Development and evaluation of in vivo tissue engineered blood vessels in a porcine model.

BACKGROUND: There's a large clinical need for novel vascular grafts. Tissue engineered blood vessels (TEBVs) have great potential to improve the outcome of vascular grafting procedures. Here, we present a novel approach to generate autologous TEBV in vivo. Polymer rods were engineered and implanted, evoking an inflammatory response that culminates in encapsulation by a fibrocellular capsule. We hypothesized that, after extrusion of the rod, the fibrocellular capsule differentiates into an adequate vascular conduit once grafted into the vasculature. METHODS AND RESULTS: Rods were implanted subcutaneously in pigs. After 4 weeks, rods with tissue capsules grown around it were harvested. Tissue capsules were grafted bilaterally as carotid artery interposition. One and 4-week patency were evaluated by angiography whereupon pigs were sacrificed. Tissue capsules before and after grafting were evaluated on tissue remodeling using immunohistochemistry, RNA profiling and mechanical testing. Rods were encapsulated by thick, well-vascularized tissue capsules, composed of circumferentially aligned fibroblasts, collagen and few leukocytes, with adequate mechanical strength. Patency was 100% after 1 week and 87.5% after 4 weeks. After grafting, tissue capsules remodeled towards a vascular phenotype. Gene profiles of TEBVs gained more similarity with carotid artery. Wall thickness and αSMA-positive area significantly increased. Interestingly, a substantial portion of (myo)fibroblasts present before grafting expressed smooth muscle cell markers. While leukocytes were hardly present anymore, the lumen was largely covered with endothelial cells. Burst pressure remained stable after grafting. CONCLUSIONS: Autologous TEBVs were created in vivo with sufficient mechanical strength enabling vascular grafting. Grafts differentiated towards a vascular phenotype upon grafting.

Bypass Graft Failure Resulting from Misidentification of the Aberrant Anatomy of a Persistent Sciatic Artery.

A persistent sciatic artery (PSA) is a rare vascular anomaly in which, in contrast to normal embryonic development, the sciatic artery does not involute. Although prone to aneurysm formation and thrombosis, this is, to our knowledge, the first case of early femoral popliteal bypass failure due to a PSA.

[A measurable connection between preventative interventions and the incidence of postoperative wound infection]. / Meetbaar verband tussen preventieve interventies en de incidentie van postoperatieve wondinfecties.

OBJECTIVE: To establish whether there was a link between the preventative interventions executed and two groups of patients: those with and those without a postoperative wound infection (POWI). DESIGN: Descriptive and comparative research. METHOD: At Rijnland Hospital, a Dutch non-academic teaching hospital, 284 indicator operations were carried out between 1 April 2009 and 31 March 2010. We investigated whether preventative interventions were carried out during these operations. The types of surgery included mastectomy with and without axillary node dissection, resection of the colon and central vascular surgery (reconstruction of the aorta via an endovascular or open approach). Four types of intervention were studied: hygienic discipline (measurement of the number of times the operating theatre doors moved), the timely administration of preoperative antibiotic prophylactics, the avoidance of preoperative shaving and the attempts at perioperative normothermia. A 'postoperative wound infection' was registered as such if it had developed within 30 days of surgery. RESULTS: In total, 22 POWIs (7.7%) were registered, arising from 284 operations: 5 POWIs (2.8%) after mammary surgery, 1 POWI (2.8%) after central vascular surgery, and 16 POWIs (21.6%) after colon surgery, respectively (see table 2). Meeting the criteria of all 4 types of intervention had no influence on the development of a POWI. A significant association to the development of a POWI was, however, determined to be the variables related to wound classification, duration of surgery and the average number of door movements per hour during surgery; specifically, 7 or more. CONCLUSION: Surveillance by way of registration and feedback of interventions and their optimisation, particularly in terms of door movement, can possibly contribute to a reduction in the number of postoperative would infections.

Effect of intraluminal thrombus on pressure transmission in the abdominal aortic aneurysm.

OBJECTIVE: To clarify the effect of intraluminal thrombus on pressure transmission. METHODS: A saccular aneurysm was inserted into an artificial circulation system. Subsequently, the saccular aneurysm was filled with eight different human aortic aneurysm thrombus samples. Starch solution in an empty aneurysm was used as a control. A pressure sensor measured the pressure in the circulation, and a second piezoelectric sensor measured the pressure in the saccular aneurysm at 3, 2, and 1 cm from the endoluminal surface (23 locations). The influence of the elastic characteristics of the aneurysm wall on the extent of pressure reduction was evaluated by experiments performed with aneurysms made of rubber and paraffin. RESULTS: The pressures measured in the empty aneurysm were identical to those measured in circulation (P > .05). The pressure measured in the thrombus was significantly lower than the pressure measured in the circulation (P < .05). The mean pressure ratio between the systolic thrombus pressure and systolic circulation pressure at 1, 2, and 3 cm was 0.90 +/- 0.09, 0.86 +/- 0.10, and 0.81 +/- 0.09, respectively. However, there was a clear correlation between the pressure in the circulation and in the thrombus (Pearson correlation coefficient: mean, r = 0.997; range, 0.975-0.999; P < .01). The change in circulatory pressure was followed by an almost identical change in thrombus pressure (regression coefficient: mean, beta = .997; range, .983-1.000; P < .01). In stiff aneurysms, the pressure reduction is less than in more compliant ones (P < .05). CONCLUSIONS: In an in vitro model, pressure in the aneurysmal sac is reduced by fibrinous thrombus. CLINICAL RELEVANCE: Endovascular aneurysm repair (EVAR) aims at reducing the pressure in the aneurysmal sac. Therefore, it seems attractive to use pressure monitoring in the aneurysmal sac as a follow-up after EVAR. This study contributes to the development of the rationale of pressure monitoring in the aneurysmal sac as a follow-up method after EVAR. The aneurysmal sac is filled with thrombus. To interpret pressure measurements in the thrombus, we have to learn about the effect of the thrombus on pressure transmission and on the pressure measurements themselves. Our study demonstrates that reduction of pressure occurs as it is transmitted through a human aortic thrombus.

Ingrowth of aorta wall into stent grafts impregnated with basic fibroblast growth factor: a porcine in vivo study of blood vessel prosthesis healing.

OBJECTIVE: Endovascular aneurysm repair is an alternative treatment of abdominal aortic aneurysm. The procedure is less invasive, and morbidity and most probably mortality are reduced. However, some problems, such as endoleakage, are yet to be resolved. Endoleakage can occur after graft migration, as a result of insufficient fixation of the stent graft. One cause is deficient healing between the aortic neck and the stent graft. We hypothesize that better healing, achieved by induction of vascular cell ingrowth into the graft material, results in better graft fixation. Previously we demonstrated ingrowth of neointima into the graft material if the stent graft is impregnated with a coat of basic fibroblast growth factor (bFGF), heparin, and collagen. In this study we evaluated healing with bFGF-heparin-collagen-coated stent grafts in vivo. METHODS: In 4 pigs, 32 endovascular stent grafts, manufactured from standard Dacron and Gianturco Z-stents, were placed in the aorta. The stent grafts were impregnated with either bFGF-heparin containing collagen (n=16) or control collagen (n=16). After 4 and 8 weeks animals were killed, and ingrowth and healing of the stent grafts were macroscopically and electron microscopically evaluated. RESULTS: After 8 weeks all bFGF-impregnated stent grafts demonstrated ingrowth of tissue and healing between the graft and the aorta, whereas the control nonimpregnated stent grafts showed no ingrowth. Microscopic evaluation demonstrated alpha-smooth muscle actin-positive cells, most probably smooth muscle cells or myofibroblasts, growing from the vascular wall through the graft material. CONCLUSION: A Dacron prosthesis impregnated with collagen, heparin, and bFGF induced graft healing in an in vivo pig model, in contrast to nonimpregnated stent grafts. This in vivo study confirms our previous findings in vitro. These results indicate that healing between Dacron and the aorta can be achieved, and suggest that type I endoleakage may be resolved by inducing healing between the aortic wall and the prosthesis with graft material containing growth factor.

Accessory thyroid gland at carotid bifurcation presenting as a carotid body tumor: case report and review of the literature.

Patients with carotid body tumors referred to vascular surgeons usually undergo magnetic resonance imaging (MRI) as part of the workup. We present a case report of a 39-year-old woman with a presumed carotid body tumor, as was expected from clinical and MRI findings. At surgery, the ectopic thyroid tissue was suspected, and resection was performed. Histologic examination showed normal thyroid tissue with no sign of malignancy. Postoperative thyroid analysis showed a normally located, properly functioning thyroid gland. Ectopic thyroid glands are generally found in the midline, as a result of abnormal median migration. Their presence lateral to the midline with a proper functioning thyroid gland in its normal position is extremely rare. Although several submandibular thyroid glands have been reported, a close relation with the carotid arteries was described only once. When MRI scans of a presumed carotid body tumor show tumor characteristics that are not fully specific for a carotid body tumor, the possibility of ectopic thyroid tissue should be entertained, which can be the patient's only properly functioning thyroid tissue. In such cases, additional assessment, including thyroid tests, should be considered before surgery.