Lupus and Vascular System Involvement
Yes, lupus significantly affects the vascular system through multiple mechanisms including vasculitis, microangiopathy, thrombosis, and accelerated atherosclerosis, but spider veins (telangiectasias) are not a typical or recognized manifestation of lupus vascular disease. 1, 2
Vascular Manifestations in Lupus
Lupus causes vascular involvement in approximately 50% of patients, affecting vessels of various sizes and leading to serious complications 2:
Small Vessel Disease (Most Common)
- Lupus vasculitis primarily affects small vessels and occurs in roughly half of SLE patients 2
- Microangiopathy causes ischemic injury through impaired perfusion, often associated with antiphospholipid antibodies 1
- Thrombotic microangiopathy can present with a TTP-like picture and requires plasma exchange therapy 1
- "Bland" vasculopathy involves fibrinoid necrosis with narrowing of small arteries/arterioles, highly associated with hypertension 1, 3
Medium and Large Vessel Disease (Less Common)
- Medium-sized vessels can be affected, though less frequently than small vessels 2
- Large vessel involvement is very rare 2
- Premature atherosclerosis is a major concern, with SLE being an independent risk factor for cardiovascular disease 1, 4
- Peripheral vascular disease can present with intermittent claudication or gangrene, particularly with longer disease duration and steroid use 4
Clinical Spectrum of Lupus Vascular Disease
The manifestations range from mild to life-threatening 2, 5:
Cutaneous involvement (most common):
- Cutaneous vasculitis is the most frequent presentation 5
- However, spider veins (telangiectasias) are NOT a recognized feature of lupus vascular disease 2, 5, 6
Visceral involvement (severe disease):
- Central nervous system vasculitis 5
- Peripheral nervous system involvement 5
- Mesenteric vasculitis (life-threatening) 2
- Pulmonary hemorrhage (life-threatening) 2
- Renal vasculopathy (poor prognosis) 1, 3
- Retinal vasculitis 5
- Mononeuritis multiplex 2
Pathogenic Mechanisms
Lupus affects the vascular system through distinct pathways 1, 6:
- Immune-mediated injury: Immune complex deposition in vessel walls causing inflammation and necrosis 3, 6
- Thrombotic/ischemic injury: Due to antiphospholipid antibodies causing thrombosis or emboli 1
- Accelerated atherosclerosis: From both traditional risk factors and disease-related factors including persistent disease activity, lupus nephritis, antiphospholipid antibodies, and glucocorticoid use 1
Important Clinical Pitfalls
Do not confuse spider veins with lupus vascular disease. Spider veins are superficial dilated venules that are cosmetic in nature and not part of the lupus disease spectrum. If a lupus patient has spider veins, consider alternative causes such as:
- Chronic liver disease
- Hormonal factors
- Venous insufficiency
- Normal aging changes
- Medication effects (particularly from chronic glucocorticoid use causing skin changes)
Recognize that lupus vasculopathy portends poor prognosis and requires aggressive immunosuppressive therapy, often with cyclophosphamide and plasma exchange 3. This is fundamentally different from the benign nature of spider veins.
Cardiovascular Risk Management
Given the significant vascular involvement in lupus, comprehensive cardiovascular risk assessment is mandatory 1, 7:
- Screen for traditional risk factors: smoking, hypertension, hyperlipidemia, diabetes 1
- Monitor disease-related factors: persistent activity, nephritis, antiphospholipid antibodies 1
- Consider low-dose aspirin for primary prevention in selected high-risk patients 1
- Calculate 10-year cardiovascular risk using SCORE, recognizing it underestimates actual risk in SLE 1
- Minimize glucocorticoid exposure to reduce cardiovascular complications 1