Course CP

The Medical Note-Taking Service Lecturer Dr. Djakiew

Date 11/24/2014
Lecture Number 3
Class of 2018 Page 1 of 11

Note-Taker: Matt Stein NOTICE &DISCLAIMER

The Medical Note-Taking Service makes every effort to provide accurate
Corrected by: uncorrected class notes. However, errors will occur from time to time. The user
Approved for distribution: yes assumes the risk for any and all errors. We recommend that you use
these notes as a supplement to your own notes.

Welcome back everyone. It’s been awhile since we’ve spent some good, quality MNTS time together.
Now I know I’ve set some pretty high standards here with my notes. In fact someone told me they only
know me as the “the guy with nice hair who writes inspirational things in his MNTS” (thank you for
complimenting my hair). BUT, today were skipping the cheesy intro. If I spoil you you’ll get tired of it
and then it wont be special anymore, and we need to keep this set of notes so fresh, and really quite
clean. I work for the people and the people need to be kept satisfied long term. Can’t you see that this is
for our future? That I am doing this for the long-term health of our relationship? Sometimes sacrifices
need to be made my lovely class. So buckle up, get ready to have Djakiew come in like a wrecking ball,
and party in the USA. I will be back in all of my cheesy glory, so do not despair. And for the sake of
continuing my Miley references, I can’t wait to see you all again.

Histology of the Cardiovascular System

Dr. Djakiew gave us a pretty straightforward lecture as always. I will point out important points I
remember from last year, but the drill is the same for histology: memorize pictures the night before the
exam for ID, and use his comprehensive syllabus, because it has everything you need.

The Circulatory System

There are two circulatory systems that exist in our body: the cardiovascular system, and the parallel
running lymphatic system. The CV system is driven by a pump, and consists of circulating blood,
while the lymphatic system contains (shockingly enough) lymph, has no pump, and has a
unidirectional flow. Lymph is pushed through its system via a number of non-pump mechanisms like
skeletal muscle contraction or gravity, and eventually dumps into the venous system. Lymphatic vessels
also contain valves to maintain unidirectional flow and prevent retrograde flow of lymph. The CV
system is a double pump (systemic and pulmonary), consisting of arteries carrying blood away
from the heart, and veins carrying blood to the heart. Arteries generally consist of oxygenated blood,
while veins contain deoxygenated blood. The one exception to this rule exists in the pulmonary
circulation where the pulmonary arteries run deoxygenated blood to the lungs, and pulmonary veins
carry oxygenated blood to the heart. The general flow of blood is from the heart to elastic
arteries/aorta, to muscular/distributing arteries to arterioles and then to capillaries. The
capillaries connect the arterial and venous sides of the systemic circulation with a few exceptions

INSERT JOKE HERE

 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 2 of 11

of course, and is where nutrient and gas exchange occurs. The venous flow of blood is from post-
capillary venules, to small/medium sized veins, to vena cava, and then to the right atrium.

Capillaries
As was previously stated this is where nutrient, gas, and waste exchange occurs. When you think of
capillaries and post-capillary venules think of exchange. Capillaries are the smallest of the blood
vessels, often only big enough to allow the passage of a single leukocyte or RBC. There are small rings
of smooth muscle called pre-capillary sphincters which regulate the flow of blood into capillaries on the
arterial side. There is also a standard structure of a capillary seen in the image below.

The 3 basic units of the capillary starting from the lumen and going
to the extracellular space are endothelial cells, basal lamina, and
pericytes. There is a single layer of endothelial cells lining the
capillary. The basal lamina surrounds this cell layer, and the
pericytes are a cell that has the ability to differentiate to an
endothelial cell if they were to die or become damaged. They
maintain the viability of the endothelial cell layer.

Types of Capillaries
There are continuous, fenestrated, and
sinusoid (discontinuous) capillaries
(pictured to the left from top to bottom). I
definitely remember the differences of these,
and their locations being on last years exam
so listen up!

• Continuous – the most common

type, found in muscle, skin, lung, and
brain. The picture above is a
continuous capillary, as is the top left
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 3 of 11

one. Continuous endothelial cells have nuclei that bulge into the lumen, and the most identifiable
structure in them are numerous pinocytotic pits and vesicles that facilitate transport.
• Fenestrated – these capillaries have numerous pores in the lining endothelium, and the pores are
spanned by a thin diaphragm, except in the kidneys where there is no diaphragm, just a thick
basement membrane. They are found in the intestines and endocrine systems as well. This type is
represented in the middle picture above. Fenestrations faciliate more rapid exchange between
the lumen of fenestrated capillaries and the fluid outside.
o An additional special type of fenestration exists in the adrenal gland and
adenohypophysis: fenestrated sinusoids. They have wider fenestrations but still have a
diaphragm spanning them hence they are not true sinusoids.
• True Sinusoids – Sinusoidal capillaries are different than fenestrated sinusoids!! They allow for
an even high degree of exchange to take place. They are usually large, and have irregularly
shaped lumens. There may be prominent intercellular spaces between endothelial cells and
fenestrations in the endothelium . The basal lamina may be missing or discontinuous. If you
see large gaps between cells you know it’s a true sinusoid. Look how different the bottom picture
looks from the other two; there are large gaps present. These exist in the liver, spleen, bone
marrow, and also in the endocrine system.

Mechanisms of Capillary Exchange

Capillaries = Exchange. There are a few different mechanisms which I will supply in a nice little list for
you.
• Open pores/gaps
• Diffusion – gases and lipid soluble substances
• Filtration – the classic battle between hydrostatic and oncotic pressures causing the movement
of water and small molecules between leaky, tight junctions.
• Vesicular transport – this is the system of pinocytotic vesicles and pits that helps moves large
molecules across the endothelium.
o
• These are electron dense molecules
being taken up by pinocytotic vesicles
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 4 of 11

• Transendothelial channels – This occurs when pinocytotic vesicles fuse together to make an
entire channel across the endothelial membrane. This facilitates more rapid transfer across the
membranes from lumen to connective tissue space.

Endothelial Cell Functions

• Adhesion molecules – play an important role in assisting various cell types in exiting the
vasculature to enter the tissue
• Produce vasoactive compounds – these help to regulate blood flow
o NO – dilate vessels
o Endothelin – constrict vessels
• Anti-thrombogenic factors
• Metabolic conversions – like from angiotensin I to angiotensis II

Structure of Larger Vessels

This is probably the most high-yield section of the note-set. The difference between the structures of
arteries and veins will definitely be tested!! In histological settings you will often find companion
arteries and veins of similar sizes running together, and this will aide us in helping to identify the
structures we are looking at. Know the histological differences between them all. Large veins run with
elastic arteries, medium veins with muscular arteries, and post-capillary venules with arterioles. 3
layers make up arteries and veins. From most interior to exterior we have the:
• Tunica intima – a single layer of endothelium, and its subendothelial connective tissue. It is
bound by the internal elastic lamina, which separates the intima from the media
• Tunica media – This is the smooth muscle layer, and is bound by the external elastic lamina
• Tunica adventitia – technically this is just connective tissue, and is continuous with the
surrounding connective tissue.
o There may be vasa vasorum present in the adventitia that provide larger arteries and
veins with nutrients and oxygen, as well as providing these services to nearby nerves that
may be in the adventitia as well.
These three layers comprise all arteries and veins, but may be present in varying amounts between the
two vessels. This helps us to distinguish between them in a histological setting.
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 5 of 11

Arteries vs. Veins or “How to score easy points on the exam”

As a general rule you should try and remember that veins have less muscle (media), more connective
tissue (adventitia), less elastic tissue (lower pressure side of system, less need to stretch), larger
lumens, and valves (to prevent retrograde flow in a low pressure system).

This table is
your friend.
Know it. Love
it. Be one with
it. I remember
the different
layers of smooth
muscle being
particularly
important.

Arteries will have a thicker intima, with a prominent IEL. The IEL will not be very prominent in
veins. The tunica media will often be the thickest layer in arteries, but can be completely absent or
very small in veins. The adventitia will be the thickest layer in most veins. Additionally, there may be
muscle fibers in the adventitia of large veins running perpendicular to the circumferential muscle
fibers running in the media. Knowing where IELs, and EEL’s are present was a huge distinguishing
feature on the exam last year as well. Compare what I wrote above to these pictures below and see
where the differences lie. The artery is on the left and the vein is on the right in the picture on the left.
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 6 of 11

Structure of Arteries
This is the aorta. Notice the I, M, and A letters
designating the intima, media, and adventitia. Notice
that the media is the largest layer. This is an elastin
stain, highlighting the elastic nature of the aorta and its
need to handle high pressures coming from the heart.
There can be 40-60 layers of smooth muscle present
in elastic arteries.

These are images of muscular arteries. Notice the

prominent IEL, and the 6-40 layers of smooth
muscle, typical of a muscular or distributing artery.
You can almost make out the EEL outside of the media
in the picture below, but it is never as prominent as the
IEL.

Arterioles only have 1-5 layers of smooth

muscle, as seen in the picture below.
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 7 of 11

Types of Microcirculation
Different types of microcirculation or capillary relationships exist.
• Arteriole – capillary bed – venule
o this is the most common and what you typically think of when you think of capillaries
• arteriovenous anastomosis – this connection bypasses capillaries completely
o this is present in the skin and is an important component in thermoregulation—blood
flows away from the skin when we are cold (skin that is cold is white), and blood flows
to the skin when you are hot to drive off heat (you become flushed when you exercise)
• Arteriole – capillary – arteriole – this happens in the kidney where filtration occurs under high
pressures. A vein on the other side of the capillary would burst, so we use a stronger arteriole
instead
• Venule – capillary – venule – This is present in the liver

Structure of Veins
We have already been over this a little bit, but just to drive the point home because it is so important:
The media is thin or absent in veins, the adventitia is thicker, you usually do not see an EEL, and
only sometimes see an IEL. It is possible to have perpendicular muscle fibers in the adventitia.
These are different than the circumferential muscle fibers in the tunica media. Veins will have an
irregularly shaped lumen that is often large compared to the size of the vessel wall.

These are post-capillary venules. Notice that they have larger lumens
than capillaries, with an irregular shape to them. I remember this
picture being pretty important last year because it shows a PCV,
collecting venule, a collecting venule, a capillary, and an arteriole.
Notice how the capillaries and arterioles have more distinctly shaped
lumens while the venules all tend to be a little wild. The tunica media
of the venules are also not prominent.
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 8 of 11

This is a medium sized vein. Notice that there are only 3-4 layers of
smooth muscle in the media. The lumen is also extremely large
compared to the size of the vessel wall. There is a large adventitia
present as well. This is also no prominent IEL, like in arteries.

Here is the vena cava. That black line

represents the entire adventitia. Its huge!
The tunica intima is small as is the media,
and there is not a prominent IEL. Notice also
the perpendicular muscle fibers that the
arrow is pointing to. This is specific to large
veins. There is also a vasa vasorum present
in the lower part of the image.

Quit Playing Games with the Layers of my Heart

Dr. Djakiew made a shoutout to one of his favorite topics: ontology follows phylogeny. If only it were
ever tested. The three layers of the heart are homologous to the three layers of vessels. Remember when
Dr. Andrews said that the heart is basically just a big blood vessel? Apparently its true.
• Endocardium – homologous to the tunica intima
o lines all internal surfaces of the heart. It consists of an
endothelium and an underlying thin layer of
connective tissue. Underneath the endothelium are the
purkinje fibers. These are specialized cardiac muscle
cells that facilitate the electrical conduction of the
heart.
• Myocardium – homologous to the tunica media
o Forms the main mass of the heart, and consists of cardiac muscle.
• Epicardium - homologous to the tunica adventitia
o forms the outermost covering of the heart
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 9 of 11

o contains glands and adipose tissue, and if you are not careful could be confused with the
endocardium/purkinje fibers.
o It is also continuous with the pericardial sac covering the entire heart

Histology of Atria vs. Ventricles

The ventricles will have a ton of myocardium (muscle

cells) because they require a lot of force to pump blood
through the two circulation systems. The atria are above,
and the ventricles are below in this picture. This is also an
AV valve present on the left side of the image.

Conducting System of the Heart

You will learn this so many times throughout the cardio portion of this course I thought about not even
including it. But I will because I love you. The SA node spontaneously generates action potentials to
start the electrical impulse in the heart which will lead to eventual contraction at the apex. It travels from
the SA node, to the AV node, to the bundle of his, down to the purkinje fibers. The purkinje fibers are
connected via gap junctions. The impulse spreads through the apex causing contraction that will force
the blood out of the heart and into elastic arteries.
! The SA NODE!!!
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 10 of 11

Lymphatic System
Home stretch. I am so tired of looking at these slides. The lymphatic system represents a drainage
system whereby fluid and plasma protein which has collected in the interstitium is returned to the
blood. The function of lymphatic vessels are to:
• Return excess 10% of interstitial fluid to the blood
• Transport absorbed lipids from the intestines to the body
• Provide immunological support
Lymphatic vessels are designed to allow unique permeability characteristics. They have a single layer
of endothelium, a discontinuous or missing basal lamina, no pericytes, and fibers of connective
tissue that anchor the endothelium to the surrounding tissue. And remember that all lymph vessels
pass through at least one lymph node before returning to the heart. The way to differentiate lymph
vessels and veins in a histological slide is to look for the presence of nucleated cells!! Veins will
contain RBC’s which do not have a nucleus. So if you see a picture with a valve, do not automatically
assume that it is a vein. It could be a lymph vessel. This was definitely tested last year.

Check out that sweet valve, and those awesome

nuclei. This is what you should look for on a
lymphatic vessel!

Clinical Correlates

• Myocardial infarctions are heart attacks due to occlusion of coronary arteries, and are
responsible for 20-25% of all deaths in the US.
• Berry Aneurysm are due to defects in the tunica media of cerebral arteries. If the media is not
functioning properly then high pressures could cause a rupture of the vessels
• Varicose veins are abnormally dilated, and tortuous veins with a valve insufficiency present.
This causes pooling of blood in the veins of extremities due to retrograde blood flow.
 Course CP
Lecturer Dr. Djakiew
Date 11/24/2014
Lecture 3
Page 11 of 11

That’s all she wrote folks. Just to let you know that as of the writing of this MNTS on the 24th of
November its going to be my birthday tomorrow. The Big 2-6. I’m getting old and time flies. My mom
always called me her little turkey because I was the cause of her missing her only Thanksgiving dinner
ever. Thanks Mom!! Look how wonderful I turned out.

That’s me with the long, died orange hair and the

incredibly cool “The Used” t-shirt. I was so edgy huh?

Questions, comments, concerns, birthday wishes can

all be sent to mks101

Note: The quality of MNTS notes depends on your feedback. We encourage you to rate this noteset on a
scale from 1 to 10, with 10 being the most helpful and 1 being the least. Please use the following link
https://docs.google.com/forms/d/1Rp81-
xXsB1yRS1xXbf0Wx8zPYHM6RfyL2nCHRLFu1AM/viewform?usp=send_form to anonymously rate
the writers. In addition, please include any errors or other reasons that substantiate your rating. Email
gumnts.2018@gmail.com with other concerns. Thank you!