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Lawson JH, Grimes RE, Wong DJN. Trainees in the independent healthcare sector: benefits for all. Anaesthesia 2024; 79:664-665. [PMID: 38469669 DOI: 10.1111/anae.16279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 03/13/2024]
Affiliation(s)
- J H Lawson
- Guy's and St Thomas' NHS Trust, London, UK
| | - R E Grimes
- Guy's and St Thomas' NHS Trust, London, UK
| | - D J N Wong
- Guy's and St Thomas' NHS Trust, London, UK
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2
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Nash KM, Boe BA, Carrillo SA, Harrison A, Iwaki R, Kelly J, Kirkton RD, Krishnamurthy R, Lawson JH, Matsuzaki Y, Prichard HL, Shah K, Shinoka T, Breuer CK. Evaluation of tissue-engineered human acellular vessels as a Blalock-Taussig-Thomas shunt in a juvenile primate model. JTCVS Open 2023; 15:433-445. [PMID: 37808023 PMCID: PMC10556952 DOI: 10.1016/j.xjon.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/14/2023] [Accepted: 05/04/2023] [Indexed: 10/10/2023]
Abstract
Objectives Palliative treatment of cyanotic congenital heart disease (CCHD) uses systemic-to-pulmonary conduits, often a modified Blalock-Taussig-Thomas shunt (mBTTs). Expanded polytetrafluoroethylene (ePTFE) mBTTs have associated risks for thrombosis and infection. The Human Acellular Vessel (HAV) (Humacyte, Inc) is a decellularized tissue-engineered blood vessel currently in clinical trials in adults for vascular trauma, peripheral artery disease, and end-stage renal disease requiring hemodialysis. In addition to restoring blood flow, the engineered HAV demonstrates the capacity for host cellular remodeling into native-like vasculature. Here we report preclinical evaluation of a small-diameter (3.5 mm) HAV as a mBTTs in a non-human primate model. Methods We implanted 3.5 mm HAVs as right subclavian artery to pulmonary artery mBTTs in non-immunosuppressed juvenile rhesus macaques (n = 5). HAV patency, structure, and blood flow were assessed by postoperative imaging from 1 week to 6 months. Histology of HAVs and surrounding tissues was performed. Results Surgical procedures were well tolerated, with satisfactory anastomoses, showing feasibility of using the 3.5 mm HAV as a mBTTs. All macaques had some immunological reactivity to the human extracellular matrix, as expected in this xenogeneic model. HAV mBTTs remained patent for up to 6 months in animals, exhibiting mild immunoreactivity. Two macaques displaying more severe immunoreactivity to the human HAV material developed midgraft dilatation without bleeding or rupture. HAV repopulation by host cells expressing smooth muscle and endothelial markers was observed in all animals. Conclusions These findings may support use of 3.5 mm HAVs as mBTTs in CCHD and potentially other pediatric vascular indications.
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Affiliation(s)
| | - Brian A. Boe
- The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Sergio A. Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
| | - Andrew Harrison
- The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
| | - Ryuma Iwaki
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - John Kelly
- The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | | | | | - Jeffrey H. Lawson
- Humacyte, Inc, Durham, NC
- Department of Surgery, Duke University, Durham, NC
| | - Yuichi Matsuzaki
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | | | - Kejal Shah
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - Toshiharu Shinoka
- The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Cardiothoracic Surgery, Nationwide Children’s Hospital, Columbus, Ohio
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
| | - Christopher K. Breuer
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Surgery, Nationwide Children’s Hospital, Columbus, Ohio
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3
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Gutowski P, Guziewicz M, Ilzecki M, Kazimierczak A, Lawson JH, Prichard HL, Przywara S, Samad R, Tente W, Turek J, Witkiewicz W, Zapotoczny N, Zubilewicz T, Niklason LE. Six-year outcomes of a phase II study of human-tissue engineered blood vessels for peripheral arterial bypass. JVS Vasc Sci 2023; 4:100092. [PMID: 36874956 PMCID: PMC9976461 DOI: 10.1016/j.jvssci.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/08/2022] [Indexed: 12/05/2022] Open
Abstract
Objective The human acellular vessel (HAV) was evaluated for surgical bypass in a phase II study. The primary results at 24 months after implantation have been reported, and the patients will be evaluated for ≤10 years. Methods In the present report, we have described the 6-year results of a prospective, open-label, single-treatment arm, multicenter study. Patients with advanced peripheral artery disease (PAD) requiring above-the-knee femoropopliteal bypass surgery without available autologous graft options had undergone implantation with the HAV, a bioengineered human tissue replacement blood vessel. The patients who completed the 24-month primary portion of the study will be evaluated for ≤10 years after implantation. The present mid-term analysis was performed at the 6-year milestone (72 months) for patients followed up for 24 to 72 months. Results HAVs were implanted in 20 patients at three sites in Poland. Seven patients had discontinued the study before completing the 2-year portion of the study: four after graft occlusion had occurred and three who had died of causes deemed unrelated to the conduit, with the HAV reported as functional at their last visit. The primary results at 24 months showed primary, primary assisted, and secondary patency rates of 58%, 58%, and 74%, respectively. One vessel had developed a pseudoaneurysm deemed possibly iatrogenic; no other signs of structural failure were reported. No rejections or infections of the HAV occurred, and no patient had required amputation of the implanted limb. Of the 20 patients, 13 had completed the primary portion of the study; however, 1 patient had died shortly after 24 months. Of the remaining 12 patients, 3 died of causes unrelated to the HAV. One patient had required thrombectomy twice, with secondary patency achieved. No other interventions were recorded between 24 and 72 months. At 72 months, five patients had a patent HAV, including four patients with primary patency. For the entire study population from day 1 to month 72, the overall primary, primary assisted, and secondary patency rate estimated using Kaplan-Meier analysis was 44%, 45%, and 60% respectively, with censoring for death. No patient had experienced rejection or infection of the HAV, and no patient had required amputation of the implanted limb. Conclusions The infection-resistant, off-the-shelf HAV could provide a durable alternative conduit in the arterial circuit setting to restore the lower extremity blood supply in patients with PAD, with remodeling into the recipient's own vessel over time. The HAV is currently being evaluated in seven clinical trials to treat PAD, vascular trauma, and as a hemodialysis access conduit.
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Affiliation(s)
- Piotr Gutowski
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Malgorzata Guziewicz
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Marek Ilzecki
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Arkadiusz Kazimierczak
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Jeffrey H. Lawson
- Humacyte, Inc, Durham, NC
- Department of Surgery, Duke University, Durham, NC
| | | | - Stanislaw Przywara
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Rabih Samad
- Department of Vascular Surgery and Angiology, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | | | - Jakub Turek
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Wojcieh Witkiewicz
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Norbert Zapotoczny
- Research and Development Centre, Department of Vascular Surgery, General Hospital, Wroclaw, Poland
| | - Tomaz Zubilewicz
- Clinic of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Laura E. Niklason
- Humacyte, Inc, Durham, NC
- Department of Anesthesia and Biomedical Engineering, Yale University, New Haven
- Department of Biomedical Engineering, Yale University, New Haven, CT
- Correspondence: Laura E. Niklason, MD, PhD, Humacyte, Inc, 2525 NC-54, Durham, NC 27713
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4
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Williams AR, Nellis J, Wegermann Z, McCartney S, Podgoreanu MV, Mehta S, Williams KD, Daubert MA, Kirkton R, Nash K, Niklason L, Lawson JH, Kypson AP. Abstract P1017: Tissue Engineered Human Acellular Blood Vessels For Coronary Artery Bypass Grafting. Circ Res 2022. [DOI: 10.1161/res.131.suppl_1.p1017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Conduit for coronary artery bypass grafting (CABG) can be limited due to poor quality or prior removal of saphenous veins. A human acellular vessel (HAV) bioengineered from vascular cells and then decellularized for implantation may provide a readily available, off-the-shelf conduit for CABG. Here we evaluate the use of small diameter HAV for CABG in a non-human primate model.
Methods:
Adult male baboons (n=7; 26.8 - 37.0 kg) were imaged by left heart catheterization and computed tomography angiography. CABG was performed using a 3.5 mm diameter HAV to the left anterior descending (LAD) or right coronary artery (RCA) via sternotomy with cardiopulmonary bypass. The proximal coronary artery was ligated to prevent competitive flow and graft transit time flowmetry (TTFM) was assessed after implant. Angiography at 2 weeks, 1, 3, and 6 months evaluated graft patency and heart function. HAVs explanted at 6 months were assessed by immunohistochemistry for host cellular response and remodeling.
Results and Conclusion:
Baboons underwent CABG using a 3.5 mm HAV from the ascending aorta to the LAD (n=2) or RCA (n=5). The diminutive LAD led to early graft loss due to size mismatch and poor runoff. HAV bypass to the dominant RCA (TTFM: 22 ± 7.7 mL/min) resulted in sustained graft patency for up to 6 months post-implantation. HAV explant histology revealed infiltration of multiple host cell populations with formation of a neoadventitial layer and evidence of luminal endothelization. HAV conduits retained structural integrity with no evidence of mechanical failure throughout the study. These results demonstrate that tissue-engineered HAVs may provide an off-the-shelf conduit for CABG.
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Cline BC, Zuchowski A, Gage SM, Martin JG, Ronald J, Southerland KW, Lawson JH, Dillavou ED, Kim CY. Hemodialysis Reliable Outflow (HeRO) graft creation in upper extremities abandoned due to stent obstruction via recanalization and HeRO outflow component insertion across stent interstices. J Vasc Access 2021; 24:11297298211048061. [PMID: 34892983 DOI: 10.1177/11297298211048061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The purpose of this study was to assess the feasibility and outcomes of recanalization and subsequent HeRO graft outflow component insertion across stent interstices in patients with an otherwise abandoned upper extremity. METHODS Over a 10-year period, 15 patients underwent central venous recanalization by interventional radiology across the interstices of one or more occluded stents for the purpose of subsequent HeRO graft creation. A tunneled central venous catheter was left across the stent and occlusions with tip in right atrium. On a later date, the catheter was used for rapid guidewire access for HeRO graft implantation in the OR by vascular surgery. Procedural and clinical outcomes were determined by retrospective review. Primary and secondary HeRO graft patency rates were estimated with the Kaplan-Meier technique. RESULTS The technical success rates of recanalization across stent interstices was 100% (15/15). Between one and four overlapping stent walls were traversed. The technical success of the patients who underwent attempted HeRO graft implantation with outflow component traversing across stent interstices was 91% (11/12). No major complications were encountered with either recanalization or HeRO graft implantation. The primary and secondary HeRO patency rates at 12 months were 64% and 80%, respectively. CONCLUSION HeRO graft insertion across stent interstices is feasible and can provide effective permanent AV access; thus, the presence of stents across the subclavian and brachiocephalic veins should not be considered a contraindication.
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Affiliation(s)
- Brendan C Cline
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
- Humacyte Incorporated, Durham, NC, USA
| | - Adam Zuchowski
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
| | - Shawn M Gage
- Physician Assistant Program, Duke University Medical Center, Durham, NC, USA
- InnAVasc Medical, Inc., Durham, NC, USA
| | - Jonathan G Martin
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
| | - James Ronald
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
| | - Kevin W Southerland
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey H Lawson
- Humacyte Incorporated, Durham, NC, USA
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ellen D Dillavou
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Charles Y Kim
- Division of Interventional Radiology, Duke University Medical Center, Durham, NC, USA
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6
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Han EX, Wang J, Kural M, Jiang B, Leiby KL, Chowdhury N, Tellides G, Kibbey RG, Lawson JH, Niklason LE. Development of a Bioartificial Vascular Pancreas. J Tissue Eng 2021; 12:20417314211027714. [PMID: 34262686 PMCID: PMC8243137 DOI: 10.1177/20417314211027714] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/08/2021] [Indexed: 12/16/2022] Open
Abstract
Transplantation of pancreatic islets has been shown to be effective, in some patients, for the long-term treatment of type 1 diabetes. However, transplantation of islets into either the portal vein or the subcutaneous space can be limited by insufficient oxygen transfer, leading to islet loss. Furthermore, oxygen diffusion limitations can be magnified when islet numbers are increased dramatically, as in translating from rodent studies to human-scale treatments. To address these limitations, an islet transplantation approach using an acellular vascular graft as a vascular scaffold has been developed, termed the BioVascular Pancreas (BVP). To create the BVP, islets are seeded as an outer coating on the surface of an acellular vascular graft, using fibrin as a hydrogel carrier. The BVP can then be anastomosed as an arterial (or arteriovenous) graft, which allows fully oxygenated arterial blood with a pO2 of roughly 100 mmHg to flow through the graft lumen and thereby supply oxygen to the islets. In silico simulations and in vitro bioreactor experiments show that the BVP design provides adequate survivability for islets and helps avoid islet hypoxia. When implanted as end-to-end abdominal aorta grafts in nude rats, BVPs were able to restore near-normoglycemia durably for 90 days and developed robust microvascular infiltration from the host. Furthermore, pilot implantations in pigs were performed, which demonstrated the scalability of the technology. Given the potential benefits provided by the BVP, this tissue design may eventually serve as a solution for transplantation of pancreatic islets to treat or cure type 1 diabetes.
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Affiliation(s)
- Edward X Han
- Department of Biomedical Engineering,
Yale School of Engineering and Applied Science, New Haven, CT, USA
| | - Juan Wang
- Vascular Biology and Therapeutics
Program, Yale School of Medicine, New Haven, CT, USA
- Department of Anesthesiology, Yale
School of Medicine, New Haven, CT, USA
| | - Mehmet Kural
- Vascular Biology and Therapeutics
Program, Yale School of Medicine, New Haven, CT, USA
- Department of Anesthesiology, Yale
School of Medicine, New Haven, CT, USA
| | - Bo Jiang
- Department of Surgery, Yale School of
Medicine, New Haven, CT, USA
- Department of Vascular Surgery, The
First Hospital of China Medical University, Shenyang, China
| | - Katherine L Leiby
- Department of Biomedical Engineering,
Yale School of Engineering and Applied Science, New Haven, CT, USA
| | - Nazar Chowdhury
- Molecular, Cellular, and Developmental
Biology, Yale University, New Haven, CT, USA
| | - George Tellides
- Vascular Biology and Therapeutics
Program, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, Yale School of
Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare
System, West Haven, CT, USA
| | - Richard G Kibbey
- Department of Internal Medicine
(Endocrinology), Yale University, New Haven, CT, USA
- Department of Cellular & Molecular
Physiology, Yale School of Medicine, New Haven, CT, USA
| | - Jeffrey H Lawson
- Department of Surgery, Duke
University, Durham, NC, USA
- Humacyte Inc., Durham, NC, USA
| | - Laura E Niklason
- Department of Biomedical Engineering,
Yale School of Engineering and Applied Science, New Haven, CT, USA
- Vascular Biology and Therapeutics
Program, Yale School of Medicine, New Haven, CT, USA
- Department of Anesthesiology, Yale
School of Medicine, New Haven, CT, USA
- Humacyte Inc., Durham, NC, USA
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Abstract
Since the advent of the vascular anastomosis by Alexis Carrel in the early 20th century, the repair and replacement of blood vessels have been key to treating acute injuries, as well as chronic atherosclerotic disease. Arteries serve diverse mechanical and biological functions, such as conducting blood to tissues, interacting with the coagulation system, and modulating resistance to blood flow. Early approaches for arterial replacement used artificial materials, which were supplanted by polymer fabrics in recent decades. With recent advances in the engineering of connective tissues, including arteries, we are on the cusp of seeing engineered human arteries become mainstays of surgical therapy for vascular disease. Progress in our understanding of physiology, cell biology, and biomanufacturing over the past several decades has made these advances possible.
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Affiliation(s)
- Laura E Niklason
- Departments of Anesthesiology and Biomedical Engineering, Yale University, New Haven, CT, USA. .,Humacyte Inc., Durham, NC 27713, USA
| | - Jeffrey H Lawson
- Humacyte Inc., Durham, NC 27713, USA. .,Department of Surgery, Duke University, Durham, NC, USA
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8
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Abstract
Advances in standards of care have extended the life expectancy of patients with kidney failure. However, options for chronic vascular access for haemodialysis - an essential part of kidney replacement therapy - have remained unchanged for decades. The high morbidity and mortality associated with current vascular access complications highlights an unmet clinical need for novel techniques in vascular access and is driving innovation in vascular access care. The development of devices, biological approaches and novel access techniques has led to new approaches to controlling fistula geometry and manipulating the underlying cellular and molecular pathways of the vascular endothelium, and influencing fistula maturation and formation through the use of external mechanical methods. Innovations in arteriovenous graft materials range from small modifications to the graft lumen to the creation of completely novel bioengineered grafts. Steps have even been taken to create new devices for the treatment of patients with central vein stenosis. However, these emerging therapies face difficult hurdles, and truly creative approaches to vascular access need resources that include well-designed clinical trials, frequent interaction with regulators, interventionalist education and sufficient funding. In addition, the heterogeneity of patients with kidney failure suggests it is unlikely that a 'one-size-fits-all' approach for effective vascular access will be feasible in the current environment.
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Affiliation(s)
- Jeffrey H Lawson
- Department of Surgery, Duke University, Durham, NC, USA.
- Humacyte, Inc., Durham, NC, USA.
| | - Laura E Niklason
- Humacyte, Inc., Durham, NC, USA
- School of Engineering & Applied Science, Yale University, New Haven, CT, USA
| | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, NC, USA
- WG (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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9
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Gutowski P, Gage SM, Guziewicz M, Ilzecki M, Kazimierczak A, Kirkton RD, Niklason LE, Pilgrim A, Prichard HL, Przywara S, Samad R, Tente B, Turek J, Witkiewicz W, Zapotoczny N, Zubilewicz T, Lawson JH. Arterial reconstruction with human bioengineered acellular blood vessels in patients with peripheral arterial disease. J Vasc Surg 2020; 72:1247-1258. [DOI: 10.1016/j.jvs.2019.11.056] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/23/2019] [Indexed: 11/30/2022]
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10
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Kirkton RD, Santiago-Maysonet M, Lawson JH, Tente WE, Dahl SLM, Niklason LE, Prichard HL. Bioengineered human acellular vessels recellularize and evolve into living blood vessels after human implantation. Sci Transl Med 2020; 11:11/485/eaau6934. [PMID: 30918113 DOI: 10.1126/scitranslmed.aau6934] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 03/06/2019] [Indexed: 12/13/2022]
Abstract
Traditional vascular grafts constructed from synthetic polymers or cadaveric human or animal tissues support the clinical need for readily available blood vessels, but often come with associated risks. Histopathological evaluation of these materials has shown adverse host cellular reactions and/or mechanical degradation due to insufficient or inappropriate matrix remodeling. We developed an investigational bioengineered human acellular vessel (HAV), which is currently being studied as a hemodialysis conduit in patients with end-stage renal disease. In rare cases, small samples of HAV were recovered during routine surgical interventions and used to examine the temporal and spatial pattern of the host cell response to the HAV after implantation, from 16 to 200 weeks. We observed a substantial influx of alpha smooth muscle actin (αSMA)-expressing cells into the HAV that progressively matured and circumferentially aligned in the HAV wall. These cells were supported by microvasculature initially formed by CD34+/CD31+ cells in the neoadventitia and later maintained by CD34-/CD31+ endothelial cells in the media and lumen of the HAV. Nestin+ progenitor cells differentiated into either αSMA+ or CD31+ cells and may contribute to early recellularization and self-repair of the HAV. A mesenchymal stem cell-like CD90+ progenitor cell population increased in number with duration of implantation. Our results suggest that host myogenic, endothelial, and progenitor cell repopulation of HAVs transforms these previously acellular vessels into functional multilayered living tissues that maintain blood transport and exhibit self-healing after cannulation injury, effectively rendering these vessels like the patient's own blood vessel.
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Affiliation(s)
| | | | - Jeffrey H Lawson
- Humacyte Inc., Durham, NC 27713, USA.,Departments of Surgery and Pathology, Duke University Medical Center, Durham, NC 27710, USA
| | | | | | - Laura E Niklason
- Humacyte Inc., Durham, NC 27713, USA.,Departments of Anesthesiology and Biomedical Engineering, Yale University, New Haven, CT 06511, USA
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11
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Cline BC, Gage SM, Ronald J, Pabon-Ramos WM, Dillavou ED, Smith TP, Lawson JH, Kim CY. Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment. J Vasc Interv Radiol 2020; 31:243-250. [DOI: 10.1016/j.jvir.2019.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 11/30/2022] Open
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12
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Morrison JJ, McMahon J, DuBose JJ, Scalea TM, Lawson JH, Rasmussen TE. Clinical implementation of the Humacyte human acellular vessel: Implications for military and civilian trauma care. J Trauma Acute Care Surg 2019; 87:S44-S47. [PMID: 31246906 DOI: 10.1097/ta.0000000000002350] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of wartime vascular injury has increased and is a leading cause of mortality and morbidity. While ligation remains an option, current resuscitation and damage control techniques have resulted in vascular repair being pursued in more than half of wartime injuries. Options for vascular reconstruction are currently limited to autologous vein or synthetic conduits, choices which have not changed in decades, both of which have problems. Autologous vein is preferable but requires time to harvest and may not be available. Synthetic grafts are poorly resistant to infection and associated with thrombotic complications. Recognizing this capability gap, the US Combat Casualty Care Research Program has partnered with academia and industry to support the development and clinical introduction of a bioengineered human acellular vessel. This human acellular vessel has the potential to be an off-the-shelf conduit that is resistant to infection and incorporates well into native tissues. This report reviews the rationale of this military-civilian partnership in medical innovation and provides an update on the clinical use and ongoing study of this new vascular technology. LEVEL OF EVIDENCE: Therapeutic, level III.
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Affiliation(s)
- Jonathan J Morrison
- From the R Adams Cowley Shock Trauma Center (J.J.M., J.J.D., T.M.S.), University of Maryland Medical System, Baltimore, Maryland; Humacyte Inc (J.M., J.H.L.), Research Triangle Park, North Carolina; and Department of Surgery (T.E.R.) at the Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
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13
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Bylsma LC, Reichert H, Gage SM, Roy-Chaudhury P, Nordyke RJ, Fryzek J, Dahl SLM, Lithgow T, Lawson JH. Clinical Outcomes of Arteriovenous Access in Incident Hemodialysis Patients with Medicare Coverage, 2012-2014. Am J Nephrol 2019; 49:156-164. [PMID: 30677763 DOI: 10.1159/000495355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/12/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic hemodialysis requires a mode of vascular access through an arteriovenous fistula (AVF), a prosthetic arteriovenous graft (AVG), or a central venous catheter (CVC). AVF is recommended over AVG or CVC due to increased patency and decreased intervention rates for those that mature. AVG are preferred over CVC due to decreased infection and mortality risk. The aims of this study were to evaluate the lifespan of AVF and AVG in maturation, sustained access use, and abandonment. METHODS The United States Renal Data System (USRDS), Medicare claims, and CROWNWeb were used to identify access placements. Patients with a first end-stage renal disease (ESRD) service from January 1, 2012 to June 30, 2014 with continuous coverage with Medicare as primary payer and ≥1 AVF or AVG placed after ESRD onset were included. Maturation was defined as the first use of the access for hemodialysis recorded in CROWNWeb. Sustained access use was defined as 3 consecutive months of use without catheter placement or replacement. Accesses that were never used at any time post-placement were considered abandoned. RESULTS The cohort included 38,035 AVF placements and 12,789 AVG placements. Sixty-nine percent of AVF and 72% of AVG matured. Fifty-two percent of AVF and 51% of AVG achieved sustained access use. One quarter of AVF and 14% of AVG were abandoned without use as recorded in CROWNWeb. CONCLUSION Although considered the gold standard for vascular access, only half of AVF and AVG placements achieved sustained access use. The USRDS database has inherent limitations but provides useful clinical insight into maturation, sustained use, and abandonment.
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Affiliation(s)
| | | | - Shawn M Gage
- Humacyte Incorporated, Morrisville, North Carolina, USA
- Department of Surgery, Duke University, Durham, North Carolina, USA
| | | | | | - Jon Fryzek
- EpidStat Institute, Ann Arbor, Michigan, USA
| | | | | | - Jeffrey H Lawson
- Humacyte Incorporated, Morrisville, North Carolina, USA,
- Department of Surgery, Duke University, Durham, North Carolina, USA,
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Lawson JH, Dahl SL, Gage SM, Pilgrim AJ, Prichard HL, Tente WE, Niklason LE. Engineering Human Acellular Vessels for Dialysis Access and Vascular Repair. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Dolmatch BL, Gurley JC, Baskin KM, Nikolic B, Lawson JH, Shenoy S, Saad TF, Davidson I, Baerlocher MO, Cohen EI, Dariushnia SR, Faintuch S, d’Othee BJ, Kinney TB, Midia M, Clifton J. Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction: Endorsed by the American Society of Diagnostic and Interventional Nephrology (ASDIN), British Society of Interventional Radiology (BSIR), Canadian Interventional Radiology Association (CIRA), Heart Rhythm Society (HRS), Indian Society of Vascular and Interventional Radiology (ISVIR), Vascular Access Society of the Americas (VASA), and Vascular Access Society of Britain and Ireland (VASBI). J Vasc Access 2018; 20:114-122. [DOI: 10.1177/1129729818791409] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Bart L Dolmatch
- Department of Interventional Radiology, Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - John C Gurley
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Kevin M Baskin
- Department of Radiology, Advanced Interventional Institute, Pittsburgh, PA, USA
| | - Boris Nikolic
- Department of Radiology, Stratton Medical Center, Albany, NY, USA
| | - Jeffrey H Lawson
- Division of Vascular and Endovascular Surgery, Duke University, Durham, NC, USA
| | - Surendra Shenoy
- Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA
| | - Theodore F Saad
- Department of Radiology, St. Francis Hospital, Nephrology Associates, Wilmington, DE, USA
| | - Ingemar Davidson
- Department of Radiology, Tulane University, New Orleans, LA, USA
| | - Mark O Baerlocher
- Department of Interventional Radiology, Royal Victoria Hospital, Barrie, ON, Canada
| | - Emil I Cohen
- Department of Radiology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean R Dariushnia
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, GA, USA
| | - Salomão Faintuch
- Division of Interventional Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Thomas B Kinney
- Department of Radiology, University of California, San Diego Medical Center, San Diego, CA, USA
| | - Mehran Midia
- Department of Interventional Radiology, McMaster University, Hamilton, ON, Canada
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16
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Zhang L, Wu JH, Otto JC, Gurley SB, Hauser ER, Shenoy SK, Nagi K, Brian L, Wertman V, Mattocks N, Lawson JH, Freedman NJ. Interleukin-9 mediates chronic kidney disease-dependent vein graft disease: a role for mast cells. Cardiovasc Res 2018; 113:1551-1559. [PMID: 29048463 DOI: 10.1093/cvr/cvx177] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/29/2017] [Indexed: 12/18/2022] Open
Abstract
Aims Chronic kidney disease (CKD) is a powerful independent risk factor for cardiovascular events, including vein graft failure. Because CKD impairs the clearance of small proteins, we tested the hypothesis that CKD exacerbates vein graft disease by elevating serum levels of critical cytokines that promote vein graft neointimal hyperplasia. Methods and results We modelled CKD in C57BL/6 mice with 5/6ths nephrectomy, which reduced glomerular filtration rate by 60%, and we modelled vein grafting with inferior-vena-cava-to-carotid interposition grafting. CKD increased vein graft neointimal hyperplasia four-fold, decreased vein graft re-endothelialization two-fold, and increased serum levels of interleukin-9 (IL-9) five-fold. By quantitative immunofluorescence and histochemical staining, vein grafts from CKD mice demonstrated a ∼two-fold higher prevalence of mast cells, and a six-fold higher prevalence of activated mast cells. Concordantly, vein grafts from CKD mice showed higher levels of TNF and NFκB activation, as judged by phosphorylation of NFκB p65 on Ser536 and by expression of VCAM-1. Arteriovenous fistula veins from humans with CKD also showed up-regulation of mast cells and IL-9. Treating CKD mice with IL-9-neutralizing IgG reduced vein graft neointimal area four-fold, increased vein graft re-endothelialization ∼two-fold, and reduced vein graft total and activated mast cell levels two- and four-fold, respectively. Treating CKD mice with the mast cell stabilizer cromolyn reduced neointimal hyperplasia and increased re-endothelialization in vein grafts. In vitro, IL-9 promoted endothelial cell apoptosis but had no effect on smooth muscle cell proliferation. Conclusion CKD aggravates vein graft disease through mechanisms involving IL-9 and mast cell activation.
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Affiliation(s)
| | | | | | | | - Elizabeth R Hauser
- Biostatistics and Bioinformatics.,Molecular Physiology Institute, Duke University Medical Center, Durham, NC, USA.,Cooperative Studies Program Epidemiology Center Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Sudha K Shenoy
- Cardiology, Department of Medicine.,Cell Biology, Duke University Medical Center, Durham, NC, USA
| | - Karim Nagi
- Cardiology, Department of Medicine.,Cell Biology, Duke University Medical Center, Durham, NC, USA
| | | | | | | | | | - Neil J Freedman
- Cardiology, Department of Medicine.,Cell Biology, Duke University Medical Center, Durham, NC, USA
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17
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Dolmatch BL, Gurley JC, Baskin KM, Nikolic B, Lawson JH, Shenoy S, Saad TF, Davidson I, Baerlocher MO, Cohen EI, Dariushnia SR, Faintuch S, Janne d’Othee B, Kinney TB, Midia M, Clifton J, Baerlocher MO, Baskin K, Clifton J, Dalley A, Dariushnia S, Davidson I, Dolmatch B, Gurley J, Haskal Z, Journeycake J, Lawson J, McLennan G, Nikolic B, Ramsburg D, Ross J, Saad T, Shenoy S, Spencer B, Thompson D, Walker TG, Walser E. Society of Interventional Radiology Reporting Standards for Thoracic Central Vein Obstruction. J Vasc Interv Radiol 2018; 29:454-460.e3. [DOI: 10.1016/j.jvir.2017.12.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 12/14/2017] [Accepted: 12/14/2017] [Indexed: 10/17/2022] Open
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Abstract
Infected prosthetic arteriovenous grafts for hemodialysis present a profound risk to patient well being. Here we present five recent cases and describe our technique for total graft excision. We also review the literature and discuss the much debated role of partial, subtotal, and total graft excision.
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Affiliation(s)
- Eugene P. Ceppa
- Department of Surgery, Duke University Medical Center, Durham - USA
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19
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Evans DC, Upton EC, Lawson JH. Axillary to Common Iliac Arteriovenous Graft for Hemodialysis Access: Case Report and Review of “Exotic” Axillary-Based Grafts. J Vasc Access 2018; 6:192-5. [PMID: 16552701 DOI: 10.1177/112972980500600407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 58-year-old Caucasian male with end-stage renal disease and peripheral arterial disease was referred to us for management of his complex vascular access. His vascular access history included a left wrist primary fistula, a left upper arm access graft, a left leg loop graft, and multiple PermCaths in his jugular veins with recurrent infections. Magnetic resonance venography (MRV) of his chest revealed extensive bilateral venous occlusions due to numerous past hemodialysis access catheters. The patient was scheduled for right lower extremity arteriovenous graft placement, but intraoperatively was found to have severe peripheral arterial disease and a thromboendarterectomy was performed instead. Lower body venous imaging demonstrated patent iliac veins. Based on these anatomic considerations a right axillary artery to right common iliac vein polytetrafluoroethylene (PTFE) graft was placed. The graft required revision twice – once for graft ultrafiltration at the arterial end of the graft and once for needle stick infection – but continues to serve as sufficient access after 15 months. Grafts based off the axillary artery have become increasingly popular in recent years and several venous outflow options have been considered, each with distinct advantages. The common iliac vein offers a central location with high flow rate and low probability of infection. Axillary artery to iliac vein arteriovenous grafting may have a place in the vascular surgeon's armamentarium for complex vascular access cases.
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Affiliation(s)
- D C Evans
- Department of Surgery, Duke University Medical Center, Durham NC 27710, USA
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20
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Lawson JH, Glickman MH, Jakimowicz T, Peden EK, Szmidt J, Witkiewicz W, Zubilewicz T, Niklason LE. Bioengineered Human Acellular Vessels for Dialysis Access: Completed Phase 2 Studies. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Lawson JH, Gutowski P, Witkiewicz W, Zubilewicz T, Niklason L. SS20 Arterial Reconstruction With Human Bioengineered Blood Vessels in Patients With Peripheral Arterial Disease. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Woo K, Ulloa J, Allon M, Carsten CG, Chemla ES, Henry ML, Huber TS, Lawson JH, Lok CE, Peden EK, Scher L, Sidawy A, Maggard-Gibbons M, Cull D. Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure. J Vasc Surg 2017; 65:1089-1103.e1. [PMID: 28222990 DOI: 10.1016/j.jvs.2016.10.099] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. METHODS The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. RESULTS Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. CONCLUSIONS The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.
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Affiliation(s)
- Karen Woo
- Division of Vascular Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif.
| | - Jesus Ulloa
- Department of Surgery, UCSF School of Medicine, University of California, San Francisco, Calif
| | - Michael Allon
- Division of Nephrology, University of Alabama School of Medicine, University of Alabama, Birmingham, Ala
| | - Christopher G Carsten
- Division of Vascular Surgery, University of South Carolina School of Medicine, University of South Carolina, Greenville, SC
| | - Eric S Chemla
- St. George's University Hospitals NHS Foundation Trust Vascular Institute, St. George's University, London, United Kingdom
| | - Mitchell L Henry
- Division of Transplantation Surgery, The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio
| | - Thomas S Huber
- Division of Vascular Surgery, University of Florida College of Medicine, University of Florida, Gainesville, Fla
| | - Jeffrey H Lawson
- Division of Vascular Surgery, Duke University School of Medicine, Duke University, Durham, NC
| | - Charmaine E Lok
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eric K Peden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
| | - Larry Scher
- Department of Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine, Bronx, NY
| | - Anton Sidawy
- Division of Vascular Surgery, George Washington School of Medicine and Health Sciences, George Washington University, Washington, D.C
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Calif
| | - David Cull
- Division of Vascular Surgery, University of South Carolina School of Medicine, University of South Carolina, Greenville, SC
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23
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Griffin AS, Gage SM, Lawson JH, Kim CY. Early infection risk with primary versus staged Hemodialysis Reliable Outflow (HeRO) graft implantation. J Vasc Surg 2016; 65:136-141. [PMID: 27687322 DOI: 10.1016/j.jvs.2016.07.114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/17/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study evaluated whether the use of a staged Hemodialysis Reliable Outflow (HeRO; Merit Medical, South Jordan, Utah) implantation strategy incurs increased early infection risk compared with conventional primary HeRO implantation. METHODS A retrospective review was performed of 192 hemodialysis patients who underwent HeRO graft implantation: 105 patients underwent primary HeRO implantation in the operating room, and 87 underwent a staged implantation where a previously inserted tunneled central venous catheter was used for guidewire access for the venous outflow component. Within the staged implantation group, 32 were performed via an existing tunneled hemodialysis catheter (incidentally staged), and 55 were performed via a tunneled catheter inserted across a central venous occlusion in an interventional radiology suite specifically for HeRO implantation (intentionally staged). Early infection was defined as episodes of bacteremia or HeRO infection requiring resection ≤30 days of HeRO implantation. RESULTS For staged HeRO implantations, the median interval between tunneled catheter insertion and conversion to a HeRO graft was 42 days. The overall HeRO-related infection rate ≤30 days of implantation was 8.6% for primary HeRO implantation and 2.3% for staged implantations (P = .12). The rates of early bacteremia and HeRO resection requiring surgical resection were not significantly different between groups (P = .19 and P = .065, respectively), nor were age, gender, laterality, anastomosis to an existing arteriovenous access, human immunodeficiency virus status, diabetes, steroids, chemotherapy, body mass index, or graft location. None of the patient variables, techniques, or graft-related variables correlated significantly with the early infection rate. CONCLUSIONS The staged HeRO implantation strategy did not result in an increased early infection risk compared with conventional primary implantation and is thus a reasonable strategy for HeRO insertion in hemodialysis patients with complex central venous disease.
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Affiliation(s)
- Andrew S Griffin
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, NC
| | - Shawn M Gage
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey H Lawson
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Charles Y Kim
- Division of Vascular & Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, NC.
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Lawson JH, Glickman MH, Ilzecki M, Jakimowicz T, Jaroszynski A, Peden EK, Pilgrim AJ, Prichard HL, Guziewicz M, Przywara S, Szmidt J, Turek J, Witkiewicz W, Zapotoczny N, Zubilewicz T, Niklason LE. Bioengineered human acellular vessels for dialysis access in patients with end-stage renal disease: two phase 2 single-arm trials. Lancet 2016; 387:2026-34. [PMID: 27203778 PMCID: PMC4915925 DOI: 10.1016/s0140-6736(16)00557-2] [Citation(s) in RCA: 223] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND For patients with end-stage renal disease who are not candidates for fistula, dialysis access grafts are the best option for chronic haemodialysis. However, polytetrafluoroethylene arteriovenous grafts are prone to thrombosis, infection, and intimal hyperplasia at the venous anastomosis. We developed and tested a bioengineered human acellular vessel as a potential solution to these limitations in dialysis access. METHODS We did two single-arm phase 2 trials at six centres in the USA and Poland. We enrolled adults with end-stage renal disease. A novel bioengineered human acellular vessel was implanted into the arms of patients for haemodialysis access. Primary endpoints were safety (freedom from immune response or infection, aneurysm, or mechanical failure, and incidence of adverse events), and efficacy as assessed by primary, primary assisted, and secondary patencies at 6 months. All patients were followed up for at least 1 year, or had a censoring event. These trials are registered with ClinicalTrials.gov, NCT01744418 and NCT01840956. FINDINGS Human acellular vessels were implanted into 60 patients. Mean follow-up was 16 months (SD 7·6). One vessel became infected during 82 patient-years of follow-up. The vessels had no dilatation and rarely had post-cannulation bleeding. At 6 months, 63% (95% CI 47-72) of patients had primary patency, 73% (57-81) had primary assisted patency, and 97% (85-98) had secondary patency, with most loss of primary patency because of thrombosis. At 12 months, 28% (17-40) had primary patency, 38% (26-51) had primary assisted patency, and 89% (74-93) had secondary patency. INTERPRETATION Bioengineered human acellular vessels seem to provide safe and functional haemodialysis access, and warrant further study in randomised controlled trials. FUNDING Humacyte and US National Institutes of Health.
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Affiliation(s)
- Jeffrey H Lawson
- Humacyte, Durham, NC, USA; Duke University, Durham, North Carolina, USA
| | - Marc H Glickman
- Humacyte, Durham, NC, USA; Sentara Heart Hospital, Norfolk, VA, USA
| | - Marek Ilzecki
- Department of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | | | - Eric K Peden
- Cardiovascular Surgery Associates, Houston, TX, USA
| | | | | | - Malgorzata Guziewicz
- Research and Development Centre, Vascular Surgery Department, General Hospital in Wrocław, Wrocław, Poland
| | - Stanisław Przywara
- Department of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Jacek Szmidt
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jakub Turek
- Research and Development Centre, Vascular Surgery Department, General Hospital in Wrocław, Wrocław, Poland
| | - Wojciech Witkiewicz
- Research and Development Centre, Vascular Surgery Department, General Hospital in Wrocław, Wrocław, Poland
| | - Norbert Zapotoczny
- Research and Development Centre, Vascular Surgery Department, General Hospital in Wrocław, Wrocław, Poland
| | - Tomasz Zubilewicz
- Department of Vascular Surgery and Angiology, Medical University of Lublin, Lublin, Poland
| | - Laura E Niklason
- Department of Anesthesia & Biomedical Engineering, Yale University, New Haven, CT, USA.
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25
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Williams JB, Harskamp RE, Bose S, Lawson JH, Alexander JH, Smith PK, Lopes RD. The Preservation and Handling of Vein Grafts in Current Surgical Practice. JAMA Surg 2015; 150:681-3. [DOI: 10.1001/jamasurg.2015.0404] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Judson B. Williams
- Department of Surgery, Duke University Medical Center, Durham, North Carolina2Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ralf E. Harskamp
- Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Saideep Bose
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey H. Lawson
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John H. Alexander
- Duke Clinical Research Institute, Duke University, Durham, North Carolina4Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Peter K. Smith
- Department of Surgery, Duke University Medical Center, Durham, North Carolina2Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Renato D. Lopes
- Duke Clinical Research Institute, Duke University, Durham, North Carolina4Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Benrashid E, Yerxa J, Lucas KA, Gabr MA, Haley J, Serrano S, McCoy CC, Otto JC, Lawson JH. Abstract 225: Parallel and Divergent Patterns of Gene Expression in Human Arteriovenous Fistula Maturation and Stenosis. Arterioscler Thromb Vasc Biol 2015. [DOI: 10.1161/atvb.35.suppl_1.225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The biologic mechanisms that differentiate successful arteriovenous fistula (AVF) maturation from stenosis are not well understood. The brachiobasilic transposition offers an opportunity for studying the vascular remodeling process. This procedure is a two stage process: first to create a brachiobasilic AVF and second, to transpose the AVF near the skin in a delayed fashion, allowing the opportunity to harvest naïve vein, mature and stenotic AVF tissue. Identifying the molecular differences with regards to success (maturation) or failure (stenosis) are vital both for dialysis access care and as a model of vein remodeling on exposure to arterial flow. We hypothesize that basilic vein transposition (BVT) can be utilized as a unique means with which to study the biologic factors that affect stenosis and maturation.
Methods/Results:
Vein tissue was obtained at the time of initial access creation as naïve segments and again at the time of basilic vein transposition (following venous “arterialization”), resulting in a cohort of patient-matched naïve, mature, and stenotic segments. Time between procedures ranged from 3-8 months, with a mean of 5. Vein segments were scored at time of collection as mature or stenotic, and confirmed by histology. Real-time PCR was performed on extracted RNA using a panel of genes implicated in the process and regulation of both successful and “unsuccessful” vascular wall remodeling. Heme oxygenase-1, matrix metalloproteinase-9 (MMP9) and osteopontin (SPP1) are significantly upregulated in both mature and stenotic vein segments (vs. naïve); MMP9 and SPP1 were also significantly upregulated in mature vs. stenotic tissue. SPP1 was exclusively expressed in the medial region of mature and stenotic AVF. Stenotic samples demonstrated a significant increase in the expression of tissue inhibitor of metalloproteinase-1 (MMP-1) and endothelin-1 (EDN-1) versus both naïve and mature samples.
Conclusion:
The BVT offers a unique opportunity to identify potential mechanisms involved in AVF maturation and stenosis. There appears to be overlap in gene expression profiles for both mature and stenotic samples, however MMP-1 and EDN-1 appear to be significantly increased in venous stenosis.
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Affiliation(s)
| | | | | | | | - Jennifer Haley
- BioMed/Med Engineering, North Carolina State Univ, Raleigh, NC
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Matsumura JS, Stroupe KT, Lederle FA, Kyriakides TC, Ge L, Freischlag JA, Ketteler ER, Kingsley DD, Marek JM, Massen RJ, Matteson BD, Pitcher JD, Langsfeld M, Corson JD, Goff JM, Kasirajan K, Paap C, Robertson DC, Salam A, Veeraswamy R, Milner R, Kasirajan K, Guidot J, Lal BK, Busuttil SJ, Lilly MP, Braganza M, Ellis K, Patterson MA, Jordan WD, Whitley D, Taylor S, Passman M, Kerns D, Inman C, Poirier J, Ebaugh J, Raffetto J, Chew D, Lathi S, Owens C, Hickson K, Dosluoglu HH, Eschberger K, Kibbe MR, Baraniewski HM, Matsumura J, Endo M, Busman A, Meadows W, Evans M, Giglia JS, El Sayed H, Reed AB, Ruf M, Ross S, Jean-Claude JM, Pinault G, Kang P, White N, Eiseman M, Jones R, Timaran CH, Modrall JG, Welborn MB, Lopez J, Nguyen T, Chacko JK, Granke K, Vouyouka AG, Olgren E, Chand P, Allende B, Ranella M, Yales C, Whitehill TA, Krupski WC, Nehler MR, Johnson SP, Jones DN, Strecker P, Bhola MA, Shortell CK, Gray JL, Lawson JH, McCann R, Sebastian MW, Tetterton JK, Blackwell C, Prinzo PA, Lee N, Padberg FT, Cerveira JJ, Lal BK, Zickler RW, Hauck KA, Berceli SA, Lee WA, Ozaki CK, Nelson PR, Irwin AS, Baum R, Aulivola B, Rodriguez H, Littooy FN, Greisler H, O'Sullivan MT, Kougias P, Lin PH, Bush RL, Guinn G, Cagiannos C, Pillack S, Guillory B, Cikrit D, Lalka SG, Lemmon G, Nachreiner R, Rusomaroff M, O'Brien E, Cullen JJ, Hoballah J, Sharp WJ, McCandless JL, Beach V, Minion D, Schwarcz TH, Kimbrough J, Ashe L, Rockich A, Warner-Carpenter J, Moursi M, Eidt JF, Brock S, Bianchi C, Bishop V, Gordon IL, Fujitani R, Kubaska SM, Behdad M, Azadegan R, Agas CM, Zalecki K, Hoch JR, Carr SC, Acher C, Schwarze M, Tefera G, Mell M, Dunlap B, Rieder J, Stuart JM, Weiman DS, Abul-Khoudoud O, Garrett HE, Walsh SM, Wilson KL, Seabrook GR, Cambria RA, Brown KR, Lewis BD, Framberg S, Kallio C, Barke RA, Santilli SM, d'Audiffret AC, Oberle N, Proebstle C, Lee Johnson L, Jacobowitz GR, Cayne N, Rockman C, Adelman M, Gagne P, Nalbandian M, Caropolo LJ, Pipinos II, Johanning J, Lynch T, DeSpiegelaere H, Purviance G, Zhou W, Dalman R, Lee JT, Safadi B, Coogan SM, Wren SM, Bahmani DD, Maples D, Thunen S, Golden MA, Mitchell ME, Fairman R, Reinhardt S, Wilson MA, Tzeng E, Muluk S, Peterson NM, Foster M, Edwards J, Moneta GL, Landry G, Taylor L, Yeager R, Cannady E, Treiman G, Hatton-Ward S, Salabsky B, Kansal N, Owens E, Estes M, Forbes BA, Sobotta C, Rapp JH, Reilly LM, Perez SL, Yan K, Sarkar R, Dwyer SS, Kohler TR, Hatsukami TS, Glickerman DG, Sobel M, Burdick TS, Pedersen K, Cleary P, Kansal N, Owens E, Estes M, Forbes BA, Sobotta C, Back M, Bandyk D, Johnson B, Shames M, Reinhard RL, Thomas SC, Hunter GC, Leon LR, Westerband A, Guerra RJ, Riveros M, Mills JL, Hughes JD, Escalante AM, Psalms SB, Day NN, Macsata R, Sidawy A, Weiswasser J, Arora S, Jasper BJ, Dardik A, Gahtan V, Muhs BE, Sumpio BE, Gusberg RJ, Spector M, Pollak J, Aruny J, Kelly EL, Wong J, Vasilas P, Joncas C, Gelabert HA, DeVirgillio C, Rigberg DA, Cole L. Costs of repair of abdominal aortic aneurysm with different devices in a multicenter randomized trial. J Vasc Surg 2015; 61:59-65. [DOI: 10.1016/j.jvs.2014.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
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Nassar GM, Glickman MH, McLafferty RB, Kevin Croston J, Zarge JI, Katzman HE, Peden EK, Lawson JH, Martinez JM, Thackeray L. A Comparison Between the HeRO Graft and Conventional Arteriovenous Grafts in Hemodialysis Patients. Semin Dial 2014; 27:310-8. [DOI: 10.1111/sdi.12173] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- George M. Nassar
- Houston Methodist Hospital; Weill Cornell University; Houston Texas
| | | | | | | | | | | | - Eric K. Peden
- Houston Methodist Hospital; Weill Cornell University; Houston Texas
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Ali AM, Lawson JH. Preserving David C Sabiston Jr's legacy in medical students' surgical education. J Am Coll Surg 2013; 217:1140-4. [PMID: 24246625 DOI: 10.1016/j.jamcollsurg.2013.07.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/17/2013] [Indexed: 10/26/2022]
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Gebhard TA, Bryant JA, Adam Grezaffi J, Pabon-Ramos WM, Gage SM, Miller MJ, Husum KW, Suhocki PV, Sopko DR, Lawson JH, Smith TP, Kim CY. Percutaneous Interventions on the Hemodialysis Reliable Outflow Vascular Access Device. J Vasc Interv Radiol 2013; 24:543-9. [DOI: 10.1016/j.jvir.2012.12.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 12/26/2012] [Accepted: 12/30/2012] [Indexed: 11/26/2022] Open
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Achneck HE, Sileshi B, Parikh A, Milano CA, Welsby IJ, Lawson JH. Pathophysiology of bleeding and clotting in the cardiac surgery patient: from vascular endothelium to circulatory assist device surface. Circulation 2012; 122:2068-77. [PMID: 21098468 DOI: 10.1161/circulationaha.110.936773] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Hardean E Achneck
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Conte MS, Nugent HM, Gaccione P, Roy-Chaudhury P, Lawson JH. Influence of diabetes and perivascular allogeneic endothelial cell implants on arteriovenous fistula remodeling. J Vasc Surg 2011; 54:1383-9. [DOI: 10.1016/j.jvs.2011.05.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 03/15/2011] [Accepted: 05/01/2011] [Indexed: 11/28/2022]
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Jantzen AE, Lane WO, Gage SM, Jamiolkowski RM, Haseltine JM, Galinat LJ, Lin FH, Lawson JH, Truskey GA, Achneck HE. Use of autologous blood-derived endothelial progenitor cells at point-of-care to protect against implant thrombosis in a large animal model. Biomaterials 2011; 32:8356-63. [PMID: 21840592 DOI: 10.1016/j.biomaterials.2011.07.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 07/21/2011] [Indexed: 10/17/2022]
Abstract
Titanium (Ti) is commonly utilized in many cardiovascular devices, e.g. as a component of Nitinol stents, intra- and extracorporeal mechanical circulatory assist devices, but is associated with the risk of thromboemboli formation. We propose to solve this problem by lining the Ti blood-contacting surfaces with autologous peripheral blood-derived late outgrowth endothelial progenitor cells (EPCs) after having previously demonstrated that these EPCs adhere to and grow on Ti under physiological shear stresses and functionally adapt to their environment under flow conditions ex vivo. Autologous fluorescently-labeled porcine EPCs were seeded at the point-of-care in the operating room onto Ti tubes for 30 min and implanted into the pro-thrombotic environment of the inferior vena cava of swine (n = 8). After 3 days, Ti tubes were explanted, disassembled, and the blood-contacting surface was imaged. A blinded analysis found all 4 cell-seeded implants to be free of clot, whereas 4 controls without EPCs were either entirely occluded or partially thrombosed. Pre-labeled EPCs had spread and were present on all 4 cell-seeded implants while no endothelial cells were observed on control implants. These results suggest that late outgrowth autologous EPCs represent a promising source of lining Ti implants to reduce thrombosis in vivo.
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Affiliation(s)
- Alexandra E Jantzen
- Department of Biomedical Engineering, Duke University, 136 Hudson Hall, Box 90281, Durham, NC 27708, USA
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Prichard HL, Manson RJ, DiBernardo L, Niklason LE, Lawson JH, Dahl SLM. An early study on the mechanisms that allow tissue-engineered vascular grafts to resist intimal hyperplasia. J Cardiovasc Transl Res 2011; 4:674-82. [PMID: 21748530 PMCID: PMC3175038 DOI: 10.1007/s12265-011-9306-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 06/26/2011] [Indexed: 11/29/2022]
Abstract
Intimal hyperplasia is one of the prominent failure mechanisms for arteriovenous fistulas and arteriovenous access grafts. Human tissue-engineered vascular grafts (TEVGs) were implanted as arteriovenous grafts in a novel baboon model. Ultrasound was used to monitor flow rates and vascular diameters throughout the study. Intimal hyperplasia in the outflow vein of TEVGs was assessed at the anastomosis and at juxta-anastomotic regions via histological analysis, and was compared to intimal hyperplasia with polytetrafluoroethylene (PTFE) grafts in the baboon model and in literature reports from other animal models. Less venous intimal hyperplasia was observed in histological sections with arteriovenous TEVGs than with arteriovenous PTFE grafts. TEVGs were associated with a mild, noninflammatory intimal hyperplasia. The extent of intimal tissue that formed with TEVG placement correlated with the rate of blood flow through tissue engineered vascular grafts at 2 weeks postimplant. Outflow vein dilatation was observed with increased flow rate. Both mid-graft flow rates and outflow vein diameters reached a plateau by week 4, which suggested that venous remodeling and intimal hyperplasia largely occurred within the first 4 weeks of implant in the baboon model. Given their compliant and noninflammatory nature, TEVGs appear resistant to triggers for venous intimal hyperplasia that are common for PTFE arteriovenous grafts, including (1) abundant proinflammatory macrophage populations that are associated with PTFE grafts and (2) compliance mismatch between PTFE grafts and the outflow vein. Our findings suggest that arteriovenous TEVGs develop only a mild form of venous intimal hyperplasia, which results from the typical hemodynamic changes that are associated with arteriovenous settings.
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O'Brien PJ, Kim CY, Gage SM, Lawson JH. PS178. Expanded Use of the Hemodialysis Reliable Outflow (HeRO) Vascular Access Device for Permanent Dialysis Access in Patients with Total Central Venous Occlusion. J Vasc Surg 2011. [DOI: 10.1016/j.jvs.2011.03.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stroncek JD, Xue Y, Haque N, Lawson JH, Reichert WM. In vitro functional testing of endothelial progenitor cells that overexpress thrombomodulin. Tissue Eng Part A 2011; 17:2091-100. [PMID: 21466416 DOI: 10.1089/ten.tea.2010.0631] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study investigated the augmentation of endothelial progenitor cell (EPC) thromboresistance by using gene therapy to overexpress thrombomodulin (TM), an endothelial cell membrane glycoprotein that has potent anti-coagulant properties. Late outgrowth EPCs were isolated from peripheral blood of patients with documented coronary artery disease and transfected with an adenoviral vector containing human TM. EPC transfection conditions for maximizing TM expression, transfection efficiency, and cell viability were employed. TM-overexpressing EPCs had a fivefold increase in the rate of activated protein C production over native EPCs and EPCs transfected with an adenoviral control vector expressing β-galactosidase (p<0.05). TM upregulation caused a significant threefold reduction in platelet adhesion compared to native EPCs, and a 12-fold reduction compared to collagen I-coated wells. Additionally, the clotting time of TM-transfected EPCs incubated with whole blood was significantly extended by 19% over native cells (p<0.05). These data indicate that TM-overexpression has the potential to improve the antithrombotic performance of patient-derived EPCs for endothelialization applications.
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Affiliation(s)
- John D Stroncek
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708-0281, USA
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Dahl SLM, Kypson AP, Lawson JH, Blum JL, Strader JT, Li Y, Manson RJ, Tente WE, DiBernardo L, Hensley MT, Carter R, Williams TP, Prichard HL, Dey MS, Begelman KG, Niklason LE. Readily available tissue-engineered vascular grafts. Sci Transl Med 2011; 3:68ra9. [PMID: 21289273 DOI: 10.1126/scitranslmed.3001426] [Citation(s) in RCA: 361] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Autologous or synthetic vascular grafts are used routinely for providing access in hemodialysis or for arterial bypass in patients with cardiovascular disease. However, some patients either lack suitable autologous tissue or cannot receive synthetic grafts. Such patients could benefit from a vascular graft produced by tissue engineering. Here, we engineer vascular grafts using human allogeneic or canine smooth muscle cells grown on a tubular polyglycolic acid scaffold. Cellular material was removed with detergents to render the grafts nonimmunogenic. Mechanical properties of the human vascular grafts were similar to native human blood vessels, and the grafts could withstand long-term storage at 4 °C. Human engineered grafts were tested in a baboon model of arteriovenous access for hemodialysis. Canine grafts were tested in a dog model of peripheral and coronary artery bypass. Grafts demonstrated excellent patency and resisted dilatation, calcification, and intimal hyperplasia. Such tissue-engineered vascular grafts may provide a readily available option for patients without suitable autologous tissue or for those who are not candidates for synthetic grafts.
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Gage SM, Ahluwalia HS, Lawson JH. Salvaging Vascular Access and Treatment of Severe Limb Edema: Case Reports on the Novel Use of the Hemodialysis Reliable Outflow Vascular Access Device. Ann Vasc Surg 2011; 25:387.e1-5. [DOI: 10.1016/j.avsg.2010.09.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Revised: 07/07/2010] [Accepted: 09/26/2010] [Indexed: 11/26/2022]
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Dixon BS, Beck GJ, Dember LM, Vazquez MA, Greenberg A, Delmez JA, Allon M, Himmelfarb J, Hu B, Greene T, Radeva MK, Davidson IJ, Ikizler TA, Braden GL, Lawson JH, Cotton JR, Kusek JW, Feldman HI. Use of aspirin associates with longer primary patency of hemodialysis grafts. J Am Soc Nephrol 2011; 22:773-81. [PMID: 21415156 DOI: 10.1681/asn.2010060582] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Extended-release dipyridamole plus low-dose aspirin (ERDP/ASA) prolongs primary unassisted graft patency of newly created hemodialysis arteriovenous grafts, but the individual contributions of each component are unknown. Here, we analyzed whether use of aspirin at baseline associated with primary unassisted graft patency among participants in a randomized trial that compared ERDP/ASA and placebo in newly created grafts. We used Cox proportional hazards regression, adjusting for prespecified baseline comorbidities and covariates. Of all participants, 43% reported use of aspirin at baseline; of these, 82% remained on nonstudy aspirin (i.e., excluding ERDP/ASA) at 1 year. After 1 year of follow-up, the incidence of primary unassisted patency among participants using aspirin at baseline was 30% (95% CI: 24 to 35%) and among those not using aspirin was 23% (95% CI: 18 to 27%). Use of aspirin at baseline associated with a dose-dependent prolongation of primary unassisted graft patency that approached statistical significance (adjusted HR, 0.83; 95% CI: 0.68 to 1.01; P=0.06). Use of aspirin at baseline did not associate with prolongation of cumulative graft patency or participant survival. In conclusion, use of aspirin associates with a trend toward longer primary unassisted patency of newly placed hemodialysis grafts similar to that observed for ERDP/ASA.
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Affiliation(s)
- Bradley S Dixon
- Division of Nephrology, University of Iowa College of Medicine, E-300D GH, 200 Hawkins Drive, Iowa City, IA 52242-1081, USA.
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Sileshi B, Achneck H, Ma L, Lawson JH. Application of energy-based technologies and topical hemostatic agents in the management of surgical hemostasis. Vascular 2010; 18:197-204. [PMID: 20643029 DOI: 10.2310/6670.2010.00015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Achieving intraoperative hemostasis is essential for excellent surgical outcomes. A variety of methods, ranging from mechanical tools and energy-based technologies to topical hemostatic agents, are available to the modern surgeon. Given that bleeding develops from different origins, from small discrete bleeding or venous oozing to arterial hemorrhage, different tools and agents have different efficacy in specific situations. In this article, we review the mechanism by which currently available hemostatic tools and agents stop bleeding and give recommendations for their use during surgery. Furthermore, the costs of the various methods are presented, allowing the provider to choose not only the most potent but also the most cost-effective treatment modality in each situation.
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Affiliation(s)
- Bantayehu Sileshi
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Achneck HE, Sileshi B, Li M, Partington EJ, Peterson DA, Lawson JH. Surgical aspects and biological considerations of arteriovenous fistula placement. Semin Dial 2010; 23:25-33. [PMID: 20331815 DOI: 10.1111/j.1525-139x.2009.00651.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Since the Fistula First Initiative was formulated in 2003, providers and payers have increasingly emphasized the need to create more arteriovenous fistulae. To maximize the chances of successful fistula maturation, a thorough understanding of the biology and surgical aspects of fistula placement are essential. A functional endothelium in the target vessels is the prerequisite for the adaptive remodeling of the vessel wall, which has to take place after fistula formation. Mechanoreceptors of the endothelium sense the increase in shear stress and, through a variety of activated signaling cascades, induce the necessary changes and vasodilation of the respective vessels. The successful fistula placement starts with a thorough preoperative evaluation, which focuses on protecting the target vessels and avoiding intravenous catheters and devices. Intraoperatively, the risk of endothelial dysfunction and hyperplasia is further minimized through an atraumatic dissection with minimal manipulation of the vein and artery. The surgical technique should also focus on decreasing the vessel compliance mismatch and avoiding an inflammatory response secondary to hematoma formation. Postoperatively, the fistula must be diligently monitored for the complications of thrombosis, postoperative steal syndrome, neuropathy, aneurysm formation, infection, and high-output cardiac failure. Early recognition of a problem is the key to saving an otherwise doomed fistula. An armamentarium of percutaneous techniques is available to the access surgeon to treat the most common causes of failed access formation. However, in some cases a surgical revision of the access site through patch angioplasty, a jump graft, and graft interposition is necessary to create a fistula which can be successfully used for hemodialysis.
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Affiliation(s)
- Hardean E Achneck
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Achneck HE, Serpe MJ, Jamiolkowski RM, Eibest LM, Craig SL, Lawson JH. Regenerating titanium ventricular assist device surfaces after gold/palladium coating for scanning electron microscopy. Microsc Res Tech 2010; 73:71-6. [PMID: 19642216 DOI: 10.1002/jemt.20757] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Titanium is one of the most commonly used materials for implantable devices in humans. Scanning electron microscopy (SEM) serves as an important tool for imaging titanium surfaces and analyzing cells and other organic matter adhering to titanium implants. However, high-vacuum SEM imaging of a nonconductive sample requires a conductive coating on the surface. A gold/palladium coating is commonly used and to date no method has been described to "clean" such gold/palladium covered surfaces for repeated experiments without etching the titanium itself. This constitutes a major problem with titanium-based implantable devices which are very expensive and thus in short supply. Our objective was to devise a protocol to regenerate titaniumsurfaces after SEM analysis. In a series of experiments, titanium samples from implantable cardiac assist devices were coated with fibronectin, seeded with cells and then coated with gold/palladium for SEM analysis. X-ray photoelectron spectroscopy spectra were obtained before and after five different cleaning protocols. Treatment with aqua regia (a 1:3 solution of concentrated nitric and hydrochloric acid), with or without ozonolysis, followed by sonication in soap solution and sonication in deionized water, allowed regenerating titanium surfaces to their original state. Atomic force microscopy confirmed that the established protocol did not alter the titanium microstructure. The protocol described herein is applicable to almost all titanium surfaces used in biomedical sciences and because of its short exposure time to aqua regia, will likely work for many titanium alloys as well.
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Affiliation(s)
- Hardean E Achneck
- Department of Surgery, Division of General Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Levy JH, Dutton RP, Hemphill JC, Shander A, Cooper D, Paidas MJ, Kessler CM, Holcomb JB, Lawson JH. Multidisciplinary Approach to the Challenge of Hemostasis. Anesth Analg 2010; 110:354-64. [DOI: 10.1213/ane.0b013e3181c84ba5] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Conte MS, Nugent HM, Gaccione P, Guleria I, Roy-Chaudhury P, Lawson JH. Multicenter phase I/II trial of the safety of allogeneic endothelial cell implants after the creation of arteriovenous access for hemodialysis use: The V-HEALTH study. J Vasc Surg 2009; 50:1359-68.e1. [DOI: 10.1016/j.jvs.2009.07.108] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Revised: 07/21/2009] [Accepted: 07/25/2009] [Indexed: 11/15/2022]
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Peterson D, Harward S, Lawson JH. Anticoagulation strategies for venous thromboembolism. ACTA ACUST UNITED AC 2009; 21:125-32. [PMID: 19767406 DOI: 10.1177/1531003509343018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Venous thromboembolism (VTE) continues to be a major source of morbidity and mortality in the United States with an estimated incidence of greater than 600 000 clinically evident cases each year. It results in more than 200 000 deaths per year and is thought to be the number one cause of preventable in-hospital deaths. This review presents the history, pathophysiology, diagnostic considerations, and treatment options for VTE.
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Evans DC, Sileshi B, Zakaria AM, Giangiacomo D, Manson RJ, Lawson JH. Genomic Modeling of Atherosclerosis in Peripheral Arterial Disease and Its Variant Phenotype in Patients with Diabetes. Vascular 2008; 16:225-35. [DOI: 10.2310/6670.2008.00037] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Microarrays can be used to discover candidate genes associated with peripheral arterial disease (PAD) and develop models that predict patient clinical status. We hypothesize that multiple phenotypes of PAD with distinct patterns of gene expression exist. We histologically characterized and extracted ribonucleic acid from 31 arterial samples collected from the lower extremities of patients undergoing amputation or free fibular grafting. Analysis using the Affymetrix U133A microarray identified 335 genes with twofold or greater differences in expression between normal and diseased arteries ( p < .01) and 104 genes with twofold or greater differences between diabetic and nondiabetic atherosclerotic arteries ( p < .1). Many genes identified have known roles in inflammatory and lipid uptake pathways. Predictive models were developed that could predict PAD and the associated diabetic phenotype with an accuracy of 71 to 90%. Developing distinct genomic models of PAD will serve as the first step toward understanding the molecular and genetic basis of PAD and subsequent application of novel therapeutics to this condition.
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Affiliation(s)
- David C. Evans
- *Department of Surgery, Duke University Medical Center, Durham, NC; †Department of Surgery, Ohio State University Medical Center, Columbus, OH; ‡Department of Pathology, Duke University Medical Center, Durham, NC
| | - Bantayehu Sileshi
- *Department of Surgery, Duke University Medical Center, Durham, NC; †Department of Surgery, Ohio State University Medical Center, Columbus, OH; ‡Department of Pathology, Duke University Medical Center, Durham, NC
| | - Aamir M. Zakaria
- *Department of Surgery, Duke University Medical Center, Durham, NC; †Department of Surgery, Ohio State University Medical Center, Columbus, OH; ‡Department of Pathology, Duke University Medical Center, Durham, NC
| | - Dana Giangiacomo
- *Department of Surgery, Duke University Medical Center, Durham, NC; †Department of Surgery, Ohio State University Medical Center, Columbus, OH; ‡Department of Pathology, Duke University Medical Center, Durham, NC
| | - Roberto J. Manson
- *Department of Surgery, Duke University Medical Center, Durham, NC; †Department of Surgery, Ohio State University Medical Center, Columbus, OH; ‡Department of Pathology, Duke University Medical Center, Durham, NC
| | - Jeffrey H. Lawson
- *Department of Surgery, Duke University Medical Center, Durham, NC; †Department of Surgery, Ohio State University Medical Center, Columbus, OH; ‡Department of Pathology, Duke University Medical Center, Durham, NC
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Adams GL, Manson RJ, Hasselblad V, Shaw LK, Lawson JH. Acute in-vivo evaluation of bleeding with GelfoamTM plus saline and Gelfoam plus human thrombin using a liver square lesion model in swine. J Thromb Thrombolysis 2008; 28:1-5. [DOI: 10.1007/s11239-008-0249-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 06/23/2008] [Indexed: 11/25/2022]
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Haney JC, Shortell CK, McCann RL, Lawson JH, Stirling MJ, Stone DH. Congenital jugular vein phlebectasia: a case report and review of the literature. Ann Vasc Surg 2008; 22:681-3. [PMID: 18462919 DOI: 10.1016/j.avsg.2008.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2007] [Revised: 01/16/2008] [Accepted: 02/13/2008] [Indexed: 01/25/2023]
Abstract
Fusiform dilation of the jugular vein, or jugular venous phlebectasia, is a rare clinical entity, with an etiology of cervical swelling. We present a case of a 15-year-old male with no antecedent history of trauma and an enlarging right neck mass. Pertinent literature and relevant diagnostic and therapeutic modalities are reviewed. While conservative management is usually prescribed, ligation and resection may be performed safely when intervention is warranted.
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Affiliation(s)
- John C Haney
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Diesen DL, Lawson JH. Bovine thrombin: history, use, and risk in the surgical patient. Vascular 2008; 16 Suppl 1:S29-S36. [PMID: 18544303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Thrombin is a common hemostatic drug used in surgical practice for over 100 years because of its simplicity and efficacy. Thrombin converts fibrinogen to fibrin, activates platelets, and induces vascular contraction. It is available in multiple forms, including human thrombin, bovine thrombin, and, most recently, human recombinant thrombin. Over 100 case reports of adverse reactions to bovine thrombin include hemorrhage, thrombosis, and substantial immune reaction when used on cardiovascular surgery patients. Approximately 30% of patients exposed to bovine thrombin develop cross-reacting antibodies. Thirty percent of patients with anticlotting factor antibodies develop abnormal coagulation that can be detected by prothrombin time, partial thromboplastin time, or thrombin time, which makes anticoagulation monitoring difficult. Patients with multiple elevated antibodies prior to surgery are also more likely to sustain adverse events. Animal studies confirm these immunological responses seen in humans. With the available clinical and laboratory data, a less immunogenic yet biologically effective thrombin should be available for use in our surgical patients.
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Affiliation(s)
- Diana L Diesen
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Sileshi B, Achneck HE, Lawson JH. Management of surgical hemostasis: topical agents. Vascular 2008; 16 Suppl 1:S22-S28. [PMID: 18544302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Intraoperative control of bleeding during any surgical procedure is vital for achieving a positive patient outcome. Hemostasis can be achieved through practical and effective systemic or topical approaches. A variety of hemostatic methods can be employed, ranging from simple manual pressure application with one finger to electrical tissue cauterization, systemic administration of blood products, and systemic administration or topical application of procoagulation agents. The key to surgical success is critically dependent on knowledgeable use of a method appropriate for the level of bleeding experienced by the patient. Topical agents can be effective as adjuncts to aid in hemostasis when bleeding is not controllable with pressure application, vessel ligation, or electrocautery. Such adjunctive hemostatic treatments include topical gelatins, collagens, oxidized celluloses, thrombin and fibrin sealants, synthetic glues, and glutaraldehyde-based glues. As with the use of systemically delivered hemostatic agents, topical treatments also carry risks with their use, and their efficacy has not been extensively studied in large randomized, placebo-controlled prospective studies. The effective use of topical agents is highly dependent on the surgeon's experience or preference and their availability in the surgical setting. In this article, we review the currently available topical hemostatic agents, compare their efficacy, and give general recommendations for their use in the operating room.
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Affiliation(s)
- Bantayehu Sileshi
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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