Oral cavity & oropharynx
Developmental anomalies
Caliber persistent artery
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PubMed Search: Caliber persistent artery
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Prognostic factors | Case reports | Treatment | Clinical images | Microscopic (histologic) description | Microscopic (histologic) images | Positive stains | Sample pathology report | Differential diagnosis | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Goldfaden JS, Vargo RJ. Caliber persistent artery. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/oralcavitycaliberpersistentartery.html. Accessed January 18th, 2025.
Definition / general
- Vascular malformation characterized by a branch of the labial artery that innervates the submucosa of the lip with a preserved caliber (diameter) (Oral Surg Oral Med Oral Pathol Oral Radiol 2023;136:1)
Essential features
- Clinically appears as a linear, tubular, occasionally arcuate elevation of the labial mucosa that ranges from mucosa colored to bluish
- This elevated structure has a hallmark pulsatile nature, which can be appreciated with manual palpation or use of a blunt ended instrument
- > 80% of caliber persistent arteries involve the lower lip of 40 - 88 year old individuals (average of 58 years); there is no gender predilection (Int J Dermatol 2016;55:11, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:308)
- Histopathologically, this entity is a thick walled artery that is often positioned close to the surface of the mucosa
Terminology
- In 1884, Gallard identified unusual vessels in 3 patients who died from a submucosal gastric hemorrhage (J Oral Maxillofac Surg 2010;68:1987)
- In 1962, Voth noticed similar abnormal vessels of the stomach wall and described them as caliber persistent [arteries] (J Maxillofac Oral Surg 2015;14:845)
- These vessels of the stomach and small intestine have also been referred to as cirsoid aneurysm, Dieulafoy disease, exacerbation simplex and submucosal arterial malformation (Int J Dermatol 2016;55:11)
- In 1962, Voth noticed similar abnormal vessels of the stomach wall and described them as caliber persistent [arteries] (J Maxillofac Oral Surg 2015;14:845)
- In 1973, Howell and Freeman described a prominent inferior labial artery in 3 patients out of a group of 90; none of the 3 patients were aware of this prominent vessel (Arch Dermatol 1973;107:386)
- These labial vessels were first designated in 1980 as caliber persistent arteries by Mikó, Adler and Endes, who reported these lower lip lesions as clinically mimicking cancer in 3 elderly men (J Oral Pathol 1980;9:137)
- Mikó, Adler and Endes stated that caliber persistent arteries of the lip are best characterized clinically by taking the quotient of the distance from the border between the epithelium and connective tissue (numerator) and its diameter (denominator); a quotient of < 1.6 - 1.7 may indicate a vascular anomaly (J Oral Pathol 1980;9:137)
- These labial vessels were first designated in 1980 as caliber persistent arteries by Mikó, Adler and Endes, who reported these lower lip lesions as clinically mimicking cancer in 3 elderly men (J Oral Pathol 1980;9:137)
ICD coding
Epidemiology
- Of reported cases, the average patient ages were between 40 and 88 years, with a mean of 58 years; caliber persistent arteries exhibit no gender predilection (Int J Dermatol 2016;55:11, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:308)
Sites
- > 80% of caliber persistent arteries involve the lower lip and there have been several reported occurrences of caliber persistent arteries of the hard palate and upper lip (Int J Dermatol 2016;55:11)
- There is one report, however, that found the upper lip is affected twice as frequently as the lower lip; though, 3 times as many lower lip lesions are biopsied as upper lip lesions (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:308)
Pathophysiology
- Caliber persistent artery is a vascular malformation that is the result of a branch of the labial artery innervating the submucosal tissue of the lip without a change in its original caliber (diameter) (Oral Surg Oral Med Oral Pathol Oral Radiol 2023;136:1)
Etiology
- Various theories have been proposed pertaining to the etiology of the caliber persistent artery, including trauma, cigarette smoking or the physical pressure a cigarette exerts against the labial mucosa (Case Rep Dent 2015;2015:747428)
- Physical pressure of a cigarette is hypothesized to reduce the thickness of the supporting connective tissue and result in arterial dilation (Case Rep Dent 2015;2015:747428)
- As caliber persistent arteries are more often seen in elderly individuals, factors such as age related atrophy, actinic cheilitis, arteriosclerosis and certain medications may also play a role (J Oral Maxillofac Surg 1998;56:895)
Clinical features
- Caliber persistent arteries present as linear, tubular, occasionally arcuate elevations of the labial mucosa that range in color from mucosa colored to bluish
- Stretching of the labial mucosa typically causes these prominent vessels to become unnoticeable
- Hallmark feature of the caliber persistent artery is its pulsatile nature, which can be appreciated with manual palpation or the use of a blunt ended instrument
- These linear elevations can ulcerate secondary to trauma (J Oral Pathol 1980;9:137)
Diagnosis
- Caliber persistent arteries are often an incidental finding on clinical examination; detection of a pulse in this tubular lesion is indicative of arterial blood flow
Prognostic factors
- Caliber persistent artery is a benign vascular anomaly with an excellent prognosis
Case reports
- 7 year old girl with a 0.4 cm, reddish, pulsating lesion of the left upper lip that heavily bleeds after minimal trauma (Int J Clin Pediatr Dent 2019;12:475)
- 56 year old woman with 2 exophytic lesions of the right upper and lower lip (J Oral Maxillofac Surg 1998;56:895)
- 58 year old man with a bleeding, recurrently ulcerating lesion of the right lower lip (Case Rep Dent 2015;2015:747428)
Treatment
- No treatment is necessary; pathologists should be aware that a sizable, superficial artery in a lip biopsy may represent the lesion observed clinically as opposed to an incidental histologic finding
- Detection of a pulse will aid in avoiding unnecessary surgery and subsequent intraoperative arterial bleeding (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:308)
Clinical images
Contributed by Richard J. Vargo, D.M.D., M.B.A.
Arcuate, tubular mucosal elevation
Microscopic (histologic) description
- Caliber persistent artery is a thick walled artery that is often positioned close to the surface of the mucosa (J Clin Pathol 2000;53:885)
- Lumen (tunica intima) is lined by endothelium; deep to this lining is an internal elastic membrane
- Endothelium may exhibit luminal hobnailing
- Tunica media of the vessel is composed of smooth muscle, which is surrounded by a tunica externa that is predominantly composed of collagen; further structural support is provided by an external elastic lamina
- Extravasated erythrocytes pooling into the adjacent stroma may also be observed
- Lumen (tunica intima) is lined by endothelium; deep to this lining is an internal elastic membrane
Microscopic (histologic) images
Contributed by Joshua Seth Goldfaden, D.D.S.
Situated near mucosal surface
Thick walled artery
Hobnailing of the endothelium
Supporting collagen (tunica externa)
Clear spaces within wall
Brisk bleeding
Positive stains
- Immunohistochemistry is often not necessary for diagnosis
- SMA or desmin may be used to highlight the smooth muscle wall of the blood vessel
- CD34 may be used to highlight the endothelium of the tunica intima (J Maxillofac Oral Surg 2015;14:845)
- Verhoeff van Gieson immunohistochemical stain can be used to appreciate the elastic fibers of the tunica intima and tunica externa
Sample pathology report
- Lower lip, left, excisional biopsy:
- Prominent arterial structure (see comment)
- Comment: In the appropriate clinical context, the histopathologic findings may represent a caliber persistent artery.
Differential diagnosis
- Angioleiomyoma (vascular leiomyoma):
- Proliferation of bland, eosinophilic smooth muscle cells that form bundles around blood vessels
- Smooth muscle cells are organized in intersecting fascicles
- Blood vessels may appear slit-like, rounded or cavernous
- Proliferation of bland, eosinophilic smooth muscle cells that form bundles around blood vessels
- Hemangioma:
- Lobules of > 3 capillary sized or cavernous vessels with a lumen lined by flattened endothelial cells
- These blood vessels lack a smooth muscle tunica media
- Lobules of > 3 capillary sized or cavernous vessels with a lumen lined by flattened endothelial cells
- Varix:
- 1 or more undulated, dilated venous structures with an endothelium lined lumen
- Thrombosis or an organizing thrombus is often identified within the lumen, which appears as concentric layers of erythrocytes and platelets (sometimes designated as lines of Zahn)
- Phlebolith formation may also be observed, which histologically appears as concentric bands of eosinophilic calcifications
- Pyogenic granuloma:
- Vascular proliferation of granulation tissue, ulceration of the surface epithelium is frequently seen
- Capillary vessels may exhibit a lobular organization and the endothelial cells are demarcated by fibrous septa (i.e., lobular capillary hemangioma)
- Vascular proliferation of granulation tissue, ulceration of the surface epithelium is frequently seen
- Mucocele:
- Pseudocystic cavity lined by granulation tissue that encompasses extravasated mucin
- Foamy histiocytes are readily appreciable
- Adjacent minor salivary gland lobules may be present
- Irritation fibroma:
- Nonencapsulated mass composed of fibrocollagenous tissue, some of which is organized in bundles, with scattered fibroblasts, occasional small blood vessels and nerves
- Mild chronic inflammation within the stroma is sometimes seen
- Nonencapsulated mass composed of fibrocollagenous tissue, some of which is organized in bundles, with scattered fibroblasts, occasional small blood vessels and nerves
Board review style question #1
A 58 year old man presents with a tubular, arcuate elevation of the lower labial mucosa that is pulsatile in nature. What is the most likely diagnosis based on the photomicrograph?
- Angioleiomyoma
- Caliber persistent artery
- Hemangioma
- Varix
Board review style answer #1
B. Caliber persistent artery. The photomicrograph reveals a thick walled artery of the submucosa in close proximity to the surface epithelium. Answer A is incorrect because angioleiomyomas consist of a proliferation of smooth muscle cells organized in fascicles that form bundles around multiple, slit-like, rounded or cavernous blood vessels. Answer C is incorrect because hemangiomas are composed of 3 or more capillary sized or cavernous vessels that lack a smooth muscle tunica media. Answer D is incorrect because a varix has a tortuous / undulated morphology and often has an intraluminal thrombus or organizing thrombus composed of concentric layers of erythrocytes and platelets.
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Board review style question #2
A 45 year old woman presents with a linear, elevated, pulsating lesion of the maxillary labial mucosa. A biopsy of the elevated lesion reveals a thick walled artery near the mucosal surface surrounded by extravasated erythrocytes. Based on the microscopic findings, what is the most appropriate diagnosis?
- Angioleiomyoma
- Caliber persistent artery
- Hemangioma
- Varix
Board review style answer #2
B. Caliber persistent artery. A thick walled artery surrounded by extravasated erythrocytes near the mucosal surface of the upper lip that clinically presents as an elevated, linear, pulsating lesion is consistent with a caliber persistent artery. Answer A is incorrect because angioleiomyomas consist of a proliferation of smooth muscle cells organized in fascicles that form bundles around multiple, slit-like, rounded or cavernous blood vessels. Answer C is incorrect because hemangiomas are composed of 3 or more capillary sized or cavernous vessels that lack a smooth muscle tunica media. Answer D is incorrect because a varix has a tortuous / undulated morphology and often has an intraluminal thrombus or organizing thrombus composed of concentric layers of erythrocytes and platelets.
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