Atherosclerotic plaque-like lesions in synthetic arteriovenous grafts: implications for atherogenesis

Haemodynamic Wall Shear Stress, Endothelial Permeability and Atherosclerosis-A Triad of Controversy

A striking feature of atherosclerosis is its patchy distribution within the vascular system; certain arteries and certain locations within each artery are preferentially affected. Identifying the local risk factors underlying this phenomenon may lead to new therapeutic strategies. The large variation in lesion prevalence in areas of curvature and branching has motivated a search for haemodynamic triggers, particular those related to wall shear stress (WSS). The fact that lesions are rich in blood-derived lipids has motivated studies of local endothelial permeability. However, the location of lesions, the underlying haemodynamic triggers, the role of permeability, the routes by which lipids cross the endothelium, and the mechanisms by which WSS affects permeability have all been areas of controversy. This review presents evidence for and against the current consensus that lesions are triggered by low and/or oscillatory WSS and that this type of shear profile leads to elevated entry of low density lipoprotein (LDL) into the wall via widened intercellular junctions; it also evaluates more recent evidence that lesion location changes with age, that multidirectional shear stress plays a key role, that LDL dominantly crosses the endothelium by transcytosis, and that the link between flow and permeability results from hitherto unrecognised shear-sensitive mediators.

The role of chronic hyperviscosity in vascular disease

The pathogenesis of several major cardiovascular diseases, including atherosclerosis, hypertension, and the metabolic syndrome, is not widely understood because the role of blood viscosity is overlooked. Low-density lipoprotein accelerates atherosclerosis by increasing blood viscosity in areas of low flow or shear, predisposing to thrombosis. Atherosclerotic plaques are organized mural thrombi, as proposed by Duguid in the mid-twentieth century. High-density lipoprotein protects against atherosclerosis by decreasing blood viscosity in those areas. Blood viscosity, at the least, contributes to hypertension by increasing systemic vascular resistance. Because flow is inversely proportional to viscosity, hyperviscosity decreases perfusion and glucose utilization by skeletal muscle, contributing to hyperglycemia in the metabolic syndrome. Therapeutic phlebotomy reduces blood pressure and serum glucose levels in the metabolic syndrome by improving blood viscosity.

MECHANICAL PROPERTIES OF GREAT ARTERIAL WALL AND CLINICAL IMPLICATION

X-ray diffraction and microscopic analysis investigate the morphological organization of the structural components in the dog carotid wall. Histological analysis confirms an anisotropic morphology of smooth muscle cells and elastic fibers in the tissue. Collagen fibers, as revealed by X-ray diffraction technique, are organized in an isotropic network in the unstretched carotid media. Collagen fibers stretch without a preferential direction of orientation when a carotid segment is deformed in the physiological range under intraluminal pressure. A mathematical model, which takes into account the isotropic distribution of the collagen fibers, is developed. The validity of this model has been tested by computing several mechanical parameters using Anliker's data on the axial and radial oscillation obtained for carotids of living dogs. In spite of the anisotropic morphology of the main constituents of the carotid media layer, from a mechanical point of view the tissue can be considered as an isotropic material for the random distribution of the collagen fibers, which represent the component of higher tensile strength.

Longitudinal assessment of hyperplasia using magnetic resonance imaging without contrast in a porcine arteriovenous graft model

RATIONALE AND OBJECTIVES

Chronic hemodialysis requires a vascular access that provides high blood-flow rates for the extracorporeal recirculation of blood. Synthetic arteriovenous (AV) grafts often fail because of clotting caused by underlying hyperplasia formation. The authors report the use of magnetic resonance (MR) imaging (MRI) without contrast agent to monitor tissue hyperplasia formation as well as luminal area in a porcine model of AV graft stenosis.

MATERIALS AND METHODS

Expanded reinforced polytetrafluoroethylene grafts were surgically placed between the common carotid artery and the external jugular vein, bilaterally, in pigs. Animals underwent MRI in a 3-T scanner at 3, 4, or 6 weeks after graft placement, followed by euthanasia and the collection of grafts and adjacent tissues for histologic analysis. Two animals underwent sequential scanning at 1, 2, 3, 5, and 7 weeks after graft placement, followed by histologic analysis.

RESULTS

Measurements of hyperplasia obtained from the MR images were compared with, and correlated well with, measurements obtained from the histologic cross-sections (r = 0.932, P = .02). The MR images provided a more complete view of the venous hyperplasia throughout the graft compared with histology. The MR images could be examined from multiple angles and were unaffected by histologic preparation artifacts.

CONCLUSION

Unlike histology, MRI provided longitudinal 3-dimensional views of hyperplasia within the AV grafts. This ability of MRI to more completely identify the geometry of hyperplasia and to quantify the tissue volume in vivo could provide benefits over histologic analysis in assessing the pathology of AV graft failure and the efficacy of antihyperplasia interventions.

Are intramural suction-squeezing effects generated by the variations in radial wall stress during each heart beat the motor of atherosclerosis? A new concept

In the early sixties, the existence of predilection sites for atherosclerotic lesions inside the arterial circulation led to the concept that low wall shear stress (WSS) was responsible, together with systemic factors like high blood pressure, hypercholesterolemia, or diabetes, for the genesis and progression of atherosclerosis. It was found later that oscillating WSS and high WSS gradients could also be incriminated. Yet, this concept, which is broadly accepted today, fails to explains several facts, for instance that some arteries (e.g. epicardial coronary arteries) are more prone to become atherosclerotic than other ones exposed to the same systemic factors (e.g. hepatic and brain arteries). In this paper, we present a quite different concept. It is based on the fact that the increase in intravascular pressure and flow that occur in the arteries during systole generates, at the predilection sites of atherosclerotic lesions (bends, bifurcations, and branchings), an increase of radial wall stress in the outer layers of the arterial wall so that this stress becomes momentarily tensile. These cyclic stress increases have a suction effect that is likely to facilitate the diffusion of atherogenic cells and substances inside the wall. Furthermore, since arteries are not primarily structured to resist inversions of radial stress, they may also create damages (e.g. disruptions of cell membranes and elastic lamellae) followed by inflammations and micro-haemorrhages in the wall. This new concept may provide a complementary (or possibly alternative) explanation of atherosclerosis.

Grafts and graft materials as vascular substitutes for haemodialysis access construction

Apart from long-term central venous catheterisation, the insertion of an arteriovenous graft (AVG) remains the only option to allow continued haemodialysis when the patient's superficial veins have been exhausted. Although, expanded PTFE has become the graft of choice for haemodialysis access throughout the world, many other organic or semi-organic materials are currently available for AVG construction. These are less prone to steal syndrome, easier to handle, more resistant to infection and may have similar, if not better, long term patencies.

Particle hemodynamics analysis of Miller cuff arterial anastomosis

OBJECTIVE

Studies of animal and human below-knee anastomoses with Miller cuffs indicate that improved graft patency results from redistribution of intimal hyperplasia away from areas critical to flow delivery, such as the arterial toe. We hypothesize that particle hemodynamic conditions are a biophysical mechanism potentially responsible for the clinically observed shift in intimal hyperplasia localization associated with better patency of the Miller configuration.

METHODS

Computational fluid dynamics analysis of vortical flow patterns, wall shear stress fields, and potential for platelet interaction with the vascular surface was performed for realistic three-dimensional conventional and Miller cuff distal end-to-side anastomoses. Sites of significant platelet-wall interaction, including elevated near-wall particle concentrations and stasis, were identified with a validated near-wall residence time model, which includes shear stress-based factors for particle activation and surface reactivity.

RESULTS

Particle hemodynamics largely coincide with the observed redistribution of intimal hyperplasia away from the critical arterial toe region. Detrimental changes in wall shear stress vector magnitude and direction are significantly reduced along the arterial suture line of the Miller cuff, largely as a result of increased anastomotic area available for flow redirection. However, because of strong particle-wall interaction, resulting high near-wall residence time contours indicate significant intimal hyperplasia along the graft-vein suture line and in the vicinity of the arterial heel.

CONCLUSIONS

While a number of interacting mechanical, biophysical, and technical factors may be responsible for improved Miller cuff patency, our results imply that particle hemodynamics conditions engendered by Miller cuff geometry provide a mechanism that may account for redistribution of intimal hyperplasia. In particular, it appears that a focal region of significant particle-wall interaction at the arterial toe is substantially reduced with the Miller cuff configuration.

Particle-hemodynamics modeling of the distal end-to-side femoral bypass: effects of graft caliber and graft-end cut

Late-stage occlusions of peripheral synthetic bypass grafts are frequently due to intimal hyperplasia and/or thrombosis at the distal anastomosis, resulting in unacceptably high failure rates. It has been widely established that hemodynamic and blood particle interactions with the vascular surface as well as surgical injury and compliance mismatch are inciting mechanisms capable of eliciting various cellular level responses associated with distal anastomotic intimal hyperplasia (IH) formation. Primary geometric factors influencing anastomotic hemodynamics include the graft-to-artery diameter ratio and graft-hood shape, which are determined by the graft caliber and initial graft-end cut selected by the vascular surgeon. In this study, the particle-hemodynamic effects of graft-end cuts (straight, curved, and S-shaped) and graft-to-artery diameter ratios (2:1 vs. 1.5:1) have been numerically assessed in four common unexpanded anastomotic configurations with respect to vortical flow patterns, wall shear stress based parameters, and platelet interactions with the vascular surface. Sites of significant platelet-wall interactions have been identified by a novel near-wall residence time (NWRT) model, which includes shear stress based factors for platelet activation and endothelial cell expression of anti-thrombogenic compounds. Of the configurations evaluated, straight and curved graft-end cuts with a graft-to-artery diameter ratio of 1.5:1 were found to reduce the particle-hemodynamic potential for IH development at locations critical to flow delivery. Nevertheless, the potential for significant IH occurrence via platelet and/or endothelial response pathways was highly evident in all conventional anastomoses considered, such that a decisively superior configuration was not determined. These results illustrate the need for alternative anastomotic designs with the intent of reducing critical hemodynamic wall parameters and mitigating regions of significant particle-wall interactions.

Numerical Simulation of Wall Shear Stress Conditions and Platelet Localization in Realistic End-to-Side Arterial Anastomoses

Research studies over the last three decades have established that hemodynamic interactions with the vascular surface as well as surgical injury are inciting mechanisms capable of eliciting distal anastomotic intimal hyperplasia (IH) and ultimate bypass graft failure. While abnormal wall shear stress (WSS) conditions have been widely shown to affect vascular biology and arterial wall self-regulation, the near-wall localization of critical blood particles by convection and diffusion may also play a significant role in IH development. It is hypothesized that locations of elevated platelet interactions with reactive or activated vascular surfaces, due to injury or endothelial dysfunction, are highly susceptible to IH initialization and progression. In an effort to assess the potential role of platelet-wall interactions, experimentally validated particle-hemodynamic simulations have been conducted for two commonly implemented end-to-side anastomotic configurations, with and without proximal outflow. Specifically, sites of significant particle interactions with the vascular surface have been identified by a novel near-wall residence time (NWRT) model for platelets, which includes shear stress-based factors for platelet activation as well as endothelial cell expression of thrombogenic and anti-thrombogenic compounds. Results indicate that the composite NWRT model for platelet-wall interactions effectively captures a reported shift in significant IH formation from the arterial floor of a relatively high-angle (30 deg) graft with no proximal outflow to the graft hood of a low-angle graft (10 deg) with 20% proximal outflow. In contrast, other WSS-based hemodynamic parameters did not identify the observed system-dependent shift in IH formation. However, large variations in WSS-vector magnitude and direction, as encapsulated by the WSS-gradient and WSS-angle-gradient parameters, were consistently observed along the IH-prone suture-line region. Of the multiple hemodynamic factors capable of eliciting a hyperplastic response at the cellular level, results of this study indicate the potential significance of platelet-wall interactions coinciding with regions of low WSS in the development of IH.