Evaluation of the patency rate of fibrous microvascular polyurethane prostheses after implantation in the rat aorta

Optimal Covering Material for Stent-Grafts Placed in the Portal Vein in a Canine Model

PURPOSE

We evaluated the suitability of Dacron, polytetrafluoroethylene (PTFE), and small intestinal submucosa (SIS) as a covering material for stent-grafts placed in the portal vein as compared with a bare stent.

METHODS

Using 24 beagle dogs, either bare stents or stent-grafts covered with Dacron, PTFE, or SIS were placed in the main trunk of the portal vein in 6 animals each. Portography was performed immediately after stent placement, and at 2, 4, and 12 weeks thereafter. Next, the extracted stents or stent-grafts were examined histopathologically. Neointimal thickness adjacent to the stent wire and at the midportion between the stent wires was compared among the groups. Then, the neointimal thickness at the sub- and supragraft sites was compared between each stent-graft group. Serial changes in the histologic features of the thickened neointima were also investigated.

RESULTS

No significant difference was noted in the mean stenotic ratio of the portal vein diameter between the bare stent and PTFE groups, whereas it was significantly higher in the Dacron and SIS groups compared with the bare stent group. In neither of the studies on neointimal thickness adjacent to the stent wire and at the midportion between the stent wires were any significant differences noted between the neointimal thickness of the bare stent group and the sum of the neointimal thickness of the PTFE group, whereas the sum of the neointimal thickness of the Dacron and SIS groups was significantly greater than that of the bare stent group at both sites. In the comparison of the supragraft neointimal thickness, the SIS group showed significantly greater thickness than the PTFE group, while the difference between the Dacron and PTFE groups was not significant. In the comparison of the subgraft neointimal thickness, the Dacron and SIS groups showed significantly greater thickness than the PTFE group.

CONCLUSION

The present results indicate that of the three covering materials examined here, PTFE is the most suitable material for grafts placed in the portal vein.

In vivo analysis of antithrombotic effectiveness of recombinant hirudin on microvascular thrombus formation and recanalization

PURPOSE

This study was undertaken to evaluate in vivo the effect of recombinant hirudin (r-hirudin [HBW 023]), a potent thrombin inhibitor, on the process of microvascular thrombus formation and recanalization.

METHODS

Thrombosis was induced photochemically in distinct arterioles (n = 25) and venules (n = 30) of the ear of 16 hairless hr/hr mice (8 to 10 weeks old, 25 to 30 g of body weight). r-Hirudin (1 mg/kg of body weight) was administered intravenously directly before thrombus induction; saline-treated animals served as controls. Thrombus formation (i.e., first platelet deposition at the endothelial lining [FPD]; inner luminal diameter reduction to 50% [D/2]; complete vessel occlusion [CVO]), vessel recanalization, microcirculatory parameters, and leukocyte-endothelial cell interaction were analyzed by means of intravital fluorescence microscopy.

RESULTS

Hirudin significantly delayed the process of thrombus formation compared with saline-treated controls in both arterioles (FPD: 381 +/- 80 vs 137 +/- 25 seconds, P < 0.05; D/2: 627 +/- 49 vs 501 +/- 71 seconds; CVO: 925 +/- 78 vs 854 +/- 60 seconds) and venules (FPD: 173 +/- 11 vs 59 +/- 4 seconds; D/2: 342 +/- 54 vs 228 +/- 27 seconds; CVO: 541 +/- 85 vs 344 +/- 43 seconds; P < 0.05). In addition, r-hirudin-treated animals showed an increased rate of vessel recanalization at 24 hours after thrombus induction (arterioles: 54% [7 of 13] vs 0% [0 of 12], P < 0.05; venules: 77% [10 of 13] vs 53% [9 of 17]), whereas microcirculatory parameters and leukocyte-endothelial cell interaction were not affected.

CONCLUSION

Our data indicate that r-hirudin not only counteracts the process of thrombus formation but also promotes vessel recanalization, thus supporting its use in clinical microvascular surgery.

Influence of luminal pore size on the patency rate and endothelialization of polymeric microvenous prostheses

In microvenous prosthetic surgery a continuous search for better patency rates is necessary to enable a clinical application. In this search for better patencies, modifications in the wall structure are being made. Directions found in the literature suggest that pore size plays an important role in achieving better patencies. Thus far, no study has been conducted to evaluate the influence of pore size on the patency rate of polyurethane microvenous prostheses. Since polyurethane is known to yield good patency rates, we conducted this study in which we compared different luminal pore sizes with regard to patency. Pore size varied from 0.6 to 20 microns in microvenous polyurethane-based prostheses (length 5-6 mm, internal diameter 1 mm). The results showed a favorable patency rate in the pore sizes larger than 5.0 microns (patency 75%) when compared to pore sizes smaller than 2.0 microns (patency 50%). This study demonstrates that microvenous polyurethane-based prostheses with a luminal pore size larger than 5.0 microns may yield better patency rates than prostheses with a luminal pore size smaller than 5.0 microns. Further studies are currently being performed to elucidate the very reasons for this effect.

Microvascular endothelial cell sodding of 1-mm expanded polytetrafluoroethylene vascular grafts

The formation of an endothelial cell lining on the inner surface of polymeric grafts may reduce the inherent thrombogenicity of synthetic implants. Endothelial cell transplantation onto the luminal surface of grafts has been suggested as one method of creating new endothelial cell linings on grafts. The purpose of this study was to morphologically evaluate the very early events of healing (between 4 and 14 days) of 1-mm-internal-diameter expanded polytetrafluoroethylene (ePTFE) grafts that were treated with autologous microvessel endothelial cells at the time of graft implantation. We evaluated the development of new intimal linings in microvascular endothelial cell-sodded 1-mm ePTFE vascular grafts and compared their healing characteristics with non-cell-treated grafts by using a rat aortic graft model. Endothelial cells were isolated from intraperitoneal fat pads of female rats and transplanted onto the grafts by using a pressure sodding method. One-centimeter-long grafts were immediately implanted as interpositional grafts in the aorta. Non-cell-treated grafts were also implanted. Grafts were explanted 4, 7, and 14 days after implantation and were evaluated by light and scanning electron microscopy. Morphometric analysis of the graft surfaces revealed the cellular coverage in sodded grafts to be 93.7 +/- 8.7% and in nonsodded grafts, 1.1 +/- 1.9%. Areas not covered by cells exhibited thrombus and bare graft. The luminal lining of cells exhibited morphological characteristics, indicating they were antithrombogenic, based on morphological criteria, and exhibited characteristics of endothelium.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure to obtain long-term patency after implantation of fibrous polyurethane prostheses in the carotid arteries of rabbits

Fibrous polyurethane prostheses were implanted in the carotid arteries and aortae of New Zealand white (NZW) and Chinchilla (CHIN) rabbits. No immediate post-implantation patency was obtained after implantation in the carotid arteries in NZW rabbits. In CHIN rabbits patency up to 1 week was obtained after carotid implantation. Attempts to increase patency rates by administration of 20 mg/kg body weight/day of both dipyridamol (DIP) and acetyl-salicylic acid (ASA) p.o., starting the week before implantation, had an adverse effect; prostheses became occluded within a few hours after implantation. Coagulation tests (Lee and White, Am J Med Sci 145:495-503, 1913) carried out with blood drawn from CHIN rabbits revealed hypercoaguability after administration of either 10 or 20 mg/kg body weight/day of both DIP and ASA compared to pre-medication values. Prostheses implanted in the aortae of both strains remained patent without anti-platelet-aggregation therapy for a 3-month observation period. It is concluded that in the NZW rabbit carotid implantation was not successful due to severe spasmic reactions and that in CHIN rabbits only very short-term patency could be obtained both with and without administration of 10 or 20 mg/kg body weight/day medication DIP and ASA.

Neointima formation in expanded polytetrafluoroethylene vascular grafts with different fibril lengths following implantation in the rat aorta

Expanded polytetrafluoroethylene (PTFE) prostheses with fibril lengths of 30 and 60 microns were implanted in the rat infrarenal aorta. Sequential scanning electron and light microscopic studies of the prostheses after implantation demonstrated a different pattern of endothelialization. Prostheses with a fibril length of 60 microns had a continuous multilayered neointima at week 25 postimplantation, whereas prostheses with a 30-microns fibril length had a discontinuous and single layer of endothelium after the same interval. It was concluded, therefore, that a prerequisite for the development of a lining in a vascular prosthesis is for the inner surface of the prosthesis to have adequate pores for effective anchoring of the invading endothelioid cells. Expanded PTFE prostheses with an internodular distance of 60 microns provided sufficient anchoring possibilities for invading endothelioid cells to form a continuous neointima.

The formation of a neo-intima in textile prostheses implanted in the aorta of rats and dogs

The formation of a neo-intima in textile prostheses implanted in the rat and dog aorta was studied by means of light- and scanning electron microscopy. Two independent cellular layers (the superficial and deep ingrowth layers) developed on the free surface and under the fibrin layer initially deposited on the inner surface of the prostheses. The superficial ingrowth layer invades the prosthesis from both the proximal and distal aortic stumps and extends over the primary fibrin layer, or replaces it. This layer consists mainly of smooth muscle cells of the triangular aortic type covered by endothelial-like cells. The deep ingrowth layer originates from cellular elements of the prosthetic bed. Fibroblasts, myofibroblasts and spindle-shaped smooth muscle cells invade the fibrin layer through the interstices of the fabric structure of the prosthesis. Precursors of endothelial cells, however, are absent from this population. The superficial and the deep ingrowth layers may become joined by progressive replacement of the fibrin layer, but remain distinguishable because of their different cellular components. When a continuous cellular layer is established on the inner surface of the prosthesis, and this is then covered by endothelial-like cells, the neo-intima formed remains stable during long-term studies.

An X-ray photoelectron spectroscopy study of the external surface of explanted microporous polyurethane vascular prostheses

XPS has been used to examine the external surfaces of microporous polyurethane vascular prostheses implanted for up to 6 months in dogs. The phenomena of bilirubin absorption and physical degradation were investigated, using three different chemical washes to clean the prostheses. Very little evidence for chemical change was found, indicating a predominant role for the mechanical or biochemical ablation of degraded material.

The inner prosthetic surface structure and re-endothelialization: an experimental study in the rat using two types of microvascular prostheses for aortic implantation

Two types of microvascular prostheses were implanted in the rat infrarenal aorta. Operations were carried out with clean, nonsterile instruments under ether anesthesia. Anastomoses were made with a continuous 8-0 suture. In group A, a 1-cm-long piece of expanded polytetrafluorethylene (PTFE) and in group B a 1-cm-long fibrous polyurethane prosthesis were implanted. Both groups consisted of 18 rats. Three rats from each group were killed at days 3, 5, 10, 20, 40, and 60 postimplantation. Prostheses were examined by scanning electron and light microscopy for the re-endothelialization. All prostheses in both groups were patent at the time of death. Re-endothelialization started in both types of prostheses the fifth day after implantation and had advanced 1-3 mm in the PTFE prostheses at day 60. However, in the fibrous polyurethane prostheses, re-endothelialization progressed and a complete new lining was achieved between days 20 and 40 postimplantation. The endothelium/neointima in the fibrous prosthesis was firmly anchored onto the prosthetic wall by means of cellular protrusions between the polyurethane fibers. In contrast to this observation, the endothelium/neointima developed in the PTFE prostheses was not anchored to the wall of the prosthesis. It is emphasized that the development of a new lining in a prosthesis may reduce the risk of endogenous, hematogenous infections. From the results of this study, we have concluded that there is a correlation between the inner surface structure and the extent of the re-endothelialization of a prosthesis. A prosthesis with a fibrous structure is much more rapidly and completely re-endothelialized than an expanded PTFE prosthesis.

Microvascular silicon replamineform grafts of 2- and 5-cm lengths: experimental studies

Replamineform silicone microvascular grafts 1 mm in diameter were cut to clinically useful lengths (2 and 5 cm) and used to reconstruct segments of the femoral artery in the rabbit. Despite initial patency and flow rates comparable to flow seen in vein graft repairs and primary repair, no long-term patency was observed. The theoretical biomechanical advantages of this kind of graft material have not solved the problem of long microvascular grafting.

Hemodynamics after autogenous, interpositional grafting in small arteries

This investigation initiates the quantitative, hemodynamic assessment of interpositional grafts in small rat arteries. The left femoral arteries in 16 Sprague-Dawley rats were transected at two levels, and were then repaired using interrupted suturing technique. This effectively provided an ideally sized and histologically matched interposition graft. The 20-MHz PUDVM method was used to measure blood velocities, and derive values for vessel lumen area, temporal mean of the spatial mean velocity (Vsm), and volumetric flows. Measurements were completed distal to the interposed graft. Variables were quantitated in the preoperative and at the 5-, 15-, and 30-minute postoperative intervals. Statistical analysis of data indicated that the interpositional grafting procedure resulted in increased vessel lumen area and decreased Vsm, but, importantly, volumetric flow (about 8.20 ml/min) remained unchanged. This study demonstrated that, although hemodynamic characteristics are altered, volumetric flow can be restored after an experimental, interpositional grafting procedure in small arteries.

History of (micro) vascular surgery and the development of small-caliber blood vessel prostheses (with some notes on patency rates and re-endothelialization)

The historical development of vascular surgery is reviewed from ancient times (Ruphus of Ephesus, Aëtius of Amida) to recent developments (sutured anastomosis by Carrel). Attempts to anastomose blood vessels by means of nonsuturing technique, using a ring or short tube of diverse materials called prostheses, were undertaken at the start of this century and continued until shortly after World War II. With the advent of modern polymeric materials, prostheses of different types, sizes, structures, and fabrics have been used to substitute for blood vessels, both experimentally and clinically. Recently, blood vessel prostheses with small (1-1.5 mm) internal diameters became available and have been implanted experimentally. Patency rates, biophysical and structural properties, the re-endothelialization and the neointima formation of several types of microvascular prostheses are briefly reviewed.

Three years experience with experimental implantation of fibrous polyurethane microvascular prostheses in the rat aorta

The results of a 3-year study in which a series of 355 implantations of 1-cm-long fibrous polyurethane microvascular prostheses into the infrarenal aorta of the rat (group A) were evaluated with respect to patency and formation, structure, and fate of the neo-intima. Rats were sacrificed at various intervals from 1 day to 2 years in order to obtain a time-related impression of the re-endothelialization and stability of the neo-intima. A second series of 51 implants was done with prostheses 10 cm in length, placed in a 1.5-cm loop in the abdominal aorta (group B). An overall patency rate of 92.7% was achieved in group A. Initially, eight technical failures caused early thrombosis of the prostheses. Sixteen prostheses became infected and subsequently occluded. The overall patency in group B was 52.9%, due to kinking from adhesion formation and normal growth of the rat. In both the long and short prostheses, a continuous multilayered neo-intima developed, growing from the aortic stumps into the prosthesis from both sides. According to the growth rate of 0.3 mm/day, a 1-cm prosthesis was re-endothelialized after +/- 20 days and a 10-cm prosthesis after +/- 9 months. Once developed, the neo-intima, consisting of myofibroblasts and smooth muscle cells covered with a flat endothelium, remained stable and continuous, throughout the observation period. The neo-intima was firmly anchored onto the prosthetic wall by means of cellular protrusions extending between the polyurethane fibres. The significance of rapid healing of an implanted prosthesis is emphasized with respect to preventing (late) hematogenous, endogenous infection of the prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)