Vascular Histocompatibility

Bio E 802 - 20

VASCULARHISTOCOMPATIBILITY

Most vascular surgeries involve arteries, which are severely damaged by atherosclerosis. Advanced atherosclerosis causes narrowing of the vascular lumen, the result of thickening of the wall where cholesterol, necrosis, calcium deposits, macrophages, and fibrous connective tissue replace the smooth muscle cells and elastic tissue of the tunica media. Generally, the most severely damaged or anatomically critical portion of the artery is removed. Then the two cut ends of the vessel are connected by the vascular graft (the junction is called an anastomosis). The reactions that vascular prostheses evoke are similar to those of an atherosclerotic deposit. Thus it is important for us to learn the process of atherosclerosis first.

Two hypotheses for atherosclerosis Injury response, Ross, Glomset -injured endothelium -WBC attachment -SMC activation-transformation -SMC make ECM -Role of PDGF Serum vs. plasma Cholesterol hypothesis -Cholesterol accumulation -familial hypercholestrolemia (FH) -Lack of LDL receptor -Macrophage have another receptor for damaged LDL -macrophage to foam cells -LDL oxidation

Two phases of SMC contractile and synthetic -Role of PDGF (hard to stop SMC growth) -Focus on vascular endothelial growth factor (VEGF), -endothelial band-aid -Role of nitric oxide allow SMC to relax -decrease in NO causes endothelial dysfunction

AtherosclerosisHistology Atherosclerosis begins with the deposition of cholesterol within the tunica media of the vessel. This leads to necrosis of the smooth muscle cells, which in turn, leads to the acute and chronic inflammatory processes. Dystrophic mineralization may occur secondary to the necrosis. This inflammatory process (which begins in the tunica media) may invade the tunica intima and disrupt the endothelium. This exposes the underlying collagen and smooth muscle to blood and results in activated platelets and presence of coagulation factor XII. Consequently, an intravascular blood clot or thrombus is formed. Any process disrupting the endothelium, such as trauma or atherosclerosis will lead to the above sequence of events and can lead to thrombosis and occlusion of the vessel.

Thus, histologically atherosclerotic arteries have narrowed lumens and cholesterol deposits within the tunica media. Necrosis of smooth muscle and resulting inflammatory cells and dystrophic mineralization can also be observed. A thrombus may be seen occluding the lumen. Thrombi are eventually penetrated by capillaries that nourish fibroblasts as they deposit collagen in a process called organization. Thus, the new surface becomes fibrous and simple squamous endothelial cells may migrate over the surface to form an incomplete intima.

The unorganized thrombus is structurally weak. An embolus is produced when something dislodges in the vascular system and becomes lodged elsewhere. A thromboembolus is an undesirable consequence of the tissue reaction to vascular grafts. Emboli often become lodged in small arteries or capillaries. An embolus causes an infarct, a local area of necrosis resulting from a severe degree of hypoxia. A clinical example of an infarct is a myocardial infarction resulting from occlusion of the coronary vessels. This causes death of an area of cardiac muscle that was supplied by that coronary vessel.

Vessels affected by atherosclerosis loose their elasticity and are prone to aneurysms. An aneurysm is a dilation of the weakened wall of a blood vessel and is prone to rupture. This pathology in the wall causes changes in its compliance, which may result in turbulent blood flow that creates areas of relative stasis. These static areas also promote blood coagulation. Advanced atherosclerosis of the terminal aorta may result in aneurysm formation. Complex cholesterol deposits and fibrous tissue replace the aortic wall.

Vascular stents

Vascular grafts

HistocompatibilityofVascularProstheses
Surgical trauma will (as usual) lead to the inflammatory cascade. In addition, remember that platelets incite thrombosis whenever they come in contact with a surface other than the endothelium. Thus, thrombosis is expected on the surface of vascular prostheses. The basic response to vascular grafts is one of blood coagulation, which involves protein adsorption, platelet adhesion and activation, as well as activation of the intrinsic coagulation system resulting in a thrombus. After fibrin is deposited, the cellular components (RBC, WBC, thrombocytes) of the thrombus break down and the thrombus is vascularized, bringing in fibroblasts that deposit collagen. This process is called organization of the thrombus. This tissue then forms a neointima upon which endothelial cells may grow. Endothelialization proceeds from the ends of the graft, but rarely reaches across the entire length of the graft.

The success of vascular grafts is dependent on partial vascular occlusion by this process. The development of a neo-intima beneath which collagen, and to a lesser degree smooth muscle and elastic tissue, may regenerate represents the most advanced degree of organization and incorporation into the host. Such a reaction may be observed in vascular grafts. The normal gross appearance of the vascular endothelium is that of a smooth, white surface. With turbulent blood flow caused by an anastomosis, a vascular graft or a heart valve, erythrocytes are traumatized and become lysed. This destruction of red blood cells hemolysis may also be observed histologically. Implants such as stents produce a result that reflects both the host response to a foreign material (the graft) and the incorporation of a foreign body into an organizing thrombus within an already damaged vessel.

Most testing of prosthetic vascular grafts is preformed in normal, non-atherosclerotic vessels. This allows examination of the organizational response to the material under optimal conditions. Significant or persistent inflammation or excessive fibrosis should be noted as significant disadvantages of the material. Materials, which are excessively inflammatory or reactive, will probably not function well in an already compromised, atherosclerotic vessel. Typical corrugated vascular grafts are organized by host connective tissue and vascular elements resembling intima. The response to prosthetic vascular grafts varies from a fibrotic foreign body response exclusively to partial regeneration of intima and subintimal muscle and connective tissue.

HistologyofOtherVascularSurgicalProcesses There are several other surgical procedures that are performed routinely to correct the hundreds of possible vascular anomalies. The anomalies themselves or the surgical procedure used to correct them can result in hemolysis. The wall of the human aorta at birth is smooth and elastic. Hemolysis causes red staining of the surface due to the intravascular destruction of erythrocytes. Free hemoglobin is released which can be incorporated into the artery. Materials used today: Poly (ethylene terephthalate)/Dacron, PTFE, poly-propylene, polyurethanes Autologus vein graft is still a gold standard for coronary bypass graft

Copyright MedReviews, LLC. Kereiakes DJ, Choo JK, Young JJ, Broderick TM. Thrombosis and drug-eluting stents: A critical appraisal. Rev Cardiovasc Med. 2004; 5:10. Reviews in Cardiovascular Medicine is a copyrighted publication of MedReviews, LLC. All rights reserved. Multiple and diverse factors contributing to stent thrombosis. CHF, congestive heart failure. Modified with permission from Honda Y, Fitzgerald PJ. Stent thrombosisan issue revisited in a changing world. Circulation. 2003;108:25.

Pathology of Stent Restenosis

Josiah Wilcox PhD Medtronic, Inc.

Endothelial injury post implantation

Implanted stent

Plaque
Stent implantation causes arterial injury, which can initiate restenosis. The restenosis process includes inflammation, migration of smooth 15 muscle cells, smooth muscle cellproliferation and extracellular matrix formation.

Platelet aggregation and activation

Drug-eluting stent struts Platelets Red blood cells Inflammatory cells Platelet deposition and activation occur at the injury site, leading to the release of cell-signaling molecules. 16

Transmigration of inflammatory cells (I)

Activated inflammatory cells Intima Cell surface receptors Media Inflammatory cells The cell-signaling molecules induce expression of cell surface receptors that bind to circulating inflammatory cells. 17

Transmigration of inflammatory cells (II)

Endothelial cells Transmigration of inflammatory cells Smooth muscle cells Inflammatory cells secreting cellsignaling molecules Once activated, these inflammatory cells roll across the18 endothelial surface and transmigrate into the lesion.

Activation of smooth muscle cells (I)

Smooth muscle cell extracellular view Cell signaling molecules activate smooth muscle cells

Smooth muscle Cell surface receptor The activated inflammatory cells secrete molecules that bind to specific receptors on smooth muscle cells. 19

Activation of smooth muscle cells (II)

Smooth muscle cell intracellular view Activated smooth muscle cell receptor mTOR activates smooth muscle cells to enter cell cycle

Bound smooth muscle cell receptors activate various intracellular smooth muscle cell proteins. One such protein, mTOR, plays a 20 central regulatory role in the cell cycle.

Activation of smoothmuscle cells (III)

Cell responds to growth factor stimulation Mitosis Cell resting phase Restriction point

Cell prepares for mitosis

DNA synthesis

Activated mTOR stimulates smooth muscle cells to advance from the G121phase to the S phase where DNA replication occurs, causing the smooth muscle cells to undergo mitosis (ie, cell proliferation).

Activation of smooth muscle cells (IV)

Extracellular matrix

Proliferating smooth muscle cells

Proliferation of smooth muscle cells increases the cellular mass in the neointima, leading to restenosis. 22

Drug diffusion

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How much late loss is clinically relevant?

Late loss 0.2 mm Late loss 0.6 mm DS 6% DS 17% Diameter stenosis 3.5-mm vessel Late loss 1.2 mm DS 34%

Patent lumen Exposed struts? Late loss 0.2 mm Late loss 0.6 mm Late loss 1.2 mm DS 8% DS 24% DS 48% Diameter stenosis 2.5-mm vessel Exposed struts? Patent lumen

Illustrations for demonstration purposes only.

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Clinical relevance of low late loss

Preprocedure
Source: HCRI EIII 9 month (IVUS 8 months).

Postprocedure

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Late stent thrombosis: Factors to consider

Discontinuation of antiplatelet therapy

Delayed endothelialization

Late stent thrombosis Late stent thrombosis

Late incomplete apposition

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Polymer hypersensitivity/ inflammation

SpecialStainsUsedinVascularCompatibility To better visualize the structures in the vasculature, several special staining procedures are required. 1. Hematoxylin and eosin for general staining of morphology. 2. Aldehyde Fuchsin or Verhoeffs stain for demonstration of elastic fibers (purple and black respectively). 3. An elastin stain often combined with a connective tissue stain such as Masson (muscle red, connective tissue green or blue) or Van Gieson's picrofuchsin (smooth muscle yellow, connective tissue red). 4. Phosphotungstic acid hematoxylin which will differentiate cardiac or smooth muscle in blue shades, connective tissue and elastin orange to red shades, and fibrin dark purple. 5. Both transmission and scanning electron microscopy are also valuable in the examination of vascular tissues. 6. Endothelial cells can be readily identified by their alkaline phosphatase and adenosine triphosphatase activity. The presence of factor VIII activity can also be demonstrated in endothelial cells by immunofluorescent techniques.