Section 1 -

Introduction Jagdish Butany John Veinot

This short course on atherosclerosis will focus on the lesions of atherosclerosis and the practical issues that result from them. The incidence of atherosclerosis related disease is on the increase, worldwide. The procedures used for its treatment are also increasing, as are the complications of these procedures. An ever-increasing number of patients undergo surgical procedures for the management of symptoms associated with atherosclerosis. Some of these patients undergo repeat procedures as devices and procedures evolve. Unfortunately some patients die. Some patients will have an autopsy. It is critical to have a good understanding of the lesions of atherosclerosis, the complications and the approaches to them, and the sequential changes related to these procedures as well the devices used in the treatment of the same. The practicing pathologist must have a good understanding of the structure of heart and an approach to the heart as well as any devices used in its management, in the right way so as npt to miss any findings and to get the greatest diagnostic and clinicopathological correlative information out of it. Many of the procedures undertaken today are new and it is essential that the changes seen and the information gleaned from them, the interventional procedures and the devices used, be conveyed back to our clinical colleagues (who may in turn have to pass the information on to the FDA or other national device regulatory body) and so that the development of these devices may continue and new generations of the devices evolve and improve. In this session, we will use a case based approach to: Present a brief overview of atherosclerosis, its risk factors and contemporary thoughts on its pathogenesis Review the pathology of atherosclerosis and coronary artery disease Review the therapeutic modalities and the pathology associated with them The material presented will be case-based. For each section, we will have a case to start off with. We will start with: Native Vessel Atherosclerotic Disease, and discuss the basis of atherosclerosis, morphology, cell constituents and other recent advances in its pathogenesis. Dr. Veinot will follow this with a discussion of: Plaque complications - complications throughout the body. The stable and the unstable plaque Plaque rupture Plaque thrombosis and erosion Section 2.Coronary Artery Bypass grafts: Dr. Veinot will introduce the topic and discuss graft types, (venous, arterial) and their morphology as well as the trends in utilization. Dr. Butany's cases will discuss the complications associated with: a) Fibrointimal hyperplasia in grafts b) "Atherosclerosis" of grafts c) Anastomotic problems d) Synthetic grafts Section 3. Interventions: Dr. Veinot a) Overview of PTCA, stent, laser, atherectomy and endarterectomy b) PTCA: Specific pathology, acute and complications. Acute and chronic complications Introduction to stent stenosis: Dr. Butany Stents A discussion of the mechanisms, acute and chronic complications. A discussion of the histotechnology methods and their use Newer Stents [Mechanical circulatory supports] 4. Vascular aneurysms: Dr. Veinot Aortic aneurysms - complications, types Penetrating aortic ulcer Dr. Butany: A. Surgical interventions: surgery of aortic aneurysms - Aortic stents Pathology associated with aortic stents B. Surgical Treatment of Heart Failure: Ventricular Assist Devices (VAD) Pathology Associated with Ventricular Assist Devices Concluding Remarks Question : Why have a short course on atherosclerosis? Everyone sees atherosclerotic lesions and their sequelae. Our clinical colleagues (cardiologists, surgeons and general practitioners) know how to deal with this. Or do they? Answer: Atherosclerosis is by far the most common cause of death, including sudden and unexpected death in men and in women, and significant morbidity in the developed world and increasingly in the developing world. According to statistics from the World Health Organization.1 "It will also soon become the number one cause of mortality in the entire world". Contemporary information about atherosclerosis, the knowledge about its multifarious aspects keeps changing and expanding, virtually everyday. Add to this the numerous and ever increasing and evolving, interventions as well as devices used by clinicians, and it becomes imperative for us, who deal with the end results, whether at autopsy or at surgical pathology (in explanted devices or in explanted hearts at transplant) to be familiar with the disease, the devices and their sequelae. Equally, if not even more important is the fact that these devices are new and evolving. If significant progress is to be made (so that when its our turn to need these devices, they will be the ultimate in their field), it is essential that used devices be analyzed and studied by skilled professionals, including pathologists, who are familiar with the devices, their potential problems and who can comment intelligently on the status of the devices and of the host tissues surrounding them.