusions.

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Vasculitis
This is a group of disorders that are characterized by inflammatory destruction of blood vessels. Both arteries and veins are affected. Lymphangitis is sometimes considered a type of vasculitis. Vasculitis is primarily due to leukocyte migration and resultant damage. Although both occur in vasculitis, inflammation of veins (phlebitis) or arteries (arteritis) on their own are separate entities.
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Vasculitis
Buerger's disease: vasculitis of the leg arteries and veins (gangrene). Systemic Lupus Erythematosus (SLE)

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Buerger's disease
This is a non-atherosclerotic vascular disease also known as thromboangiitis obliterans (TAO), and is strongly associated with heavy tobacco use.

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Systemic Lupus Erythematosus


SLE is an autoimmune disease that can affect any part of the body. SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidneys, and nervous system. The course of the disease is unpredictable, with periods of illness (called flares) alternating with remissions. The disease occurs nine times more often in women than in men, especially in women in child-bearing years ages 15 to 35, and is also more common in those of nonEuropean descent. Typical skin manifestations are a butterfly rash on the face and photosensitivity.
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SLE Butterfly Rash

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Restless Leg Syndrome (RLS)


This is NOT a blood vessel disease. It is a neurological condition that is characterized by the irresistible urge to move the legs. The need to move is often accompanied by uncomfortable sensations. RLS symptoms start or become worse when resting. RLS symptoms are relieved soon after starting an activity.
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