Book Review

Vascular Pathology

N Engl J Med 1995; 333:1432-1433November 23, 1995

Article

Vascular Pathology
Edited by W.E. Stehbens and J.T. Lie. 797 pp., illustrated. New York, Chapman & Hall, 1995. $169. ISBN: 0-412-48640-7

This book contains 22 chapters written or coauthored by 25 workers in the field of vascular disease. It covers the classic aspects of disease in a comprehensive, if somewhat uneven fashion. Modern approaches to cellular and molecular disease are touched on in some sections but go largely unmentioned. In his introduction Dr. Stehbens, the principal editor, takes a classic approach to vascular disease, providing numerous historical references in a manner that helps the reader understand the nature and topography of the circulatory system. Much recent research has expanded our understanding of this field in relation to shear stress and rheology, but unfortunately, there is relatively little discussion here of the recent data on rheologic changes and their effects on the structure of the endothelium and thus the artery wall. New observations have been made about molecular elements at the genetic level, such as the shear-stress response elements of particular genes, including genes for adhesion molecules and growth factors, that are related to changes in hemodynamics. These and other cellular and molecular topics are missing from this book.

In chapter 1, on the general features of the circulatory system, Dr. Stehbens suggests that the disappearance of elastic fibers may be a degenerative process, whereas recent data suggest that such alterations may represent active lytic changes by enzymes in the artery wall, such as elastase. A more balanced presentation of these observations would have been of greater use. The chapter is well illustrated with diagrams that should be useful to teachers, cardiologists, and surgeons.

Several chapters present and discuss the process of atherogenesis in relation to the development of the lesions of atherosclerosis. The controversies and questions concerning the various hypotheses about atherogenesis would have been easier to comprehend and evaluate had they been grouped together in one section. Unfortunately, the reader must forage through several chapters to find all the hypotheses, ideas, criticisms, and suggestions in the book on this subject. Most of the issues are covered, but the discussions are not centralized, balanced, or focused. Chapters 6 (by Stehbens), 7 (by Hoff), and 9 (by Parums) review many aspects of atherogenesis, which is stated by Stehbens to be degenerative, by Parums to be inflammatory, and by Hoff to be metabolic.

In a long chapter on atherosclerosis, Stehbens suggests that intimal proliferation of smooth muscle is the earliest change in the development of lesions in the artery wall. Several recent studies of infants and the Pathological Determinants among Youth study suggest that lipid infiltration associated with monocyte-derived macrophages may be the earliest such change. It can be found in both infants and young adults and may often occur in the intimal pads or cushions, referred to by Stehbens, that develop at a very early stage in the aorta.

In one place Dr. Stehbens states that “rupture of large atherosclerotic arteries is extremely rare.” This is true of large, elastic arteries such as the aorta, but it has become increasingly clear that rupture of the thin, fibrous cap that covers unstable fibrous plaques in the coronary arteries may frequently cause sudden death and myocardial infarction. Finding markers to identify people who are at risk because of unstable advanced lesions of atherosclerosis is now recognized as important to the treatment of the disease.

The chapter on the connective-tissue components of the vessel wall is reasonably comprehensive and discusses atherosclerosis in relation to the constituents and deficiencies of the matrix. This chapter adequately summarizes what has become an increasingly important and complex field. It is rapidly expanding, and recent references would have been very useful.

A reasonable catalogue of the diseases of blood vessels in metabolic disorders is presented in chapter 5. Readers who require more detail will need to refer to available textbooks of medicine.

The burgeoning field of modified lipoproteins — specifically, oxidized, glycosylated, and otherwise modified lipoproteins — and their role in atherogenesis is dealt with principally in chapter 7 by Hoff, as well as in several other places in the book. Unfortunately, some of the most recent data on modified lipoproteins, their recognition by the several forms of scavenger receptors, and their roles in atherogenesis are missing. Cerebrovascular disease and atheroembolism are well covered with regard to the classic pathological findings, as are diseases of veins and lymphatic vessels. There are also thorough reviews of abnormal arteriovenous communications and fistulae and of venous disease.

Lüscher and colleagues provide an interesting chapter with a brief but balanced discussion of systemic hypertension, its relation to the structural changes associated with increased peripheral vascular resistance (as demonstrated by Folkow), and its relation to vascular disease. There is no discussion of the molecular genetics of hypertension, but a well-illustrated section on the pathological changes associated with hypertension follows this chapter.

The remainder of the book deals with pulmonary hypertension, vasculitis, Buerger's disease, and nonatherosclerotic disease, as well as neoplasms and diagnostic approaches to imaging. Unfortunately, the references do not go beyond 1993. Much has happened since then, so the book is already out of date. The editors make clear in the preface and in the writing (as is their prerogative) the biases they bring to the subject. This book will be useful to many who seek discourse on particular topics. Its major shortcomings are the lack of focus in many chapters and the lack of a balanced presentation of many important issues.

Russell Ross, Ph.D.
University of Washington School of Medicine, Seattle, WA 98195-7470