Mechanical factors affecting hemostasis and thrombosis

Procoagulant activity in hemostasis and thrombosis: Virchow's triad revisited

Virchow's triad is traditionally invoked to explain pathophysiologic mechanisms leading to thrombosis, alleging concerted roles for abnormalities in blood composition, vessel wall components, and blood flow in the development of arterial and venous thrombosis. Given the tissue-specific bleeding observed in hemophilia patients, it may be instructive to consider the principles of Virchow's triad when investigating mechanisms operant in hemostatic disorders as well. Blood composition (the function of circulating blood cells and plasma proteins) is the most well studied component of the triad. For example, increased levels of plasma procoagulant proteins such as prothrombin and fibrinogen are established risk factors for thrombosis, whereas deficiencies in plasma factors VIII and IX result in bleeding (hemophilia A and B, respectively). Vessel wall (cellular) components contribute adhesion molecules that recruit circulating leukocytes and platelets to sites of vascular damage, tissue factor, which provides a procoagulant signal of vascular breach, and a surface upon which coagulation complexes are assembled. Blood flow is often characterized by 2 key variables: shear rate and shear stress. Shear rate affects several aspects of coagulation, including transport rates of platelets and plasma proteins to and from the injury site, platelet activation, and the kinetics of fibrin monomer formation and polymerization. Shear stress modulates adhesion rates of platelets and expression of adhesion molecules and procoagulant activity on endothelial cells lining the blood vessels. That no one abnormality in any component of Virchow's triad fully predicts coagulopathy a priori suggests coagulopathies are complex, multifactorial, and interactive. In this review, we focus on contributions of blood composition, vascular cells, and blood flow to hemostasis and thrombosis, and suggest that cross-talk among the 3 components of Virchow's triad is necessary for hemostasis and determines propensity for thrombosis or bleeding. Investigative models that permit interplay among these components are necessary to understand the operant pathophysiology, and effectively treat and prevent thrombotic and bleeding disorders.

Platelet adhesion from shear blood flow is controlled by near-wall rebounding collisions with erythrocytes

The efficacy of platelet adhesion in shear flow is known to be substantially modulated by the physical presence of red blood cells (RBCs). The mechanisms of this regulation remain obscure due to the complicated character of platelet interactions with RBCs and vascular walls. To investigate this problem, we have created a mathematical model that takes into account shear-induced transport of platelets across the flow, platelet expulsion by the RBCs from the near-wall layer of the flow onto the wall, and reversible capture of platelets by the wall and their firm adhesion to it. This model analysis allowed us to obtain, for the first time to our knowledge, an analytical determination of the platelet adhesion rate constant as a function of the wall shear rate, hematocrit, and average sizes of platelets and RBCs. This formula provided a quantitative description of the results of previous in vitro adhesion experiments in perfusion chambers. The results of the simulations suggest that under a wide range of shear rates and hematocrit values, the rate of platelet adhesion from the blood flow is mainly limited by the frequency of their near-wall rebounding collisions with RBCs. This finding reveals the mechanism by which erythrocytes physically control platelet hemostasis.

In vitro and computational thrombosis on artificial surfaces with shear stress

Implantable devices in direct contact with flowing blood are associated with the risk of thromboembolic events. This study addresses the need to improve our understanding of the thrombosis mechanism and to identify areas on artificial surfaces susceptible to thrombus deposition. Thrombus deposits on artificial blood step transitions are quantified experimentally and compared with shear stress and shear rate distributions using computational fluid dynamics (CFD) models. Larger steps, and negative (expanding) steps result in larger thrombus deposits. Fitting CFD results to experimental deposit locations reveals a specific shear stress threshold of 0.41 Pa or a shear rate threshold of 54 s(-1) using a shear thinning blood viscosity model. Thrombosis will occur below this threshold, which is specific to solvent-polished polycarbonate surfaces under in vitro coagulation conditions with activated clotting time levels of 200-220 s. The experimental and computational models are valuable tools for thrombosis prediction and assessment that may be used before proceeding to clinical trials and to better understand existing clinical problems with thrombosis.

Pulse pressure and long-term survival after coronary artery bypass graft surgery

BACKGROUND

Data from longitudinal studies reveal that widened pulse pressure (PP) is a major predictor of coronary heart disease and mortality, but it is unknown whether PP similarly decreases survival after coronary artery bypass graft (CABG) surgery for coronary heart disease. We therefore assessed long-term survival in patients with increased PP at the time of presentation for CABG surgery.

METHODS

In this retrospective observational study of patients undergoing CABG surgery between January 1993 and July 2004, 973 subjects were included for assessment of long-term survival. Baseline arterial blood pressure (BP) measurements were defined as the median of the first 3 measurements recorded by the automated record keeping system before induction of anesthesia. The effect of baseline PP on survival after surgery was evaluated using a Cox proportional hazards regression model and bootstrap resampling with baseline mean arterial BP, systolic BP, diastolic BP, diabetes, Hannan risk index, aprotinin use, and cardiopulmonary bypass time as covariates.

RESULTS

There were 220 deaths (22.9%) during the follow-up period (median, 7.3 yr [Q1: 5, Q3: 10 yr]) including 94 deaths from cardiovascular causes. Increased baseline PP was a significant predictor of reduced long-term survival (P < 0.001) along with Hannan risk index (P < 0.001), duration of cardiopulmonary bypass (P < 0.001), and diabetes (P < 0.001). Baseline systolic (P = 0.40), diastolic (P = 0.38), and mean arterial BPs (P = 0.78) were not associated with long-term survival. The hazard ratio for PP (adjusted for other covariates in the model) was 1.11 (1.05-1.18) per 10-mm Hg increase.

CONCLUSIONS

An increase in perioperative PP is associated with poor long-term survival after CABG surgery. Together with our previous report linking PP to in-hospital fatal and nonfatal vascular complications, the established models for surgical risk assessment, patient counseling, and treatment should be revised to include PP.

A novel binding site for ADAMTS13 constitutively exposed on the surface of globular VWF

ADAMTS13 metalloprotease regulates the multimeric size of von Willebrand factor (VWF) by cleaving the Tyr1605-Met1606 bond in the VWF A2 domain. The mechanisms of VWF recognition by ADAMTS13 have yet to be fully resolved. Most studies have focused on the role of exosites within the VWF A2 domain, involved in interaction with the ADAMTS13 spacer domain. In the present study, we expressed different C-terminal domain VWF fragments and evaluated their binding to ADAMTS13 and its truncated mutants, MDTCS and del(TSP5-CUB). Using plate binding assay and surface plasmon resonance, we identified a novel ADAMTS13 binding site (K(D) approximately 86 nM) in the region of VWF spanning residues 1874 to 2813, which includes the VWF D4 domain and that interacts with the C-terminal domains of ADAMTS13. We show that the interaction occurs even when VWF is in static conditions, assumed to be globular and where the VWF A2 domain is hidden. We demonstrate that C-terminal VWF fragments, as well as an antibody specifically directed toward the VWF D4 domain, inhibit VWF proteolysis by ADAMTS13 under shear conditions. We propose that this novel VWF C-terminal binding site may participate as the initial step of a multistep interaction ultimately leading to proteolysis of VWF by ADAMTS13.

Effect of desmopressin on erythrocyte aggregation

Experiments on rats showed that desmopressin in doses recommended for single injections to humans increased erythrocyte aggregation. A close correlation between erythrocyte aggregation index and blood viscosity, on the one hand, and plasma content of acid glycosaminoglycans on the other was detected.

Acoustic determination of early stages of intravascular blood coagulation

The blood coagulation system (BCS) is a complex biological system playing a principal role in the maintenance of haemostasis. Insufficient activity of the BCS may lead to bleeding and blood loss (e.g. in the case of haemophilia). On the other hand, excessive activity may cause intravascular blood coagulation, thromboses and embolization. Most of the methods currently used for BCS monitoring suffer from the major disadvantage of being invasive. The purpose of the present work is to demonstrate the feasibility of using ultrasonic methods for non-invasive registration of the early stages of blood coagulation processes in intensive flows. With this purpose, a special experimental set-up was designed, facilitating the simultaneous detection of optical and acoustic signals during the clotting process. It was shown that (i) as microemboli appear in the flow during the early stage of blood coagulation, the intensity of the Doppler signal increases twofold, and (ii) microemboli formation in the early stages of blood clotting always reveals itself through an acoustic contrast. Both of these effects are well defined, so we hope that they may be used for non-invasive BCS monitoring in clinical practice.

Rate of mixing controls rate and outcome of autocatalytic processes: theory and microfluidic experiments with chemical reactions and blood coagulation

This article demonstrates that the rate of mixing can regulate the rate and outcome of both biological and nonbiological autocatalytic reaction systems that display a threshold response to the concentration of an activator. Plug-based microfluidics was used to control the timing of reactions, the rate of mixing, and surface chemistry in blood clotting and its chemical model. Initiation of clotting of human blood plasma required addition of a critical concentration of thrombin. Clotting could be prevented by rapid mixing when thrombin was added near the critical concentration, and mixing also affected the rate of clotting when thrombin was added at concentrations far above the critical concentration in two clinical clotting assays for human plasma. This phenomenon was modeled by a simple mechanism--local and global competition between the clotting reaction, which autocatalytically produces an activator, and mixing, which removes the activator. Numerical simulations showed that the Damköhler number, which describes this competition, predicts the effects of mixing. Many biological systems are controlled by thresholds, and these results shed light on the dynamics of these systems in the presence of spatial heterogeneities and provide simple guidelines for designing and interpreting experiments with such systems.

Assessment of blood coagulation under various flow conditions with ultrasound backscattering

Several in vitro studies have employed ultrasonic techniques to detect varying properties of coagulating blood under static or stirred conditions. Most of those studies mainly addressed on the development and feasibility of modalities and however were not fully considering the effect of blood flow. To better elucidate this issue, ultrasonic backscattering were measured from the coagulating porcine blood circulated in a mock flow loop with various steady laminar flows at mean shear rates from 10 to 100 s(-1). A 3 ml of 0.5 M CaCl2 solution for inducing blood coagulation was added to that of 30 ml blood circulated in the conduit. For each measurement carried out with a 10-MHz transducer, backscattered signals digitized at 100-MHz sampling frequency were acquired for a total of 20 min at temporal resolution of 50 A-lines per s. The integrated backscatter (IB) was calculated for assessing backscattering properties of coagulating blood. The results show that blood coagulation tended to be increased corresponding to the addition of CaCl2 solution: the IB was increased approximately 6.1 +/- 0.6 (mean +/- standard deviation), 5.4 +/- 0.9, and 4.5 +/- 1.2 dB at 310 +/- 62, 420 +/- 88, and 610 +/- 102 s associated with mean shear rates of 10, 40, and 100 s(-1), respectively. The rate of increasing IB for evaluating the growth of clot was estimated to be 0.075 +/- 0.017, 0.052 +/- 0.027, and 0.038 +/- 0.012 delta dB delta s(-1) corresponding to the increase of mean shear rates. These results consistently demonstrate that higher shear rate tends to prolong the duration for the flowing blood to be coagulated and to decrease the rate of IB. Moreover, the laminar flow was changed to turbulent flow during that the blood was clotting discerned by spatial variations of ultrasound backscattering in the conduit. All these results validate that ultrasound backscattering is feasible to be utilized for detecting and assessing blood coagulation under dynamic conditions.

Platelets interact with tissue factor immobilized on surfaces: effects of shear rate

BACKGROUND

While procoagulant activities of Tissue Factor (TF) have been widely investigated, its possible pro-adhesive properties towards platelets have not been studied in detail.

MATERIAL AND METHODS

We explored the interaction of platelets with human Tissue Factor (hTF) firmly adsorbed on a synthetic surface of polyvinilidene difluoride (PVDF) using different shear rates. For studies at 250 and 600 s(-1), TF firmly adsorbed was exposed to flowing anticoagulated blood in flat perfusion devices. Deposition of platelets and fibrin were evaluated by morphometric, immunocytochemical and ultrastructural methods. Prothrombin fragment 1 + 2 (F1 + 2) levels were also measured. Experiments at 5000 s(-1), were performed on the Platelet Function Analyzer (PFA-100) with experimental cartridges with collagen (COL) or collagen-hTF (COL + TF). Haemostatic effect of recombinant activated FVIIa (rFVIIa) was assessed in the same experimental settings.

RESULTS

Platelet deposition on hTF reached 19.8 +/- 1.3% and 26.1 +/- 3.4% of the total surface, at 250 and 600 s(-1), respectively. Fibrin formation was significantly higher at 250 s(-1) than at 600 s(-1) (P < 0.05). The addition of rFVIIa did not influence platelet deposition but raised fibrin formation and thrombin generation at both shear rates (P < 0.05). At 5000 s(-1), closure times (CT) in the PFA-100 were significantly shortened in the presence of hTF (154.09 +/- 14.69 s vs. 191.45 +/- 16.09 s COL alone; P < 0.05). Addition of rFVIIa did not cause a further reduction of CT.

CONCLUSIONS

Our studies demonstrate that hTF is an adhesive substrate for platelets and suggest that the von Willebrand factor could mediate these interactions. At low and intermediate shear rates, rFVIIa enhanced the procoagulant action of hTF, but this effect was not observed at very high shear rates.

Platelet function under high-shear conditions from platelet concentrates

BACKGROUND

Platelet (PLT) collection and storage affect the functional capacity of PLTs in PLT concentrates (PCs). Therefore, PLTs' functional quality should be studied before transfusion.

STUDY DESIGN AND METHODS

PCs (n = 15) were collected by a standard apheresis procedure (Trima, Gambro BCT) and were stored for 7 days. Samples were taken to assess PLT adhesion and aggregate formation by a cone and plate analyzer (Impact-R, DiaMed) on Days 1, 3, 5, and 7 after harvesting. This device allows testing PLT function under high-shear stress close to physiologic conditions. Concomitantly, P-selectin expression and the residual responsiveness to TRAP-6 were determined by flow cytometry.

RESULTS

PLT adhesion, as measured by surface coverage, decreased during the entire observation period; likewise, the size of aggregates was significantly lower on Days 5 and 7 compared to Day 1 (p < 0.02). P-selectin expression increased from Day 5 to Day 7 (p < 0.04), whereas TRAP-6-inducible expression remained stable until Day 5 of storage and decreased significantly on Day 7 (p = 0.04).

CONCLUSIONS

Our results show that high-shear-induced PLT adhesion and aggregation on the polystyrene surface deteriorate upon storage, suggesting decreased PLT function in vivo. Thus, the Impact-R may be a useful tool to assess the functional capacity of PLTs under various PLT harvesting and storage procedures.

The cooperative activity between the carboxyl-terminal TSP1 repeats and the CUB domains of ADAMTS13 is crucial for recognition of von Willebrand factor under flow

ADAMTS13 cleaves von Willebrand factor (VWF) between Tyr(1605) and Met(1606) residues at the central A2 subunit. The amino-terminus of ADAMTS13 protease appears to be sufficient to bind and cleave VWF under static and denatured condition. However, the role of the carboxyl-terminus of ADAMTS13 in substrate recognition remains controversial. Present study demonstrates that ADAMTS13 cleaves VWF in a rotation speed- and protease concentration-dependent manner on a mini vortexer. Removal of the CUB domains (delCUB) or truncation after the spacer domain (MDTCS) significantly impairs its ability to cleave VWF under the same condition. ADAMTS13 and delCUB (but not MDTCS) bind VWF under flow with dissociation constants (K(D)) of about 50 nM and about 274 nM, respectively. The isolated CUB domains are neither sufficient to bind VWF detectably nor capable of inhibiting proteolytic cleavage of VWF by ADAMTS13 under flow. Addition of the TSP1 5-8 (T5-8CUB) or TSP1 2-8 repeats (T2-8CUB) to the CUB domains restores the binding affinity toward VWF and the inhibitory effect on cleavage of VWF by ADAMTS13 under flow. These data demonstrate directly and quantitatively that the cooperative activity between the middle carboxyl-terminal TSP1 repeats and the distal carboxyl-terminal CUB domains may be crucial for recognition and cleavage of VWF under flow.

Examination of platelet function in whole blood under dynamic flow conditions with the cone and plate(let) analyzer: effect of erythrocytosis and thrombocytosis

We studied cone and plate(let) analysis (CPA) for evaluating global platelet function in whole blood under arterial flow conditions (approximately 1,800 seconds(-1)). CPA allows direct visualization and quantitation of platelet adhesion (surface coverage [SC]) and determination of average aggregate size (AS) following brief shearing of a small blood sample (3.2% sodium citrate) in plastic wells. By using blood from healthy volunteers manipulated to alter platelet or RBC counts and blood from patients with myeloproliferative disorders (MPDs), quantitative and qualitative changes in SC and AS were observed. Thrombocytosis resulted in increased SC, whereas erythrocytosis increased AS. The RBC volume (mean corpuscular volume) had no effect. It is interesting that differences in CPA AS were discerned among subgroups of patients with MPD undergoing different treatment regimens. These studies suggest that CPA platelet deposition patterns may provide novel insight into global platelet function during hemodynamic flow.

In vitro shear stress modulates antithrombogenic potentials of human endothelial progenitor cells

BACKGROUND

Recent study suggested that endothelial progenitor cells (EPCs), a novel therapeutic approach for endothelial dysfunction, present limited antithrombogenic potentials. However, few attempts have been done to improve the antithrombogenic potentials of EPCs. Our previous study proved that in vitro shear stress contributes to the increase in t-PA production by human EPCs. Here, we further investigated whether in vitro shear stress contributes to the secretion of antithrombogenic substances including plasminogen activator inhibitor-1 (PAI-1) and prostaglandin I(2) (PGI(2)) by human EPCs.

METHODS

The peripheral blood mononuclear cells of healthy subjects were induced into EPCs. Then the human EPCs were treated with four levels of shear stress including stationary condition low media and high flow shear stress. The production of PAI-1 and 6-keto-prostaglandin F1(1alpha)(6-Keto-PGF(1alpha)) by human EPCs with shear stress treatment were measured.

RESULTS

In vitro medium and high flow shear stress inhibited PAI-1 secretion by human EPCs, but low flow shear stress had no effect on PAI-1 secretion by human EPCs. All levels of shear stress significantly increased 6-Keto-PGF(1alpha )production by human EPCs in a dose-dependent manner.

CONCLUSIONS

The present study demonstrates that in vitro shear stress can promote PGI(2 )secretion and inhibit PAI-1 secretion by human EPCs, which improves the antithrombogenic potentials of human EPCs.

On the biology of saphenous vein grafts fitted with external synthetic sheaths and stents

Autologous saphenous vein is used as a conduit to bypass atherosclerotic lesions in both the coronary artery (coronary artery bypass graft surgery [CABG]) and in femoral arteries (infrainguinal bypass graft surgery [IIBS]). Despite the undoubted success and benefits of the procedures, graft failure occurs in 50% of cases within 10 years after surgery. A principal cause of late vein graft failure is intimal and medial hyperplasia and superimposed atherogenesis. Apart from lipid lowering therapy, no intervention has hitherto proved clinically effective in preventing late vein graft failure which clearly constitutes a major clinical and economic problem that needs to be urgently resolved. However, we have studied the effect of external synthetic stents and sheaths in pig models of vein into artery interposition grafting and found them to have a profound effect on vein graft remodelling and thickening. In this review, therefore, we will summarise the mechanisms underlying vein graft failure and how these stents influence these processes and the possible mechanisms involved as well as the application of these devices in preventing vein graft failure clinically.

Influence of the needle bore size on platelet count and routine coagulation testing

The phlebotomy technique, particularly the use of small-bore needles, may influence the reliability of coagulation testing and platelet count. Routine coagulation tests were assayed in blood specimens collected from 22 consecutive patients in three separate, sequential phlebotomies, using butterfly devices with different needle sizes. Test results of samples collected with 23 and 25 G needles were compared with those obtained with the currently recommended 21 G needle. Although both the prothrombin time and activated partial thromboplastin time displayed a trend towards lower values employing the smaller 23 and 25 G needles, results did not differ significantly from the reference 21 G needle specimen, with the exceptions of D-dimer (25 G versus 21 G needle, 186 +/- 70 versus 178 +/- 66/ml, P < 0.01) and platelet count (23 G versus 21 G needle, 246 +/- 55 versus 254 +/- 56 x 10(-3)/l, P < 0.01; 25 G versus 21 G needle, 240 +/- 55 versus 254 +/- 56 x 10(-3)/l, P < 0.01). None of the mean biases recorded for the parameters was clinically meaningful, nor did they exceed the current desirable analytical quality specifications for desirable bias. Results of the present investigation suggest that, when a proper technique is used and within certain limitations, butterfly devices with small-bore needles may be a reliable alternative to draw venous blood for platelet count and coagulation testing.

The impact of blood rheology on the molecular and cellular events underlying arterial thrombosis

There is an increasing appreciation of the importance of disturbed blood flow, especially turbulent flow, in the pathogenesis of vascular disease. However, the precise mechanism(s) by which rheological changes accelerate the atherothrombotic process remains incompletely understood. Atherosclerotic lesions typically develop in vascular regions exhibiting bifurcated or curved architectures. Such regions exhibit complex blood flow profiles with considerable divergence from uniform laminar flow. These altered flow behaviours can promote deposition of pro-atherogenic lipids and proteins to the vessel wall and modulate the adhesive function of endothelial, platelets and leukocytes. Once developed, atherosclerotic lesions can further exacerbate flow disturbances, establishing a potential hazardous cycle of accelerated atherogenesis. At the cellular level, alterations in fluid flow can lead to significant changes in signal transduction, leading to a variety of functional and morphological changes. In particular, disturbed rheology has a significant impact on the adhesion and activation mechanisms utilised by platelets and leukocytes with high shear, playing an important role in accelerating platelet activation and thrombus growth. This review focuses on the impact of blood rheology on the cellular and molecular events underlying thrombosis, with particular emphasis on the role of platelets in this process.

Fluid Dynamic Assessment of Three Polymeric Heart Valves Using Particle Image Velocimetry

Polymeric heart valves have the potential to reduce thrombogenic complications associated with current mechanical valves and overcome fatigue-related problems experienced by bioprosthetic valves. In this paper we characterize the in vitro velocity and Reynolds Shear Stress (RSS) fields inside and downstream of three different prototype trileaflet polymeric heart valves. The fluid dynamic differences are then correlated with variations in valve design parameters. The three valves differ in leaflet thickness, ranging from 80 to 120 mum, and commisural design, either closed, opened, or semi-opened. The valves were subjected to aortic flow conditions and the velocity measured using three-dimensional stereo Particle Image Velocimetry. The peak forward flow phase in the three valves was characterized by a strong central orifice jet of approximately 2 m/s with a flat profile along the trailing edge of the leaflets. Leakage jets, with principle RSS magnitudes exceeding 4,500 dyn/cm(2), were observed in all valves with larger leaflet thicknesses and also corresponded to larger leakage volumes. Additional leakage jets were observed at the commissural region of valves with the open and the semi-open commissural designs. The results of the present study indicate that commissural design and leaflet thickness influence valve fluid dynamics and thus the thrombogenic potential of trileaflet polymeric valves.

A Model for the Formation and Lysis of Blood Clots

Both biochemical and mechanical factors have to be taken into account if a meaningful model for the formation, growth, and lysis of clots in flowing blood is to be developed. Most models that are currently in use neglect one or the other of these factors. We have previously reported a model [J Theoret Med 2003;5:183-218] that we believe is a step in this direction, incorporating many of the crucial biochemical and rheological factors that play a role in the formation, growth, and lysis of clots. While this model takes into account the extrinsic pathway of coagulation, it largely ignores the intrinsic pathway. Here, we discuss some of the general issues with respect to mathematical modeling of thrombus formation and lysis, as well as specific aspects of the model that we have developed.

Mathematical Modeling and Computer Simulation in Blood Coagulation

Over the last two decades, mathematical modeling has become a popular tool in study of blood coagulation. The in silico methods were able to yield interesting and significant results in the understanding of both individual reaction mechanisms and regulation of large sections of the coagulation cascade. The objective of this paper is to review the development of theoretical research in hemostasis and thrombosis, to summarize the main findings, and outline problems and possible prospects in the use of mathematical modeling and computer simulation approaches. This review is primarily focused on the studies dealing with: (1) the membrane-dependent reactions of coagulation; (2) regulation of the coagulation cascade, including effects of positive and negative feedback loops, diffusion of coagulation factors, and blood flow.

Endothelial injury and acquired aspirin resistance as promoters of regional thrombin formation and early vein graft failure after coronary artery bypass grafting

OBJECTIVE

The predominant mechanism of early graft failure after coronary artery bypass grafting remains in doubt. Aspirin administered in the initial hours after coronary artery bypass grafting improves graft patency, implicating prostanoid synthesis in the pathogenesis. We hypothesized that synergy between endothelial disruption in the venous conduit and aspirin resistance would cause vein graft failure.

METHODS

Aspirin resistance, defined by diagnostic findings on at least two of three separate assays, was serially assessed in 225 patients undergoing off-pump coronary artery bypass grafting. Endothelial cell integrity was determined in surplus segments obtained from 408 vein grafts. The deposition of intraluminal thrombin within the vein was determined by comparing serum F1.2 levels between the coronary sinus and the aorta after grafting. Intraoperative blood flow in the grafts was measured with transit-time technology, and patency was assessed with electrocardiographically gated multichannel computed tomographic coronary angiography on day 5. Aspirin was the sole antithrombotic agent used during the study.

RESULTS

Thrombosed grafts (16/408) showed more endothelial cell loss at the time of grafting than did those grafts that remained patent (10.8% +/- 21.5% vs 51.4% +/- 39.1% integrity, P < .01). Aspirin resistance occurred in 67 patients (30%). Graft thrombosis was associated with aspirin resistance (P < .04) and reduced endothelial integrity (P < .01). These factors coexisted in 14 of 16 grafts that failed and were associated with elevated coronary sinus F1.2 levels.

CONCLUSION

Aspirin resistance and relatively compromised venous endothelial cell integrity together marked patients whose vein grafts failed within days after off-pump coronary artery bypass grafting. These observations form a basis for identifying patients at risk and developing approaches to prevent vein injury or to selectively intervene in high-risk circumstances.

Mechanical mechanisms for thrombosis in microvessels

The hypothesis that thrombus can be induced in curved vessels due to mechanical stimuli was tested both experimentally and computationally. Our in vivo experiments on the mesentery of Sprague-Dawley rats (250-300 g) showed that thrombi were formed in non-injured curved microvessels (post-capillary venules, 20-50 micrometer in diameter), and they were initiated at the inner side of the vessel. We observed thrombus formation in 7 out of 32 microvessels after they were stretched and curved for 10-60 mm. To investigate the mechanical mechanisms of thrombus induction, we performed 3-D computational simulation using commercial software, FLUENT. The blood flow was approximated as a Newtonian laminar flow with Reynolds number around 0.01 in this type of microvessels. We considered the vessels with different curvatures (90 degrees and 180 degrees) as well as different shaped-cross sections (circular and elliptic). Computational results demonstrated that the shear rate and shear rate gradient and at the inner side of the vessel were higher than those at the opposite side. The differences became larger in more bended and elliptic-shaped microvessels. This suggested that higher shear rate and shear rate gradient are two of the factors that initiate the thrombosis in curved post-capillary venules. Our results are consistent with others in branched venules.

Numerical Analysis of the Hemodynamics and Embolus Capture of a Greenfield Vena Cava Filter

Background: Vena Cava filters are used to prevent pulmonary embolism in patients with deep vein thrombosis who are unresponsive to anticoagulation therapy. Various filter designs exist in the market with different characteristics distinguishing them. An understanding of the characteristics of these filters is desirable in order to develop better designs. Methods: A computational fluid dynamical study of the flow over an unoccluded stainless steel Greenfield Vena Cava filter (Boston Scientific, Watertown, MA) to determine its properties has been performed. Simulation of flow over a filter placed axisymmetrically in a rounded inferior vena cava has been performed at a Reynolds numbers of 1000 and the consequences of the flow (by studying parameters like shear stress and stagnation zones) have been discussed. Furthermore, a new finite element based numerical method has been developed that allows the study of capturing properties of Inferior Vena Cava filters. The key idea is the introduction of a thin-wire-model (TWM) that enables a drastic reduction in the computational cost while still maintaining control on the physics of the problem. This numerical technique has been applied to evaluate the embolus capture characteristic of a Greenfield filter. Results: The flow around the unoccluded filter is found to be steady and laminar at the conditions studied. A recirculation/stagnation zone develops immediately downstream of the filter head. This zone is significantly larger when the central hole is occluded. The shear stress and stagnation zone properties for such a flow over a Greenfield filter are compared with existing literature (in vitro studies). A graph showing the regions wherein clots escape or get captured has been determined by a means of numerical simulations. The data has further been analyzed to determine the probability of clot capture as function of the clot size. Conclusions: The stagnation zone formed behind the head of the Greenfield filter is found to be smaller in size when compared to that of the same filter with the central hole occluded. A map of the shear stress distribution shows a small region having the potential for thrombogenesis. The non-Newtonian properties of blood are not seen to cause much variation in the flow field when compared to the Newtonian model. However variation in the cava size leads to a significant change in the shear stresses. This study also establishes a novel method wherein computational means are used to determine the efficacy of clot capturing of filters. These techniques can further be used to compare the different characteristics among filters.

Tissue factor-dependent coagulation is preferentially up-regulated within arterial branching areas in a baboon model of Escherichia coli sepsis

Endothelium plays a critical role in the pathobiology of sepsis by integrating systemic host responses and local rheological stimuli. We studied the differential expression and activation of tissue factor (TF)-dependent coagulation on linear versus branched arterial segments in a baboon sepsis model. Animals were injected intravenously with lethal doses of Escherichia coli or saline and sacrificed after 2 to 8 hours. Whole-mount arterial segments were stained for TF, TF-pathway inhibitor (TFPI), factor VII (FVII), and markers for endothelial cells (ECs), leukocytes, and platelets, followed by confocal microscopy and image analysis. In septic animals, TF localized preferentially at branches, EC surface, leukocytes, and platelet aggregates and accumulated in large amounts in the subendothelial space. FVII strongly co-localized with TF on ECs and leukocytes but less so with subendothelial TF. TFPI co-localized with TF and FVII on endothelium and leukocytes but not in the subendothelial space. Focal TF increases correlated with fibrin deposition and increased endothelial permeability to plasma proteins. Biochemical analysis confirmed that aortas of septic baboons expressed more TF mRNA and protein than controls. Branched segments contained higher TF protein levels and coagulant activity than equivalent linear areas. These data suggest that site-dependent endothelial heterogeneity and rheological factors contribute to focal procoagulant responses to E. coli.

Fibrin-targeted contrast agent for improvement of in vivo acute thrombus detection with magnetic resonance imaging

OBJECTIVE

Plaque rupture leading to thrombosis and occlusion is a major source of acute coronary syndromes. Methods for accurate detection of thrombosis in veins or arteries may expand our capacity to predict clinical complications and guide therapeutic decisions. We sought to demonstrate the feasibility of in vivo acute thrombus detection using a fibrin-targeted gadolinium based magnetic resonance contrast agent (EP-1242).

METHODS

Carotid thrombosis was induced in 12 guinea pigs by external injury and blood stasis. MR images were obtained after thrombus formation pre- and post- EP-1242 injection, using a T1-weighted high-resolution fast spin-echo sequence.

RESULTS

An occlusive fibrin-rich thrombus was achieved in all animals. Correlation for thrombus location was excellent between MRI and histology (R=0.94; P<0.001). Contrast-enhanced MRI significantly improved thrombus detection when compared to non contrast-enhanced MRI (100% versus 41.6%; p<0.001). In addition, thrombus signal intensity (SI) was significantly increased after injection (SI(30 min-post)=4.39+/-0.12 versus 1.0; p<0.001). Contrast-to-noise ratio (CNR) was 43.8+/-7.2, 30 min post-injection (P<0.001). No enhancement was seen in the uninjured control arteries.

CONCLUSIONS

We demonstrate the feasibility of in vivo MRI for carotid thrombus detection using a novel fibrin-targeted contrast agent. This technique significantly improves detection of small size thrombi in an animal model of occlusive fibrin-rich thrombosis.

A comparison of flow field structures of two tri-leaflet polymeric heart valves

Polymeric heart valves have the potential to reduce thrombogenic complications associated with current mechanical valves and overcome fatigue-related problems experienced by bioprosthetic valves. In this in vitro study, the velocity fields inside and downstream of two different prototype tri-lealfet polymeric heart valves were studied. Experiments were conducted on two 23 mm prototype polymeric valves, provided by AorTech Europe, having open or closed commissure designs and leaflet thickness of 120 and 80 microm, respectively. A two-dimensional LDV system was used to measure the velocity fields in the vicinity of the two valves under simulated physiological conditions. Both commissural design and leaflet thickness were found to affect the flow characteristics. In particular, very high levels of Reynolds shear stress of 13,000 dynes/cm2 were found in the leakage flow of the open commisure design. Maximum leakage velocities in the open and closed designs were 3.6 m/s and 0.5 m/s respectively; the peak forward flow velocities were 2.0 m/s and 2.6 m/s, respectively. In both valve designs, shear stress levels exceeding 4,000 dyne/cm2 were observed at the trailing edge of the leaflets and in the leakage and central orifice jets during peak systole. Additionally, regions of low velocity flow conducive to thrombus formation were observed in diastole. The flow structures measured in these experiments are consistent with the location of thrombus formation observed in preliminary animal experiments.

Flow Visualization in a Model of a Bifurcated Stent-Graft

PURPOSE

To use an in vitro flow model to investigate the flow patterns in a bifurcated stent-graft for abdominal aortic aneurysm (AAA) repair.

METHODS

Experiments were performed in an in vitro test rig incorporating a simplified non-planar model of an AAA. A two-component bifurcated device consisting of a stent structure and transparent polyurethane "graft" was deployed in the AAA model. Using a blood analogue fluid, a pulsatile blood flow waveform simulating resting flow condition was produced by means of a piston pump system. Flow patterns in the lateral and anteroposterior planes of the stent-graft were recorded and analyzed using flow visualization techniques.

RESULTS

The flow patterns within the stent-graft were complex and influenced by the geometry of the stent-graft itself, as well as that of the aortic neck and iliac vessels. Regions of flow separation, low velocity and stagnation, and slow oscillatory flow near the walls were seen in the main body of the stent-graft. Constriction at the stump in the contralateral limb resulted in flow disturbances and flow separation. Kinking at the junctions of stent segments and folding of the graft compounded these complex flow structures.

CONCLUSIONS

The flow structures within stent-grafts are complex, with features that may predispose to thrombus formation. Arterial geometry, including aortic neck angulation and iliac vessel tortuosity, and the design of the stent-graft are factors that influence hemodynamics and may impact the performance of aortic stent-grafts.

Association of the fibrinolytic system and hemorheology with symptoms in patients with carotid occlusive disease

BACKGROUND AND OBJECTIVES

The risk of stroke caused by a symptomatic high-grade carotid stenosis (CS) is high. Disturbed balance between the procoagulant and fibrinolytic activity in blood associated with unfavorable hemorheology could render CS symptomatic. We wanted to assess whether hemostatic and fibrinolytic plasma markers as well as basic indicators of hemorheology differentiate asymptomatic and symptomatic patients with a high-grade CS and whether they are associated with the macroscopic appearance of the plaque and the rate of microembolization.

METHODS

We recruited 92 consecutive consenting patients referred to the neurological or the surgical department of our university teaching hospital for treatment of their high-grade CS. Blood samples were collected before surgery for determination of prothrombin fragments F1 and 2, thrombin-antithrombin complex, tissue-type plasminogen activator (tPA) activity and antigen, plasminogen activator inhibitor-1 (PAI-1) activity and antigen, D-dimer, homocysteine, fibrinogen, in plasma, and hematocrit in blood, and the patients underwent transcranial Doppler ultrasonology for evaluation of microembolic signals (MES).

RESULTS

Patients with symptomatic plaques had higher hematocrit levels (p = 0.04), as well as trends for higher tPA antigen and MES rate (p = 0.07). Hematocrit, tPA antigen, and PAI-1 antigen and activity were positively correlated with the degree of stenosis. Ulceration was more common in symptomatic plaques but did not reflect variables of hemostasis or fibrinolysis. In multivariate analysis, tPA antigen and hematocrit were risk factors for a symptomatic high-grade stenosis.

CONCLUSION

Mediators of fibrinolysis and unfavorable hemorheology may contribute to the development of a symptomatic disease in patients with a high-grade CS.

Polymerization of fibrin: specificity, strength, and stability of knob-hole interactions studied at the single-molecule level

Using laser tweezers, we measured for the first time the forces of individual knob-into-hole interactions underlying fibrin polymerization. Exposure of A-knobs in desA-fibrin or its fragment from the central part of the molecule (N-terminal disulphide knot, NDSK) resulted in strong interactions with fibrinogen or fragment D (containing only a- and b-holes), producing a binding strength of approximately 125 to 130 pN. The interactions were not present in the absence of either knobs or holes and were abrogated by a specific inhibitor of fibrin polymerization, a peptide mimic of the A-knob (GPRPam). Exposure of both the A- and B-knobs in desAB-fibrin or desAB-NDSK did not change the rupture force spectra compared with the desA molecules, and their interactions with fibrinogen remained highly sensitive to GPRPam but not to GHRPam (B-knob), suggesting that neither A:b nor B:b nor B:a contacts contributed significantly to binding strength in addition to A:a contacts. The A:a interactions had a relatively small zero-force off-rate of approximately 10(-4) s(-1) and tight knob-to-hole contacts characterized by a transition state distance of approximately 0.3 nm. The results demonstrate that the knob-hole binding during thrombin-induced fibrin polymerization is driven by strong, stable, and highly specific A:a bonding, whereas A:b, B:b, or B:a interactions were not detected.

Correlation of in vivo clot deposition with the flow characteristics in the 50 cc penn state artificial heart: a preliminary study

Flow stasis in an artificial heart may provide a situation where thrombus develops. Should part, or all, of the clot dislodge, a thromboembolism may lead to stroke(s), neurologic deficits, or even death. In an effort to determine if the regime of low shear or stasis exists, a two-dimensional particle image velocimetry (PIV) system was implemented to measure the velocity field within the 50 cc Penn State Artificial Heart. The velocity measurements were decomposed nearest the wall to obtain wall shear rates along the bottom of the chamber. The PIV measurements were made in three image planes across the depth of the chamber to reconstruct a surface distribution of the wall shear rates at the bottom over the entire heart cycle. The wall shear rate is shown to be spatially nonuniform, with persistently low wall shear rates. An area near the front edge of the chamber at the bottom showed wall shear rates not exceeding 250 s(-1). This was an area of clot formation seen in vivo, suggesting a link may exist between the low wall shear rate zone and thrombus formation.

Lack of insulin-like growth factor binding protein-3 protease activation by venous cannulation

Disruption of the endothelium activates thrombogenic and fibrinolytic enzymes that cleave insulin-like growth factor binding protein-3 (IGFBP-3) in vitro. The aim of the present human study was to determine whether blood sampling, i.e., venous stasis and cannulation increase IGFBP-3 proteolysis before and/or after surgery by activating these enzymes. Serum samples obtained immediately after cannulation were compared with samples obtained from a previously inserted venous catheter. Cannulation did not increase serum IGFBP-3 proteolytic activity pre- and post-operatively, as determined by in vitro degradation of 125I-IGFBP-3. Furthermore, there was no effect on in vivo IGFBP-3 fragmentation assessed by western immunoblot. In addition, a standardized venous stasis did not affect IGFBP-3 proteolytic activity or fragmentation. Comparison of IGFBP-3 proteolytic activity before and after surgery demonstrated a significant post-operative increase. However, this could not be demonstrated immediately after the initial cannulation, due to a large individual variation at this time-point before surgery.

Biomaterial-associated thrombosis: roles of coagulation factors, complement, platelets and leukocytes

Our failure to produce truly non-thrombogenic materials may reflect a failure to fully understand the mechanisms of biomaterial-associated thrombosis. The community has focused on minimizing coagulation or minimizing platelet adhesion and activation. We have infrequently considered the interactions between the two although we are generally familiar with these interactions. However, we have rarely considered in the context of biomaterial-associated thrombosis the other major players in blood: complement and leukocytes. Biomaterials are known agonists of complement and leukocyte activation, but this is frequently studied only in the context of inflammation. For us, thrombosis is a special case of inflammation. Here we summarize current perspectives on all four of these components in thrombosis and with biomaterials and cardiovascular devices. We also briefly highlight a few features of biomaterial-associated thrombosis that are not often considered in the biomaterials literature: The importance of tissue factor and the extrinsic coagulation system. Complement activation as a prelude to platelet activation and its role in thrombosis. The role of leukocytes in thrombin formation. The differing time scales of these contributions.

Platelet--cancer interactions: mechanisms and pharmacology of tumour cell-induced platelet aggregation

During haematogenous metastasis, cancer cells migrate to the vasculature and interact with platelets resulting in tumour cell-induced platelet aggregation (TCIPA). We review: 1. The biological and clinical significance of TCIPA; 2. Molecular mechanisms involved in platelet aggregation by cancer cells; 3. Strategies for pharmacological regulation of these interactions. We conclude that pharmacological regulation of platelet-cancer cell interactions may reduce the impact of TCIPA on cancer biology.

Ex vivo evaluation of erythrocytosis-enhanced platelet thrombus formation using the cone and plate(let) analyzer: effect of platelet antagonists

Red blood cells (RBC) contribute significantly to haemostasis and thrombosis under oscillatory flow conditions, and erythrocytosis has been associated with increased thrombotic risk. To measure the dynamic influences of RBC on platelets, we used a recently described cone and plate(let) analyzer (CPA), evaluating the effect of haematocrit (Hct) on platelet function in whole blood under arterial flow conditions (1800/s, 2 min, 25 degrees C). Anticoagulated blood, reconstituted to varying haematocrits with autologous RBC, demonstrated a significant increase in adherent platelet aggregate formation at Hct levels >45%. This increase was not affected by pretreatment of blood with 0.05 mmol/l aspirin, but was prevented by antagonists of P2Y1, P2Y12, or P2X1, ADP and ATP receptors, and by converting exogenous ADP to ATP with creatine phosphate/creatine phosphokinase. As negligible platelet granule secretion was measured during CPA analysis, but metabolic inhibition of RBC with sodium azide or glutaraldehyde fixation inhibited erythrocytosis-enhanced increases in platelet aggregate size, adenine nucleotides contributing to shear-induced platelet aggregate formation appear to be derived from erythrocytes. These findings support the use of CPA for ex vivo evaluation of the contribution of RBC to platelet function and its inhibition under physiological shear conditions.

Nonchannel drug targets in atrial fibrillation

Atrial fibrillation (AF) is the most common clinical arrhythmia and one of the most important factors for ischemic stroke. In general, AF is treated with "channel-blocking drugs" to restore sinus rhythm and warfarin is recommended in the majority of patients to prevent atrial thrombus formation and thromboembolic events. In the recent years, a tremendous amount has been learned about the pathophysiology and molecular biology of AF. Thus, pharmacologic interference with specific signal transduction pathways with "non-channel-blocking drugs" appears promising as a novel antiarrhythmic approach to maintain sinus rhythm and to prevent atrial clot formation. Therefore, this review will highlight some novel "nonchannel drug targets" for AF therapy.

Hypercholesterolemia promotes P-selectin-dependent platelet-endothelial cell adhesion in postcapillary venules

OBJECTIVE

The objectives of this study were to determine whether hypercholesterolemia promotes platelet-endothelial cell (P/E) adhesion in murine postcapillary venules and define the contributions of endothelial or platelet associated P-selection to hypercholesterolemia-induced P/E interactions.

METHODS AND RESULTS

Wild-type (WT) or P-selectin deficient (P-sel-/-) platelets were isolated and labeled with the fluorochrome CFSE and administered to either WT or P-sel-/- mice placed on a normal diet (ND) or high cholesterol diet (HCD). Intravital videomicroscopy was used to quantify platelet saltation and firm adhesion. HCD-WT mice exhibited a time-dependent increase in P/E cell interactions (relative to ND-WT). Flow cytometry revealed an increased expression of P-selectin on circulating platelets of HCD-WT mice at 2 weeks compared with ND-WT mice. When WT platelets were monitored in HCD-P-sel-/- mice, P/E adhesion was dramatically reduced. However, when P-sel-/- platelets were monitored in HCD-WT recipients, P/E adhesive interactions were reduced even further, comparable to ND-WT mice.

CONCLUSIONS

These results indicate that elevated cholesterol levels promote P/E adhesion in postcapillary venules and that whereas both endothelial and platelet P-selectin contribute to hypercholesterolemia-induced recruitment of platelets, platelet-associated P-selectin seems to play a more important role in producing the prothrombogenic phenotype in venules.

Alternatively spliced human tissue factor: a circulating, soluble, thrombogenic protein

Tissue factor (TF) is an essential enzyme activator that forms a catalytic complex with FVII(a) and initiates coagulation by activating FIX and FX, ultimately resulting in thrombin formation. TF is found in adventitia of blood vessels and the lipid core of atherosclerotic plaques. In unstable coronary syndromes, plaque rupture initiates coagulation by exposing TF to blood. Biologically active TF has been detected in vessel walls and circulating blood. Elevated intravascular TF has been reported in diverse pro-thrombotic syndromes such as myocardial infarction, sepsis, anti-phospholipid syndrome and sickle-cell disease. It is unclear how TF circulates, although it may be present in pro-coagulant microparticles. We now report identification of a form of human TF generated by alternative splicing. Our studies indicate that alternatively spliced human tissue factor (asHTF) contains most of the extracellular domain of TF but lacks a transmembrane domain and terminates with a unique peptide sequence. asHTF is soluble, circulates in blood, exhibits pro-coagulant activity when exposed to phospholipids, and is incorporated into thrombi. We propose that binding of asHTF to the edge of thrombi contributes to thrombus growth by creating a surface that both initiates and propagates coagulation.

Vortex-mediated mechanical stress induces integrin-dependent cell adhesion mediated by inositol 1,4,5-trisphosphate-sensitive Ca2+ release in THP-1 cells

In the downstream regions of stenotic vessels, cells are subjected to a vortex motion under low shear forces, and atherosclerotic plaques tend to be localized. It has been reported that such a change of shear force on endothelial cells has an atherogenic effect by inducing the expression of adhesion molecules. However, the effect of vortex-induced mechanical stress on leukocytes has not been investigated. In this study, to elucidate whether vortex flow can affect the cell adhesive property, we have examined the effect of vortex-mediated mechanical stress on integrin activation in THP-1 cells, a monocytic cell line, and its signaling mechanisms. When cells are subjected to vortex flow at 400-2,000 rpm, integrin-dependent cell adhesion to vascular cell adhesion molecule-1 or fibronectin increased in a speed- and time-dependent manner. Next, to examine the role of Ca(2+) in this integrin activation, various pharmacological inhibitors involved in Ca(2+) signaling were tested to inhibit the cell adhesion. Pretreatment of cells with BAPTA-AM, thapsigargin +NiCl(2), or U-73122 (a phospholipase C inhibitor) inhibited cell adhesion induced by vortex-mediated mechanical stress. We also found that W7 (a calmodulin inhibitor) blocked the cell adhesion. However, pretreatment of cells with GdCl(3), NiCl(2), or ryanodine did not affect the cell adhesion. These data indicate that vortex-mediated mechanical stress induces integrin activation through calmodulin and inositol 1,4,5-trisphosphate-mediated Ca(2+) releases from intracellular Ca(2+) stores in THP-1 cells.

A Model Incorporating Some of the Mechanical and Biochemical Factors Underlying Clot Formation and Dissolution in Flowing Blood

Multiple interacting mechanisms control the formation and dissolution of clots to maintain blood in a state of delicate balance. In addition to a myriad of biochemical reactions, rheological factors also play a crucial role in modulating the response of blood to external stimuli. To date, a comprehensive model for clot formation and dissolution, that takes into account the biochemical, medical and rheological factors, has not been put into place, the existing models emphasizing either one or the other of the factors. In this paper, after discussing the various biochemical, physiologic and rheological factors at some length, we develop a model for clot formation and dissolution that incorporates many of the relevant crucial factors that have a bearing on the problem. The model, though just a first step towards understanding a complex phenomenon, goes further than previous models in integrating the biochemical, physiologic and rheological factors that come into play.