Veins are no arteries: even moderate arterial pressure induces significant adhesion molecule expression of vein grafts in an ex vivo circulation model

AIM

Coronary artery bypass grafting (CABG) is a standard procedure for treatment of coronary heart disease. Eighty percent of all CABGs are performed with venous grafts which then get exposed to an arterial pressure after surgery. This widely used procedure, however, is complicated by the development of alterations in the vein graft wall, leading to a decreased patency rate and graft failure. This study enlightens the influence of an even moderate arterial pressure on the gene expression of adhesion molecules in venous grafts which play a decisive role for the early induction of atherogenesis.

METHODS

Segments of porcine vena jugularis and arteria carotis were mounted in a simulated bypass circuit and subjected to pulsatile flow. Vessel segments were examined for adhesion molecule expression with quantitative real-time - polymerase chain reaction (qRT-PCR) and adherence of leukocytes was observed by confocal laser scanning microscopy and scanning electron microscopy.

RESULTS

Veins grafts subjected to an even moderate arterial pressure showed a 14-fold increase of ICAM-1 expression already after 4 hours. An arterial pressure of around 100/80 mmHg was enough to stimulate the adhesion molecule expression Furthermore it led to a 9-fold increase of leukocyte adhesion to the venous endothelium, but, in contrast this was not the case in arteries.

CONCLUSION

This study showed, that already 100 mmHg upregulates the expression of several adhesion molecules in pig veins followed by increased adhesion of leukocytes. Therefore, our data demonstrate the advantage of arteries for CABG, and that new therapeutic strategies are urgently necessary to protect vein grafts either physically or pharmacologically if arteries are not available for CABG.

Matrix metalloproteinase expression in vein grafts: role of inflammatory mediators and extracellular signal-regulated kinases-1 and -2

Matrix metalloproteinases (MMPs) play key roles in vascular remodeling. We characterized the role of inflammatory mediators and extracellular signal-regulated kinases (ERKs) in the control of arterialized vein graft expression of MMP-9, MMP-2, and membrane-type 1-MMP (MT1-MMP) and of the tissue inhibitor of metalloproteinases-2 (TIMP-2). For this purpose we used a canine model of jugular vein to carotid artery interposition graft and analyzed the vein grafts at various postoperative times (30 min to 28 days) using the contralateral vein as a control. To study the role of ERK-1/2, veins were incubated with the mitogen-activated protein kinase kinase (MEK-1/2) inhibitor UO126 for 30 min before being grafted. Vein graft extracts were analyzed for MMPs, TIMP-2, tumor necrosis factor-alpha (TNF-alpha), polymorphonuclear neutrophil (PMN) infiltration, myeloperoxidase (MPO), and thrombin activity, and for ERK-1/2 activation. Vein graft arterialization resulted in rapid and sustained (8 h to 28 days) upregulation of vein graft-associated MMP-9, MMP-2, MT1-MMP, thrombin activity, and TNF-alpha levels with concomitant TIMP-2 downregulation. MMP-2 activation preceded MT1-MMP upregulation. PMN infiltration and vein graft-associated MPO activity increased within hours after arterialization, indicating a prompt, local inflammatory response. In cultured smooth muscle cells, both thrombin and TNF-alpha upregulated MT1-MMP expression; however, only thrombin activated MMP-2. Inhibition of ERK-1/2 activation blocked arterialization-induced upregulation of MMP-2, MMP-9, and MT1-MMP. Thus, thrombin, inflammatory mediators, and activation of the ERK-1/2 pathway control MMP and TIMP-2 expression in arterialized vein grafts.

[Immunogenicity of bovine jugular vein conduits treated with different cross-linking methods]

OBJECTIVE

To evaluate the immunogenicity of bovine jugular vein conduits (BJVCs) treated with different cross-linking methods.

METHODS

The BJVCs were treated with glutaradehyde (GA), dye-mediated photooxidation (DMP) and polyepoxy compound (PC) (n = 10). The tissue homogenates obtained from BJVCs treated with PC, GA, DMP, and fresh BJVCs, were mixed with the complete Freand adjavant to form the emulsive antigen, which were used to immunize rabbits correspondently. The antibody concentrations to BJVCs in those rabbits' serum were measured by counter double immuno diffusion. The immunologic responses to the BJVCs in different groups were measured with Western blotting.

RESULTS

The positive bands appeared when the sera of rabbits were immunized by fresh BJVCs reacted with antigens of fresh BJVCs, but no bands appeared when the sera of rabbits were immunized by fresh BJVCs reacted with those antigens of the BJVCs treated with GA, DMP, and PC in Western blotting.

CONCLUSION

The immunogenicity of BJVCs treated with PC, DMP, and GA can be reduced significantly and meet the clinical standard.

Wall shear modulation of cytokines in early vein grafts

OBJECTIVE

Pro-inflammatory cytokine-driven mechanisms have been implicated in vein graft failure, though little is known about the effect of hemodynamic factors and anti-inflammatory counter-regulatory mechanisms. We hypothesized that early temporal expression of the pro-inflammatory cytokine interleukin (IL)-1 beta and the anti-inflammatory cytokine IL-10 proceeds by way of wall shear stress-dependent pathways in the arterializing vein graft.

METHODS

Rabbits (n = 27) underwent bilateral jugular vein carotid interposition grafts, and simultaneous unilateral distal carotid branch ligation, to produce both low-flow and high-flow grafts in the same animal. Vein grafts were harvested at 1, 3, 7, 14, and 28 days and were assessed for architecture, wall shear stress, and cytokine messenger RNA levels (quantitative real-time two-step reverse transcription polymerase chain reaction).

RESULTS

The model resulted in an immediate 90% flow reduction (P <.001, paired t test) in the vein graft on the ligated side, and a 36% increase (P =.01) in contralateral graft flow. This persisted as approximately 15-fold flow differential throughout the 28-day period. The construction yielded a 15-fold differential in wall shear stress between low-flow and high-flow vein grafts (P <.001, two-way repeated measures analysis of variance). Intimal hyperplasia began by day 3, and was 6-fold more in low wall shear grafts by 28 days (230.6 +/- 35.4 microm intimal thickness vs 36.1 +/- 17.6 microm for low shear versus high shear grafts; P =.001). For both cytokines time independently affected mRNA expression (P <.001, global analysis of variance). Exposure of vein grafts to the arterial circulation markedly up-regulated IL-1 beta at 1 day, with significantly more induction in the low shear setting (P =.002). IL-1 beta protein localized to the developing neointima at days 1 and 3. Conversely, IL-10 slowly increased until day 14, with significantly more expression in the high shear grafts (P <.001).

CONCLUSIONS

Vein graft adaptation induces early pro-inflammatory cytokine IL-1 beta expression and delayed protective IL-10 expression (most notable under high shear conditions), both of which are modulated by wall shear. These differential temporal windows offer strategies for appropriately timed pro-inflammatory or anti-inflammatory therapies to interrupt pathologic vein graft adaptations.

CLINICAL RELEVANCE

Neointimal hyperplasia continues to limit the durability of vein bypass grafts. Emerging evidence suggests that inflammatory mechanisms drive the neointimal hyperplasic response. This study demonstrates that specific hemodynamic forces (altered wall shear stress) differentially affect early pro-inflammatory interleukin (IL)-1 beta and delayed anti-inflammatory IL-10 signaling. These distinct temporal windows for IL-1 beta and IL-10 cytokine expression offer strategies for appropriately timed pro-inflammatory and anti-inflammatory therapies to interrupt pathologic vein graft adaptations.

Influence of species, environmental factors, and tissue cellularity on calcification of porcine aortic wall tissue

Valve tissue calcification has complex host, implant, and mechanical determinants. We studied the influence of species (rat v sheep), environmental factors (presence v absence of blood contact and arterial stress), and tissue cellularity (normal v acellularized tissue) on porcine aortic wall mineralization. Porcine aortic wall samples underwent standard glutaraldehyde-fixation or combined enzyme-detergent acellularization. Samples were implanted subcutaneously in rats (n = 8) and in juvenile sheep (n = 8). Furthermore, in juvenile sheep, similar samples were implanted into the jugular vein (blood contact) and into the carotid artery (blood contact and arterial stress). After 8 and 12 weeks, tissue was explanted and evaluated by X-ray, light- and electron-microscopy, and calcium content measurement (atomic absorption spectrometry). On the Von Kossa staining, auto-fluorescence of elastic fibers was used to identify the relation between calcific deposits and elastin. Subcutaneously implanted, glutaraldehyde-fixed tissue calcified severely in rat, but much less in sheep (calcium content: 56.2 +/- 13.6 v 9.9 +/- 9.0 microg/mg, respectively; P <.001). In sheep, the presence of blood contact (venous implants) increased wall calcification significantly (36.9 +/- 15.8; P <.001), but hemodynamic stress (arterial implants) had no additional mineralizing effect on the aortic wall (P >.05 v venous implants). Calcification of glutaraldehyde-fixed tissue occurred predominantly at the level of cells and cellular remnants, as confirmed by electron- and fluorescence-microscopy, locating calcific deposits in between elastic fibers. Acellularized tissue calcified significantly less, but an inflammatory response towards the tissue led to fragmentation, lysis, and subsequent calcification of elastic fibers. Results from subcutaneous implantations show large inconsistencies in calcification between the species. In sheep, blood contact increases aortic wall calcification significantly, while arterial stress has no additional effect. The sheep-jugular implantation model can be used as a simplified model for further study of aortic wall calcification and new antimineralization treatments. Calcification of glutaraldehyde-fixed aortic wall tissue is initiated at the level of cellular remnants, with little or no contribution from elastic fibers. Acellularization can avoid this cell-mediated calcification, but an additional treatment (glutaraldehyde, cryopreservation, photo-fixation,.) will be necessary to avoid the inflammation leading to elastolysis and consequent calcification of elastic fibers.

Upper jugular lymph nodes (submuscular recess) in non-squamous-cell cancer of the head and neck: surgical considerations

Cervical lymphadenectomy of level II encompasses lymph nodes associated with the upper internal jugular vein and the spinal accessory nerve (SAN). Removal of tissue superior to the SAN (submuscular recess-(SMR)) was recently shown to be unwarranted in selected cases of squamous-cell cancer. Thirty-five patients with non-squamous-cell cancer (SCC) of the head and neck treated with cervical lymphadenectomy were prospectively evaluated. Thirty-seven neck dissection specimens were histologically analysed for the number of lymph nodes involved with cancer. At the time of surgery, level II was separated into the supraspinal accessory nerve component (IIa) and the component anterior to the SAN (IIb). Neck dissections were most commonly performed for cancer of the thyroid gland (19) followed in frequency by the parotid gland (seven), skin: melanoma (five), basal-cell cancer (two), and other sites (four). Twenty-five neck dissections were modified-selective procedures and 12 were either radical or modified radical neck dissection. Twenty-nine necks were clinically N+ and eight N0. Histological staging was pathologically N+ in 32 neck dissection specimens. Level IIb contained an average of 12 nodes and the IIa component contained a mean of 5.0 nodes. Level II contained metastatic disease in 28 of 32 histologically node-positive specimens (87 per cent). Level IIa was involved with cancer in six cases (16 per cent), five of which were pre-operatively staged as clinically N+. All cases (100 per cent) with level IIa involvement had level IIb positive nodes. Three of the level IIa positive cases were cancer of the parotid gland comprising 43 per cent of this sub-group of patients. Incidence of involvement of SMR in non-SCC cases is not uncommon. The additional time required and morbidity associated with dissection of the supraspinal accessory nerve component of level II are probably justified when performing neck dissection in cancer of the thyroid gland. The SMR should be excised in cancer of the parotid gland. Large-scale prospective controlled studies with long-term follow-up periods are necessary to support resection of level IIb only.