A comparative study of endothelium-derived relaxing factor-mediated relaxation and smooth muscle cell function in arterial and venous vein bypass grafts

Mechanotransduction in Coronary Vein Graft Disease

Autologous saphenous veins are the most commonly used conduits in revascularization of the ischemic heart by coronary artery bypass graft surgery, but are subject to vein graft failure. The current mini review aims to provide an overview of the role of mechanotransduction signalling underlying vein graft failure to further our understanding of the disease progression and to improve future clinical treatment. Firstly, limitation of damage during vein harvest and engraftment can improve outcome. In addition, cell cycle inhibition, stimulation of Nur77 and external grafting could form interesting therapeutic options. Moreover, the Hippo pathway, with the YAP/TAZ complex as the main effector, is emerging as an important node controlling conversion of mechanical signals into cellular responses. This includes endothelial cell inflammation, smooth muscle cell proliferation/migration, and monocyte attachment/infiltration. The combined effects of expression levels and nuclear/cytoplasmic translocation make YAP/TAZ interesting novel targets in the prevention and treatment of vein graft disease. Pharmacological, molecular and/or mechanical conditioning of saphenous vein segments between harvest and grafting may potentiate targeted and specific treatment to improve long-term outcome.

Vein graft failure: current clinical practice and potential for gene therapeutics

Autologous saphenous vein is commonly used as a conduit to bypass atherosclerotic lesions in coronary and femoral arteries. Despite the wide use of arterial conduits, which are less susceptible to complications and failure, as alternative conduits, the saphenous vein will continue to be used in coronary artery bypass grafting until acceptable alternative approaches are evaluated. Hence, preservation of vein graft patency is essential for the long-term success. Gene therapy is attractive in this setting as an ex-vivo technology to genetically manipulate the conduit before grafting. The use of safe and efficient vectors for delivery is a necessity as well as a strategy to improve patency in the long term. Here, we review the current clinical practice, the pathogenesis of bypass graft failure and adenovirus-mediated gene therapy strategies designed to improve late vein graft failure by modulation of smooth muscle cells in the vein wall.

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.

Early adaptive responses of the vascular wall during venous arterialization in mice

Venous arterialization occurs when a vein segment is transposed as a bypass graft into the arterial circulation, resulting in a structural and functional reorganization of the vascular wall in response to the new local biomechanical environment. Although the anatomical changes of venous arterialization have been well characterized, the molecular mechanisms of vascular remodeling remain incompletely understood. Here, we present a novel model of venous arterialization in mice wherein the external jugular vein is connected to the common carotid artery. The hemodynamic characteristics of the arterialized vein, as assessed by ultrasound and magnetic resonance imaging, resemble features of the arterial circulation. Temporal analyses of the morphological changes in the venous segment at 1, 3, and 7 days after surgery demonstrate preservation of the endothelium at all time points and formation of multiple smooth muscle layers by day 7. Expression of endothelial E-selectin and VCAM-1 was documented at early time points, concomitant with the presence of neutrophils and monocytes/macrophages in the vascular wall. In addition, endothelium-dependent permeability was decreased in the arterialized vein when compared to the contralateral control vein. Thus, this novel mouse model of venous arterialization displays anatomical and cellular features present in other species, and should help to characterize the molecular mechanisms of this adaptive response of the vascular wall to changes in its biomechanical environment.

Remodeling of the zero-stress state of femoral arteries in response to flow overload

The goal of this study is to quantitatively describe the remodeling of the zero-stress state of the femoral artery in flow overload. Increased blood flow, approximately as a unit step change, was imposed on the femoral artery by making an arteriovenous (a-v) fistula with the epigastric vein. The a-v fistula was created in the right leg of 36 rats, which were divided equally into six groups (2 days and 1, 2, 4, 8, and 12 wk after the fistula). The vessels in the left leg were used as controls without operative trauma. The in vivo blood pressure, flow, and femoral outer diameter and the in vitro zero-stress state geometry were measured. The in vivo shear rate at the endothelial surface increased approximately as a step function by approximately 83%, after 2 days, compared with the control artery. The arterial luminal and wall area significantly increased postsurgically from 0.15 +/- 0.02 and 0.22 +/- 0.02 mm(2) to 0.28 +/- 0.04 and 0.31 +/- 0.05 mm(2), respectively, after 12 wk. The wall thickness did not change significantly over time (P > 0.1). The opening angle decreased to 82 +/- 4.2 degrees postsurgically when compared with controls (102 +/- 4.4) after 12 wk and correlated linearly with the thickness-to-radius ratio. Histological analysis revealed vascular smooth muscle cell growth. The remodeling data are expressed mathematically in terms of indicial functions, i.e., change of a particular feature of a blood vessel in response to a unit step change of blood flow. The indicial function approach provides a quantitative description of the remodeling process in the blood vessel wall.

Characterization of dopamine-mediated relaxation in experimental vein bypass grafts

BACKGROUND

Dopamine is an endogenous inotropic agent commonly used during coronary artery surgery and in the medical therapy of a revascularized patient. In this study the responses of intimal hyperplastic vein grafts to dopamine are examined.

METHODS

The in vitro isometric tension responses to dopamine of common carotid jugular vein bypass grafts in New Zealand White rabbits were determined. The responses were compared to those obtained in the jugular vein and in the common carotid artery. Both endothelialized and denuded vessels were precontracted with prostaglandin F(2alpha) and the responses to dopamine were assessed. The contributions of nitric oxide and prostanoids to the response were also determined.

RESULTS

Each vessel showed a biphasic dose response to dopamine with relaxation at low concentrations followed by contraction at high concentrations. Dopamine relaxation in the jugular vein was endothelial independent while in the carotid artery it was endothelial dependent and decreased. The sensitivity of both vessels was significantly greater than the vein graft (6.62 +/- 0.12; P < 0. 05); however, after endothelial denudation, the sensitivity of dopamine-mediated relaxation of the vein graft (8.91 +/- 0.09) was significantly enhanced. Preincubation with L-NMMA (to block NO synthesis) inhibited vein graft relaxation to dopamine and preincubation with indomethacin (to block cyclooxygenase activity) inhibited carotid artery relaxation to dopamine. Addition of phenoxybenzamine, a broad alpha-adrenergic antagonist, enhanced dopamine relaxation in the jugular vein and depressed the relaxation in the carotid artery. There was no effect on the dopamine response in the vein graft. Jugular vein and carotid artery responded to dopamine with cholera toxin-sensitive (Galpha(s)) responses. In contrast, dopamine relaxation in the vein graft was enhanced by inhibition of Galpha(s).

CONCLUSION

Dopamine relaxation in vein grafts is mediated in part by NO but not by either prostanoids or alpha-adrenergic receptor activation. It is diminished compared to native vessels due to an endothelium-dependent, Galpha(s)-mediated pathway.

Functional characterization of alpha1-adrenergic receptors in experimental vein grafts

BACKGROUND

Studies on the pharmacology of the smooth muscle cells in vein bypass grafts suggest that the function of G-proteins and adrenergic receptors is altered. This study examines the alpha-adrenergic responsiveness of smooth muscle cells in vein bypass grafts as compared with those in the common carotid arteries and external jugular veins.

METHODS

New Zealand White rabbits received jugular vein interposition bypass grafts of the common carotid. Vessel segments of the vein bypass grafts harvested after 28 days, common carotid arteries, and external jugular veins were sectioned into 5-mm rings (four per vessel) for studies of isometric tension in response to phenylephrine (10(-10) to 10(-4) M) alone and in the presence of prazosin, an alpha1-adrenergic antagonist; WB4101 and 5-methylurapidil (5-MU), alpha1A antagonists; chloroethylclonidine (CEC); an alpha1B antagonist; or the Gi/o G-protein inhibitor pertussis toxin (PTx).

RESULTS

All vessels had prazosin-sensitive responses. The jugular veins appear to have functional alpha1A receptors (WB4101 and 5-MU sensitive, CEC insensitive) which are associated with pertussis toxin-sensitive G-proteins. Carotid arteries appear to have atypical alpha1 receptors (WB4101 and 5-MU insensitive, CEC insensitive) associated with pertussis toxin-insensitive G-proteins. Vein grafts appear to have functional alpha1B receptors (WB4101 and 5-MU insensitive, CEC sensitive) which are associated with pertussis toxin-insensitive G-proteins.

CONCLUSIONS

These results show that placement of a vein into the arterial circulation induces a change in alpha1-adrenergic receptor subtypes (alpha1A to alpha1B) and in the G-protein coupling of the receptors (PTx sensitive to PTx insensitive), reflecting a signficant phenotypic change in smooth muscle cell signal transduction.

Time course of the regression of intimal hyperplasia in experimental vein grafts

A previous study in which vein grafts were removed from the arterial circulation and reimplanted into the venous circulation of the same animal demonstrated regression of vein graft intimal hyperplasia and medial thickening within 14 days. The present study was designed to characterize the kinetics of the morphological and ultrastructural changes over this 14-day period. Twenty-one male New Zealand White rabbits received a reversed vein interposition bypass graft of the right common carotid artery. Fourteen days after the procedure, 21 vein grafts were isolated, removed, and reimplanted into the contralateral external jugular venous system as veno-venous interposition bypass grafts (reversal grafts). The grafts were harvested at 60 minutes, 1 day, 3 days, 5 days, 7 days, and 14 days after reversal. Before insertion into the venous circulation, the vein graft had a confluent endothelial cell surface with multiple layers of smooth muscle cells representing intimal hyperplasia. After 1 hour, the reversal graft retained an intact endothelial cell layer with no evidence of tissue edema or cellular disruption. By 24 hours, there were a few blood cells on the endothelial cell surface. There was no inflammatory infiltrate seen in the subendothelium, and the smooth muscle cells were unaltered. At 3 days, the endothelial cell lining remained intact with no polymorphonucleocytes in the subendothelium or within the graft wall. Underlying smooth muscle cells at this time were noted to contain cytoplasmic vacuoles. At 5 days, there were no inflammatory cells seen on the surface or within the vein graft wall, but many of the underlying smooth muscle cells within the intimal hyperplasia were noted to be fragmented and to have clumping of chromatin. After 7 days, the endothelial cells remained intact and there was widespread evidence of apoptosis beneath the subendothelium with highly fragmented smooth muscle cells, some of which were histologically in the process of breaking up. At 14 days, the grafts retained uniform endothelial cell surfaces. Most of the smooth muscle cells that composed the intimal hyperplasia seen before implantation as a reversal graft were gone. Areas of newly laid down collagen could be observed. There were no acute inflammatory cells but for some mast cells seen in the graft wall. This study demonstrates that in this model, regression of intimal hyperplasia was associated with apoptosis of the smooth muscle cells and the deposition of collagen. There was no evidence that this process is mediated by an acute inflammatory response. Regression therefore appears to be due to induction of smooth muscle cell apoptosis by either a reduction in pressure or flow or a combination of both factors. The findings will enable a systematic cellular and molecular analysis of the biology of regression, which may afford clues to better understand the biology of the developing intimal hyperplasia.

Kinetics of altered angiotensin II responses in experimental vein grafts

Following vein grafting, responses in the arterial vein bypass grafts to angiotensin II, a known mitogen, increase. It is not known when these changes occur or whether these changes are due to alterations in endothelial cell function, excision/implantation of the vessel, or exposure to arterial hemodynamics. Two studies were designed to examine these questions. New Zealand White rabbits underwent excision of the external jugular vein, common carotid artery, an external jugular veno-venous bypass (VVG), or a common carotid veno-arterial bypass (VAG). Half the jugular veins and carotid arteries were mechanically denuded of their endothelium. All vein grafts were harvested at 28 days. A set of VAG was also harvested at 1, 3, 7, and 14 days. Isometric tension studies to angiotensin II (10(-10) to 10(-4) M) were performed on rings from each jugular vein, carotid artery, and vein graft. Jugular veins had a triphasic response to angiotensin II. Deendothelialized jugular veins had a triphasic response with an increased first phase and a much reduced second phase. Carotid arteries (6.87 +/- 0.18 and 6.15 +/- 0.18; with and without endothelium; means +/- SEM, -log10[EC50); p < .05), VVG (6.69 +/- 0.15), and VAG (7.42 +/- 0.29; p < .05 compared to VVG) showed a monophasic response to angiotensin II at 28 days. This monophasic response in VAG to angiotensin II was recordable at 7 days postoperatively and there was no further change in its sensitivity between 14 and 28 days. These results suggest that the induction of altered angiotensin II responses is dependent on exposure to the arterial circulation, that alterations in VAG responses occur within the first 7 days of vein grafting, and that VAG at 28 days become more sensitive to angiotensin II than the carotid vessels into which they are placed. These changes in smooth muscle cell sensitivity to a known smooth muscle cell mitogen (angiotensin II) may contribute to the development of intimal hyperplasia in the veno-arterial graft.