Guest Editorial
Veterinary Pathology
Pulmonary Veno-occlusive Disease
and Pulmonary Hypertension in Dogs:
Striking Similarities to the Human Condition
K. R. Stenmark1, G. M. Krafsur2, and R. M. Tuder3
Pulmonary hypertension (PH) in both humans and animals
remains an enigmatic problem. PH in all species can occur
idiopathically or can be associated with a wide variety of dis-
ease conditions. As such, PH has been grouped into various
classes and most recently into 5 distinct categories at the 2013
World Congress on Pulmonary Hypertension in Nice.16 All
forms of chronic PH involve pulmonary vascular remodeling
that can be characterized by a predominance of pulmonary
arterial remodeling, vein remodeling, or a variable contribution
of both. 18 In idiopathic pulmonary arterial hypertension
(iPAH), the pulmonary vascular remodeling affects largely the
precapillary arteries; on the other hand, in venous PH, includ-
ing pulmonary veno-occlusive disease (PVOD) and PH due to
left heart dysfunction, venous remodeling predominates but is
often accompanied by pulmonary arterial changes. In fact,
these can be pronounced, to an extent exceeding that seen in
precapillary PH. Importantly, it is increasingly appreciated that
most forms of PH, including those caused by hypoxia, inter-
stitial lung disease, thromboembolism, and connective tissue
diseases, may involve both arterial and venous remodel-
ing.13,14,17,18 Unfortunately, in humans and animals, precise
descriptions and documentation of pulmonary vein remodeling
are still lacking in most of these conditions, and in animals,
there have been no reports of PVOD causing severe PH and
death.
In this issue of the journal, Williams et al19 provide what
appears to be the first description of a condition in adult dogs
that shares many of the pathologic and clinical features of
PVOD that are observed in humans. There were significant
consistencies in these dogs with the human condition with
regard to clinical presentation, radiologic findings, and lung
pathology.13,14 Similar to humans with PVOD, almost all of
the affected dogs presented with dyspnea, exercise limitation,
fatigue, and syncope. The dogs reported in these studies all
exhibited respiratory distress in the context of what was ulti-
mately shown to be severe pulmonary arterial hypertension
(PAH). Also, similar to humans, progressive worsening of clin-
ical signs was observed. PVOD can manifest acutely, and pre-
sentation with sudden death has been described as is the case
with dogs.8 Again, similar to humans, it is difficult to distin-
guish PVOD from PAH on clinical grounds alone since the
2016, Vol. 53(4) 707-710
The Author(s) 2016
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DOI: 10.1177/0300985816647454
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clinical signs, as in humans, can be similar if not identical.
Therefore, other studies need to be done to confirm the diag-
nosis. Echocardiography, which is always performed in human
patients presenting with these findings, demonstrated evidence
for increased pulmonary artery pressure as estimated by the
velocity of the resurgent jet of flow through the tricuspid
valve.13 It should of course be mentioned that in humans, false
positives using this approach are common, and a formal diag-
nosis of PH requires confirmation by right heart catheteriza-
tion, although this is probably not possible to perform routinely
in animals.4 Radiologic studies are also helpful in establishing
the diagnosis of PVOD. In humans, PVOD is suspected based
on radiologic findings showing a combination of pulmonary
artery enlargement, features of postcapillary congestion, and
a normal-size left atrium.14 Septal Kerley B-lines in a subplural
distribution, interstitial edema, and plural effusions are the
principal plain chest radiographic clues to a postcapillary loca-
tion of vascular obstruction. A diffuse alveolar pulmonary
edema pattern is an additional important finding. These find-
ings again seem to be largely recapitulated in dogs presenting
with PVOD and PH.
PVOD is a fibrotic disease process that predominately
involves venules, small veins, and the veins in interlobular
septa (ie, invaginations of pleural connective tissue demarcat-
ing up to 20 primary lobules of alveolar tissue), usually with
relative sparing of the large veins of the hilum.13,17 The walls
of affected small pulmonary veins show variable occlusive
intima lesions and media thickening as a result of a disorga-
nized smooth muscle hypertrophy and collagen matrix
1
School of Medicine, Section of Pediatric Critical Care and Cardiovascular
Pulmonary Research, University of Colorado at Denver, Anschutz Medical
Campus, Aurora, CO, USA
2
Veterinary Medicine, Colorado State University, Ft Collins, CO, USA
3
School of Medicine, Section of Pulmonary Sciences and Critical Care,
University of Colorado at Denver, Anschutz Medical Campus, Aurora,
CO, USA
Corresponding Author:
K. R. Stenmark, University of Colorado at Denver, Anschutz Medical Campus,
12700 E. 19th Ave, Aurora, CO 80045, USA.
Email: kurt.stenmark@ucdenver.edu
708
Figure 1. Pulmonary veno-occlusive disease (PVOD), lung, human.
Known causes of PVOD include mutations in EIF2AK4, reduced pul-
monary vascular EGR/apelin signaling, and chemotherapy agents.
However, most human cases are idiopathic. Shown is a classic example
of human PVOD with luminal ingrowth of connective tissue (arrows)
in a pulmonary vein (V); arrowhead shows an organized thrombus.
deposition (Fig. 1). These changes result in luminal narrowing,
with eventual complete occlusion due to recent, or most fre-
quently, intraluminal-organized thrombosis. The partial or
complete occlusion of the intima, once diagnosed with an elas-
tic stain (which highlights the intima basal lamina), is diagnos-
tic of veno-occlusive disease. The lung may be involved in a
patchy or diffuse pattern. The fibrotic intimal proliferative
changes and postcapillary obstruction in PVOD can lead to
capillary angioectasia and even to capillary angioproliferation,
lesions that are typically seen in classic pulmonary capillary
hemangiomatosis (PCH).14 In fact, it has been reported that
PCH-like angioproliferative lesions are found in most patients
with PVOD, and conversely arterial and venular lesions are
also common in PCH.8 It is again important to note that the
clinical and radiologic features are similar in both conditions.
These observations have led to the speculation that PVOD and
PCH may in fact represent 2 variances of the same disease.10
The extensive pathologic studies in the dogs described in this
study are very consistent with the human PVOD/PCH spectrum
of disease (Fig. 1). It is also important to note, as was found in
the dogs, that although the predominant lesions in PVOD are
found in the pulmonary veins and venules, both the arterial and
capillary components of the pulmonary vasculature are often
concomitantly involved. Pulmonary arteries in patients with
PVOD often show medial hypertrophy and eccentric intimal
fibrosis, key histologic characteristics that are shared with
PAH. Interestingly, no plexiform lesions, which are often abun-
dant in the lungs of patients with PAH, are seen in those with
PVOD. Again, this is true in dogs.
Unfortunately, study of pulmonary veins in the setting of
lung or cardiac disease has been significantly limited by the
difficulty of their reliable identification through histological,
anatomic, or molecular means. Recently, the ephrin B4 recep-
tor (EphB4), a developmental venous marker, has been shown
to identify pulmonary veins in adult mice.2 However, this
Veterinary Pathology 53(4)
finding is probably not relevant to other species as careful
embryologic studies in humans have demonstrated overlap of
EphB4 expression between pulmonary veins and arteries, and
furthermore, EphB4 does not appear to be present in the pul-
monary veins of the rat, suggesting that EphB4 may not be a
marker applicable to humans or animal species other than the
mouse.5,6 To address these challenges, a study was recently
undertaken to search for unique molecular markers in pulmon-
ary veins. Using a technique termed venous backfilling, veins
were identified and then, using laser capture microdissection,
isolated venous RNA was obtained for identification of vein
markers6 (Fig. 2). The investigators detected urokinase plasmi-
nogen activator receptor (uPAR) expression preferentially in
normal pulmonary veins of mice, rats, and human lungs.6 In
control mice, rats, and human lung tissues, uPAR expression
could be detected by immunofluorescence, primarily in the
media and less so in the intima, and was specific to pulmonary
veins (Fig. 2d). To follow up on these observations, the inves-
tigators used an aortic banding (AOB) model in rats to mimic
PH associated with left heart dysfunction and also evaluated
tissues from patients with PH due to left heart disease (PH-
LHD). In both the rats and humans, the investigators found that
uPAR expression was elevated in pulmonary veins and was
significantly associated with cell proliferation. Phos-
phoERK1/2 was also elevated in the pulmonary arteries and
veins of AOB and PH-LHD patients, suggesting its role as a
link between uPAR expression and vascular remodeling, which
is consistent with the described roles of uPAR signal transduc-
tion.9 These findings are useful to human and animal investi-
gations as they provide an immunohistochemical marker to
confirm the identity of pulmonary veins that could be of value
in the diagnosis of PVOD (Fig. 2ae). Hopefully, future studies
will identify further markers specific for pulmonary veins and
also other molecular signaling pathways that are specific to
pulmonary veins and that may be pathophysiologically
involved in the disease process.
The observations of significant venous changes in humans
and now dogs raise questions as to the mechanisms involved in
generating pulmonary venous abnormalities. Recently, a heri-
table form of PVOD was discovered to be due to mutations in
the gene eukaryotic translation initiation factor 2 alpha kinase 4
(EIF2AK4).3 Heritable PVOD due to EIF2AK4 mutations is
transmitted in an autosomal recessive manner as opposed to the
autosomal dominant manner that has been described for the
heritable form of BMPR2-related PAH. Interestingly, biallelic
EIF2AK4 mutations were present in perhaps approximately
20% of patients with PVOD with sporadic disease, suggesting
that even patients without a family history might have a famil-
ial form of the disease.3 However, at present, it remains unclear
as to the mechanisms by which EIF2AK4 mutations induce
pulmonary vascular remodeling.
Multiple case reports have reported a link between che-
motherapeutic agents and radiation therapy with PVOD.10,15
A recent detailed study of chemotherapy-induced PH from the
French PH network was reviewed.15 This study found that
alkylating and alkylating-like agents represent a significant risk
Stenmark et al 709

Figure 2. Given the difficulty in recognizing pulmonary veins (ve) in histological sections, we have developed a technique through which they can
be better identified using a backfilling approach (please refer to Hunt et al6 for details) (a). Fluorescent-tagged solutions are perfused retro-
gradely via the left atrium, allowing visualization independent of location and overall structural characteristics of the pulmonary venous system.
(b) The fluorescent marker (delivered via the left atrium) is colocalized with ephrin B4 receptor in mice, which is detected by immunohis-
tochemistry for ephrin B4 (brown, arrows). (c) Rat pulmonary vein (ve) highlighted by backfilling with agarose and 1-mm fluorescent beads (blue:
DAPI nuclear fluorescence). (d) Urokinase plasminogen activator (uPAR) is normally expressed in the intima and media of pulmonary veins, as
highlighted in green fluorescence for smooth muscle cell actin in sham (control animals) (SMA, arrows). However, in rats with pulmonary venous
hypertension due to aortic banding (AOB), uPAR is also expressed in remodeled pulmonary arteries. Immunofluorescence for SMA (green) and
uPAR (red); costaining shows as yellow/orange. (e) uPAR expression is greater in normal pulmonary veins than in normal pulmonary arteries of
rat lung, with increased pulmonary arterial expression after aortic banding. The asterisks represent significant difference. Reprinted with
permission from the American Journal of Physiology.

factor for the development of PVOD. In addition, the investi- mouse, rat, and rabbit.15 Interestingly, in rats, the severity of
gators showed that cyclophosphamide (CP), the most fre- PH and vascular remodeling was sex dependent, with females
quently used alkylating agent identified in their human study, being more susceptible than males, as well as time and dose
was capable of inducing PH in 3 different animal models: dependent. These studies represent the first evidence that an
710
animal model can be created to induce and thus study mechan-
isms involved in PVOD. Other natural animal systems exhibit
pathologic changes consistent with PVOD. In calves sponta-
neously developing right heart failure at an altitude (brisket
disease), recent reports suggest that there is also a high inci-
dence of pulmonary venous lesions consistent with PVOD in
the context of PH and associated arterial changes.7 Initial
reports suggest that these lesions are similar to those observed
in the lungs of patients with scleroderma who have PAH. Thus,
various spontaneous and induced conditions of animals exhibit
PVOD in the context of PH and may provide useful models to
study mechanisms pertinent to human disease.
What can be done to treat or at least ameliorate the clinical
signs found in animals and humans with PVOD? In humans,
little is known. Most prospective studies evaluating novel tar-
geted PAH therapies have generally excluded patients with
PVOD. This is principally due to a number of published obser-
vations of severe and occasionally fatal adverse outcomes with
these treatments.11 It is speculated that treatment with PAH-
specific vasodilator therapies may cause an augmentation of
pulmonary arterial blood flow against the fixed resistance of
occluded pulmonary venules and veins. This increased hydro-
static pressure gradient may cause vascular leak, which can
progress to severe pulmonary edema. However, it should be
noted that small case series have shown some success in treat-
ing carefully selected individuals with prostacyclin, bosantin,
and/or sildenafil.1,12 Therefore, at present, limited therapeutic
options are available. General recommendations include limit-
ing physical activity and avoidance of concomitant medica-
tions that can potentially aggravate PH, such as b-adrenergic
receptor blockers. Warfarin anticoagulation, which is routinely
used in idiopathic PAH, should be considered with caution in
PVOD given the association with occult alveolar hemorrhage.
Diuretics may offer some symptomatic benefit in those with
right ventricular volume overload that is not controlled by diet-
ary measures alone.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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