Vascularization of skin grafts

Advanced in vitro Research Models to Study the Role of Endothelial Cells in Solid Organ Transplantation

The endothelium plays a key role in acute and chronic rejection of solid organ transplants. During both processes the endothelium is damaged often with major consequences for organ function. Also, endothelial cells (EC) have antigen-presenting properties and can in this manner initiate and enhance alloreactive immune responses. For decades, knowledge about these roles of EC have been obtained by studying both in vitro and in vivo models. These experimental models poorly imitate the immune response in patients and might explain why the discovery and development of agents that control EC responses is hampered. In recent years, various innovative human 3D in vitro models mimicking in vivo organ structure and function have been developed. These models will extend the knowledge about the diverse roles of EC in allograft rejection and will hopefully lead to discoveries of new targets that are involved in the interactions between the donor organ EC and the recipient's immune system. Moreover, these models can be used to gain a better insight in the mode of action of the currently prescribed immunosuppression and will enhance the development of novel therapeutics aiming to reduce allograft rejection and prolong graft survival.

Quantitative analysis of the microvasculature growing in the fibrin interface between a skin graft and the recipient site

Current tissue engineering techniques have failed to provide an established microvasculature in skin substitutes, a requisite for the maintenance of graft viability and rapid revascularization subsequent to graft transplantation in vivo. To improve outcomes for both conventional skin grafts and skin substitutes, the existing knowledge gap concerning the spatio-temporal mechanisms of skin graft revascularization must be abrogated. The current knowledge gap is due, at least in part, to a lack of appropriate diagnostic methods to quantify skin graft revascularization. To enhance the understanding of skin graft revascularization, we quantitatively evaluated revascularization of autologous skin grafts in a rat model by quantifying 2- and 3-dimensional vascular metrics in the fibrin interface 3, 7, and 10 days after transplantation. In this study, the fibrin interface appeared to be completely replaced with fibrovascular tissue by postoperative day 10. Although the mean vessel diameter was about 10 mum for the time points sampled, the mean vessel number, area, and volume fraction increased about 2.5-fold from postoperative day 3 to 7 and then decreased about 1.27-fold at postoperative day 10. There was no significant difference between 2- and 3-dimensional vascular metrics based on Bland-Altman analysis. In conclusion, these data establish a standard for metrics of vessels growing in the fibrin interface of a rat autologous skin graft and its donor site and suggests that once the blood supply has been restored to a viable transplant, the number, area, and volume fractions of vessels decrease to levels found at postoperative day 3.

Analysis of skin graft survival using green fluorescent protein transgenic mice

Skin grafting has become a basic and established operation technique; however, it is not clear how skin grafts adapt to recipient beds and replace their functions. In this study, we analyzed the origin of cells in adapted transplants by using green fluorescent protein (GFP) transgenic mice, which emits green fluorescence in the whole body. The dorsal skins of GFP transgenic mice were transplanted to the back of wild-type mice. Similarly, wild-type skins were transplanted to the back of GFP transgenic mice. Since transplantation with full thickness back skin was not successful due to severe immunorejection, tail skins, which contain fewer epidermal Langerhans cells, were used for the experiments. Six months after transplantation, immunohistochemical analysis of the grafts revealed that tissues derived from ectodermal origin such as the epidermis, hair follicles, and sebaceous glands survived in transplanted grafts, but that other tissues such as the dermis, nerves and blood vessels are partly replaced by tissues from recipient beds. Our results further demonstrated that transplantation analyses with GFP transgenic mice could be a useful approach to study the origin of cells in transplants.

Vascularization and engraftment of a human skin substitute using circulating progenitor cell-derived endothelial cells

We seeded tissue engineered human skin substitutes with endothelial cells (EC) differentiated in vitro from progenitors from umbilical cord blood (CB-EC) or adult peripheral blood (AB-EC), comparing the results to previous work using cultured human umbilical vein EC (HUVEC) with or without Bcl-2 transduction. Vascularized skin substitutes were prepared by seeding Bcl-2-transduced or nontransduced HUVEC, CB-EC, or AB-EC on the deep surface of decellularized human dermis following keratinocyte coverage of the epidermal surface. These skin substitutes were transplanted onto C.B-17 SCID/beige mice receiving systemic rapamycin or vehicle control and were analyzed 21 d later. CB-EC and Bcl-2-HUVEC formed more human EC-lined vessels than AB-EC or control HUVEC; CB-EC, Bcl-2-HUVEC, and AB-EC but not control HUVEC promoted ingrowth of mouse EC-lined vessels. Bcl-2 transduction increased the number of human and mouse EC-lined vessels in grafts seeded with HUVEC but not with CB-EC or AB-EC. Both CB-EC and AB-EC-induced microvessels became invested by smooth muscle cell-specific alpha-actin-positive mural cells, indicative of maturation. Rapamycin inhibited ingrowth of mouse EC-lined vessels but did not inhibit formation of human EC-lined vessels. We conclude that EC differentiated from circulating progenitors can be utilized to vascularize human skin substitutes even in the setting of compromised host angiogenesis/vasculogenesis.

Quantification of Total and Perfused Blood Vessels in Murine Skin Autografts Using a Fluorescent Double-Labeling Technique

BACKGROUND

Two theories exist regarding the revascularization of skin autografts: direct anastomosis between graft vessels and bed vessels, and ingrowth of bed vessels (angiogenesis) into the graft. This study characterizes revascularization, spatially and chronologically, in a murine skin autograft model using a double-labeling technique.

METHODS

Full-thickness (1 cm2) skin grafts were performed on adult male C57/Bl6 mice. After 48 hours, 60 hours, 3 days, 5 days, and 14 days (n = 3 mice per time point) terminal intracardiac perfusion with a fluorescein/dextran dye demonstrated vascular filling of graft blood vessels. Fluorescence immunohistochemistry of CD31+ endothelial cells allowed counting of total vessels and fluorescein perfusion quantification of patent vessels in the lateral graft area, central graft area, graft bed, and wound margins.

RESULTS

Initial filling of graft vessels was seen after 48 hours. This included vessels in the papillary dermis of the graft, and there was no significant difference in the percentage of filled vessels in the deep dermis of the graft compared with the papillary dermis of the graft. A rapid increase in vessel filling was seen between 48 and 60 hours in all areas of the graft. Vessel filling occurred mainly in the central area of the graft rather than in the lateral areas.

CONCLUSIONS

The short time course of vessel filling indicates that the initial onset of revascularization is attributable to early anastomoses between graft and bed vessels, mainly in the central area of the graft. These findings have implications for both autograft revascularization in a clinical setting and in the development of tissue-engineered skin substitutes.

Inosculation of tissue-engineered capillaries with the host's vasculature in a reconstructed skin transplanted on mice

The major limitation for the application of an autologous in vitro tissue-engineered reconstructed skin (RS) for the treatment of burnt patients is the delayed vascularization of its relatively thick dermal avascular component, which may lead to graft necrosis. We have developed a human endothelialized reconstructed skin (ERS), combining keratinocytes, fibroblasts and endothelial cells (EC) in a collagen sponge. This skin substitute then spontaneously forms a network of capillary-like structures (CLS) in vitro. After transplantation to nude mice, we demonstrated that CLS containing mouse blood were observed underneath the epidermis in the ERS in less than 4 days, a delay comparable to our human skin control. In comparison, a 14-day period was necessary to achieve a similar result with the non-endothelialized RS. Furthermore, no mouse blood vessels were ever observed close to the epidermis before 14 days in the ERS and the RS. We thus concluded that the early vascularization observed in the ERS was most probably the result of inosculation of the CLS network with the host's capillaries, rather than neovascularization, which is a slower process. These results open exciting possibilities for the clinical application of many other tissue-engineered organs requiring a rapid vascularization.

Resistance of established porcine islet xenografts to humoral rejection by hyperimmune sera

BACKGROUND

Although preformed natural antibodies cause hyperacute rejection of primarily vascularized xenografts, tissue grafts such as skin or islets are revascularized by in-growth of host capillaries and therefore might be resistant to circulating antibodies. We examined the effect of hyperimmune serum and primed T cells on the survival of long-term porcine islet xenografts in diabetic nude mice.

METHODS

Porcine islets were transplanted beneath the kidney capsule of streptozotocin-induced diabetic BALB/c athymic mice. Hyperimmune serum and sensitized splenocytes were prepared by repeated immunization of BALB/c mice with porcine lymph node cells. Splenic T cells were enriched by nylon wool column separation. Tissues were examined by immunohistology using murine- and porcine-specific monoclonal antibodies.

RESULTS

Porcine islets survived in nude mice for > 100 days with high levels of circulating porcine C-peptide and maintenance of normoglycemia. Injection of the hyperimmune sera (IgG) into normoglycemic nude mice bearing porcine islets for > 70 days failed to induce rejection despite the continued presence of circulating anti-porcine cytotoxic antibody. Injection of sensitized T cells caused acute rejection of long-term (>140 days) porcine islets, whereas injection of naive T cells had no effect. Histologically, porcine islets removed from mice treated with hyperimmune serum showed no staining for IgG. Long-surviving porcine islet grafts showed strong staining for interleukin (IL)-10 and a lesser amount of IL-4 but no staining for IL-2 or interferon-gamma. Although fresh porcine islets were positive for swine leukocyte antigen class 1 antigen and intercellular adhesion molecule (ICAM)-1 but negative for mouse platelet endothelial cell adhesion molecule and ICAM-2, long-surviving porcine islets showed positive endothelial staining for mouse platelet endothelial cell adhesion molecule and ICAM-2.

CONCLUSIONS

Established islet xenografts are resistant to hyperimmune serum as a result of a lack of target endothelial antigens, whereas they remain susceptible to rejection caused by primed T cells. Local production of Th2 cytokines may explain the inability of long-surviving islet xenografts to activate injected naive T cells.

Success of delayed full-thickness skin grafts after Mohs micrographic surgery

BACKGROUND

Specific factors affect the outcome of full-thickness skin grafts after Mohs micrographic surgery. No recent clinical studies have systematically investigated the clinical factors that may affect the success of full-thickness skin grafts.

OBJECTIVE

Our objective was to analyze patient data to define factors that may influence the success of full-thickness skin grafts.

METHODS

We reviewed the clinical course of 117 patients who had full-thickness skin grafts after Mohs micrographic surgery. We analyzed these cases using patient variables, tumor variables, and skin graft variables and then correlated these variables to skin graft success.

RESULTS

Delay of skin graft placement (> 1 day) was significantly correlated with subsequent skin graft success (p = 0.015). Skin graft necrosis was more likely to develop in men than in women (p = 0.021).

CONCLUSION

A delay of 2 to 8 days between Mohs micrographic surgery and full-thickness skin graft placement resulted in a lower incidence of skin graft necrosis than no delay or a delay of 1 day.

Recessive dystrophic epidermolysis bullosa phenotype is preserved in xenografts using SCID mice: development of an experimental in vivo model

Recessive dystrophic epidermolysis bullosa (RDEB) is a subgroup of hereditary blistering diseases characterized by repetitive wounding and healing with subsequent extensive scarring. The purpose of this study was to establish a xenograft model that retains the RDEB phenotype and thus might be used as an experimental in vivo model to explore the molecular and biochemical mechanisms of the chronically wounded phenotype of RDEB. Full-thickness, tumor-free RDEB skin tissues were grafted onto the dorsum of severe combined immunodeficiency (SCID) mice. At 4, 8, 12, and 24 weeks after grafting, the xenografts were removed for examination. Immunofluorescence studies were performed using species-specific antibodies to human class I antigen, mouse class I antigen, human type IV and VII collagens and with cross-reacting antibody against bullous pemphigoid antigen (BPA). Staining with the antibody to human class I antigen, W6/32, and with the antibody to mouse class I antigen, 20.8.4s, confirmed the species-specific results obtained with the type IV and type VII collagen and laminin antibodies. The RDEB grafts showed essentially no staining with the type VII collagen antibody. Antibodies against laminin and BPA showed normal staining patterns in RDEB grafts. There was an overall paucity of anchoring fibrils in the grafts when examined with electron microscopy. Blisters could be induced in these grafts with minor trauma and showed a sublamina densa separation by immunomapping and electron microscopy. As late as 24 weeks post-transplantation, the RDEB grafts remain human, are not significantly replaced by mouse cells, and retain the RDEB disease phenotype.

Evaluating blood flow in full-thickness skin grafts utilizing the laser Doppler

Full-thickness skin grafts follow a consistent clinical pattern of color and textural changes. Measurements with the Laser Doppler Velocimeter correlate with these observed changes, yielding reproducible temporally associated blood flow rates. Previous physiologic and histologic studies for skin grafts are discussed.

Assessment of the viability of skin grafts

A number of tests are available to monitor the blood flow in free and distant pedicle skin grafts. The information from these tests aids in the development of measures to enhance vascularization and is occasionally needed to make clinical decisions in patients with distant pedicle grafts. Measurements of the disappearance of an intradermally injected small amount of 133Xe allows determination of a clearance rate and blood flow before and after clamping the original blood supply through the base. With 99mTc, which is generally more readily available, a flow index and block index can be determined. Clinically both procedures give equally good results in determining a safe time for pedicle base separation. The fluorescein test allows assessment of regional blood flow distribution within the pedicle.

Local blood flow and vascular permeability of autonomic ganglion-transplants in the brain

The purpose of this study was to determine whether the blood vessels of transplanted neural tissue retain their functional characteristics. Quantitative autoradiography was used to measure local blood flow (F) with iodoantipyrine and the blood-to-tissue transfer constant (K) with alpha-aminoisobutyric acid in superior cervical ganglion (SCG) allografted to the surface of ventricle IV and into the cerebellum of the same rat. The F of the intraparenchymal grafts was slightly lower than that of the intraventricular grafts; F decreased between 1 and 4 weeks in SCG grafts at both sites. The permeability-surface area (PS) product of the microvessels and extraction fraction of AIB were calculated from these results and indicated restricted transvascular passage of the amino acid in both the in situ and grafted SCG. Surface area (S) and average length (L) of the microvessels were determined morphometrically and their permeability (P) was calculated from these data. Although K and PS decreased in the grafts compared to in situ SCG, a comparable decrease in S indicated that P was similar for the microvessels of both in situ and 1-week-old SCG transplants: 3.5-4.3 x 10(-6) cm/s. Between 1 and 4 weeks after transplantation, the P of the microvessels decreased to approximately 1.6-2.3 x 10(-6) cm/s without any change in S. Thus, the blood vessels of SCG grafts within or upon the brain initially retain the functional attributes of in situ SCG microvessels, but the average permeability of the graft microvessels decreases to approximately one half of the initial value by 4 weeks after transplantation.

Blood flow to palatal mucosal grafts in mandibular labial vestibuloplasty measured by 133Xe clearance technique

In 11 subjects, the blood flow to alveolar and palatal mucosa was measured by intra-mucosal injection of 133Xe. Later, mandibular labial vestibuloplasty was performed with mucosal grafts in all of them. The use of a stent was omitted. The subjects were followed by clinical observation and by blood flow measurements up to 6 weeks postoperatively. At certain intervals (3 and 10 days, 4 and 6 weeks), 133Xe clearance in the graft was determined. Under normal conditions, the mean blood flows to the alveolar and to palatal mucosa were 53.2 +/- 12.9 and 58.3 +/- 3.5 ml/100 g/min, respectively. The difference between them was statistically insignificant (P greater than 0.05). The graft blood flow was 13.4 +/- 3.2 and 21.7 +/- 15.0 ml/100 g/min on the 3rd and 10th days after operation. The decrease in both compared to normal values was statistically significant (P less than 0.001). The blood flow reached almost normal levels (46.2 +/- 16.9 ml/100 g/min) and above (63.9 +/- 9.7 ml/100 g/min; P less than 0.05) at 4 and 6 weeks after operation, respectively. These results were in agreement with the clinical observations. The palatal donor area healed in 3-5 weeks. The graft showed complete adaptation with the surrounding tissue and healing in 4-6 weeks. Our results also indicated that injections in the graft do not retard graft healing.

Patterns of angiogenesis in neural transplant models: I. Autonomic tissue transplants

Functional vascular connections must form rapidly to prevent ischemic damage to grafted neural tissues. The temporal sequence by which transplant circulation is re-established provides information about the angiogenic capacity of either intact or damaged CNS blood vessels. This study compares the time course and mechanism of vascular reperfusion in allografts of superior cervical ganglia or adrenal medulla inserted either into the fourth ventricle or directly into the parietal cortex of perinatal rats. Tritiated thymidine was administered to recipients to determine angiogenic patterns at various postoperative time periods. After processing for light microscopic autoradiography, host and graft endothelial labelling indices were determined in order to establish the temporal sequence and location of vascular proliferation. Correlative electron microscopy depicted the morphological changes in transplant vasculature. Some recipients were prelabelled with 3H thymidine prior to transplantation to determine if host vessels invaded the grafts. Intraventricular graft vessels initially collapsed but sustained minimal ischemic damage and were completely reperfused by 24 hours postoperative. Adjacent intact host vessels attained peak 3H thymidine incorporation at 20 hours. Intrinsic graft vessels were radioactively labelled only after 48 hours. Intraparenchymal transplants surrounded by minimal trauma exhibited a similar temporal sequence of reperfusion and host endothelial proliferation. Intrinsic graft vessels in intraparenchymal grafts sustained more severe damage. With increased trauma, a concomitant delay in graft reperfusion time was observed. Grafts within prelabelled hosts rarely contained any labelled endothelium, indicating that anastomotic connections were made between original, intrinsic graft vessels and nearby host vascular sprouts. This study demonstrates that mature autonomic tissue stimulates the growth of adjacent host vessels when transplanted to undamaged brain surfaces. The anastomosis of nascent host vessels with pre-existing graft vessels is responsible for the rapid re-establishment of circulation within the transplants. A similar mechanism occurs within intraparenchymal grafts, although the rapidity of reperfusion appears to be predicated on the amount of trauma present at the graft site.

Dynamic vascular changes in free skin grafts

Vascular changes in full-thickness skin grafts in rats were examined at various intervals after grafting using microangiography. The grafted skin and its bed showed dynamic vascular changes that were considered to be related to release of an " angiogenetic factor" produced by the skin under oxygen-deficient conditions such as ischemia. The first filling of contrast medium in the grafts was observed 24 hours after grafting. Both primary and secondary revascularization were observed.

The restoration of the vasculature of skin autografts in the rabbit

The restoration of the vasculature of full-thickness skin autografts was investigated on the rabbit ear, the grafted discs of skin being replaced with their original orientation, or rotated 90 or 180 degrees. Circulation in the graft was first detected 1 day after grafting, increasing on the 2nd and successive days. The larger arteries in the grafts survived and became permanently joined at the periphery of the grafts to adjacent severed arteries in the host by well-defined and often tortuous segments termed junction vessels. The pre-operative vascular pattern was re-established when grafts were replaced without rotation but comparable survival of arteries also occurred when the grafted discs of skin were rotated. In most grafts, the segment of artery became stabilized by 4-9 weeks; more than 75% of the length of the arterial segments survived in 83% of grafts, with minimal accompanying histological changes in their walls. There was some increase in number and aborization of small vessels in the established grafts, although the vascular pattern was essentially similar to that of unoperated skin. The factors possibly involved in the survival of the large arteries in the grafts include the relative rigidity of the arterial wall, the early establishment of circulation, and the favourable haemodynamic position of the grafts.

The role of passenger leukocytes in the anomalous survival of neonatal skin grafts in mice

The anomalous survival of neonatal C3H skin grafts on CBA mice is correlated with the emigration of passenger leukocytes from the graft vasculature. Thus, newborn homografts whose leukocyte populations are eliminated by X-irradiation or by transient sojourn on an intermediate adult C3H host, do not display prolonged survival. Moreover, the continued presence of the newborn grafts is not requisite to the maintenance of the unresponsive state, an observation consonant with the demonstration that CBA mice bearing long-term neonatal C3H skin grafts are leukocyte chimeras. In contrast, neonatal male C57 skin grafts may persist on C57 females after heavy irradiation of the donor, or after passage on an intermediate adult male host. In addition, tolerance is broken by removal of long-persistant newborn grafts from hitherto unresponsive females, and chimerism is not detectable in female C57 mice tolerant of infant male isografts. Finally, leukocytes of neonatal C3H origin, inoculated subcutaneously into CBA males, may occasionally render these animals unresponsive to subsequent adult C3H skin homografts, whereas those taken from infant C57 males usually sensitize their adult female hosts. Thus, passenger leukocytes are implicated in the extended survival of C3H neonatal homografts on CBA recipients, but not in the persistence of H-Y-incompatible neonatal skin isografts on C57 females.