Edmo Atique Gabriel

Sthefano Atique Gabriel

Editors

Inflammatory
Response in
Cardiovascular Surgery

123
Inflammatory Response in Cardiovascular Surgery
Edmo Atique Gabriel • Sthefano Atique Gabriel
Editors

Inflammatory Response
in Cardiovascular Surgery
Editors
Edmo Atique Gabriel Sthefano Atique Gabriel
Department of Cardiovascular Department of Vascular Surgery
Surgery University Nove de Julho Pontifical Catholic University of Campinas
São Paulo São Paulo
Brazil Brazil

ISBN 978-1-4471-4428-1 ISBN 978-1-4471-4429-8 (eBook)

DOI 10.1007/978-1-4471-4429-8
Springer London Heidelberg New York Dordrecht

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This book is dedicated to God and to our parents Edmo Gabriel
and Maria Lucia Atique Gabriel.

Edmo Atique Gabriel

Sthefano Atique Gabriel
Preface

The inflammatory response is of vital importance in any kind of cardiovascular procedure.

However, for several years, this concept has been underestimated and overlooked worldwide.
This textbook is intended to serve as a useful tool to provide information on the inflammatory
response in cardiovascular surgery.
The scope of this textbook is of interest to various professionals, such as cardiovascular sur-
geons, vascular surgeons, transplantation physicians, anesthesiologists, intensive care physi-
cians, cardiovascular and vascular fellows, basic science physicians, students, and researchers.
It is divided into sections on general topics, vascular and cardiovascular subjects of great
importance for understanding the surgical inflammatory universe. Arranging topics into vascu-
lar and cardiovascular sections was difficult but key as there are many details and particulari-
ties related to vascular diseases as well as to cardiovascular or cardiothoracic diseases.
Immunologic and physiologic concepts are clarified from the early stages of the book with
the aim of preparing readers for the subsequent discussions. For this purpose, topics such as
the neuroendocrine response, pathogenesis of atherosclerosis, and mechanisms of inflammation
are meticulously addressed. Moreover, these preliminary chapters are fundamental to a better
understanding of the inflammatory response in all cardiovascular diseases.
Later chapters elucidate the inflammatory aspects of carotid, venous, arterial, and abdomi-
nal aortic aneurysm, peripheral aneurysm, trauma, and visceral pathologies. However, all were
written emphasizing the surgical view of pathologic conditions.
In the section about carotid disease, we discuss in detail the inflammatory aspects present
in both endarterectomy and carotid angioplasty – two important therapeutic options in the
treatment of ischemic brain disease. In the section about abdominal aortic aneurysm, we
emphasize its pathogenesis and associated inflammatory aspects, and we include chapters
related to endovascular treatment of abdominal aortic aneurysm and endovascular treatment of
ruptured abdominal aortic aneurysm.
In the section on critical limb ischemia, we address approaches to arteritis responsible for
limb ischemia and include comments on a very current topic transplantation for limb salvage.
In the section on venous disease, we focus on the aspects involved in the inflammation and
origin of thromboembolic complications.
Likewise, the cardiovascular or cardiothoracic sections are systematically organized in such
a way that general topics as such cardiopulmonary bypass and thyroid hormones come before
specific topics such as coronary artery, valve, and congenital heart diseases, thoracoabdominal
aneurysm, heart/lung transplantation, ventricular assist devices, and stem cells. On these many
featured topics, the authors provide a broad range of very interesting information about inflam-
mation from surgical perspective.
In addition to the traditional topics in cardiovascular surgery, new discussions, for example
on the inflammatory aspects of cardiovascular surgery for lung protection, inflammatory
aspects related to heart and lung transplantation, both in children and in adults, and the role of
stem cells in cardiovascular surgery are included.

vii
viii Preface

We wish to thank all contributors who spent time and made untiring efforts to provide infor-
mation about the inflammatory response in cardiovascular surgery by writing great chapters.
Finally, we express our gratitude to the publisher, Springer, for giving us the opportunity to put
together a textbook on the remarkable concept of the inflammatory response in cardiovascular
surgery.

Sao Paulo, Brazil Edmo Atique Gabriel

Sao Paulo, Brazil Sthefano Atique Gabriel
Acknowledgments

We thank Springer for the diligent attention and assistance they provided us and for their
efforts to make this book possible.

Edmo Atique Gabriel

Sthefano Atique Gabriel

ix
Contents

Part I General Topics

1 Neuroendocrine Response and Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Riad N. Younes and Fernando C. Abrão
2 The Role of Lymphocytes in the Pathogenesis of Atherosclerosis:
Focus on CD4+ T Cell Subsets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Ingrid E. Dumitriu and Juan Carlos Kaski
3 Immunological Mechanisms of Inflammation . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Nilo José Coêlho Duarte, Cyro Alves de Brito, and Alberto José da Silva Duarte

Part II Carotid Diseases

4 Role of Lipoproteins in Carotid Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . 29

Efthymios D. Avgerinos and Christos D. Liapis
5 Carotid Endarterectomy: Inflammatory Aspects . . . . . . . . . . . . . . . . . . . . . . . . 37
Sthefano Atique Gabriel and Edmo Atique Gabriel
6 Endovascular Treatment of Carotid Disease: Inflammatory Aspects . . . . . . . . 41
Sthefano Atique Gabriel and Edmo Atique Gabriel

Part III Abdominal Aortic Aneurysm

7 Role of Matrix Metalloproteinases and Aortic Wall Degradation

in Abdominal Aortic Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
George A. Antoniou and George S. Georgiadis
8 Role of Haptoglobin in Abdominal Aortic Aneurysm . . . . . . . . . . . . . . . . . . . . . 51
Valerio Napolioni
9 Inflammatory Aortic Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Guilherme Vieira Meirelles
10 Endovascular Treatment of Abdominal Aortic Aneurysms:
Current Approaches and New Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Armando de Carvalho Lobato, Robert Guimarães do Nascimento,
and Ariele Milano de Oliveira
11 Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms . . . . . . . 73
Frank J. Veith, Mario Lachat, Dieter Mayer, Zoran Rancic, Todd L. Berland,
and Neal S. Cayne

xi
xii Contents

Part IV Critical Lower Limb Ischemia

12 Thromboangiitis Obliterans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Otacílio de Camargo Júnior and Juliana Lech de Camargo
13 Inflammatory Markers and Mortality in Critical Lower Limb Ischemia . . . . . 91
Anders Gottsäter
14 Arterial Wall Remodeling and Restenosis
Following Vascular Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Xue Ma and Randolph L. Geary
15 Shear Stress and Endothelial Cell Retention in
Critical Lower Limb Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Caroline Jadlowiec and Alan Dardik
16 Arterial Transplantation for Limb Salvage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Thomas Hölzenbein, Nina Mader, Manuela Aspalter, Sophina Trubel,
and Klaus Linni

Part V Vascular Trauma

17 Disseminated Intravascular Coagulation in Vascular Trauma. . . . . . . . . . . . . . 125

Ramyar Gilani, Peter I. Tsai, Matthew J. Wall Jr., and Kenneth L. Mattox
18 Temporary Intravascular Shunt in Complex Vascular Injury . . . . . . . . . . . . . . 131
Ding Wei-wei and Li Jie-shou

Part VI Venous Diseases

19 Metalloproteinases in Acute Venous Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Anita C. Thomas
20 Idiopathic Venous Thromboembolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Crina Sinescu
21 Inflammation, Thrombogenesis, Fibrinolysis, and Vein Wall
Remodeling After Deep Venous Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Jose Antonio Diaz and Daniel D. Myers Jr.
22 Varicose Veins: Venous Wall Changes, Inflammation,
and Matrix Metalloproteinases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Joseph D. Raffetto

Part VII Visceral Vasculopathy

23 Management of Aneurysms in Takayasu’s Arteritis . . . . . . . . . . . . . . . . . . . . . . 193

Christian Espinoza Silva, Diego Soto Valdés, and Vania Rozas Almeida
24 Mesenteric Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Mateus Picada-Correa and Gustavo S. Oderich

Part VIII Peripheral Aneurysms

25 Inflammatory Peripheral Arterial Aneurysms. . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Gianluca Faggioli, Rodolfo Pini, Mauro Gargiulo, Antonio Freyrie,
Raffaella Mauro, and Andrea Stella
Contents xiii

26 Endovascular Femoropopliteal Interventions: Evolving Devices . . . . . . . . . . . . 221

Cassidy Duran and Jean Bismuth

Part IX Cardiopulmonary Bypass

27 Modulation of Inflammatory Response in Cardiopulmonary Bypass . . . . . . . . 231

Shahzad G. Raja
28 The Systemic Inflammatory Response Syndrome Following
Cardiopulmonary Bypass in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Harald L. Lindberg and Tom N. Hoel
29 Vacuum-Assisted Venous Drainage in Cardiac Surgery . . . . . . . . . . . . . . . . . . . 255
Wakako Fukuda, Takeshi Goto, and Ikuo Fukuda
30 Miniaturize CPB Versus Off-Pump Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Francesco Formica
31 Thyroid Hormones and Cardiovascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . 265
Edmo Atique Gabriel and Sthefano Atique Gabriel
32 Inflammatory Response in Cardiovascular Surgery . . . . . . . . . . . . . . . . . . . . . . 275
Kaan Kaya
33 Lung Protection in Cardiovascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Edmo Atique Gabriel and Sthefano Atique Gabriel

Part X Coronary Artery Disease

34 Fifteen Years of ‘No-Touch’ Saphenous Vein Harvesting

in Patients Undergoing Coronary Artery Bypass Surgery:
What Have We Learned? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Michael R. Dashwood and Domingos S.R. Souza
35 Platelets and Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Meinrad Gawaz, Harald Langer, and Tobias Geisler

Part XI Heart Valve Diseases

36 Role of Bone Morphogenetic Proteins in Valvulogenesis . . . . . . . . . . . . . . . . . . 307

Russell A. Gould and Jonathan T. Butcher
37 Dysfunctional Mechanisms of Anti-inflammation in Aortic Stenosis . . . . . . . . 317
David A. Fullerton and Xianzhong Meng
38 Heart Valve Surgery and the Antiphospholipid Syndrome . . . . . . . . . . . . . . . . 321
Carlos A. Mestres, Cecilia Marcacci, Gerard Espinosa,
Jose L Pomar, Andrea Colli, and Ricard Cervera

Part XII Congenital Heart Diseases

39 Neurohormonal Factors in Pediatric Heart Surgery . . . . . . . . . . . . . . . . . . . . . . 333

Jacek Kolcz
40 Antifibrinolytic Therapy in Pediatric Congenital Heart Surgery . . . . . . . . . . . 341
Ehrenfried Schindler
xiv Contents

41 Thromboembolism in Cyanotic Heart Disease:

Mechanisms and Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
Toshio Nakanishi
42 Endovascular Management of Coarctation of the Aorta . . . . . . . . . . . . . . . . . . 355
Edward B. Diethrich

Part XIII Thoracoabdominal Aortic Aneurysm

43 Inflammatory Response in Open and Endovascular Treatment . . . . . . . . . . . . 369

Edmo Atique Gabriel and Sthefano Atique Gabriel
44 Surgical Treatment of Aortic Aneurysm in Patients with Aortitis . . . . . . . . . . . 375
Maqsood M. Elahi and Kenton J. Zehr

Part XIV Heart and Lung Transplantation

45 Cytokine Profile in Heart Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385

Ahmet Ruchan Akar, Serkan Durdu, Bahadır Inan, and Mustafa Sırlak
46 Platelet Activation After Lung Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . 393
David Sternberg and Joshua Sonett
47 Role of BNP in Pediatric Heart Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . 399
Marcelo Biscegli Jatene and Estela Azeka
48 Nutritional Factors, Oxidative Stress and Lung Transplantation . . . . . . . . . . . 403
Janet Madill, Bianca Arendt, Chung-Wai Chow, and Johane Allard

Part XV Ventricular Assist Device

49 Mechanical Unloading and Heart Remodeling Features . . . . . . . . . . . . . . . . . . 413

Nikolaos A. Diakos, Omar Wever-Pinzon, Anthony S. Zannas, and Stavros G. Drakos

Part XVI Stem Cells in Cardiovascular Surgery

50 Cytokine Profiles in Cardiac Diseases

and Marrow Stromal Cells Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Nasser Alkhamees, Alice LeHuu, and Dominique Shum-Tim
51 Hypoxic Preconditioning of Cardiac Progenitor
Cells for Ischemic Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Shiyue Xu and Gangjian Qin

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Contributors

Fernando C. Abrão MD Department of Surgery, Faculty of Medicine, University of Sao

Paulo, Hospital Sao Jose, São Paulo, Brazil
Ahmet Ruchan Akar, MD, FRCS CTh Department of Cardiovascular Surgery,
Heart Center, Ankara University School of Medicine, Dikimevi, Ankara, Turkey
Department of Multi-disciplinary Stem Cell and Regenerative Medicine,
Stem Cell Institute, Ankara University, Ankara, Turkey
Nasser Alkhamees, MD Divisions of Cardiac Surgery and Surgical Research,
Department of Surgery, McGill University Health Center, Montreal, QC, Canada
Johane Allard, MD Department of Medicine, University Health Network (UHN), Toronto,
ON, Canada
Vania Rozas Almeida Servicio Cardiovascular, National Institute of Thorax, Providencia,
Santiago, Chile
George A. Antoniou, MD, PhD Department of Vascular and Endovascular Surgery,
Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation
Trust, Manchester, UK
Bianca Arendt, PhD Department of Medicine, University Health Network (UHN), Toronto,
ON, Canada
Manuela Aspalter, MD Department of Vascular and Endovascular Surgery, PMU Salzburg,
Salzburg, Austria
Efthymios D. Avgerinos, MD, FEBVS Department of Vascular Surgery, Medical School of
Athens, Attikon University Hospital, Athens, Greece
Estela Azeka, MD, PhD Pediatric Cardiology and Adult Congenital Heart Disease Unit,
Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Sao Paulo,
Brazil
Todd L. Berland, MD Department of Surgery, New York University Medical Center,
New York, NY, USA
Jean Bismuth, MD The Methodist DeBakey Heart and Vascular Center, The Methodist
Hospital, Houston, TX, USA
Jonathan T. Butcher, PhD Department of Biomedical Engineering, Cornell University,
Ithaca, NY, USA
Neal S. Cayne, MD Department of Surgery, New York University Medical Center,
New York, NY, USA
Ricard Cervera, MD, PhD, FRCP Department of Autoimmune Diseases,
Hospital Clinico, University of Barcelona, Barcelona, Spain

xv
xvi Contributors

Chung-Wai Chow, MD Lung Transplant Program, University of Toronto,

Toronto, ON, Canada
Andrea Colli, MD, PhD Department of Cardiovascular Surgery, Cardiac Surgery Unit,
University of Padova, Padova, Italy
Alberto José da Silva Duarte, PhD Clinical Laboratory, Hospital do Coração, São Paulo,
Brazil
Faculty of Medicine, Universidade de São Paulo, São Paulo, Brazil
Central Laboratory of the Hospital das Clínicas, Faculty of Medicine, Universidade de São
Paulo, São Paulo, Brazil
Laboratory of Medical Investigation Unit 56, Faculty of Medicine, University of Sao Paulo,
São Paulo, Brazil
Alan Dardik, MD, PhD VA Connecticut Healthcare System, West Haven, CT, USA
Department of Surgery and the Interdepartmental Program in Vascular Biology and
Therapeutics, Yale University School of Medicine, New Haven, CT, USA
Michael Dashwood, PhD Department of Clinical Biochemistry, Royal Free and University
College Medical School, London, UK
Cyro Alves de Brito, PhD Center of Immunology, Adolfo Lutz Institute, São Paulo, Brazil
Juliana Lech de Camargo Department of Medicine, University of Taubate, Sao Paulo,
Brazil
Otacilio de Camargo Júnior Pontifical Catholic University of Campinas,
Department of Vascular/Endovascular Surgery, Celso Pierro Maternity Hospital,
Sao Paulo, Brazil
Department of Vascular Surgery, Pontifical Catholic University of Campinas,
Sao Paulo, Brazil
Armando de Carvalho Lobato, PhD Department of Vascular and Endovascular surgery,
Institute of Vascular and Endovascular Surgery of Sao Paulo, (ICVE-SP), Sao Paulo, Brazil
Vascular and Endovascular Surgery, Portuguese Beneficent Hospital of Sao Paulo,
Sao Paulo, Brazil
Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
Brazilian Society of Angiology and Vascular Surgery (SBACV), Sao Paulo, Brazil
University Nove de Julho, Sao Paulo, Brazil
Ariele Milano de Oliveira University Nove de Julho, Sao Paulo, Brazil
Nikolaos A. Diakos, MD Heart Failure Program (Division of Cardiology) and Molecular
Medicine Program (Eccles Institute of Human Genetics), University of Utah, Salt Lake City,
UT, USA
Jose Antonio Diaz, MD Conrad Jobst Vascular Research Laboratories, Section of Vascular
Surgery, Department of Surgery, School of Medicine, University of Michigan, Ann Arbor,
MI, USA
Edward B. Diethrich, MD Founder and Medical Director of The Arizona Heart Foundation,
Department of Cardiovascular and Endovascular Surgery, Phoenix, AZ, USA
Robert Guimarães do Nascimento Department of Vascular and Endovascular Surgery,
Institute of Vascular and Endovascular Surgery of Sao Paulo, (ICVE-SP), Sao Paulo, Brazil
Brazilian Society of Angiology and Vascular Surgery (SBACV), Sao Paulo, Brazil
Contributors xvii

Stavros G. Drakos, MD Heart Failure Program (Division of Cardiology) and Molecular

Medicine Program (Eccles Institute of Human Genetics), University of Utah, Salt Lake City,
UT, USA
Nilo José Coêlho Duarte, MD Clinical Laboratory, Hospital do Coração,
São Paulo, Brazil
Central Laboratory of Hospital das Clinicas, Faculty of Medicine, University de São Paulo,
São Paulo, Brazil
Ingrid E. Dumitriu, MD, PhD, FHEA Division of Clinical Sciences, Cardiovascular
Sciences Research Centre, St. George’s University of London, London, UK
Cassidy Duran, MD The Methodist DeBakey Heart and Vascular Center, The Methodist
Hospital, Houston, TX, USA
Serkan Durdu, MD, PhD Department of Cardiovascular Surgery, Heart Center,
Ankara University School of Medicine, Dikimevi, Ankara, Turkey
Department of Multi-disciplinary Stem Cell and Regenerative Medicine,
Stem Cell Institute, Ankara University, Ankara, Turkey
Maqsood M. Elahi, MD, PhD Department of Cardiothoracic Surgery, Glenfield Hospital,
Leicester, UK
Gerard Espinosa, MD, PhD Department of Autoimmune Diseases, Hospital Clinico,
University of Barcelona, Barcelona, Spain
Gianluca Faggioli, MD Chirurgia Vascolare, Policlinico S. Orsola, Bologna, Italy
Department of Vascular Surgery, University of Bologna, Bologna, Italy
Francesco Formica, MD Cardiac Surgery Clinic, Department of Surgical Science,
University of Milano-Bicocca, San Gerardo Hospital, Milan, Italy
Antonio Freyrie, MD Department of Vascular Surgery, University of Bologna,
Bologna, Italy
Ikuo Fukuda, MD, PhD Department of Thoracic and Cardiovascular Surgery,
Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
Wakako Fukuda, MD Department of Thoracic and Cardiovascular Surgery,
Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
David Fullerton, MD Division of Cardiothoracic Surgery, The University of Colorado
School of Medicine, Aurora, CO, USA
Edmo Atique Gabriel, MD, PhD Department of Cardiovascular Surgery,
University Nove de Julho, São Paulo, Brazil
Sthefano Atique Gabriel, MD Department of Vascular Surgery, Pontifical Catholic
University of Campinas, São Paulo, Brazil
Mauro Gargiulo, MD Department of Vascular Surgery, University of Bologna,
Bologna, Italy
Meinrad Gawaz, MD Department of Cardiology, University of Tübingen,
Tübingen, Germany
Randolph L. Geary, MD, FACS Department of Vascular and Endovascular Surgery,
Wake Forest University School of Medicine, Winston-Salem, NC, USA
Department of Pathology, Section on Comparative Medicine, Wake Forest University School
of Medicine, Winston-Salem, NC, USA
xviii Contributors

Tobias Geisler, MD Department of Cardiology, University of Tübingen, Tübingen, Germany

George S. Georgiadis, MD Department of Vascular and Endovascular Surgery,
University Hospital of Alexandroupolis, Democritus University of Thrace,
Alexandroupolis, Greece
Ramyar Gilani, MD Division of Vascular Surgery and Endovascular
Therapy of Michael E. DeBakey, Department of Surgery, Baylor College of Medicine,
Houston, TX, USA
Takeshi Goto, ME Department of Thoracic and Cardiovascular Surgery,
Hirosaki University Graduate School of Medicine and Hospital, Aomori, Japan
Department of Clinical Engineering, Hirosaki University School of Medicine and Hospital,
Aomori, Japan
Anders Gottsäter, MD, PhD Department of Clinical Sciences, Vascular Center,
Lund University, Skåne University Hospital, Malmö, Sweden
Russell A. Gould, BS Department of Biomedical Engineering, Cornell University,
Ithaca, NY, USA
Tom N. Hoel, MD, PhD Department of Thoracic and Cardiovascular Surgery,
University of Oslo, Rikshospitalet University Hospital, Rikshospitalet, Norway
Thomas Hölzenbein, MD, PhD Department of Vascular and Endovascular Surgery,
PMU Salzburg, Salzburg, Austria
Bahadır Inan, MD Department of Cardiovascular Surgery, Heart Center,
Ankara University School of Medicine, Dikimevi, Ankara, Turkey
Caroline Jadlowiec, MD Department of Surgery and the Interdepartmental Program in
Vascular Biology and Therapeutics, Yale University School of Medicine, West Haven,
CT, USA
VA Connecticut Healthcare System, New Haven, CT, USA
Marcelo Biscegli Jatene, MD Pediatric Cardiothoracic Surgery Unit, Heart Institute
(InCor), University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
Pediatric Cardiology and Adult Congenital Heart Disease Unit, Heart Institute (InCor),
University of Sao Paulo Medical School, Sao Paulo, Sao Paulo, Brazil
Li Jie-shou, MD Department of Surgery, Jinling Hospital, Medical School of Nanjing
University, Nanjing, Jiangsu, China
Juan Carlos Kaski, MD, DM (Hons), DSc, FRCP, FACC, FESC Division of Clinical
Sciences, Cardiovascular Sciences Research Centre, St. George’s University of London,
London, UK
Kaan Kaya, MD Division and Department of Cardiovascular Surgery, Ozel Ulus Hastanesi,
Ankara, Turkey
Jacek Kolcz, MD, PhD, FECTS Department of Pediatric Cardiac Surgery,
Polish – American Children’s Hospital, Jagiellonian University, Krakow, Poland
Mario Lachat, MD Department of Vascular Surgery, University Hospital Zurich,
Zurich, Switzerland
Harald Langer, MD Department of Cardiology, University of Tübingen,
Tübingen, Germany
Contributors xix

Alice Le Huu, MD, MSc Divisions of Cardiac Surgery and Surgery Research,
Department of Surgery, McGill University Health Center, Montreal, QC, Canada
Christos D. Liapis, MD, FACS, FRCS Department of Vascular Surgery, Medical School
of Athens, Attikon University Hospital, Athens, Greece
Harald L. Lindberg, MD, PhD Department of Thoracic and Cardiovascular Surgery,
University of Oslo, Rikshospitalet University Hospital, Oslo, Norway
Klaus Linni, MD Department of Vascular and Endovascular Surgery, PMU Salzburg,
Salzburg, Austria
Xue Ma, MD Department of Vascular and Endovascular Surgery, Wake Forest University
School of Medicine, Winston-Salem, NC, USA
Department of Pathology, Section on Comparative Medicine, Wake Forest University School
of Medicine, Winston-Salem, NC, USA
Nina Mader, MD Department of Vascular and Endovascular Surgery, PMU Salzburg,
Salzburg, Austria
Janet Madill, PhD, MD Lung Transplant Program, University of Toronto, Toronto, ON, Canada
Cecilia Marcacci, MD Department of Cardiovascular Surgery, Hospital Clinico, University
of Barcelona, Barcelona, Spain
Kenneth L. Mattox, MD Michael E. DeBakey Department of Surgery, Baylor College
of Medicine, Houston, TX, USA
Raffaella Mauro, MD Department of Vascular Surgery, Sant’Orsola-Malpighi Hospital,
Bologna, Italy
Dieter Mayer, MD Departments for Vascular Surgery and Wound Care, University Hospital
Zurich, Zurich, Switzerland
Guilherme Vieira Meirelles, MD Department of Vascular Surgery, Celso Pierro Hospital
and Maternity, Campinas, SP, Brazil
Xianzhong Meng, MD, PhD Division of Cardiothoracic Surgery, The University
of Colorado School of Medicine, Aurora, CO, USA
Carlos A. Mestres, MD, PhD, FETCS Department of Cardiovascular Surgery,
Hospital Clinico, University of Barcelona, Barcelona, Spain
Daniel D. Myers Jr., DVM, MPH, DACLAM Conrad Jobst Vascular Research
Laboratories, Section of Vascular Surgery, Department of Surgery, School of Medicine,
University of Michigan, Ann Arbor, MI, USA
Conrad Jobst Vascular Research Laboratories, Section of Vascular Surgery/Unit for
Laboratory Animal Medicine, School of Medicine, University of Michigan,
Ann Arbor, MI, USA
Toshio Nakanishi, MD Department of Pediatric Cardiology, Heart Institute,
Tokyo Women’s Medical University, Tokyo, Japan
Valerio Napolioni, PhD School of Biosciences and Biotechnologies, University
of Camerino, Camerino, Italy
Gustavo S. Oderich, MD Division of Vascular and Endovascular Surgery, Mayo Clinic,
Rochester, MN, USA
Mateus Picada-Correa, MD Division of Vascular and Endovascular Surgery, Mayo Clinic,
Rochester, MN, USA
xx Contributors

Rodolfo Pini, MD Department of Vascular Surgery, University of Bologna, Bologna, Italy

Jose L. Pomar, MD, PhD, FETCS Department of Cardiovascular Surgery, Hospital
Clinico, University of Barcelona, Barcelona, Spain
Gangjian Qin, MD Department of Medicine, Cardiology, Feinberg Cardiovascular
Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Joseph D. Raffetto, MD, MS FACS, FSVM Division of Vascular and Endovascular
Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Department of Surgery, VA Boston Healthcare System, West Roxbury, MA, USA
Shahzad G. Raja, BSc, MBBS, MRCS, FRCS(C-Th) Department of Cardiac Surgery,
Harefield Hospital, London, UK
Zoran Rancic, MD Department of Cardiovascular Surgery, University Hospital of Zurich,
Zurich, Switzerland
Department of Surgery, University of Niš, Niš, Serbia
Ehrenfried Schindler Department for Pediatric Anesthesiology, German Pediatric Heart
Center, Asklepios Klinik Sankt Augustin, Sankt Augustin, Germany
Dominique Shum-Tim, MD, CM, MSc, FRCSC, FACS, FAHA Divisions of Cardiac
Surgery and Surgical Research, Department of Surgery, McGill University Health Center,
Montreal, QC, Canada
The Montreal Children’s Hospital, The Montreal General Hospital, Montreal, QC, Canada
Department of Surgery, McGill University, Montreal, QC, Canada
Christian Espinoza Silva, MD, PhD Cardiovascular and Heart Transplant Surgeon,
Servicio Cardiovascular, National Institute of Thorax, Santiago, Chile
Crina Sinescu, MD, PhD, FESC Department of Cardiology, Carol Davila University of
Medicine, Bucharest, Romania
Mustafa Sırlak, MD Department of Cardiovascular Surgery, Heart Center,
Ankara University School of Medicine, Ankara, Turkey
Joshua Sonett, MD Lung Transplant Program, General Thoracic Surgery,
Columbia University Medical Center, New York, NY, USA
Domingos S.R. Souza, MD, PhD Department of Cardiovascular Surgery and
Anesthesiology, Örebro University, Örebro, Sweden
Andrea Stella, MD Department of Vascular Surgery, Sant’Orsola-Malpighi Hospital,
Bologna, Italy
David Sternberg, MD Lung Transplant Program, Henry Ford Health System, Detroit,
MI, USA
Anita C. Thomas, PhD Department of Cardiovascular Surgery - Bristol Heart Institute,
Bristol Royal Infirmary, Bristol, UK
Sophina Trubel, MD Department of Vascular and Endovascular Surgery, PMU Salzburg,
Salzburg, Austria
Peter I. Tsai, MD Cardiothoracic Surgery, Ben Taub General Hospital, Houston, TX, USA
Diego Soto Valdés Resident of General Surgery, Department of Surgery,
University of Santiago of Chile, Santiago, Chile
Contributors xxi

Frank J. Veith, MD Department of Surgery, Division of Vascular Surgery,

New York University Medical Center, New York, NY, USA
Department of Surgery, Division of Vascular Surgery, The Cleveland Clinic,
Cleveland, OH, USA
Division of Cardiovascular Surgery, Clinic for Cardiovascular Surgery,
University Hospital Zurich, Zurich, Switzerland
Matthew J. Wall Jr., MD Cardiothoracic Surgery, Trauma and Critical Care,
Baylor College of Medicine, Houston, TX, USA
Ding Wei-wei, MD, PhD Department of General Surgery, Nanjing General Hospital
of Nanjing Military Command, Institute of People’s Liberation Army for General Surgery,
The Clinical College of the Nanjing University Medical School, Nanjing, Jiangsu, China
Omar Wever-Pinzon Heart Failure Program (Division of Cardiology) and Molecular
Medicine Program (Eccles Institute of Human Genetics), University of Utah,
Salt Lake City, UT, USA
Shiyue Xu, MD Department of Medicine, Cardiology, Feinberg Cardiovascular Research
Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Riad N. Younes, MD, PhD Department of Surgery, Faculty of Medicine, University of Sao
Paulo, Hospital Sao Jose, São Paulo, Brazil
Anthony S. Zannas, MD, MSc Department of Psychiatry, Duke University Medical Center,
Durham, NC, USA
Kenton J. Zehr, MD Division of Cardiothoracic Surgery and Center for Aortic Disease,
Scott & White Clinic, Texas A & M Health Sciences Center College of Medicine,
Temple, TX, USA
 Part I
General Topics
 Neuroendocrine Response and Shock
1
Riad N. Younes and Fernando C. Abrão

Historical Aspects restored, shock is reversed. However, in cases where injury is

severe and prolonged, cell perfusion is not restored before
The concept of shock has evolved throughout the centuries several cell mediators are released and activated, triggering a
since the early descriptions of traumatic injury. Hippocrates cascade of irreversible reactions and leading to irreversible
(460–380 BC) recognized certain principles of wound care, shock. Thus, this syndrome can range from subclinical
such as elevating an injured limb; however, at that time the hypoperfusion to multiple organ dysfunction.
correlation between blood loss and death had not yet been The key point of hypoperfusion is tissue hypoxia. Oxygen,
identified. In the 20th century, two physiologists, Cannon and as an essential nutrient for proper metabolism, becomes less
Bayliss [1], developed studies in laboratory animals, postulat- available in relation to tissue demands. Then oxygen debt
ing that systemic responses resulting from severe muscle occurs, where the oxygen demand is greater than the oxygen
injury were caused by a toxin that caused motor tonus loss, supply. Therefore, even in conditions of adequate oxygen
venous blood sequestration, and hypotension. supply, such as sepsis, metabolism acceleration caused by
Nevertheless, in 1930 Alfred Blalock [2] defined the con- systemic inflammatory response results in increased oxygen
cept of hypovolemia as a primary mechanism in the pathogen- demand, which is not supplied.
esis of traumatic shock. Blalock was able to demonstrate in
experiments with dogs that the local loss of blood and plasma
through injuries was sufficient to contribute to a blood pres- Shock Mediators
sure decrease. Currently, through advances in molecular biol-
ogy, studies of shock are intended to identify and manipulate As mentioned before, any severe or prolonged injury can
several inflammatory mediators that are activated in severe trigger tissue hypoperfusion and shock. The way shock is
stress situations. Prevention of organ ischemia and oxygen triggered has been the object of many studies, and it is cur-
uptake by tissues are also very exciting lines of research in the rently known that neuroendocrine and inflammatory media-
study of shock and may lead to better results than the 50 % of tors are closely related to the onset, maintenance, and
mortality in some specific types of shock [3]. irreversibility of shock. This occurs through several interre-
lated reaction cascades that constitute the concept of sys-
temic inflammatory response. Before we discuss the
Definition neuroendocrine part of the inflammatory response, we will
mention the other major groups of mediators of this
Shock, regardless of its cause, can be defined as a syndrome inflammatory response: endotoxins, complement fragments,
that results from inadequate tissue perfusion, causing cells to eicosanoids (prostaglandins), kinins, nitric oxide, cytokines
not be able to meet their metabolic needs. As a consequence, (interleukins), platelet-activating factor, endogenous opioids,
metabolism alterations occur, which cause cell dysfunction, and oxidizing agents [4].
inflammatory mediator production, and cell injury. At this
point, two outcomes are possible. If cell perfusion can be
Signs That Trigger Trauma Response
R.N. Younes, MD, PhD (*) • F.C. Abrão, MD
The afferent sensory nerve fibers provide the most direct
Department of Surgery, Faculty of Medicine, University of Sao Paulo,
Hospital Sao Jose, São Paulo, Brazil and fastest pathway for signals to reach the CNS after the
e-mail: rnyounes@yahoo.com stress. It has often been suggested that pain may act as an

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 3

DOI 10.1007/978-1-4471-4429-8_1, © Springer-Verlag London 2013
4 R.N. Younes and F.C. Abrão

initial afferent signal after the trauma, and many studies Role of the Neuroendocrine Axis in the
have suggested that the afferent nerve signals from the Systemic Inflammatory Response (Shock)
injured area are essential to stimulate the hypothalamic-
pituitary-adrenal axis [5]. The adrenocortical response to Inflammation is primarily an immune response aimed at pro-
trauma was not observed in laboratory animals after section- tecting the organism from the devastating effects of patho-
ing of the peripheral nerves to the traumatized area, transec- gens, chemicals, and tissue injury. It is well established that
tion of the spinal cord above the injury, or sectioning through once the body sustains an insult, local inflammatory media-
the medulla oblongata. A similar response pattern to dener- tors, such as prostaglandins and interleukins, begin to circu-
vation before the trauma has been described in humans. late in the blood stream. These act both locally to direct
Growth hormone (GH) and adrenocorticotropic hormone inflammation and globally to indicate to the central nervous
(ACTH) levels in serum rise within 1 h after incision in system the need for both an added nutritional substrate
patients who receive general anesthesia and are undergoing directed toward vital organ systems and blunted systemic
cholecystectomy or inguinal hernia repair. However, this inflammation. The hypothalamic-pituitary axis responds
hormone response did not occur in patients undergoing with cortisol and similar hormones, which in the short term
abdominal procedures when an epidural block was used increase circulating carbohydrates, lipids, and proteins while
together with general anesthesia [6]. simultaneously leading the immunologic response [9].
Fluid loss from the vascular compartment stimulates the
pressure volume receptors, initiating a series of cardiovascu-
lar adjustments measured by the CNS. The cardiac output Signal Integration and Effector Mechanisms
decreases, the peripheral resistance increases, and blood is
redistributed to vital organs in order to keep them working. The early response to trauma/acute illness is characterized
With the progressive loss of volume in the trauma area, the by stimulation of the hypothalamic-pituitary-adrenal (HPA)
resulting hypoperfusion reduces tissue oxygenation and dis- axis, increased levels of ACTH, prolactin, and growth hor-
rupts the acid-base balance. Then, chemoreceptor stimula- mone (GH), and often a reduction in thyroid hormone secre-
tion acts as an additional afferent stimulus for vasomotor and tion. GH is normally released from the anterior pituitary
respiratory centers during hypovolemia. As fluid loss after gland in a pulsatile manner, whereas thyroid-stimulating
trauma is closely related to the extent of tissue injury, these hormone (TSH) and prolactin release is continuous, with a
specific mechanisms allow a quantitative response to occur superimposed pulsatile component. However, in protracted
after the trauma (i.e., the response is directly proportional to critical illness, the endocrinological profile is one of sup-
the injury extension). pressed anterior pituitary hormone secretion. Despite this,
The circulating substances can directly or indirectly stim- cortisol levels remain high, possibly because of a pathway
ulate the CNS and activate the trauma response. The release involving endothelin [10, 11]. The pulsatile release of GH,
of cytokines, produced in the injured area, may signal the prolactin, and TSH is markedly reduced, predominantly in
brain to initiate these alterations. Conversely, it has been amplitude, whereas the frequency of secretory pulses is
shown that cytokines are produced within the brain and have maintained. The synchronous release of GH, prolactin, and
been found in the cerebrospinal fluid of patients after head TSH is also lost, but can be improved by administering
injury and meningitis. growth hormone-releasing peptide (GHRP)-2, but not growth
There is an extensive nerve fiber network of interleukin 1 hormone-releasing hormone or thyrotropin [12]. This sug-
(IL-1) that innervates the hypothalamus, and this cytokine gests the existence of an endogenous GHRP-like ligand,
may be influential at the beginning and direct the metabolic coordinating anterior pituitary hormone release.
response to stress. For instance, chronic brain exposure to The central nervous system, in addition to being activated
IL-1 resulted in catabolism in the rat. Significant weight loss, by the pathway described above, has an important role in
negative nitrogen balance, and hyperthermia have been dem- shock-related immunoregulation according to the most
onstrated in animals infused with IL-1 in the central ventricle recent studies.
in comparison with controls infused with saline solution. It is the catecholaminergic stimulation pathway [13]. In
This response to stress was associated with activation of the the acute phase of stress response, increased sympathetic
hypothalamus-pituitary-adrenal axis [7]. outflow stimulates a surge of catecholamines, increasing the
The release of cytokines, as well as of prostaglandins and level by as much as tenfold [14, 15].
interleukins, may initiate homeostatic adjustments or, in case They are a well-known participant in the acute stress
of severe injury such as sepsis, necrohemorrhagic pancreati- response and help to increase cardiac output [16], increase
tis, and so on, the release of these substances can cause potent basal energy expenditure [17], attenuate normal anabolic
stimuli that can generate a cascade effect on the metabolism, activity, and increase the breakdown of skeletal muscle [18,
triggering poor tissue perfusion [8]. 19] for manufacturing acute-phase proteins. Some studies
1 Neuroendocrine Response and Shock 5

[20, 21] demonstrated that a beta blockade can interfere with are opposed to insulin storage or anabolic functions. In the
the long-term catabolism of severely burned patients and short term, they maintain blood glucose levels and prevent
decrease the heart rate [21, 22]. In addition, norepinephrine hypoglycemia. The more chronic hormonal development
and epinephrine have been demonstrated to have immune accelerates the body’s catabolism [39].
capabilities by enhancing expression of immune mediators Glucocorticoids are also released after stress, and steroids
and exhibiting effects on T-helper cells in animal and human have potent effects on the metabolism of substrates and min-
models [23–29]. erals. Cortisol is produced in response to increasing concen-
Sympathetic activity, primarily because of its association trations of ACTH released from the anterior pituitary.
with the stress response, has received most of the attention Cortisol metabolizes amino acids from skeletal muscle and
from researchers, but parasympathetic activity during stress increases hepatic gluconeogenesis; it also causes severe
has recently been discovered to attenuate the stress response insulin resistance, and these effects cause the apparent hyper-
as well. Afferent activity has been demonstrated to enhance glycemia associated with acute illness [39].
cytokine for brain activation of the immune response The production of catecholamines – epinephrine and
[30–32]. norepinephrine – may be the most basic of hormonal
Efferent activity has also been shown to decrease systemic responses to stress, in addition to having an important role in
levels of TNF-a and prevent lethal hypotension [33]. the immunoregulation of shock, as described above. These
Acetylcholine, just like catecholamines, has immunoactive hormones exert regulatory effects on cardiac output, regional
capabilities. It actively inhibits the release of inflammatory circulation, blood glucose levels, and oxidative metabolism.
interleukins such as IL-6 and IL-18, but not IL-10, which is Epinephrine stimulates glycogenolysis, which in skeletal
an antiinflammatory protein [33]. In addition, studies have muscle promotes lactate production and, consequently, met-
shown that nicotine might be an effective tool in fighting abolic acidosis. Furthermore, epinephrine at higher concen-
inflammatory bowel disease, and there is less inflammatory trations markedly inhibits insulin production, thus facilitating
activity in the bowel mucosa of smokers [34–36]. The real the mobilization of amino acids and lipids [40].
impact of sympathetic and parasympathetic innervation on In normal subjects, the infusion of any of these catabolic
the immune response is yet to be elucidated, but there is hormones alone causes minimal changes in metabolism and
ample research activity trying to do so. circulation. However, when the three hormones are infused
Even less is known about the long-term effects of auto- together, the effects are synergistic and sustained. A negative
nomic stimulation during a stress response. Because of the nitrogen balance, gluconeogenesis, and hypermetabolism,
difficulty of studying long-term critical illness in both human the main components in the response to trauma, are observed
and animal models, it is easy to see why there is more infor- and associated with hydro-saline retention. Thus, it seems
mation about the acute phase. Some have generally postu- that the simultaneous production of the counter-regulatory
lated that continued stimulation of reactionary systems by hormones glucagon, cortisol, and epinephrine is in part
long-term stress results in an attenuated response [37, 38]. responsible for post-trauma alterations.
This has been demonstrated in lifetime stress and aging [38], We will specifically discuss the main hormones involved
but diminished activity of the autonomic nervous system in the endocrine response to shock below.
during critical illness has yet to be shown.

Adrenal Glucocorticoids
Peripheral Hormonal Environment
In critical illness, plasma cortisol levels are usually increased,
Hypothalamic stimulation creates a range of hormonal alter- but exhibit loss of the normal circadian rhythm. This period
ations in patients after trauma: throughout all phases of of increased cortisol synthesis may result in decreased pro-
trauma, there is a sharp increase in the counter-regulatory duction of other adrenal steroid hormones. However, adrenal
hormones glucagon, glucocorticoids, and catecholamines. In insufficiency during critical illness is being described with
contrast, plasma concentrations of the patient’s anabolic hor- increasing frequency, particularly in association with sys-
mone, insulin, may be reduced, normal, or elevated. During temic sepsis with shock [41], although variations in the
the initial response phase, insulin concentrations are normal definition of the condition have led to inconsistencies in the
or increased. However, the effects of high concentrations of reported incidences. Although adrenal insufficiency in criti-
insulin on peripheral tissues (skeletal muscle and adipose tis- cal illness may exhibit classic manifestations such as abdom-
sue) are blocked. The cause of severe insulin resistance is inal pain, pyrexia, confusion, and hypotension (resistant to
related to decreased food intake and an altered hormonal treatment), the signs are nonspecific and common in patients
environment, which exerts anti-insulin activity. The counter- in the intensive care unit. The diagnosis should always be
regulatory hormones glucagon, cortisol, and catecholamines considered in patients with increasing inotropic requirements
6 R.N. Younes and F.C. Abrão

in spite of adequate antimicrobial therapy and the absence of the immune system in experimental animals have been attrib-
convincing evidence of ongoing or worsening infection. uted to gender differences in the HPA axis or to an effect of
Serum cortisol levels have been variably associated with sex hormones. Although total GH secretion is similar in both
mortality in critical illness, with nonsurvivors exhibiting sexes, a greater loss of pulsatile GH secretion is seen in male
increased, reduced, or similar cortisol levels compared with compared to female patients during protracted critical ill-
controls [42]. Thus, the appropriate cortisol levels and ness, thus potentially conferring an outcome advantage on
responses to corticotrophin in critically ill patients are con- the female [46].
troversial. Nevertheless, the importance of adequate cortisol High-dose GH administration (five to ten times the stan-
levels in critical illness is clear. In a large group of intensive dard replacement doses) has been shown to improve the
care unit trauma patients, mortality was found to have nitrogen balance in patients with burns, after trauma, in early
increased from the range of 19–29 to 47 % when cortisol sepsis, and in postoperative surgical patients. However, high-
synthesis was (unknowingly) blocked by the routine use of dose GH, administered to adult patients requiring prolonged
the sedative etomidate [43]. When the cortisol responses to intensive care after surgery, multiple trauma, or acute respi-
corticotrophin in patients at the onset of septic shock were ratory failure, has been associated with increased lengths of
examined [44], a baseline serum cortisol >940 nmol/l and a hospital stay, longer duration of mechanical ventilation, and
maximum increase in cortisol levels <250 nmol/l in response increased mortality. GH administration had not been previ-
to corticotrophin were associated with increased mortality. ously shown to be associated with increased mortality.
Three patterns of activation of the HPA axis in septic shock Patient metabolic status at the time of GH administration
were identified using these parameters. The release of large may be of significance in relation to effect. Another apparent
amounts of nitric oxide through the action of inducible nitric anomaly is the finding that, in a porcine model of sepsis, the
oxide synthase is a feature of sepsis. Glucocorticoids inhibit effects of GH and IGF-1 on carbohydrate metabolism were
the induction of this enzyme if administered before the onset markedly different [47], as the GH effect takes place partly
of shock. However, nitric oxide induces S-nitrosylation of through IGF-1.
critical sulfhydryl groups in the glucocorticoid receptor, with
subsequent reduced binding of glucocorticoids [45]. This
may explain why glucocorticoids have not been previously Thyroid Hormones
shown to be effective when administered in patients with
established sepsis. Laboratory measurements of thyroid function in critically ill
However, studies about the treatment of adrenal patients are frequently “abnormal” and are always difficult
insufficiency are controversial. Improvement in shock rever- to interpret. The euthyroid sick syndrome describes abnor-
sal and a trend toward decreased mortality were seen with malities in thyroid function seen in critically ill patients who
supra-physiological doses of hydrocortisone (100 mg three do not exhibit overt thyroid disease. Such patients may or may
times daily). The use of smaller doses of hydrocortisone was not have problems at the cellular level [31, 48]. Biochemical
associated with reduced duration of vasopressor therapy and features may include several of the following: reduced total
ventilation and a trend toward earlier resolution of sepsis- triiodothyronine (T3) levels with a more modest reduction
induced organ dysfunction [41, 42]. in free T3, increased reverse T3, and possible reduced total
thyroxin (T4), with normal free T4 levels. TSH is usually
low or within the low-normal range. The most common
Growth Hormone expression of this condition is low T3 syndrome. Patients
exhibiting this condition usually have a normal total T4
Growth hormone increases plasma glucose levels and facili- level and should be considered euthyroid. Proposed mecha-
tates protein sparing (which protects lean body mass), lipoly- nisms include impaired responsiveness of the thyroid to
sis, immunocompetence, and sodium and water retention. Its TSH, reduced serum binding of thyroid hormones, or
secretion is inhibited by long-term glucocorticoid adminis- reduced peripheral conversion of T4 to T3. Glucocorticoids
tration and stimulated by hypoglycemia, exercise, sleep, high inhibit 5¢ monodeiodinase, which catalyzes the conversion
protein intake, and increased levels of leucine and arginine. of T4 to T3. Cytokines, however, exert no inhibitory effect
GH is thought to act directly and also by stimulating hepatic on 5¢-monodeiodinase activity. It has been postulated that
production of insulin-like growth factor-1 (IGF-1). endogenous cortisol has an inhibitory effect on TSH con-
During stress or illness, baseline GH is often elevated and centrations in patients with euthyroid sick syndrome [49]. In
diurnal variation reduced. However, continued stress, as typ- low T4 and T3 syndromes, those exhibiting the lowest
ical in critical illness, may be associated with reduced GH plasma T4 levels have the highest mortality, but no outcome
and IGF-1 levels and therefore with an attenuation of the benefit has been shown by administering T3 or T4 to these
anabolic processes. Differences in stress responses within patients [50].
1 Neuroendocrine Response and Shock 7

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 The Role of Lymphocytes in
the Pathogenesis of Atherosclerosis: 2
Focus on CD4+ T Cell Subsets

Ingrid E. Dumitriu and Juan Carlos Kaski

Introduction monocytes differentiate into macrophages that take up lipids

(LDLs) in either their native form or following modification
Recent advances in the mechanisms that underlie the [e.g., oxidized LDLs (oxLDLs)] [3]. Uptake of oxLDLs into
pathogenesis of atherosclerosis suggest that chronic macrophages triggers secretion of inflammatory cytokines
inflammation and the immune system actively contribute to such as interferon (IFN)-g that will induce further upregula-
the development and aggravation of this disease. Classical tion of adhesion molecules by endothelium and facilitate the
atherosclerosis was mainly attributed to the deposition of lip- recruitment of a novel wave of monocytes and lymphocytes.
ids [e.g., low-density lipoproteins (LDLs)] into the intima of Atherosclerotic lesions can evolve in time and constitute a
medium-sized and large arteries, resulting in the progressive central lipid area surrounded by infiltrates of lymphocytes,
thickening of the vessel wall. However, the identification of macrophages, and foam cells (macrophages loaded with
immune cells such as macrophages and T lymphocytes in lipids). A proliferation of vascular smooth muscle cells
atherosclerotic plaques sparked the interest of researchers in (VSMCs) in the media accompanies the intimal changes, as
understanding the precise roles of these cells in atherosclero- well as the formation of a fibrous cap, which is constituted
sis. Several lines of research in both animal models of athero- by a layer of endothelial cells and VSMCs [4]. Further pro-
sclerosis and patients have consolidated the view that the gression of atherosclerotic plaques may prevent oxygenation
innate and adaptive immune systems are important mediators of the center of the lesion, which results in cell death and the
of the inflammatory process that drives atherosclerosis [1]. formation of a necrotic core. This can also activate angiogen-
esis pathways that associate with generation of neovessels
and intraplaque haemorrhage. The presence of high numbers
The Immune Response in Atherosclerosis of immune cells, a thin cap, and a large necrotic core has
been linked to vulnerability of the atherosclerotic plaques
One of the earliest changes implicated in the development and predisposition to rupture. One of the mechanisms that
of atherosclerotic plaques is endothelial dysfunction. From can precipitate plaque rupture is the release of extracellu-
an immunological point of view, this manifests as elevated lar matrix–degrading enzymes, matrix metalloproteinases
levels of adhesion molecules and an increased permeability from activated intraplaque macrophages [5]. T cells and in
of the endothelium, which result in recruitment of immune particular CD4+ T lymphocytes have pivotal roles in regulat-
cells from the circulation and an influx of lipids into the ing macrophage activation and in orchestrating the chronic
intima [2]. Monocytes and T cells recruited from the circula- immune response in atherosclerosis [6].
tion populate the developing atherosclerotic plaques, where

The Basics of T-Cell-Mediated Immune

Responses

I.E. Dumitriu, MD, PhD, FHEA (*) Immune responses mediated by T cells are initiated by rec-
J.C. Kaski, MD, DM (Hons), DSc, FRCP, FACC, FESC, FAHA ognition of antigens (structures derived from pathogens in
Division of Clinical Sciences, the case of immune responses to infectious organisms or
Cardiovascular Sciences Research Centre,
altered endogenous cells in cancer or autoimmune disorders)
St. George’s University of London, Cranmer Terrace,
SW17 0RE London, UK and form the basis of adaptive immunity. The antigens are
e-mail: i.dumitriu@sgul.ac.uk recognized and processed by antigen-presenting cells

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 9

DOI 10.1007/978-1-4471-4429-8_2, © Springer-Verlag London 2013
10 I.E. Dumitriu and J.C. Kaski

(APCs), primarily dendritic cells (DCs) and macrophages, Proatherogenic T Cell Subsets
which are strategically positioned in the skin, mucosa of the
respiratory and intestinal tract, and tissue stroma to facilitate Th1 Cells
pathogen detection and capture [7, 8]. DCs, the most potent
of the APCs, are uniquely equipped to trigger the activation Th1 cells are characterised by production of inflammatory
of naive T cells. Following antigen uptake, DCs undergo a cytokines, of which IFN-g is considered the signature
series of changes that enable them to migrate from peripheral cytokine of this CD4+ T cell lineage. These cells have impor-
tissues into the lymphoid organs and to upregulate the expres- tant roles in cell-mediated immune responses as they provide
sion of molecules such as costimulatory ligands. Naive T crucial signals for optimal macrophage activation. However,
cells that recirculate between blood and lymph nodes in many disorders associated with chronic inflammation are
search of antigens come in contact with DCs displaying anti- due to uncontrolled Th1 function (e.g. diabetes, rheumatoid
gen on major histocompatibility complex (MHC) molecules arthritis). Th1 cells have been found to have mainly pro-
and scan them for the presence of cognate antigen. If antigen atherogenic effects. Indeed, they constitute an important part
recognition occurs, it will provide the first signal required for of the T lymphocytes infiltrating atherosclerotic plaques in
T cell activation, while interaction between costimulatory both human disease and in experimental animal models.
receptors on T lymphocytes (e.g. CD28) and their corre- Deletion of IFN-g or of the receptor for this cytokine has
sponding ligands on DCs generates the second (costimula- been found to reduce atherosclerosis in murine models of
tory) signal for activation [9]. Activated T cells proliferate atherosclerosis (Apoe−/− and Ldlr−/− mice) [16–18]. Similarly,
and differentiate into various effectors, depending on the Apoe−/− mice treated with IFN-g developed larger athero-
cytokines released by the antigen-presenting DCs (signal sclerotic plaques [19]. In line with these results, another
three). Two main types of T lymphocytes have been described: group found that Ldlr−/− mice deficient in T-bet, a transcrip-
the helper T (Th) cells (identified by the expression of the tion factor that is essential for Th1 cell differentiation, had
CD4 marker) and the cytotoxic T lymphocytes (CTL) that significantly reduced atherosclerosis compared to T-bet-
express CD8 and lyse cells infected by viruses or cancer expressing Ldlr−/− mice [20]. In other models, IFN-g was
cells. The main function of Th cells is to alter the function of found to have opposite effects on atherogenesis. Ldlr−/−
other cells of the immune system (e.g. macrophages, B cells, mice that were lethally irradiated to wipe out their immune
T cells). Distinct subsets of CD4+ T cells have been charac- cells and then reconstituted with bone marrow from Ifn-g−/−
terised subsequently, which include Th1, Th2, Th17 and mice were surprisingly found to have enhanced atheroscle-
regulatory T (Treg) cells. As all these cells express the marker rosis, suggesting that IFN-g could protect from atherosclerosis
CD4, they are usually distinguished by the cytokines they [21]. IFN-g has multiple effects on various cells involved in
produce and the transcription factors expressed. Interestingly, atherogenesis: (1) it stimulates the expression of MHC II on
different subsets of CD4+ T cells vary considerably with endothelial cells and VSMCs [22, 23], which could endow
respect to the target cells on which they act and the effects these cells with the ability to present antigens; (2) it enhances
induced. Recognition of pathogens by DCs (or macrophages) endothelial activation and the recruitment of T cells and
induces the secretion of cytokines that guide the differentia- macrophages into atherosclerotic lesions; (3) it triggers the
tion of naive T cells into a specific CD4+ T cell subset. activation of macrophages and DCs, which increases their
Differentiation into Th1 cells is mediated by interleukin-12 ability to present plaque-derived antigens to T cells and to
(IL-12), while IL-4 is instrumental in the generation of Th2 amplify the immune response; (4) it induces production of
cells [10, 11]. Th17 cells differentiate from naive CD4+ T matrix metalloproteinases from macrophages, which could
cells in the presence of IL-6 and possibly transforming cause apoptosis of VSMCs and promote thinning of the
growth factor-b (TGF-b) [12–14]. Treg cells can differenti- fibrous cap and plaque rupture; (5) it inhibits the differentia-
ate either in the thymus (naturally occurring Treg) similarly tion and proliferation of VSMCs and the synthesis of col-
to conventional T lymphocytes or in the periphery (inducible lagen, which could further contribute to rupture of the
Treg) under the influence of TGF-b or IL-10 [15]. plaques [24].
Most of the T cells present in atherosclerotic plaques
belong to the CD4+ subset, while CD8+ T cells are scarce.
Very little information is available on the precise contribu- CD4+CD28null T Cells
tion of CD8+ T cells to atherosclerosis, while their CD4+
counterparts have been extensively investigated and found Another proinflammatory CD4+ T lymphocyte subset that
to be crucial players in the chronic immune response that expands in patients with chronic inflammatory conditions
drives atherosclerosis. The next sections will focus on the but is very low in healthy individuals is known as the
main CD4+ T cell subsets that have been implicated in CD4+CD28null T cells [25]. The feature that distinguishes
atherogenesis. these cells is the absence of the costimulatory receptor CD28,
2 The Role of Lymphocytes in the Pathogenesis of Atherosclerosis: Focus on CD4+ T Cell Subsets 11

which has important roles in the optimal activation of T cells and Th17 cell expansion [38]. As Th17 cells have potent
following antigen recognition on APCs [9]. CD28 is proinflammatory functions and contribute to the pathogene-
expressed constitutively on naive CD4+ T cells and it inter- sis of many autoimmune diseases, they are being actively
acts with ligands expressed on APCs (i.e. CD80 and CD86). investigated in atherosclerosis. As Th17 cells have
In the absence of co-stimulatory signals transduced by CD28, proinflammatory roles, it would be expected that they pro-
T cells become unresponsive to antigen. The frequency of mote atherosclerosis. Indeed, IL-17A blockade in Apoe−/−
CD4+CD28null T cells increases significantly in patients with mice reduced the development of atherosclerotic plaques
acute coronary syndrome (ACS) compared to patients with [39]. In addition, attenuated atherosclerosis is observed in
stable angina (SA) and healthy subjects [25]. This T cell sub- lethally irradiated Ldlr−/− mice upon reconstitution with
set has been suggested to contribute to plaque rupture as they IL-17R-deficient bone marrow cells compared to bone mar-
have been isolated from unstable coronary plaques and are row from wild-type counterparts [40]. Other studies on Th17
known to be an important source of IFN-g [26, 27]. In addi- in atherosclerosis have generated contradictory results.
tion, CD4+CD28null T cells express molecules that endow Depletion of B cells from Apoe−/− or Ldlr−/− mice resulted in
them with cytotoxic function (perforin, granzyme A and B) atherosclerosis reduction, which surprisingly was the conse-
[28]. Of note, conventional CD4+CD28+ T cells do not quence of elevated secretion of IL-17 from T cells [41]. The
express perforin and granzymes, which are usually found contribution of Th17 cells to human atherosclerosis is not
only in cytotoxic CD8+ T lymphocytes and natural killer much clearer. Th17 cells were proposed to promote athero-
(NK) cells. CD4+CD28null T cells have been shown to kill sclerosis by acting in concert with Th1 cells following evi-
endothelial cells and SMCs in vitro, which could further sug- dence that T cells from human coronary arteries express
gest a role in plaque rupture [29] for this T cell subset. IL-17 in addition to IFN-g [42]. However, increased expres-
Recently, it was found that patients with high frequencies sion of IL-17 was found to correlate with markers of stability
of CD4+CD28null T cells are more likely to undergo recurrent in plaques from carotid or coronary atherosclerosis [43].
acute coronary events (i.e. myocardial infarction) [30] than Therefore, further research in both animal models and
those with limited expansion of these cells. Diabetes melli- patients with atherosclerosis is required to clarify the roles of
tus, a risk factor for ACS, also associates with CD4+CD28null Th17 cells in this disease.
T cell expansion [31]. Moreover, high frequencies of
CD4+CD28null T cells correlate with the occurrence of the
first cardiovascular event and a poor ACS outcome in dia- Anti-atherogenic T Cell Subsets
betic patients [31].
The precise mechanisms that lead to the expansion of Th2 Cells
CD4+CD28null T cells in ACS are not completely known. The
proinflammatory cytokine TNF-a was suggested to down- Th2 cells produce IL-4, IL-5 and IL-13 cytokines and gener-
regulate the expression of CD28 [32, 33]. Previous work ally have opposing effects to Th1 lymphocytes. The cytok-
from our group demonstrated that 50 % of CD4+CD28null T ines secreted by Th2 cells have important roles in driving the
cell clones derived from ACS patients recognise the endog- production of antibodies from B lymphocytes, which are
enous antigen human heat shock protein 60 (hHSP60) [34, involved in the immune response to extracellular microbes
35]. We have recently demonstrated that CD4+CD28null T [44]. However, Th2 cells have also been implicated in disor-
cells from ACS patients express elevated levels of costimula- ders associated with chronic inflammation such as allergies
tory receptors of the tumour necrosis family receptor and and asthma [45]. Initially it was thought that Th2 cells pro-
that these receptors regulate the production of inflammatory tect from atherosclerosis. BALB/c Apoe−/− mice, which are
cytokines and expression of perforin and granzyme B by known to have predominant Th2 responses, were found to
CD4+CD28null T cells [36]. Targeting this subset of T cells have significantly less atherosclerosis than C57BL/6 Apoe−/−
could yield promising results for the induction of plaque sta- mice (in which the immune response is mediated preferen-
bility in ACS patients. tially by Th1 cells) [46]. Similarly, deletion of the transcription
factor that regulates the generation of Th1 cells (i.e. T-bet) in
Ldlr−/− mice results in immune responses mediated preferen-
Th17 Cells tially by Th2 cells; this associated with decreased atheroscle-
rosis compared to wild-type Ldlr−/− mice [20]. However,
Th17 cells secrete IL-17, a proinflammatory cytokine, and animal models deficient in IL-4 have generated controversial
have important roles in the immune response to infectious findings. Deletion of IL-4 in Apoe−/− mice (which impairs the
pathogens [37]. TGF-b and IL-6 have been shown to induce differentiation of naive T cells into Th2 effectors) was found
the differentiation of naive CD4+ T lymphocytes into Th17 to reduce atherogenesis [47]. Similar results were obtained
cells [12, 14], while IL-23 regulates the production of IL-17 following reconstitution of Ldlr−/− mice with IL-4-deficient
12 I.E. Dumitriu and J.C. Kaski

bone marrow [48], suggesting that Th2 cells could promote have been recently contradicted by a study that investigated
atherogenesis. Therefore, the role of Th2 cells in atheroscle- a larger group of patients. No relationship was found between
rosis is not completely understood. the frequency of circulating Tregs and the extent or severity
of carotid or coronary atherosclerosis [57]. Surprisingly,
STEMI patients showed a decrease in Tregs, NSTEMI asso-
Regulatory CD4+ T Cells ciated with an increased frequency of this cell subset, and in
stable angina there was no change in Treg frequency. Whether
Regulatory T cells (previously known as suppressor T cells) these contrasting results are due to inclusion of a larger num-
are a subset of CD4+ T lymphocytes specialised in the main- ber of patients or to the markers used to identify Tregs (i.e.
tenance of immune tolerance to self and inhibition of exces- characterised as CD4+CD25hiCD127lo Tregs in [57], while
sive immune responses. Treg cells can develop either in the Tregs were quantified as CD4+CD25hi in the previous two
thymus or be generated in the periphery during an active studies [55, 56]) is not known and remains to be addressed
immune response. The thymus-derived Tregs are known as by future research.
naturally occurring (nTreg), while the ones generated in the
periphery are named inducible Tregs (iTreg) [15]. The mark-
ers that distinguish Tregs from other CD4+ T lymphocytes Immunotherapy in Atherosclerosis:
and allow identification of regulatory T cells are CD25 (the Fact or Fiction?
a chain of the IL-2 receptor, which is expressed at high lev-
els on Tregs), CD127 (which is not expressed/present in low Further proof that the immune system has a central role in
levels in Tregs) and the transcription factor Foxp3 [49]. atherosclerosis and that it could be targeted therapeutically
Defects in Tregs have been implicated in the pathogenesis of with beneficial effects is provided by some of the therapeutic
autoimmune disorders [50, 51] and could also contribute to agents currently in use in coronary atherosclerosis. Recent
atherogenesis. In animal models Tregs were found to protect data suggest that the efficiency of these drugs is not due just
from atherosclerosis both in the initial and late stages of the to their main pharmacological targets but that they addition-
disease [52]. Depletion of CD4+CD25hi Tregs from Apoe−/− ally alter the function of immune cells such as T lympho-
mice by treatment with anti-CD25 monoclonal antibodies cytes. Statins, which are prescribed to lower LDL levels in
significantly enhanced atherosclerosis [53]. In addition, an patients with atherosclerosis, have been shown to decrease
increased number of inflammatory T cells and macrophages the frequency of inflammatory CD4+CD28null T cells
infiltrated atherosclerotic plaques in Apoe−/− mice depleted significantly [58] and increase Tregs [59] in ACS patients.
of Tregs. This was accompanied by a decrease in collagen Selective blockade of TNF-a could represent another strat-
levels in the plaques, similar to findings in vulnerable plaques egy to decrease the inflammatory immune response in ath-
from human patients [53]. In another model, lethally irradi- erosclerosis. Indeed, TNF-a blockade improves endothelial
ated Ldlr−/− mice reconstituted with Treg-deficient bone mar- function in RA patients [60]. In addition, neutralising anti-
row developed larger atherosclerotic plaques compared to bodies against TNF-a have been shown to restore CD28
mice reconstituted with wild-type bone marrow [53]. Another expression by CD4+CD28null T cells cultured in vitro, which
proof for a protective role of Tregs in atherosclerosis comes may suggest that TNF-a blockade could inhibit the expan-
from a model in which TGF-b signalling was disrupted, sion of this inflammatory lymphocyte subset in patients with
which resulted in increased atherosclerosis in Apoe−/− mice atherosclerosis [61].
[54]. TGF-b is a potent immunosuppressive cytokine that is Another therapeutic strategy to modulate chronic
secreted by Tregs and is believed to be one of the mecha- inflammatory immune responses that could be applied in
nisms responsible for the immunosuppressive effects of these atherosclerosis focuses on expanding the numbers or func-
cells. tion of Tregs in patients. This hypothesis has been tested
In humans, the markers used for identification of Tregs with successful results in animal models of atherosclerosis.
are less specific than in animals, as they can also be upregu- Ldlr−/− mice tolerised to oxLDL or HSP60 (antigens involved
lated in recently activated conventional T cells. Initial studies in atherogenesis) developed significantly smaller atheroscle-
in humans have suggested that Tregs were altered in patients rotic lesions compared to Ldlr−/− animals [62, 63]. Of note,
with ACS similarly to findings in autoimmune diseases. tolerised Ldlr−/− mice had higher numbers of
Indeed, the frequency of circulating CD4+CD25hi Tregs was CD4+CD25+Foxp3+ Tregs in the spleen and mesenteric
significantly decreased in patients with ACS (STEMI) when lymph nodes, suggesting that oral tolerance to oxLDL or
compared to stable angina patients or healthy subjects [55]. HSP60 associated with expansion of Tregs and suppression
Moreover, the suppressive function of Tregs from ACS of the immune response. In another model, adoptive transfer
patients was impaired compared to the suppressive ability of of Tr1 cells (a subtype of inducible Tregs that characteristi-
Tregs from healthy individuals [56]. However, these findings cally secrete the immunosuppressive cytokine IL-10) reduced
2 The Role of Lymphocytes in the Pathogenesis of Atherosclerosis: Focus on CD4+ T Cell Subsets 13

atherosclerosis in Apoe−/− mice [64]. These results suggest 16. Buono C et al. Influence of interferon-gamma on the extent and
that activation and expansion of Tregs in vivo may provide a phenotype of diet-induced atherosclerosis in the LDLR-
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 Immunological Mechanisms
of Inflammation 3
Nilo José Coêlho Duarte, Cyro Alves de Brito,
and Alberto José da Silva Duarte

Introduction attracts substances out of the blood and retains them. These
substances, such as cytokines and chemokines, are produced
Cardiovascular diseases (CVDs) are the leading cause of during the inflammatory response to ischemic injury, mediat-
death worldwide. The World Health Organization has esti- ing various reactions and attracting leukocytes to the lesion.
mated that around 17.3 million people died from CVDs in Despite the clinical therapeutic advances for CVDs,
2008, representing 30 % of all global deaths. Of these deaths, surgery is still widely used to treat them, and it has been
an estimated 7.3 million were due to coronary heart disease reported that major general surgery causes profound
and 6.2 million to stroke [1]. alterations in immunity. After an initial proinflammatory
The majority of the CVDs are induced by atherosclerosis, phase associated with innate immunity, an immunosup-
which is associated with a chronic inflammatory process in pressive response mediated mainly by cells of the adap-
which the immune system has an important role. The natural tive immune system takes place. Therefore, surgical stress
evolution of this process is the formation of a thrombus that inhibits innate immunity from the time of incision until
can cause a partial or complete blockage of the blood flow, about the first postoperative day. This is a crucial period
inducing damage to the organ, such as the heart or brain. with greater susceptibility to bacterial infections. In gen-
Because of the blood flow blockage in a coronary artery, eraly, this susceptibility may be caused by the absence
the ischemic environment results in myocardial infarction of recovery of innate immunity and lead to postoperative
and the death of cardiomyocytes. The established disorder complications. The goal of further clinical studies must be
to establish the immunomodulating property of the individ-
ual, which is very important for controlling innate immu-
nity and inflammation in each patient.
N.J.C. Duarte, MD (*)
For understanding the alterations established in the post-
Clinical Laboratory, Hospital do Coração,
São Paulo, Brazil operative period, we first describe how the inflammation,
innate immunity, and adaptive immune response take place
Central Laboratory of Hospital das Clínicas, Faculty of Medicine,
University of São Paulo, and sequentially understand which modifications are imposed
São Paulo, Brazil by the surgery. Finally, we describe some trials attempting to
e-mail: njcduarte@gmail.com modulate immunity to inhibit the immunosuppression gener-
C.A. de Brito, PhD ated by the perioperative period.
Center of Immunology, Adolfo Lutz Institute,
São Paulo, Brazil
A.J. da Silva Duarte, PhD Inflammation
Clinical Laboratory, Hospital do Coração,
São Paulo, Brazil
Inflammation is the body’s reply to injury or irritation, a
Faculty of Medicine, University of São Paulo,
protective attempt to both remove the stimulant and initiate
São Paulo, Brazil
the healing process. This response involves both innate and
Central Laboratory of Hospital das Clínicas, Faculty of Medicine,
adaptive immunity, as well as diverse molecular and cellular
University of São Paulo,
São Paulo, Brazil processes (e.g., chemotaxis, phagocytosis, mitosis, and cell
differentiation) by the affected tissues.
Laboratory of Medical Investigation Unit 56, Faculty of Medicine,
University of São Paulo, In the past, inflammation was associated with infec-
São Paulo, Brazil tions and the immune system. However, recent evidence

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 15

DOI 10.1007/978-1-4471-4429-8_3, © Springer-Verlag London 2013
16 N.J.C. Duarte et al.

a b

c d

Fig. 3.1 Mechanisms involved in cell migration. (a) Inflammatory in the blood to approach the endothelium, starting with a process of
mediators, such as cytokines and chemokines, are produced during the “rolling” by the interaction between the adhesion molecules expressed
inflammatory response to the pathogen or tissue proteins resulting from by the endothelial cells and the leukocyte molecules. At this time, the
the cell damage. This response aims to isolate and destroy the pathogen chemokines will influence the cell migration pattern. (c) Antigen-
and regenerate the injured tissue. (b) Expression of adhesion molecules presenting cells migrate from the tissue to lymphoid organs where the
facilitates the attachment of circulating cells to the endothelium and to adaptive immune response begins. (d) Activated lymphocytes leave the
tissue structures. The alteration in the blood flow allows the leukocytes lymphatic circulation and migrate to the inflammation site

suggests that a broader range of disorders have inflammation injury, infectious agent, chemical injury, burn injury, radia-
markers. These include cancer, acute cerebrovascular tion, tissue injury due to lack of organ perfusion, and oxygen
stroke, Alzheimer’s disease, chronic arterial and venous supply) (Fig. 3.1a). In general, the inflammatory cascade
disease, myocardial ischemia, and systemic arterial hyper- includes several microvascular reactions, such as elevated
tension [2]. permeability in microvessels, attachment of circulating cells
The various forms of inflammation differ according to to the vessels in the vicinity of the injury site, migration of
their location in the tissue, the organ where they occur, and several cell types, cell apoptosis, and growth of new tissue
the nature and severity of the tissue injury (e.g., mechanical and blood vessels.
3 Immunological Mechanisms of Inflammation 17

Fig. 3.2 Defense barriers Vessel Wall

against infections. The first Innate Immunity Adaptive Immunity
line of defense is composed by
the natural barriers, which are Skin
formed by the skin and mucosal
epithelial surface, the corporal
fluids, and the normal bacterial Neutrophil
flora. The loss of integrity in any CD8
Virus
of these barriers, with or without
infection, initiates the innate NK
Complement
immunity. Next, the adaptive
immune response is initiated,
which is characterized by Bacteria
specificity and memory
Eosinophil CD4

Basophil
Parasite
Macrophage

An important form of cell activation in the microcircula- and platelet activation factor), and neuropeptides [substance
tion is the expression of membrane adhesion molecules that p and calcitonin gene-related peptide]. Parallel to this event,
facilitate the attachment of circulating cells to the endothe- there is the activation of the blood coagulation cascade (pro-
lium and to tissue structures over which they migrate. The duction of chemotactic peptides), fibrinolytic system, com-
alteration in the blood flow allows the leukocytes in the blood plement activation, and kinin system (production of
to approach the endothelium, starting with a process of “roll- bradykinin) [3, 4].
ing” by the interaction between the adhesion molecules The activation of the cells involved in the innate immune
expressed by the endothelial cells (E-selectin, expressed by response induces the secretion of various cytokines, such as
the activated endothelial cell, and P-selectin, which has con- IL-1, IL-6, IL-8, IL-12, IL-18, and TNF-a. IL-1 acts in the
stitutive expression) and leukocyte molecules (L-selectins) vascular endothelium, increasing leukocyte adhesion, and in
(Fig. 3.1b). After this, the action of leukotriene B4, platelet the bone marrow, increasing leukocyte production. In syn-
activation factor, and interleukin (IL)-8 triggers a conforma- ergy with IL-18, IL-1 triggers the intracellular signalization
tional change of the integrins expressed in the leukocytes with the activation via nuclear factor kB (NF-kB ), which
[leukocyte function-associated (LFA)-1 or CD11a/18 and induces the production of many cytokines and chemokines
Mac-1 or CD11b/18] enabling a firm interaction with the [3, 4]. IL-1 and TNF-a bind to the thermoregulatory recep-
intercellular adhesion molecule (ICAM)-1 and ICAM-2 tors in the hypothalamus, causing fever. TNF-a increases the
molecules expressed by the endothelial cells. The interaction vascular permeability of the endothelium, allowing the accu-
of the leukocytes with platelet endothelial cell adhesion mol- mulation of immunoglobulins and complement proteins in
ecules allows its passage to the tissue through diapedesis and the injured tissue. IL-6 is responsible for the stimulation and
migration to the inflammatory site. At this time, the chemok- differentiation of the B lymphocytes and together with IL-1
ines will influence the cell migration pattern, IL-8 and and TNF-a acts in the liver, promoting the synthesis of the
CXCL7 being important to neutrophil migration, CCL2, acute phase proteins, such as C-reactive protein (CRP). IL-8
CCL3, and CCL4 to monocyte migration, and CCL11 to is important in the cell migration to the damaged tissue,
eosinophil migration [3, 4]. especially neutrophils, and IL-12, which is responsible for
Inflammatory mediators, such as cytokines and chemok- the activation of the natural killer cells (NK) [2].
ines, are produced during the inflammatory response to the
pathogen or tissue proteins resulting from the cell damage.
This response aims to isolate and destroy the pathogen and Innate Immunity
regenerate the injured tissue (Fig. 3.1c, d). It starts with the
contraction or dilation of the arteriole muscle wall and the The first line of defense of the organism against infections is
dilation of the venules by contraction of the actin and myosin composed by its natural barriers, which are formed by the
filaments of the endothelial cells. This mechanism is due to skin and mucosal epithelial surface, the corporal fluids, and
the action of the mediators produced by local mast cells and the normal bacterial flora (Fig. 3.2). The loss of integrity in
macrophages. Some of these mediators are histamine, lipid any of these barriers, with or without infection, initiates the
mediators (leukotrienes- B4, C4, and D4, prostaglandins, innate immune response. Other elements that compose the
18 N.J.C. Duarte et al.

innate immunity include the complement system, resides within the cells is a potential DAMP when released
inflammatory mediators, chemokines, cytokines, pathogen- after cell death. In fact, the systemic and/or local DAMPS,
associated molecular pattern recognition receptors, antimi- such as heat shock proteins (HSP), surfactant protein A, and
crobial peptides, and some populations of the immune cells. protein of the high mobility group 1 (HMGB1), are elevated
The innate immune response depends on cells such as in inflammatory and autoimmune disorders, including CVDs
phagocytes, NK cells, NKT lymphocytes, g:d T cells, and the [6]. These molecules have gained much attention in DAMP-
B-1 lymphocytes capable of directly recognizing antigens. mediated activation of the innate immune system and subse-
The phagocytes comprehend the neutrophils and monocytes/ quent inflammation after cardiac ischemia. The mechanisms
macrophages, which recognize the pathogens opsonized by by which DAMPs activate and control leukocyte behavior
antibodies and C3b or by the CD14 and CD204 receptors. In and whether DAMPs can be used as therapeutic targets in
phagocytosis antigens are internalized, forming a membrane order to modulate detrimental inflammatory responses
vesicle named the phagosome, which joins with a pre-formed remain unclear.
vesicle (lysosome) rich in substances that act in the elimina- PAMPs and DAMPs activate innate immunity through
tion of the pathogen. This substances are produced primarily some receptors, contributing to the inflammatory process
by the process of oxidative respiration [lysosomal oxidase, even in the absence of pathogens. The molecules and recep-
nicotinamide adenine dinucleotide phosphate (NADPH), and tors capable of interacting with those molecules are called
other enzymes] where several cytotoxic products derived pattern-recognition receptors/molecules (PRRs/PRMs).
from oxygen are formed, such as the superoxide anion (O2-), PRRs are responsible for the cell/antigen interaction in the
hydrogen peroxide (H2O2), free oxygen (O2), hydroxyl radi- inflammatory site, collaborating in phagocytosis, cytokines
cal (OH), and hypochlorous acid (HOCl). Nitrogen oxides secretion, and intracellular signalization. PRMs are soluble,
(nitric oxide-NO), antimicrobial peptides (cationic), secreted proteins, such as surfactant protein (SP)-A, SP-D,
lysozyme, acid hydrolases, and competitors, such as lacto- mannose binding protein (MBL), ficolins, and CRP.
ferrin, an iron chelator, are also produced. The macrophages Two categories of PRRs are recognized: (1) scavenger
are also responsible for secretion of IL-12, a cytokine impor- receptors, which mediate the capture, uptake, and presenta-
tant to the cellular activation. tion of antigen, and (2) Toll-like receptors (TLR), which lead
The NK cells can potentially secrete IFN-g, which is vital the activation of proinflammatory pathways.
to the control of infection by intracellular pathogens, such as Toll-like receptors (TLRs) constitute a family of host
the Herpes virus, Leishmania, and Listeria monocytogenes, defense receptors, which are expressed in different cell types,
before the activation of the antigen-specific T lymphocytes. especially in immune system cells, but also in keratinocytes
Other cytokines involved in the innate response are inter- and epithelial cells, among others (Fig. 3.3). To date, 13
feron type a and b (IFN-a and IFN-b), which have the capac- TLRs have been identified in mammals, including 10 in
ity to inhibit viral replication, activate NK cells, and increase humans and 12 in mice [7]. Among the TLR ligands are
the expression of major histocompatibility complex (MHC-1) microbial compounds, such as peptideoglycan (TLR 1, 2, 3,
molecules in the infected cells, increasing their susceptibility 6), viral double-stranded RNA (TLR 3), lipopolysaccharide
to attack by cytotoxic T cells. (TLR 4), flagellin (TLR 5), single-stranded RNA (TLR 7, 8),
bacterial and viral DNA containing non-methylated cytosine-
guanine dinucleotide (CpG) (TLR 9) [8], and uropathogenic
Innate Receptors E. coli and T. gondii profilin (TLR 11 in mice) [9].
The intracellular events that occur during the activation of
As a result of evolutionary progress, all multicellular organ- TLR are mediated by myeloid differentiation factor 88
isms have developed mechanisms to recognize invading (MyD88), except in the activation of TLR3, which is medi-
organisms by specific receptors to structures common to the ated by the molecule TRIF (TIR domain-containing adapter
majority of pathogens. These molecular patterns associated inducing IFN-b). The activation of TLR4 is mediated by
with pathogens are called pathogen-associated molecular both MyD88 and TRIF [10]. MyD88-dependent pathway
patterns (PAMPs). They are highly conserved products asso- promotes early activation of nuclear factor kappa B (NF-kB),
ciated with several microorganisms, such as the bacterial which leads to production of proinflammatory cytokines,
outer membrane, lipopolysaccharides (LPS), glycopeptides particularly TNF-a. Furthermore, the MyD88-independent
(PGN), lipotechoic acid (LTA), cytosine-phosphate-guanine pathway, mediated by TRIF, promotes activation of the late
unmethylated motifs (CpG), double-stranded RNA from phase of NF-kB and interferon regulatory factor (IRF),
RNA viruses, and mannans from fungal walls [3]. inducing the synthesis of IFN-b and the expression of genes
However, molecular patterns associated with tissue dam- induced by type 1 IFN. The activation of NF-kB is well rec-
age are called damage/danger-associated molecular patterns ognized as a hallmark of innate immunity activation after
(DAMPs) [5]. In theory, every single molecule that normally cardiac ischemia. As the signaling cascade triggered by
3 Immunological Mechanisms of Inflammation 19

Fig. 3.3 Toll-like receptors Extracellular

(TLRs) constitute a family of
innate immunity receptors. The
intracellular events that occur LPS Flagellin PGN
during the activation of TLR are
TLR4 TLR5 TLR1 TLR2
mediated by myeloid TLR6
differentiation factor 88
(MyD88) or by the molecule TIR
domain-containing adapter-
inducing IFN-b (TRIF). TLR
activation promotes activation of
nuclear factor kappa B (NF-kB),
which leads to production of
proinflammatory cytokines

IRAK
c-JUN/ATF1
Nucleus
JNK/p38
AP1
TRAF6 JNKK1

NF-κB
NIK
P P IkB
IKK complex NF-κB
Intracellular Proinflammatory genes expression

TLRs also involves NF-kB, a new paradigm of noninfectious MHC molecules are glycoproteins encoded by highly poly-
activation of the innate immune system following cardiac morphic genes, also called HLA (human leukocyte antigen)
ischemia can be postulated. genes in humans. There are two types of MHC molecules
In an experimental model, a rapid activation of Irak-1, an related to antigen presentation, the class I and class II,
important kinase in the response via TLR, has been shown which differ in structure and expression pattern in different
after transient ischemia. This activation is caused by increased cell types. MHC-I molecules are composed of two polypep-
levels of HSP60 binding to TLR4 in triggering the tide chains: a largest a chain, consisting of three domains,
inflammatory process in cardiac tissue [11]. It was also non-covalently linked to a smaller chain named b2 micro-
observed that treatment of cardiomyocytes with HSP60 leads globulin. MHC-I is expressed on all nucleated cells of the
to the activation of caspase-3 and -8, suggesting the activa- body and associated with the peptides present in the cyto-
tion of apoptotic pathways. Indeed, HSP60 induces apopto- sol, such as molecules of cytosolic pathogens, especially
sis in rat cardiomyocytes in part by binding to TLR4 [12]. viruses, to present them to CD8+ T cells [3]. Class II MHC
Moreover, apoptosis induced by myocardial ischemia/reper- molecules, on the other hand, are expressed on antigen-pre-
fusion injury is significantly attenuated in mice deficient in senting cells (APCs) and activated T lymphocytes. They
TLR4 or treated with anti-HSP60 [11]. consist of a non-covalent complex of two chains, a and b,
each with two domains, which cross the membrane. These
molecules bind to peptides derived from the degradation of
Adaptive Immunity antigens in vesicular compartments of macrophages, den-
dritic cells, and B lymphocytes, which will be presented to
The main characteristics of the adaptive immune response CD4+ T cells.
are specificity and memory. Unlike the innate immune The binding of the complex peptide:MHC to a specific
responses, adaptive immune responses are not initiated in the TCR is the first event necessary for activation of T lympho-
inflammatory site, but in the peripheral lymphoid tissues. It cytes. However, for the occurrence of an efficient activation
occurs after antigen-presenting cells (APCs), such as mac- of the immune response the involvement of accessory mole-
rophages and dendritic cells, migrate from the inflamed tis- cules is required. The binding of LFA-1 molecules, CD2 and
sue to the nearest lymphoid tissue, carrying antigen particles ICAM-3, expressed by T lymphocytes, and ICAM-1 and 2,
that are presented to T lymphocytes (Fig. 3.4). LFA-3, and dendritic cell-specific intercellular adhesion
Unlike B cells, T lymphocytes recognize antigen only molecule-3-grabbing non-integrin (DC-SIGN) by APCs
when it is associated with major histocompatibility com- allows T lymphocytes to come into contact with large num-
plex (MHC) molecules expressed on the cell surface. The bers of MHC molecules on the APC surface [4].
20 N.J.C. Duarte et al.

TLR

T cell B cell

– T-B interaction
– increased antibody production

TLR
IFN-g
MΦ TLR CD4+
APC T cell
T cell
IL-4
Th1/Th2 mixed response
IL-12

Efficient Ag presentation – Clonal expansion TLR CD8+ Target

and T-cell activation – Memory cells T cell cell

Strong cytotoxic activity

Fig. 3.4 Linking innate and adaptive immunity. Toll-like receptor Immune adjuvants improve the interaction between T and B cells,
agonists, such as DAMPs, increase expression of MHC and costimula- secretion of Th1/Th2 cytokines, and antibody production, and they
tory molecules in APCs, causing proper activation of T cells, which increase CTL activity in newborns (Adapted from de Brito et al. [13])
promotes T cell clonal expansion and generation of memory cells.

Another group of molecules involved in cell activation is Cytokines secreted by cells involved in the innate response
the group of co-stimulatory molecules. In addition to antigen are crucial in determining a specific “T helper” (Th) response
recognition via the TCR, a “second signal” or co-stimulatory despite many factors, such as the antigen’s route of entry into
signal is necessary for cell activation. The absence of co- the body, antigen dose, and co-stimulators, and also influence
stimulatory molecule interaction can promote T cell anergy the adaptive immune response. The CD4+ T cells can dif-
or deletion by apoptosis [14]. The anergy is characterized by ferentiate into different subtypes (Th1, Th2, Th3, Th17, reg-
the inability of lymphocytes to produce IL-2, even after an ulatory T cells, etc.) according to the pattern of cytokine
antigenic stimulus, preventing the proliferation of specific secretion. Th1 lymphocytes secrete mainly IFN-g, IL-2, and
clones and the generation of effector cells. Once activated, T TNF-a, whereas Th2 lymphocytes produce IL-4, IL-5, and
cells initiate the proliferation phase, induced by autocrine IL-13 [15].
production of IL-2. At this stage there is an increased expres- In general, Th1 lymphocytes stimulate a cellular immune
sion of the a chain of the IL-2 receptor and increased recep- response characterized primarily by the activation of mac-
tor affinity for the cytokine. After a period of rapid growth, rophages. This process is mediated by soluble or cell surface
which can range from 3 to 7 days, T lymphocytes differenti- molecules of T lymphocytes, such as IFN-g, granulocyte-
ate into effector cells that will perform specialized functions, macrophage colony-stimulating factor (GM-CSF), TNF-a,
such as helper or cytotoxic T cells [3, 4]. Effector T lympho- CD40L, and FasL [16]. Activated macrophages produce high
cytes exhibit a series of phenotypic and functional changes levels of oxygen radicals and nitric oxide (NO), antibacterial
that distinguish them from naïve T lymphocytes. The change peptides, and proteases. The activation of these cells increases
in expression of some adhesion molecules, such as decreased the expression of MHC-II molecules and B7, CD40, and
CD62L and increased CD2, LFA-1, and CD44, stops the TNFR receptors, enhancing antigen presentation to T lym-
recirculation through the lymph nodes and favors the effector phocytes and amplifying the immune response. Th2 lympho-
T cell migration to the inflammatory focus and other non- cytes produce cytokines that stimulate mainly the humoral
lymphoid tissues. immune response, i.e., the production of antibodies. IL-4
3 Immunological Mechanisms of Inflammation 21

induces the switch to IgE, increases the expression of MHC-II The inflammatory state can also be related to the kind and
molecules on B lymphocytes, stimulates T lymphocytes, the complexity of the surgery. Major surgery is associated
increases the proliferation of mast cells, and inhibits mac- with neutrophil dysfunction, as indicated by the reduced
rophage activation. IL-5 stimulates the growth and differen- chemotactic ability, phagocytic ability, and superoxide anion
tiation of eosinophils [17]. production [28, 29]. In addition, surgical injury can lead to a
multifactorial perioperative response including activation of
complement, coagulation, fibrinolytic, and kallikrein cas-
Immune Dysfunction on Perioperative Period cades, activation of WBCs with degranulation and protease
enzyme release, production of other free radicals, synthesis
In 1999, the Center for Disease Control and Prevention of various cytokines, and their consequences [30].
(CDC) in the USA presented the guideline for prevention of In fact, a correlation between the increased level of TNF-a
surgical site infection. Surgical site infections are the third with subsequent significant alteration of cell surface recep-
most frequently reported nosocomial infection. When surgi- tors (CD11a, CD11b, CD11c, CD18 and L-selectin) at
cal patients with nosocomial surgical site infection died, 60 min post-balloon inflation has been reported. It is neces-
77 % of the deaths were reported to be related to the infec- sary to remember that these molecules play an important role
tion. Therefore, it is necessary be aware of the major altera- in diapedesis, associated with the inflammatory process
tions caused in the body by surgery, detectable during the established after the surgery [31].
perioperative days. In general, it starts by the vanishing of Similarly, Schumacher et al. [32] reported an upregula-
the skin barrier, which protects against bacterial invasion, tion of adhesion molecules, such as ICAM-1, E-selectin, and
and the inflammatory process, which is established during P-selectin, and release of cytokines within 12–24 h after
surgery. These alterations affect the innate immunity, the first implantation of the endovascular device even though a short
line of host defense, as much as the adaptive response, dur- period of moderate increase of IL-6 and IL-8 has been
ing major general surgery [18]. observed. Asimakopoulis et al. [33] also observed increased
In fact, it has been possible to recognize that even an elec- CD11b (Mac-1) expression on neutrophils at 24 h post-oper-
tive aortic surgery utilizing synthetic graft material, as well ation extending to the third postoperative day. CD11b is the
as experiments with vascular graft materials in vitro, induce intercellular adhesion molecule-1 ligand and could reflect
systemic reactions and inflammatory responses [19–25]. the modulation of this adhesion molecule during the periop-
Rudensky et al. [26] have attempted to compare the systemic erative period. In contrast, Gabriel et al. [27] identified the
response following two specific cardiac surgery procedures, peak level of ICAM-1 and L-selectin in the first postopera-
coronary artery bypass grafting (CABG), versus isolated tive month and after this period of time a decrease in the
valve surgery. This study concluded that valve surgery levels of both markers. Others demonstrated a significant
seemed to induce a stronger proinflammatory state than increase in neutrophil CD11b expression in samples taken
CABG. A significant postoperative increase was observed in 15 min after commencement of surgery, but not in subse-
both white blood cells (WBC) and monocyte counts, proba- quent samples, possibly attributable to marginalization of the
bly reflecting the postoperative inflammatory response activated leucocytes into tissues. In addition, these results
invoked by the trauma. demonstrated that the expected inflammatory response is
WBCs are the key effector cells that are rapidly mobilized present in both premature and late phases after cardiac sur-
to heal devitalized tissue to prevent secondary microbial gery, such as implantation of a vascular prosthesis [27].
invasion (Fig. 3.1a–d). This mobilization is associated with Together, these results suggest that during the entire
the inflammatory status achieved in order to protect the inflammatory period the expression of those adhesion mole-
organism. At this point, numerous alterations due to the dam- cules will be raised, reflecting increased mobilization of cells
age environment are established. Analysis of the inflammatory between the vessels and the extracellular environment, an
response in endovascular stent treatment of aortic aneurysms, action necessary in all phases of the injury caused by the
for example, also showed elevation of the leukocyte count, surgery.
which occurred in the premature phase of follow-up, while Cytokines play an important role in both up- and down-
the lymphocyte and platelet count occurred in a late phase of regulation of inflammation, and it is involved from the begin-
follow-up. The sedimentation velocity values began to ning of the innate immune response, trying to stop all injuries
increase 6 h after the surgical procedure, increasing to its and avoiding any infections [34]. In particular, cytokines
peak value in 7 days. The levels of C reactive protein (CRP) have been studied as a means to demonstrate the severity of
increased 6 h after surgery, resulting in a peak value at 48 h. surgical tissue injury.
Between 48 h and 7 days, a decrease in serum values was The response of cytokines to trauma can be divided in
observed, and around the second postoperative month, the three phases [35]. In the first phase, there is a local produc-
CRP values were practically undetectable [27]. tion of cytokines to neutralize the trauma stimulus and initiate
22 N.J.C. Duarte et al.

healing and repair. In the second phase, small amounts of the influences the expression of TLRs on leukocytes in addition
cytokines are present in the systemic circulation, which help to the synthesis of various cytokines. The stress due to the
to optimize the defense mechanism. In the third phase, the CABG because of cardiopulmonary bypass induces immedi-
amount of circulating cytokines is higher than in the initial ate release of HSP70 and TLRs from myocardial cells to the
phases because it is required for the repair process, leading to circulation. The HSP70 released modulates the monocyte
an abnormal inflammatory response. This may result in an TLR2 and TLR4 expression, mediating the synthesis of
extensive endothelial injury by both the direct effect of the inflammatory cytokines. In fact, human adherent monocytes
mediating agents and the WBC-endothelial interaction. responded to recombinant HSP70 with IL-6 and TNF release
The recent discovery of naturally occurring soluble recep- when tested in vitro.
tors for TNF-a (sTNFr1, sTNFr2), a competitive antagonist These results indicate that TLR4 appears to be involved in
for IL-1b (IL-1ra), and true antiinflammatory cytokines, such an HSP70-mediated activation of innate immunity through
as IL-10, IL-4, and IL-13, has led to the concept of a “cytokine cytokine synthesis [18]. Confirming these findings, it has
balance” [36]. The antiinflammatory cytokines block the been shown that TLR4 monoclonal antibodies inhibited the
process or at least suppress the intensity of the cascade. cytokine response.
Therefore, a “balance” between the effects of proinflammatory What will be the consequences of these alterations over
(IL-1b, TNF-a, IL-6) and antiinflammatory cytokines is the adaptive immune response? It is known that TNF-a pro-
thought to determine the outcome of disease or inflammation duction can be inhibited by cortisol, whose concentration
established by any tissue injury [37]. increases during surgery and can potentiate IL-10 production
Especially with ruptured aneurysms, IL-1b and TNF-a [39, 40]. These findings correlate with a decrease in mono-
proinflammatory cytokines produce fever, inflammation, tis- cyte HLA-DR expression and could reflect the participation
sue destruction, and in some cases shock and death. However, of the adaptive immune response in the immunosuppression
it has been possible to reduce the biological activities of observed during surgical trauma.
IL-1b and TNF-a by neutralizing antibodies, soluble recep- In fact, a significant decrease in absolute lymphocyte
tors, and receptor antagonists. In fact, blocking IL-1b and counts is observed, especially of the T cell population, and a
TNF-a has been successful in patients with rheumatoid significant decrease in human leukocyte antigen-DR
arthritis or inflammatory bowel disease but has not been suc- (HLA-DR) antigen expression on monocytes has also been
cessful in humans with sepsis [19–25]. reported [41, 42]. Expression of these antigens reflects the
Several studies have tried to correlate the clinical outcome adaptive immune response activity.
and inflammatory response. Plasma concentrations of IL-1b Many others studies have found similar depression of cel-
and TNF-a were found to be significantly higher in patients lular immunity parameters in cardiac surgery patients
presenting a ruptured abdominal aortic aneurysm compared [43–49]. Several investigators have found a correlation
with those operated on electively [19, 38]. between the degree of postoperative immunosuppression,
The surgical trauma per se also correlates well with the especially the decrease in HLA-DR antigen expression, and
measurements of IL-6. The premature elevation of IL-6 lev- the subsequent development of postoperative infection or
els before the first hour after the end of the procedure complications in both general and cardiac surgery [49, 50].
achieved a peak value at 24 h and began to decrease in the Others, such as Asimakopoulis et al. [33], have reported a
first postoperative month, when values similar to before the postoperative immunosuppressive response represented by
procedure were observed. Sequentially, the release of IL-6, the significant decrease in lymphocyte count and in HLA-DR
together with other proinflammatory factors, enables WBCs antigen expression on monocytes maintained during the 2
to release TNF-a. However, the TNF-a levels may reflect, postoperative days in valve surgery versus the CABG group.
but do not strictly predict the clinical outcome in patients The significant drop in the absolute lymphocyte count
with a ruptured aneurysm. observed by these authors must reflect a significant decrease
The inflammatory curve response during the perioperative in all types, including T cells, B cells, and NK cells. These
period shows elevated IL-8 values, which decline up to 24 h. authors also observed a decrease in CD4+ and CD8+
In sequence, it begins to increase until 48 h, being followed T cells.
by a new decrease until 3 months after the procedure. These The consequences of the decrease in HLA-DR expression
results deserve more studies, looking for IL-8’s importance can be very important to the outcome of the perioperative
as a preoperatively preexisting marker of the inflammation period. Several studies have reported a significant correlation
level and as a possible prognostic marker [27]. between the degree of decrease in HLA-DR antigen expres-
It is also important to stress that chemokine/cytokine pro- sion and the duration of this decrease with the development
duction, as we have seen before, plays an important role in of infectious and non-infectious postoperative complications
host defense via the TLR. In fact, recent studies conducted [49–51]. However, Kawasaki et al. [52] could not demonstrate
by Dybdahl et al. [18] have demonstrated that surgical stress such a correlation in their study. The cellular immunological
3 Immunological Mechanisms of Inflammation 23

responses, LPS hyporesponsiveness, and suppression of extracellular domains (ECDs), natural antagonists, and small
monocyte mCD14 may explain the involvement of the innate molecule inhibitors, (2) inhibition of signaling pathways
immune dysfunction via the deactivation of macrophages/ activated downstream of TLR stimulation using small mol-
monocytes and neutrophils established during the periopera- ecules to target MyD88/TRAF/IRAK complex formation,
tive period. In addition to CD14, recent studies have demon- mitogen-activated protein kinases (MAPK), or IkB kinase
strated that surgical stress also influences the expression of (IKK) activity, and (3) using PAMP antagonists, such as
TLRs on leukocytes, which is important, as discussed before, LPS inhibitors. Some of these compounds have reached
to the outcome of the postoperative period. phase II clinical trials, and the results are currently awaited,
Despite the feeling that the state of immune depression while others, particularly those targeting common signaling
might contribute to the development of postoperative infec- pathways, such as MAPK, have proved to be of limited
tion, the studies reported here did not find that any measured efficacy [59].
parameters can predict the eventual infectious state that can Purification of beneficial DAMPs for therapeutic applica-
be established during the perioperative period. tions is another attractive idea, but also very challenging. In
addition, genetic variations can influence the responsiveness
of the immune system to certain DAMPs and therefore be of
Perioperative Immune Modulation great importance to cardiac repair mechanisms. For this rea-
son, future studies should address the genetic determinants
Detrimental inflammatory responses during surgery have of processes associated with danger signaling.
been consistently observed over several decades. Despite our The current body of knowledge about the role of DAMPs
detailed understanding of inflammation, novel therapeutic in the infarcted myocardium does not explain why the local
strategies from the preclinical arena have not yet been intro- enhancement of several candidates, as opposed to their sys-
duced into the clinical setting. Therefore, it is necessary to temic elevation, improves cardiac function. A better under-
describe some promising ways to control the immune reac- standing of both spatial and temporal functions of endogenous
tions that take place during surgical stress. ligands will be of utmost importance to the development of
Immunonutrition is one of the strategies for improving successful therapies for cardiac ischemia.
patient outcome during the perioperative period. In fact, In fact, it has been suggested that TLR 4 may mediate, at
immunonutrients, such as several amino acids, glutamine, least in part, myocardial ischemia/reperfusion injury.
omega-3 fatty acids, antioxidant vitamins and minerals, Therefore, inhibition of TLR 4 activation, for example, may
and nucleotides, are able to modulate innate immune be a potential therapeutic target to attenuate ischemia/reper-
function [53]. fusion-induced tissue damage in the clinical settings [60].
Mayer et al. demonstrated that omega-3 fatty acids have Another therapeutic way to manipulate the immune sys-
antiinflammatory effects, including lowering blood leuko- tem could be based on immunomodulation in which the
cyte counts, serum C-reactive protein (CRP) concentration, overall immune response deviates from a Th1- to a Th2-type
and production of inflammatory cytokines by isolated endo- response, but also have side effects. In models of multiple
toxin-stimulated mononuclear cells [54]. On other hand glu- sclerosis, tolerization with myelin antigens induces a protec-
tamine may enhance HSP expression and reduce inflammatory tive Th2 response in the acute phase, but, in the long term,
cytokine release [55]. such a Th2 response promotes B cell differentiation and
Other strategies involving different goals have been leads to a humoral attack against myelin that worsens the
described. TLRs, for example, have been postulated as ideal neurological outcome [61]. Worsening in the chronic phase
candidates to bridge the gap between cardiac-related injury has also been reported in tolerization applied to models of
and circulating mediators of inflammation. Evidence exists cerebral ischemia [62]. Therefore, the delayed effects of
that TLRs are indeed crucial for post-infarction healing pro- humoral immunity could counteract the short-term benefit of
cesses, but are also mediators of reperfusion injury. They suppression of cellular immunity. Protocols involving cytok-
can recognize injury-related molecules released after cell ines as possible modulators of the immune response have
stress, cell death, or both, as DAMPS [56] and be activated also been designed.
by them [57, 58]. The release of IL-6, possibly together with other
Endogenous activators of TLRs are interesting as therapeu- proinflammatory factors, enables white blood cells to release
tic targets, and they are likely to be safe because most of them TNF-a [63]. Especially in ruptured aneurysms, IL-1b and
are only released after tissue injury and might not have a sys- TNF-a are proinflammatory cytokines that produce fever,
temic biological function under physiological conditions. inflammation, tissue destruction, and in some cases shock
Current strategies concerning the clinical development of and death [64, 65]. It is possible to reduce the biological
the TLR blockade include: (1) global blockade of individual activities of IL-1b and TNF-a by neutralizing antibodies,
TLR functions using neutralizing antibodies, soluble TLR soluble receptors, and receptor antagonists [66–71]. In fact,
24 N.J.C. Duarte et al.

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 Part II
Carotid Diseases
 Role of Lipoproteins in Carotid
Arterial Disease 4
Efthymios D. Avgerinos and Christos D. Liapis

Introduction of triglycerides and cholesteryl esters surrounded by

phospholipids, cholesterol, and constituent proteins known
Lipoproteins and their disorders are among the most sub- as apolipoproteins [1–3].
stantiated risk factors for atherosclerosis and cardiovascular Lipoproteins are classified is based on their density (ratio
diseases, acting through a well-established pathway: abnor- of lipid to protein). They can be separated using a centrifuge
malities in lipid metabolism lead to pathologic lipid accumu- into high-density lipoproteins (HDLs), low-density lipopro-
lation in the vessel wall, oxidative and chronic inflammatory teins (LDLs), intermediate-density lipoproteins (IDLs),
sequelae, and the formation of atherosclerotic lesions, ulti- very-low-density lipoproteins (VLDLs), and the least dense
mately leading to clinical events. particles, known as chylomicrons (Table 4.1). Apolipo-
Although the majority of the evidence implicating lipo- proteins (apos), carried in the outer layer of lipoproteins,
proteins in atherosclerosis have traditionally emerged from have functional significance that can be split into four major
the coronary vasculature, we now know that carotid artery roles: (1) assembly and secretion of the lipoprotein (apo A-I,
disease (CAD), as a coronary heart disease (CHD) equiva- apo B-100, apo B-48), (2) structural integrity of the lipopro-
lent, shares similar links to both the pathophysiological path- tein (apo B, apo E, apos A–I, apo A-II), (3) coactivator or
ways and treatment strategies. Over the past decade, however, inhibitor of enzymes (apos A-I, apos A-V, apo C-I, apo C-II,
many studies have begun to yield important information on apo C-III), and (4) binding or docking to specific receptors
the effect of lipoproteins’ on the natural history of CAD and and proteins for cellular uptake of the entire particle or selec-
on the benefits of recognizing and managing these disorders. tive uptake of a lipid component (apos A-I, apo B-100, apo
This chapter addresses the role of lipoproteins in patients E) (Table 4.2). The effects of many other apolipoproteins
with CAD, including their physiology and metabolism, clini- (apo A-IV, apo A-V, apo D, apo H, apo J, apo L, apo M) are
cal evidence of their effects, and contemporary management still not completely understood [1–3].
of their disorders. Lipoproteins have different affinities for different lipids.
In fasting serum, most of the cholesterol is carried on LDL
particles, while most of the triglycerides are found in VLDL
Physiology and Metabolism of Lipoproteins and chylomicron particles. Chylomicrons contain more
than 80 % triglycerides, approximately 60 % VLDL, 10 %
Plasma lipoproteins are molecular complexes that transport LDLs, and 50 % HDLs. Esterified cholesterol comprises
and facilitate exchanges of water-insoluble lipids (choles- 37 % LDLs, 10 % VLDLs, and 15 % HDLs; free choles-
terol and triglycerides) from the intestine and liver through terol comprises approximately 10 % LDLs and VLDLs;
the bloodstream to the various cells of the body, where they phospholipids comprise 15 % VLDLs, 20 % LDLs, and
can be stored, used for important synthetic processes, and 30 % HDLs [1–3].
metabolized to yield energy. They consist of a central core The lipid metabolism follows two pathways, the exog-
enous (dietary, intestinal) and the endogenous (hepatic).
The intestine transports lipids from digested food into the
bloodstream through the lymphatic system, and the liver
E.D. Avgerinos, MD, FEBVS • C.D. Liapis, MD, FACS, FRCS (*) exports the lipids it synthesizes. Pathway defects in lipo-
Department of Vascular Surgery, Medical School of Athens,
protein synthesis, processing, and clearance can lead to
Attikon University Hospital,1 Rimini Street, Chaidari,
Athens 12462, Greece accumulation of atherogenic lipids in the plasma and
e-mail: liapis@med.uoa.gr endothelium.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 29

DOI 10.1007/978-1-4471-4429-8_4, © Springer-Verlag London 2013
30 E.D. Avgerinos and C.D. Liapis

Table 4.1 Characteristics of major lipoproteins

Component Origin Size (nm) Density (g/ml) Protein (%) Apolipoproteins
Chylomicrons Intestine 100–1,000 <0.95 1–2 C-I, C-II, C-III, E, A-I, A-II,
A-IV, B-48
VLDL Liver, intestine 30–80 0.95–1.006 7–10 B-100, C-I, C-II, C-III
IDL VLDL 25–50 1.006–1.019 11–18 B-100, E
LDL VLDL 20–25 1.019–1.063 18–25 B-100
HDL Liver, intestine 5–15 1.063–1.210 32–57 A-I, A-II, A-IV C-I, C-II,
VLDL, chylomicrons C-III D, E

Table 4.2 Location and function of apolipoproteins

lymphatics into the circulation and finally to adipose and
Apolipoprotein Location Function muscle tissue for energy use or storage. Cholesterol-rich
A-I HDL Major component of HDL chylomicron remnants then circulate back to the liver for
particle, ACAT activation
degradation and reuptake of their core constituents.
A-II HDL Major component of HDL
particle
A-IV HDL Major component of HDL
particle, absorption Endogenous Lipid Metabolism
A-V VLDL, HDL Triglyceride metabolism
B-100 VLDL, IDL, LDL, LDL receptor ligand As dietary fat content varies, the body must ensure readily
Lp(a) available triglyceride to meet energy demands. Hepatic
B-48 Chylomicrons Major component of
secretion of VLDL particles serves this function. IDL, LDL,
chylomicrons
C-I Chylomicrons Triglyceride metabolism
and HDL particles are derived following several complex
C-II Chylomicrons, LPL activation VLDL de-lipidation processes and bi-directional transfer of
VLDL, HDL constituents. Lipoproteins synthesized by the liver transport
C-III Chylomicrons, LPL inhibition endogenous triglycerides and cholesterol. Lipoproteins cir-
VLDL culate through the blood continuously until the triglycerides
D HDL LCAT they contain are taken up by peripheral tissues or the lipopro-
E Chylomicrons, LDL receptor ligand and teins themselves are cleared by the liver. Factors that stimu-
VLDL, IDL, HDL apo-E receptor ligand
late hepatic lipoprotein synthesis generally lead to elevated
H Chylomicrons, B2 glycoprotein
VLDL, LDL, HDL plasma cholesterol and triglyceride levels.
J HDL Complement system
L 1-6 HDL Not known Very-Low-Density Lipoproteins
M HDL Not known Each VLDL particle contains apolipoproteins from the C
(a) Lp(a) Tissue injury and E family and one molecule of apo B-100 per particle.
ACAT Acetyl-CoA acetyltransferase, LPL lipoprotein lipase, LCAT VLDL is the way the liver exports excess triglycerides
lecithin cholesterol acyltransferase derived from plasma-free fatty acids and chylomicron rem-
nants. As triglycerides are removed from the peripheral adi-
Exogenous (Dietary) Lipid Metabolism pose and muscle tissue, two additional atherogenic lipoprotein
particles are formed, VLDL remnants and IDLs.
Over 95 % of dietary lipids are triglycerides. The gastroin-
testinal tract has highly efficient fat absorption mechanisms. Intermediate-Density Lipoproteins
Dietary triglycerides are digested in the stomach and duode- Intermediate-density lipoproteins are the product of VLDL
num into monoglycerides and free fatty acids by gastric and chylomicron metabolism. IDLs are cholesterol-rich
lipase, emulsification from vigorous stomach peristalsis, and VLDLs and chylomicron remnants that are either cleared by
pancreatic lipase. Dietary cholesterol esters are de-esterified the liver or metabolized by hepatic lipase into LDL, which
into free cholesterol by these same mechanisms. retains apo B.
Monoglycerides, free fatty acids, and free cholesterol are
then solubilized in the intestine by bile acid micelles, which Low-Density Lipoproteins
shuttle them to the intestinal villi for absorption. Once Low-density lipoproteins are the products of VLDL and IDL
absorbed into the enterocyte, they are reassembled into trig- metabolism and the most cholesterol-rich and atherogenic of
lycerides and packaged with cholesterol into chylomicrons, all lipoprotein particles. LDL binds to specific LDL recep-
the largest lipoproteins. Chylomicrons transport dietary TGs tors on the surface of each cell, and such binding facilitates
and cholesterol from within enterocytes through the transfer of the remaining cholesterol to these cells, where it
4 Role of Lipoproteins in Carotid Arterial Disease 31

can be stored for future use to make such chemical products Nonhepatic scavenger receptors, most notably on mac-
as cell membranes, steroid hormones, and bile acids. About rophages, take up excess circulating oxLDL not processed
70 % of these receptors are located within the liver, which by hepatic receptors. Monocytes rich in oxLDL migrate into
clears the majority of LDL particles, while the rest are taken the subendothelial space and become macrophages; these
up by non-hepatic scavenger receptors. The number of LDL macrophages then take up more oxLDL and form foam cells
receptors is regulated by the intracellular concentration of [9]. Groups of foam cells then accumulate underneath the
cholesterol within each cell. When the intracellular choles- endothelium and become the initial lesion of atherosclerosis,
terol content of the cells is low, LDL receptor synthesis is the fatty streak. As this process continues, the foam cells
upregulated, receptor numbers increase, and the LDL con- undergo the process of apoptosis, or cell death, which allows
centration of circulating plasma diminishes. On the other the lipid contained in them to spill out to from the lipid core
hand, when intracellular cholesterol is increased, LDL recep- of an atherosclerotic plaque. Some plaques continue to grow,
tor synthesis is downregulated, receptor numbers diminish, become fibrotic, and intrude on the arterial lumen. These
and LDL within the circulation rises. When plasma LDL is fibrotic plaques may be stable; however, when the lipid core
present in excess, atherosclerosis results in proportion to the enlarges and oxidizes an intense local inflammatory reaction
degree of circulating LDL [1–3]. is induced that results in the infiltration of additional mac-
There are two forms of LDL: large (buoyant) and small, rophages and inflammatory cells. The fibrous cap thins and
dense LDL. Small, dense LDL (sdLDLD) is rich in choles- becomes prone to rupture and ulceration, which may lead to
terol esters and particularly atherogenic. The increased atherothromboembolic cerebrovascular events. This unstable
atherogenicity of small, dense LDL derives from less efficient plaque is also known as vulnerable plaque [1–3].
hepatic LDL receptor binding, leading to prolonged circula-
tion and exposure to the endothelium and increased
oxidation. Clinical Evidence Implicating Lipoproteins
to Carotid Atherosclerosis
High-Density Lipoproteins
High-density lipoproteins are initially cholesterol-free lipo- Multiple clinical data have currently elucidated the underly-
proteins that are synthesized in both enterocytes and the liver ing association of the major lipoproteins to atherosclerosis.
as lipid-poor discoid particles. HDL’s overall role is to obtain Several studies have particularly focused on carotid athero-
cholesterol from peripheral tissues and other lipoproteins sclerosis, but even more studies on the incidence of stroke
and transport it to where it is needed most, to other cells, related to serum lipids. While there are several possible
other lipoproteins, and the liver (for clearance). This process mechanisms underlying the association of lipids and stroke,
is known as “reverse cholesterol transport” and plays an one of the most important is probably the effects of lipids on
important role in the antiatherogenic properties of the HDL the formation of carotid artery plaque. Available clinical data
particle. relating lipids to carotid atherosclerosis and stroke are fur-
ther analyzed.

Pathophysiology of Atherosclerosis
Low-Density Lipoprotein
Increased lipid levels can cause endothelial injury, which
eventually results in endothelial dysfunction and increased LDL cholesterol has been shown to be among the most pre-
permeability, allowing circulating atherogenic lipoprotein dictive lipoprotein fractions for determining carotid athero-
particles (VLDL, IDL, LDL) to penetrate and initiate the sclerosis and stroke, being directly proportional to its
pathologic process of atherosclerosis. The developmental concentration over a wide range of values. The majority of
atherosclerotic process is the same for all vascular beds, evidence derives from large statin trials to lower LDL cho-
including the carotids. lesterol that showed reductions in carotid atherosclerosis
LDL has a leading role in the atherogenic process, pre- progression, a need for carotid intervention, and cerebrovas-
dominately mediated through its oxidized fraction, as sug- cular events, mainly the Heart Protection Study and SPARCL
gested by its accumulation within macrophages at all stages [10–12].
of plaque formation. Various reactive intermediates, deriva- In addition, LDL fractions are intensively investigated as
tives of reactive oxygen and/or reactive nitrogen species, potentially more accurate predictors of carotid artery disease,
mediate the oxidative modification of LDL (oxLDL) [4–6]. mainly oxLDL and sdLDL. Clinical studies have shown an
OxLDL co-stimulates an inflammatory response to attract increase in plasma and plaque levels of oxLDL in patients
and stimulate the proliferation of both macrophages and vas- with symptomatic carotid plaques compared to asymptom-
cular smooth muscle cells [7, 8]. atic ones [13, 14]. Even more, baseline oxLDL levels may
32 E.D. Avgerinos and C.D. Liapis

predict carotid disease progression in asymptomatic subjects, to atherosclerosis [31–36]. A recent systematic review and
independent of other cardiovascular risk factors [15]. meta-regression analysis of randomized trials on lipid-
Regarding sdLDL, several lines of evidence suggest that it modifying drugs concluded that additional studies are needed
could be more atherogenic than the large (buoyant) particles to more precisely quantify the detrimental effect of triglycer-
of LDL and a more accurate predictor of carotid atheroscle- ide levels on stroke risk and to establish the efficacy of trig-
rosis compared to the traditionally measured LDL [16–21]. lyceride-lowering therapy in addition to LDL cholesterol
Many authors advocate that both plasma oxLDL and sdLDL reduction [37].
assessments can be used as biomarkers for carotid disease
progression, providing a link between lipoprotein disorders
and inflammation [13–15, 18–21]. Lipoprotein (a)

Lipoprotein (a) consists of an LDL particle with its apolipo-

Intermediate Density Lipoprotein protein-a. The apo-a component is characterized by five
cysteine-rich regions known as “kringles.” One of these
Although LDL cholesterol is widely accepted as the major regions is homologous with plasminogen and is thought to
risk factor for the development and progression of athero- competitively inhibit fibrinolysis and thus predispose to
sclerosis, its measurements generally include IDL. The thrombosis [38]. Lp(a) has been suggested as a direct pro-
Monitored Atherosclerosis Regression Study (MARS) pro- moter of atherosclerosis through various mechanisms, but
vided further evidence for the role of these lipoproteins in the the metabolic pathways of its production and clearance are
progression of carotid atherosclerosis and supported the sug- not yet well characterized. Apoprotein-(a) fragments have
gestion that the risk of atherosclerosis attributable to LDL been demonstrated to accumulate in unstable carotid plaques
may be the result of the IDL included within the traditional close to eroded and ulcerated areas, suggesting a strong cor-
LDL measurements [22, 23]. A later study on patients with relation with atherosclerotic plaque destabilization [39].
carotid artery disease (stenosis >50 %) showed that fasting A recent meta-analysis of observational studies on Lp(a) and
and postprandial triglyceride-rich lipoproteins (mainly cerebrovascular disease suggested that elevated Lp(a) is an
VLDL and IDL) are elevated compared to controls and cor- independent risk factor for stroke [40].
relate to echo-lucent, rupture-prone carotid plaques [24].

Lipoprotein-Associated Phospholipase A2
High-Density Lipoprotein
Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a
HDL has been shown to have both direct and indirect member of the phospholipase A2 superfamily of enzymes
antiinflammatory effects with potential antithrombotic results that hydrolyze phospholipids. Lp-PLA2 binds mainly to cir-
[25, 26]. However, the literature remains contradictory on culating LDL, multiplying its atherogenic potential [41, 42].
the real protective effect of HDL against carotid atheroscle- Lp-PLA2 was initially attributed an atheroprotective role;
rosis and stroke [27–29]. A recent systematic review of however, recent evidence has highlighted its important role
observational epidemiological studies concluded that in the promotion of atherosclerosis [42].
although more evidence exists for an inverse association Lp-PLA2 has been localized to human carotid plaques.
between HDL cholesterol levels and stroke or carotid athero- Atherosclerotic plaques from symptomatic patients demon-
sclerosis risk, further studies are needed [30]. strated greater levels of Lp-PLA2 than plaques obtained from
asymptomatic patients [43, 44]. Additionally, blood levels of
Lp-PLA2 have been shown to be an independent predictor of
Triglycerides (Very-Low-Density future stroke and transient ischemic events [45–48].
Lipoprotein – Chylomicron)

VLDL particles and chylomicrons represent the main trig- Lipoprotein Ratios
lyceride carriers in the circulation. Though clearly associated
with cardiovascular disease, the exact mechanisms by which There is mounting evidence that serum lipid ratios may be
triglyceride-rich lipoproteins exert their noxious effect on better predictors of vascular risk than the traditional lipid
the vascular wall are matters of debate. It is still unclear measures. The Northern Manhattan Study on carotid athero-
whether it is the number of triglyceride-rich lipoprotein par- sclerosis indicated that the relative levels of LDL and HDL
ticles or triglyceride-rich lipoprotein cholesterol or the asso- may be more predictive than either LDL or HDL [49]. Very
ciated small, dense LDL and low HDL that contribute most recently, a large-scale epidemiological study of healthy
4 Role of Lipoproteins in Carotid Arterial Disease 33

Table 4.3 Lipoprotein-targeted medications Report of the National Cholesterol Education Program
Clinical evidence against (NCEP) Expert Panel on Detection, Evaluation, and
Predominant carotid atherosclerosis and Treatment of High Blood Cholesterol (HBC) in Adults
lipoprotein effect related events (Adult Treatment Panel III) [55, 56], while vascular scientific
Statins societies have already published carotid disease-focused
Atorvastatin ↓↓↓ LDL Carotid plaque stabiliza-
guidelines [57–59]. In addition, new data and novel lipopro-
Fluvastatin ↓ VLDL tion. Attenuates disease
Lovastatin ↑ HDL progression tein targets have accumulated in literature.
Pravastatin Stroke prevention
Rosuvastatin Reduced rates of carotid
Simvastatin revascularization
Pharmacologic Therapies
Pitavastatin
Niacin ↓ LDL Regression of carotid
↓ VLDL intima-media thickness Statins
↑↑↑ HDL Statins are hydroxymethylglutaryl-coenzyme A (HMG-
↓ Lp(a) CoA) reductase inhibitors preventing the formation of
Ezetimibe ↓↓ LDL Regression of carotid mevalonate during sterol synthesis, increasing LDL choles-
↓ VLDL intima-media thickness terol clearance from plasma and decreasing liver VLDL and
↑ HDL LDL production. In addition, they have mild elevating HDL
Bile acid sequestrants and lowering triglyceride actions, and they seem to confer
Cholestyramine ↓↓ LDL – antiinflammatory, so-called “pleiotropic,” effects against
Colestipol ↑ VLDL atherosclerosis progression. Regarding their association
Colsevelam with carotid atherosclerosis, several large-scale studies cur-
Fibrates rently evidence their effects on carotid plaque stabilization,
Bezafibrate ↓↑ LDL Stroke prevention disease progression, and stroke prevention [10–12, 60–65].
Fenofibrate ↓↓↓ VLDL Notably, The Stroke Prevention by Aggressive Reduction in
Gemfibrozil ↑ HDL
Cholesterol Levels Study (SPARCL) randomly assigned
Omega-3 fatty acids
patients with TIA or stroke within 1–6 months without
Eicosapentaenoic ↓ VLDL Regression of carotid
intima-media thickness known coronary heart disease (CHD) and low-density lipo-
Docosahexaenoic
protein cholesterol 100–190 mg/dl to treatment with
atorvastatin 80 mg per day or placebo. The study showed
subjects undergoing carotid intima media measurements that, among others, intense lipid lowering reduced the risk
over an 8 year follow-up confirmed these results [50]. of stroke by 16 % [11]. A secondary analysis of the subjects
Ample evidence also exists on the strong association with carotid stenosis not requiring revascularization at the
between the triglyceride: HDL cholesterol ratio (TG:HDL-C) time of randomization demonstrated that they had greater
and coronary heart disease. Respectively for carotid artery benefit when all cerebro- and cardiovascular events were
disease, in a retrospective analysis of more than 1,000 patients combined. In the group with carotid artery stenosis,
with ischemic stroke or transient ischemic attack, an elevated treatment with atorvastatin was associated with a 33 %
level of the serum TG:HDL-C ratio, but not LDL-C, was asso- reduction in the risk of any stroke and a 43 % reduction in
ciated with large artery atherosclerotic stroke [51]. Similar the risk of major coronary events. Later carotid revascular-
results have been demonstrated for intracranial vascular disease ization was reduced by 56 % in the group randomized to
[52]. These findings urged some authors to introduce the term atorvastatin [12].
“atherogenic index” [log(TG:HDL-C)]. Pathophysiologically, The current guideline can be summarized as follows:
this index indirectly represents sdLDL [53, 54]. Statins are recommended in patients with ischemic stroke,
TIA, asymptomatic carotid stenosis >50 %, and/or comorbid
coronary artery disease, or evidence of an atherosclerotic ori-
Lipoproteins as Target of Carotid Artery gin. The target goal is an LDL-C of <2.6 mmol/l (100 mg/
Disease Prevention Strategies dl), and < 1.8 mmol/l (70 mg/dl) for very high-risk persons
with multiple risk factors [57].
The well-defined association of lipoproteins to cardiovascu-
lar disease and to carotid atherosclerosis and its associated Nicotinic Acid (Niacin)
events has triggered several studies and large-scale trials Niacin is the most effective drug for increasing HDL, but
investigating lipid reduction strategies, both pharmacologi- also decreases triglyceride and LDL cholesterol levels. It is
cal (Table 4.3) and non-pharmacological. Their results and also probably the only medication showing a direct lowering
associated recommendations are summarized in the Third effect on Lp(a). Its mechanism of action is conferred by
34 E.D. Avgerinos and C.D. Liapis

inhibiting lipoprotein synthesis and improving the clearance Miscellaneous

of triglyceride-rich lipoproteins from the circulation [1–3]. Given the numerous studies that demonstrate an association
Niacin is generally used to enhance the statin lipid-lowering between Lp-PLA2 and increased coronary and carotid risk,
effect. The ARBITER 6–HALTS (Arterial Biology for the there has been interest in pharmacologically targeting
Investigation of the Treatment Effects of Reducing Cholesterol Lp-PLA2. Darapladib is a selective Lp-PLA2 inhibitor;
6–HDL and LDL Treatment Strategies) trial compared the phase I and II studies have shown a dose-dependent reduc-
effects of two combination therapies – either niacin or tion in Lp-PLA2 activity, while phase III trial results on the
ezetimibe added to long-term statin therapy – on carotid its clinical effect are awaited [41].
intima-media thickness over a 14-month period. This com- Finally, future therapies will include peroxisome prolif-
parative effectiveness trial showed that the use of extended- erator-activated receptor agonists that have thiazolidine-
release niacin causes a significant regression of carotid dione-like and fibrate-like properties, LDL-receptor
intima-media thickness when combined with a statin [66]. activators, LPL activators, and recombinant apo E to be used
for LDL reduction and reconstituted mutant HDL or par-
Ezetimibe tially delipidated HDL for increasing HDL. Cholesterol vac-
Ezetimibe is a cholesterol absorption inhibitor, blocking cination (to induce anti-LDL antibodies and hasten LDL
intestinal absorption of cholesterol and phytosterol. Ezetimibe clearance from serum) and gene transfer are attractive thera-
lowers LDL cholesterol and causes small increases in HDL pies that are under study but years away from being avail-
and a mild decrease in triglycerides. Ezetimibe can be used able for use [71].
as a monotherapy in patients intolerant to statins or added to
statins for patients who do not achieve target lipoprotein lev-
els. Controversy currently exists on its actual clinical efficacy. Nonpharmacologic Therapies
While the ARBITER 6-HALTS trial showed that ezetimibe
added to pravastatin or atorvastatin causes significant regres- Implementation of lifestyle changes, including exercise,
sion of carotid intima-media thickness, the Ezetimibe and weight loss, and a low-fat diet, is effective as a first line strat-
Simvastatin in Hypercholesterolemia Enhances Athero- egy for plasma lipid reduction. Physical activity, eating large
sclerosis Regression (ENHANCE) trial failed to demonstrate amounts of fruits and vegetables, legumes, and whole grains,
similar outcomes [67]. and taking dietary supplements containing plant sterols or
stanols have been shown to reduce LDL and VLDL while
Bile Acid Sequestrants increasing HDL [1–3]. While no particular studies exist,
Bile acid sequestrants (colestipol, cholestyramine, coleseve- their lipid-lowering effect defines their beneficial action on
lam) block intestinal bile acid reabsorption, forcing upregu- carotid atherosclerosis.
lation of hepatic LDL receptors to recruit circulating
cholesterol for bile synthesis, however elevating plasma trig- Conclusions
lycerides. They are currently used as adjuncts to statin thera- The role of lipoproteins in carotid artery disease is an
pies and have been proved to reduce cardiovascular mortality, enormously expanding field of research currently evi-
but no particular studies on their effect on carotid atheroscle- dencing a strong association of the disease’s natural his-
rosis exist [1–3]. tory and related events. In addition, well-defined and
targeted treatment strategies are increasingly effective in
Fibric Acid Derivatives (Fibrates) carotid risk reduction. As their physiology and metabo-
Fibrates (gemfibrozil and fenofibrate) predominately reduce lism are better understood, novel lipoprotein subfractions
triglycerides and, at a lower rate, increase HDL cholesterol. are playing a role in clinical practice, and novel concep-
Their effect on LDL cholesterol is variable. They seem to tually appealing therapies are awaited in the years to
stimulate fatty acid oxidation in the liver and muscle and come.
downregulate hepatic VLDL synthesis. Although they have
been shown to reduce the risk of stroke [68], no independent
effect on carotid atherosclerosis has yet been demonstrated.
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 Carotid Endarterectomy: Inflammatory
Aspects 5
Sthefano Atique Gabriel and Edmo Atique Gabriel

Introduction Carotid Plaque Formation and Vulnerability

Carotid artery stenosis is a common disease related to the Various processes involved in the progression of
occurrence of transient ischemic attacks and strokes. Carotid atherosclerotic lesions have been shown to be associated
endarterectomy (CEA), first performed by De Bakey in 1953, with plaque vulnerability, such as inflammation, lipid accu-
is a widely applied method to prevent recurrent neurological mulation, apoptosis, proteolysis, thrombosis, and angiogen-
symptoms and stroke in patients with severe carotid artery esis. Several morphological characteristics are related to
stenosis. However, 3–7 % of CEA procedures are compli- plaque instability, including an atheromatous, thin fibrous
cated by disabling or nondisabling strokes [1, 2]. cap; a large lipid core; less collagen; noncalcified ulceration;
The relation among carotid plaque characteristics, plaque intraplaque hemorrhage; infiltration of inflammatory cells;
embolization, and adverse clinical outcome remains poorly proteolysis; and remodeling [4, 5].
understood. Despite growing evidence that inflammation and Serum inflammatory biomarkers are important predictors
its biomarkers have a key role in the development of athero- of atherosclerotic complications. In carotid artery disease,
sclerosis and its clinical outcomes or disease stage, the pre- high-sensitivity C-reactive protein correlates with morpho-
cise molecular and cellular mechanisms associated with logical features of rapidly progressive carotid atherosclero-
thrombotic events are still unknown [1–3]. sis, defined by ultrasound categorization, and could be an
Several studies suggest that plaque characteristics are important risk predictor for stroke [6]. This biomarker also
causally related to the development of cardiovascular events. adds prognostic information for risk prediction of cardiovas-
The vulnerable, unstable plaque consists of inflammatory cular events and discriminates between stable and unstable
cells, particularly macrophages and T lymphocytes, accumu- coronary artery disease.
lated lipid, and a thin fibrous cap and is associated with Brea et al. found that serum amyloid A increases mono-
plaque rupture, thrombosis, and subsequent atherosclerotic cyte and macrophage cytokine production and is elevated
events [1–3]. in atherosclerotic lesions. Their study concluded that ele-
vated serum amyloid A levels can identify patients with
ischemic stroke caused by atherothrombosis [7].
Blankenberg et al. observed that IL-18 promotes the Th-1
immune response and enhances the production of matrix
S.A. Gabriel, MD (*)
Department of Vascular Surgery, metalloproteinase. In carotid stenosis, IL-18 expression is
Pontifical Catholic University of Campinas, especially increased in unstable lesions and positively cor-
São Paulo, Brazil relates with carotid intima-media thickness [8].
Department of Vascular Surgery, Kerr et al. concluded that IL-6 has pro-atherogenic prop-
Celso Pierro Hospital and Maternity, Campinas, São Paulo, Brazil erties, and in patients with acute coronary syndromes, base-
e-mail: sthefanogabriel@yahoo.com.br
line IL-6 levels are associated with a greater risk of stroke.
E.A. Gabriel, MD, PhD IL-6 also amplifies the inflammatory cascade, and its expres-
Department of Cardiovascular Surgery,
sion is elevated in unstable plaque regions [9].
University Nove de Julho,
São Paulo, Brazil Schindhelm et al. have linked myeloperoxidase to athero-
e-mail: edag@uol.com.br sclerosis. This enzyme is involved in the oxidation process of

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 37

DOI 10.1007/978-1-4471-4429-8_5, © Springer-Verlag London 2013
38 S.A. Gabriel and E.A. Gabriel

LDL and thereby promotes foam cell formation in the vascu- Table 5.1 Box-plot graphs showing medians and interquartile ranges
lar wall. In carotid artery stenosis, however, myeloperoxi- of intracellular cytokines in 67 patients undergoing carotid endarterec-
tomy (CEA) and in 39 not undergoing CEA. Patients who underwent
dase has not proven to be of additional value in the CEA versus patients who did not: tumor necrosis factor (TNF)-a, P =
identification of high-risk plaques [10]. 0.02; interferon (IFN)-g, P = 0.001; interleukin (IL)-1b P = 0.04; IL-6,
Heider et al. observed that serum pregnancy-associated P = 0.0003; IL-8, P = 0.009; IL-4, P = 0.0001; IL-10, P = 0.001 by
plasma protein-A (PAPP-A) levels in carotid artery disease Mann-Whitney non-parametric test
Patients undergoing CEA
showed a positive predictive value for the presence of unsta-
95 Patients not undergoing CEA
ble plaques. However, their study also concluded that
85
asymptomatic patients had significantly higher PAPP-A val-
75
ues compared to symptomatic patients [11].

% of positive cells
65
55
45
Inflammatory Cytokines in Carotid 35
Atherosclerosis 25
15
Inflammatory cells are responsible for secreting growth 5
factors and cytokines that are important predictors of car-
TNF–α IFN–γ IL–1β IL–6 IL–8 IL–4 IL–10
diovascular events when in high levels in the blood circula-
tion. Profumo et al., analyzing cytokine expression in
circulating T lymphocytes in patients undergoing CEA, growth. However, the question of whether inflammatory
observed elevated intracellular expression of tumor necro- cytokine expression has a direct causal relation with carotid
sis factor (TNF)-a, interferon (IFN)-g, and interleukin arterial disease or only reflects the inflammatory disease pro-
(IL)-4 in circulating T lymphocytes from patients with cess remains unanswered.
carotid atherosclerosis, particularly from patients with
complicated plaques (Table 5.1) [12]. More recently, intra-
cellular cytokine monitoring in peripheral blood lympho- Gender Differences in Carotid Plaques
cytes and monocytes was shown to be useful in the follow-up
of patients after CEA to predict the onset or progression of In their study on sex differences in the composition of plaques
contralateral disease [13]. in patients undergoing CEA, Rerkasem et al. found that plaques
When studying the presence of inflammatory cytokines in from females had significantly less lipid and more fibrous tis-
patients undergoing CEA, intracellular cytokine expression sue than those from males, and the perioperative stroke and
was found to be significantly higher in patients undergoing death rate in females and males was 3.3 and 3.6 %, respectively
CEA who had stenosis ³70 % (TNF-a, IFN-g, IL-1b, IL-6, [15]. This might reflect the fact that women have a more stable
IL-4, and IL-10), with previous stroke (IFN-g, IL-1b, IL-6, plaque component than men because unstable carotid plaques
IL-8, IL-4, and IL-10), and with amaurosis fugax (IFN-g, have a high lipid content, thin fibrous caps, a high inflammatory
IL-6, IL-4, and IL-10) than in patients not undergoing CEA cell content, and increased protease activity.
(Table 5.2) [14]. Proinflammatory cytokines, such as TNF-a, Halvorsen et al. also supported the notion that women
IFN-g, IL-1b, IL-6, and IL-8, and antiinflammatory cytokines, have more stable plaques with an ultrasound study on carotid
such as IL-4 and IL-10, were also found in significantly arteries that showed that women had significantly fewer
higher percentages in patients undergoing CEA than in echolucent plaques than men [16].
patients who were not [3]. Hellings et al. observed that the differences in plaque his-
Significantly higher levels of IL-8-positive cells were tology between men and women were paralleled by the
observed in patients with contralateral than in those with inflammatory and protease activity in atherosclerotic plaques
monolateral carotid disease, demonstrating an association of (Table 5.2). Women showed lower IL-8 values than men.
IL-8-positive cells with the onset or progression of contralat- IL-6 levels were not different between men and women.
eral disease after CEA [13, 14]. Protease activity was lower in women, with matrix metallo-
The higher pro- and antiinflammatory cytokine expres- proteinase-8 showing significantly lower values than in men.
sion in patients with stenosis of ³70 % than in those with Asymptomatic women showed lower levels of IL-8, matrix
stenosis of <70 % could indicate plaque instability and metalloproteinase-8 activity, and matrix metalloproteinase-9
immunological mechanisms leading to atherosclerotic plaque activity compared with asymptomatic men [17].
5 Carotid Endarterectomy: Inflammatory Aspects 39

Table 5.2 Box-plot graphs showing medians and interquartile ranges of intracellular cytokines in the 39 patients not undergoing carotid endart-
erectomy (CEA) and in the 56 patients undergoing CEA divided according to the indications for surgery [18 asymptomatic patients with stenosis
³70 %, 14 patients with stenosis <70 % and stroke, 7 patients with stenosis <70 % and amaurosis fugax (AFX), 17 patients with stenosis <70 %
and transient ischemic attack (TIA)]. Patients with stenosis of 70 % versus patients with stenosis of <70 %: tumor necrosis factor (TNF)-a and
interleukin (IL)-6, P = 0.004; interferon (IFN)-g and IL-10, P = 0.01; IL-1b, P = 0.02; IL-4, P = 0.006. Patients with stroke versus asymptomatic
patients: IFN-g, P = 0.005; IL-1b and IL-4, P = 0.004; IL-6, P <0.0001; IL-8, P = 0.0001; IL-10, P = 0.03. Patients with AFX versus asymptomatic
patients: IFN-g, P = 0.007; IL-6 and IL-10, P = 0.03; IL-4, P = 0.003
90 TNF–α
80
Patients not undergoing CEA
70
% of positive cells

60 Patients with stenosis>70%

50
40 Patients with stroke
30
20 Patients with AFX
10
Patients with TIA
0

IFN–γ 60 IL–1β
80
70
50
60 % of positive cells
% of positive cells

40
50
40 30

30 20
20
10
10
0 0

IL–6 90 IL–8
65
60 80
% of positive cells

55 70
50
% of positive cells

45 60
40 50
35
30 40
25 30
20
15 20
10 10
5
0 0

IL–4 IL–10
55
50 10-0
45
40 7-5
% of positive cells

% of positive cells

35
30
25 5-0

20
15 2-5
10
5
0 0
40 S.A. Gabriel and E.A. Gabriel

Previous studies have shown that the presence of these 7. Brea D, Sobrino T, Blanco M, et al. Usefulness of haptoglobin and
matrix metalloproteinases plays an important role in cell serum amyloid A proteins as biomarkers for atherothrombotic isch-
emic stroke diagnosis confirmation. Atherosclerosis. 2009;205(2):
migration, degradation of the fibrous cap, expansive remod- 561–7.
eling, and intraplaque neovessel formation. This might sug- 8. Blankenberg S, Luc G, Ducimetiere P, et al. PRIME Study Group
gest that matrix metalloproteinase contributes to plaque Interleukin-18 and the risk of coronary heart disease in European
instability [18, 19]. men: the Prospective Epidemiological Study of Myocardial
Infarction (PRIME). Circulation. 2003;108(20):2453–9.
9. Kerr R, Stirling D, Ludlam CA. Interleukin 6 and haemostasis. Br J
Conclusion Haematol. 2001;115(1):3–12.
Investigation of inflammatory cytokine provides an insight 10. Schindhelm RK, van der Zwan LP, Teerlink T, Scheffer PG.
into the inflammatory mechanisms related to carotid ath- Myeloperoxidase: a useful biomarker for cardiovascular disease
risk stratification? Clin Chem. 2009;55(8):1462–70.
erosclerosis. However, a still unanswered question is 11. Heider P, Pfäffle N, Pelisek J, et al. Is serum pregnancy-associated
whether cytokine expression in the peripheral blood has a plasma protein a really a potential marker of atherosclerotic
causal relation with carotid atherosclerosis or simply carotid plaque stability? Eur J Vasc Endovasc Surg. 2010;39(6):
reflects the inflammatory disease process. Studies should 668–75.
12. Profumo E, Siracusano A, Ortona E, et al. Cytokine expression in
be performed on this issue, and in the future they will lead circulating T lymphocytes from patients undergoing carotid endar-
to improved therapeutic protocols and reduced athero- terectomy. J Cardiovasc Surg. 2003;44:237–42.
sclerosis-related mortality. 13. Profumo E, Esposito C, Buttari B, et al. Intracellular expression of
cytokines in peripheral blood from patients with atherosclerosis
before and after carotid endarterectomy. Atherosclerosis. 2007;
191:340–7.
14. Profumo E, Buttari B, Tosti ME, et al. Association of intracellular
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clinical or ultrasound indications for carotid endarterectomy in
1. Ferguson GG, Eliasziw M, Barr HW, Clagett GP, Barnes RW, patients with carotid atherosclerosis. Clin Exp Immunol. 2008;
Wallace MC, et al. The North American Symptomatic Carotid 152(1):120–6.
Endarterectomy Trial: surgical results in 1415 patients. Stroke. 15. Rerkasem K, Gallagher PJ, Grimble RF, Calder PC, Shearman CP.
1999;30:1751–8. Sex difference in composition of plaques of patients undergoing
2. Hansson GK. Mechanisms of disease: inflammation, atherosclero- carotid endarterectomy. Vascular. 2010;18(2):77–81.
sis, and coronary artery disease. N Engl J Med. 2005;352:1685–95. 16. Halvorsen DS, Johnsen SH, Mathiesen EB, et al. The association
3. Halvorsen B, Otterdal K, Skjelland M, et al. Atherosclerotic plaque between inflammatory markers and carotid atherosclerosis is sex
stability—what determines the fate of the plaque? Prog Cardiovasc dependent: the Tromso Study. Cerebrovasc Dis. 2009;27:392–7.
Dis. 2008;51(3):183–94. 17. Hellings WE, Pasterkamp G, Verhoeven BA, et al. Gender- associ-
4. Hermus L, Lefrandt JD, Tio RA, Breek JC, Zeebregts CJ. Carotid ated differences in plaque phenotype of patients undergoing carotid
plaque formation and serum biomarkers. Atherosclerosis. endarterectomy. J Vasc Surg. 2007;45:289–96.
2010;213(1):21–9. 18. Loftus IM, Naylor AR, Goodall S, Crowther M, Jones L, Bell PR.
5. Zhou W, Chai H, Ding R, Lam HY. Distribution of inflammatory Increased matrix metalloproteinase-9 activity in unstable carotid
mediators in carotid and femoral plaques. J Am Coll Surg. 2010; plaques. A potential role in acute plaque disruption. Stroke.
211(1):92–8. 2000;31:40–7.
6. Schillinger M, Exner M, Mlekusch W, et al. Inflammation and 19. Molloy KJ, Thompson MM, Jones JL, Schwalbe EC, Bell PR,
Carotid Artery—risk for Atherosclerosis Study (ICARAS). Naylor AR, et al. Unstable carotid plaques exhibit raised matrix
Circulation. 2005;111(17):2203–9. metalloproteinase-8 activity. Circulation. 2004;110:337–43.
 Endovascular Treatment of Carotid
Disease: Inflammatory Aspects 6
Sthefano Atique Gabriel and Edmo Atique Gabriel

Introduction including high-sensitive C-reactive protein, interleukin

(IL)-6, IL-18, matrix metalloproteinase (MMP), tissue inhibi-
Recent studies have shown an important interest in the tor of MMP (TIMP), soluble intercellular adhesion molecule
inflammatory aspects of carotid artery stenting; however, the 1 (sICAM-1), and osteopontin (OPN), have an important
pathophysiology of the vascular wall reaction after stent function as predictors of future vascular events [4, 5].
implantation is not yet entirely understood. Chronic vascular In their study of the local release of inflammatory bio-
inflammation is associated with the development of resteno- markers during carotid artery stenting with plaque echogenic-
sis after balloon angioplasty and stent implantation. Virmani ity and calcification, Abe et al. [6] observed that systemic
and Farb [1] have observed that intimal and medial injury IL-6 levels were associated with a recent stroke/transient
and lipid core penetration by the stent struts cause a perivas- ischemic attack and arteriosclerosis obliterans, and local
cular inflammatory response. This vascular inflammatory plaque IL-6 levels were associated with a recent history of
process is also correlated with the severity of arterial injury stroke/transient ischemic attack. IL-6, IL-18, and OPN levels
during stent implantation [1, 2]. were markedly increased at the plaque site in comparison to
The inflammatory phenomenon caused by stent insertion the systemic values. However, the local levels of TIMP-1,
plays an important role in vascular smooth muscle cell MMP-2, and sICAM-1 were similar to their systemic ones.
proliferation and late neointimal growth. It is know that When analyzing the plaque echogenicity, the local levels
vascular smooth muscle cell proliferation and subsequent of both IL-6 and OPN were significantly higher than the sys-
hypertrophic neointima formation at the treated artery may temic levels in lower and higher echogenic groups. However,
be responsible for in-stent restenosis [1–3]. the level of local release of IL-6 (delta IL-6) was higher in
lower echogenic lesions than in higher echogenic lesions,
and the percent stenosis was not associated with the level of
Inflammatory Biomarkers and Carotid local release of IL-6 [6].
Artery Stenting Considering the plaque calcification and serum
inflammatory biomarkers, Abe et al. also observed that the
Inflammation is currently recognized as an important factor in local IL-6 levels significantly increased in both mild and
the development, progression, and rupture of atherosclerotic severe calcification lesions. The OPN level also significantly
plaques. Elevated levels of circulating inflammatory markers, increased in local samples of both mild and severe calcification
lesions. The local level of IL-18 was slightly higher than the
systemic level in both the mild and severe calcification
S.A. Gabriel, MD (*)
Department of Vascular Surgery, groups [6].
Pontifical Catholic University of Campinas, These findings indicate that inflammatory markers are
São Paulo, Brazil produced and stored in carotid plaques in vivo. Moreover,
Department of Vascular Surgery, among the inflammatory markers, IL-6 and OPN are mark-
Celso Pierro Hospital and Maternity, edly released from atheromatous carotid plaques after carotid
Campinas, São Paulo, Brazil
artery stenting. In addition, local IL-6 levels dramatically
e-mail: sthefanogabriel@yahoo.com.br
increased in the lower echogenic groups, suggesting that the
E.A. Gabriel, MD, PhD
amount of local IL-6 is related to plaque instability. However,
Department of Cardiovascular Surgery,
University Nove de Julho, São Paulo, Brazil less release of IL-6 in the severe calcification group than in
e-mail: edag@uol.com.br the mild calcification group may suggest that extensively

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 41

DOI 10.1007/978-1-4471-4429-8_6, © Springer-Verlag London 2013
42 S.A. Gabriel and E.A. Gabriel

calcified plaques are more stable than mildly calcified ones. The role of vascular inflammation in the development of
Therefore, patients with extensive calcification of the carotid in-stent restenosis is mostly triggered by an endothelial
plaque are less likely to have symptomatic disease [7]. disruption and abrasion caused by balloon inflation and stent
placement. This vascular injury initiates the release of several
mediators leading to adhesion of thrombocytes, neutrophils,
Inflammation and In-Stent Restenosis and monocytes. These cells, for their part, release vasoactive,
thrombogenic, lymphocytic, and mitogenic substances,
Wasser et al., analyzing the effect of periinterventional which lead to vasoconstriction, vascular remodeling, neointi-
serum inflammation markers and procedure-related techni- mal proliferation, thrombosis, and inflammation, finally
cal factors during carotid artery stenting on the develop- resulting in in-stent restenosis [9, 10].
ment of an in-stent restenosis during long-term follow-up, In their study on the mechanisms of carotid artery stent
concluded that a post-procedurally elevated leukocyte restenosis by intravascular ultrasound study, Clark et al. con-
count as an inflammatory serum marker is an independent sidered that procedural factors during carotid artery stenting
predictor for subsequent in-stent restenosis. Moreover, the could play an important role in the development of in-stent
occurrence of in-stent restenosis is markedly regulated by restenosis. They concluded that the wider the stent was, the
stent dimensions; therefore, the thinner and longer the less likely the occurrence of in-stent restenosis during fol-
deployed stent, the more frequently a restenosis could be low-up because a stent with a larger diameter results in a
detected [8]. reduced flow velocity, fewer turbulences, and thus less fre-
In their study, Wasser et al. observed a statistically quent in-stent restenosis [11].
significantly higher median C-reactive protein value in the Schillinger et al., analyzing the importance of periinter-
group of patients with an in-stent restenosis than in the group ventional serum levels of acute-phase reactants in 6-month
of patients without an in-stent restenosis during follow-up. restenosis after stent implantation in the carotid artery,
The post-interventional leukocyte count showed a significant observed that within the first 48 h after intervention, a
increase in patients with the occurrence of an in-stent rest- significant increase of C-reactive protein and serum amyloid
enosis during follow-up. The stent cell design did not differ A levels was found in patients with and without restenosis.
between the groups with and without in-stent restenosis dur- However, patients with 6-month restenosis had significantly
ing follow-up; however, there was a significantly narrower higher postintervention serum levels of acute-phase reactants
stent width in the group with the occurrence of an in-stent compared with the levels in patients without restenosis, and
restenosis, as well as a trend toward in-stent restenosis for- they had a significantly higher relative increase of C-reactive
mation during follow-up in those patients with a longer stent protein and serum amyloid A levels during the first 48 h after
length (Table 6.1) [8]. intervention (Table 6.2) [12, 13].

Table 6.1 Periprocedural variables

Variable No restenosis (n = 198) In-stent restenosis (n = 12) p value
Serum parameters
Leucocytepre count/ml (mean, SD) 7,626 (±2,040) 8,300 (±3,013) 0.283
CRPpre mg/dl (median, IQR) 2 (0–6.6) 10.4 (1.45–23.7) 0.022a
Leucocytepost count/ml (mean, SD) 8,526 (±2,525) 10,433 (±4,177) 0.035a,b
CRPpost mg/dl (median, IQR) 10.1 (4.5–24.9) 9 (3.0–11.2) 0.314
Cholesterol mg/dl (mean, SD) 195 (±49) 192 (±58) 0.885
Triglycerides mg/dl (mean, SD) 148 (±72) 123 (± 61) 0.439
LDL mg/dl (mean SD) 133 (± 40) 123 (± 50) 0.587
HDL mg/dl (mean, SD) 47.8 (± 13) 44.8 (± 13) 0.620
Interventional parameters
Predilatation 21 (10.9 %) 3 (25.0 %) 0.153
Postdilatation 189 (95.5 %) 10 (83.3 %) 0.125
Multiple stents used 10 (5.1 %) 1 (8.3 %) 0.485
Stent length (mean, SD) 37.6 (±5.5) 40.7 (±7.0) 0.068a,b
Stent width (mean, SD) 7.4 (±1.0) 6.9 (±1.1) 0.019a,b
Closed cell stent design 165 (83.3 %) 11 (91.7 %) 0.695
doi:10.1371/journal.pone.0022683.t002
pre preprocedural (within 24 h before CAS), post postprocedural (within 24 h after CAS), CRP C-reactive protein
a
Factors included in multiple regression analysis
b
Factors remained significant after multiple regression analysis
6 Endovascular Treatment of Carotid Disease: Inflammatory Aspects 43

Table 6.2 Periprocedural complications within 30 days after CAS 2. Kornowski R, Hong MK, Tio FO, et al. In-stent restenosis: contri-
according to preprocedural CRP levels butions of inflammatory responses and arterial injury to neointimal
hyperplasia. J Am Coll Cardiol. 1998;31:224–30.
Normal CRP Elevated CRP 3. Yutani C, Ishibashi-Ueda H, Suzuki T, et al. Histologic evidence of
(n = 94) (n = 36) P value* foreign body granulation tissue and de novo lesions in patients with
Minor stroke 2 (2.1 %) 5 (13.9 %) 0.0174 coronary stent stenosis. Cardiology. 1999;92:171–7.
Major stroke 1 (1.1 %) 1 (2.8 %) 0.4787 4. Libby P, Ridker PM, Maseri A. Inflammation and atherosclerosis.
Death 0 (0 %) 2 (5.6 %) 0.0751 Circulation. 2002;105:1135–43.
Any stroke or death 3 (3.2 %) 8 (22.2 %) 0.0015 5. Koenig W, Khuseyinova N. Biomarkers of atherosclerotic plaque
instability and rupture. Arterioscler Thromb Vasc Biol. 2007;27:
Note CRP indicates C-reactive protein 15–26.
*P values are from c2 analysis 6. Abe Y, Sakaguchi M, Furukado S, Okazaki S, Fujinaka T, Sakoda
S, et al. Associations of local release of inflammatory biomarkers
during carotid artery stenting with plaque echogenicity and
Conclusion calcification. Cerebrovasc Dis. 2010;30:402–9.
Inflammation is directly associated with the development, 7. Uwatoko T, Toyoda K, Inoue T, Yasumori K, Hirai Y, Makihara N,
progression, and rupture of atherosclerotic plaques and et al. Carotid artery calcification on multislice detector-row com-
puted tomography. Cerebrovasc Dis. 2007;24:20–6.
with the in-stent restenosis. Serum inflammatory bio-
8. Wasser K, Schnaudigel S, Wohlfahrt J, Psychogios M-N, Knauth
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serum amyloid A, play an important role in the genesis of markers and stent characteristics in carotid artery stenting. PLoS
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sclerotic phenomena after carotid artery angioplasty.
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However, following the development of medical treat- 10. Kornowski R, Hong MK, Tio FO, Bramwell O, Wu H, et al. In-stent
ment and the increasing number of studies in the medical restenosis: contributions of inflammatory responses and arterial
area, more studies should be conducted with the aim to injury to neointimal hyperplasia. J Am Coll Cardiol. 1998;31(1):
224–30.
explore the inflammatory aspects of carotid artery stent-
11. Clark DJ, Lessio S, O’Donoghue M, Tsalamandris C, Schainfeld R,
ing. This effort may contribute to clarifying our under- et al. Mechanisms and predictors of carotid artery stent restenosis:
standing of the pathophysiology of inflammation in a serial intravascular ultrasound study. J Am Coll Cardiol. 2006;
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Lipidol. 1999;10:499–506.
 Part III
Abdominal Aortic Aneurysm
 Role of Matrix Metalloproteinases
and Aortic Wall Degradation 7
in Abdominal Aortic Aneurysms

George A. Antoniou and George S. Georgiadis

Introduction to explain the mechanisms of degeneration of the aortic wall

tissues resulting in aneurysm. Current concepts converge on
Abdominal aortic aneurysm (AAA) is the most common the fact that a dysregulation in connective tissue metabolism
type of true aneurysm. Aneurysm is defined as local dilata- instigating and/or resulting from local inflammatory
tion of at least 1.5 times the expected normal arterial diame- responses under the influence of different environmental
ter. In clinical practice, a practical definition for AAA of a triggering events is responsible for the clinical manifestation
transverse diameter of greater than 3 cm is used. It is present of aneurysm [6, 7]. Delineation of underlying pathogenic
in 5–10 % of men aged between 65 and 79 years [1]. Its mechanisms may give further insight into the biological
major complication is rupture, which presents as a surgical processes of disease development and have implications in
emergency. The mortality associated with rupture is high: clinical practice and a pharmacotherapeutic potential.
approximately 80 % of those who reach the hospital and
50 % of those undergoing emergency surgery for ruptured
AAA will die [2]. In the United States, ruptured AAA is the Pathogenesis and Biology
15th leading cause of death overall [3]. Elective aneurysm of Abdominal Aortic Aneurysm
repair is associated with a 30-day mortality of 2–6 % [4].
These mortality figures have not changed in the past decades, Aneurysms result from a chronic degenerative process that
despite improvements in operative techniques and periopera- evolves over a long period of time. The National Heart, Lung,
tive management. Furthermore, the incidence of AAA seems and Blood Institute established a consensus on current
to be increasing, which cannot be explained only by improve- research needs to maximize the overall impact of the aneu-
ments in detection [5]. rysm research program and defined current areas of research
The aortic aneurysm constitutes a significant health prob- focusing on proteolytic degradation of the aortic wall con-
lem, which creates substantial social and financial burdens nective tissue as well as inflammatory and immunological
for health and surgical services in several countries. The nat- responses as the main culprits in the pathogenic mechanisms
ural course is well defined and is characterized by ongoing of abdominal aortic aneurysm formation [6, 7]. Important
progression and development of acute, potentially life- structural elements of the aortic wall are elastin and collagen,
threatening complications. The pathogenesis of aneurysmal which are found in the arterial media and adventitia and pro-
disease of the aorta is complex and multifactorial. Several vide passive strength to the wall, whereas medial smooth
underlying pathophysiological processes have been described muscle cells define its active properties. Elastin is the main
component of the media, and it provides and distributes ten-
sile strength along the arterial wall. It is synthesized during
G.A. Antoniou, MD, PhD (*)
the early stages of aortic wall development and has an esti-
Department of Vascular and Endovascular Surgery,
Manchester Royal Infirmary, mated half-life of 60 years. A study examining the ultrastruc-
Central Manchester University Hospitals NHS Foundation Trust, ture of elastin elements found that there was an 81.6 %
Manchester, UK reduction in elastin lamella in the aortic wall of patients with
email: antoniou.ga@hotmail.com
abdominal aortic aneurysm, concluding that elastolysis is a
G.S. Georgiadis, MD primary event in aneurysm formation [8]. Solid evidence
Department of Vascular and Endovascular Surgery,
exists supporting that elastin degradation occurs in the early
University Hospital of Alexandroupolis,
Democritus University of Thrace, stages of the pathogenic process of aneurysm development
Alexandroupolis, Greece [8–10]. On the other hand, collagen is the primary structural

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 47

DOI 10.1007/978-1-4471-4429-8_7, © Springer-Verlag London 2013
48 G.A. Antoniou and G.S. Georgiadis

Table 7.1 Role of MMPs in the pathogenesis of aortic aneurysm

Matrix
metalloproteinase Enzyme Genetic location Main ECM substrates Role in aortic aneurysm
MMP-1 Collagenase 1 11q22-q23 Collagens (I, II, III, VII, VIII, X), Collagenolysis, associated with risk
gelatin, fibronectin, vitronectin, laminin, of rupture
aggrecan
MMP-2 Gelatinase A 16q13 Collagens (I, II, III, IV, V, VII, X, XI), Elastolysis, dominant role in early
gelatin, elastin, fibronectin, vitronectin, stages of aneurysm formation
laminin
MMP-3 Stromelysin 1 11q23 Collagens (III, IV, V, VII, IX, X, XI), Elastin and collagen degradation,
gelatin, elastin, fibronectin, vitronectin, activates other pro-MMPs,
laminin angiogenesis
MMP-8 Collagenase 2 11q21-q22 Collagens (I, II, III), aggrecan Collagen degradation, aneurysm
rupture
MMP-9 Gelatinase B 20q11.2-q13.1 Collagens (IV, V, XI, XIV), gelatin, Elastolysis, collagenolysis, dominant
elastin, vitronectin, laminin, aggrecan role in later stages of aneurysm
formation and rupture
MMP-12 Macrophage 11q22.2-q22.3 Collagens (I, IV, V), gelatin, elastin, Elastolytic activity
elastase fibronectin, vitronectin, laminin
MMP-13 Collagenase 3 11q22.3 Collagens (I, II, III, IV, VI, IX, X, XIV), Collagenolysis, associated with risk
gelatin, fibronectin, aggrecan of rupture
MMP-14 MT1-MMP 14q11-q12 Collagens (I, II, III), gelatin, fibronectin, Activates pro-MMP-2
tenascin, vitronectin, laminin

element of the adventitia, is composed of three polypeptide higher MMP-9 mRNA expression in moderate-diameter
chains forming a triple-helical structure, and, unlike elastin, (5–6.9 cm) than small-diameter (<4 cm) aneurysms [17].
is under a continuous process of synthesis and degradation Evidence suggests that MMP-9 is the dominant proteolytic
throughout life. It provides stiffness to the arterial wall. enzyme promoting continued expansion and rupture [17, 18].
A report found increased collagen and a prominent Peterson et al. demonstrated that levels of MMP-9 were
inflammatory cell infiltration in the aneurysm wall compared increased in ruptured aneurysms compared to large intact
with non-aneurysmal aortas [11]. Increased collagenolytic aneurysms [19]. Several other MMPs have been demon-
activity in the aneurysmal aorta being correlated with aneu- strated to play a role in the aneurysm degrading and
rysm size was demonstrated in another report [12]. It seems inflammatory process (Table 7.1). Regulation of MMP activ-
that collagen synthesis increases during the early stage of ity is achieved at different levels, with TIMPs having been
aneurysm formation, however at later stages degradation suggested as an important regulator of extracellular matrix
exceeds synthesis, resulting in continuing aneurysm expan- degradation. The balance of aortic wall remodeling between
sion and ultimately rupture [11–13]. The aortic wall extra- MMPs and their inhibitors favors collagen and elastin degra-
cellular matrix, apart from the structural elements of elastin dation. However, the initiating events and the mechanisms
and collagen, contains embedded inflammatory cells, smooth for propagating these proteolytic enzymes in the aortic wall
muscle cells, cytokines, growth factors, proteinases, and remain to be identified.
proteinase inhibitors. It is a complex structure that, apart Investigations have also demonstrated a significant
from its scaffold properties to the aortic wall, exerts a num- immunological contribution to the pathogenesis of the dis-
ber of biological activities and regulates elastin and collagen ease. Lymphocytes represent the main cell population found
synthesis and degradation, smooth muscle cell apoptosis, in inflammatory infiltrates in aortic aneurysms. Schonbeck
chemotaxis and cell migration, inflammation and immune et al. identified that the majority of the lymphocytes were
responses, and angiogenesis. T-helper (Th)-2-restricted CD3+ T lymphocytes, as deter-
There is ample evidence that matrix degradation by a mined by Western blot and immunohistochemical analysis,
variety of proteolytic enzymes, mainly MMPs, is integral to with increased Th-2-associated expression of interleukin
aneurysm development and that an imbalance between (IL)-4, IL-5, and IL-10 [20]. It seems that exogenous and/or
MMPs and their inhibitors (TIMPs) impairs normal physio- endogenous factors disrupting the intima/adventitia and
logic aortic wall remodeling [14, 15]. Elastolysis is an early exposing elastin and interstitial collagen instigate an immune
event in aneurysm formation. Freestone et al. demonstrated response resulting in a cascade of inflammatory events
that MMP-2 was the dominant gelatinase in small aneu- [21, 22]. Immune cells, including macrophages and lym-
rysms, suggesting that it is the inciting enzyme in aneurysm phocytes, along with smooth muscle cells and fibroblasts
genesis [16]. As opposed to MMP-2, McMillan et al. found promote a strong inflammatory reaction, which activates
7 Role of Matrix Metalloproteinases and Aortic Wall Degradation in Abdominal Aortic Aneurysms 49

proteolytic enzymes and extracellular matrix degradation. as well as those involved in mechanisms of connective tissue
Elastin and collagen degradation products in turn propagate metabolism and inflammatory response have been exten-
a sequestered inflammatory reaction, leading to further sively investigated. In particular, polymorphic sites and gene
degeneration of the aortic wall, aneurysm expansion, and mutations of proteins of the structural components of the
rupture. Oxidative stress significantly contributes to the connective tissue (elastin, collagen), extracellular matrix-
pathophysiology of inflammation. Zhang et al. demonstrated degrading enzymes and their inhibitors (MMPs, TIMPs),
increased expression of inducible nitric oxide synthase in and inflammation promotion agents (interleukins, platelet-
the aneurysm wall tissues as compared with normal aorta activating factor, nitric oxide synthase, inflammatory recep-
[23]. An integral part of the whole process is a reduction in tors) have been investigated separately in gene association
medial smooth muscle cells (apoptosis), which are the prin- observational studies. Nevertheless, no single gene has yet
cipal cell type producing extracellular matrix components been isolated as the key factor interpreting the genetic basis
[24, 25]. It seems however, that during life, as oxidative of aortic aneurysm. A small number of families have a genet-
stress increases and assaults increasingly occur at the ically determined type III collagen defect (COL3A1), in
endothelial and smooth muscle levels, there is a natural bio- which cases the abdominal aortic aneurysm is considered to
logical antiinflammatory process that counteracts the ten- be a manifestation of Ehlers-Danlos syndrome [35].
dency toward inflammatory degradation. Th-2-associated Furthermore, mutations in the fibrilin-1 gene (15q21.1),
cytokines suppress macrophage expression of MMP-9, resulting in abnormal fibrilin-1 synthesis, secretion, or use,
which suggests that Th-2 immune responses might restrain are responsible for Marfan syndrome, which is a hereditary
aneurysmal degeneration [26]. connective tissue disorder associated with thoraco-abdominal
Understanding of the significance of MMPs in biology aortic aneurysms and dissections [36].
and pathology has led to the development of numerous potent
synthetic inhibitors of matrix metalloproteinases. Such
agents may be of great therapeutic value, and some of them Future Perspectives
are in clinical trials for the treatment of cancer and
inflammatory conditions [27]. Tetracyclines non-selectively Pharmacotherapeutic approaches to prevent or slow down
inhibit MMPs via mechanisms similar to those of endoge- the development and progression of the disease constitute a
nous inhibitors and have been shown to effectively prevent virgin field in medical research. Targeted approaches with
elastin and collagen destruction as well as aneurysmal dilata- the design of specific inhibitors of key players in the connec-
tion [28–30]. tive tissue degeneration process might provide novel phar-
macological methods to decelerate aneurysm progression.
Further knowledge about mechanisms of regulation of MMP
Genetics of Aortic Aneurysm gene expression may direct therapeutic strategies toward
tissue-targeted gene therapies with agents that selectively
Although the etiology of aortic aneurysm is assumed to be inhibit specific MMPs.
multifactorial, genetic influences appear to be independently
associated with both disease states. A genetic predisposition
to abdominal aortic aneurysm development is demonstrated References
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 Role of Haptoglobin in Abdominal
Aortic Aneurysm 8
Valerio Napolioni

Haptoglobin, an Anti-inflammatory activate naive T cells, and abundant Hp has been detected in
Plasma Protein cytoplasmic compartments of Langerhans cells and in neu-
trophils [7, 8]. Also, Hp binds to mast cells through another
Haptoglobin (Hp) is a plasmatic protein encoded by the HP yet unidentified receptor, possibly modulating their func-
gene (OMIM*140100, gene map locus 16q22.1). Its main tion [9]. Last, high density lipoprotein (HDL) particles can
function in blood plasma is binding free hemoglobin (Hb) become proinflammatory through direct interactions of
released from erythrocytes with high affinity and thereby Hp-Hb complexes with apolipoprotein A1 [10].
inhibiting its oxidative activity. The Hp-Hb complex is then
removed by the reticuloendothelial system (mostly the
spleen). Hp is widely used in clinical settings where the Hp Haptoglobin Protein Structure
assay is implemented to screen for and monitor intravascular and Its Polymorphism
hemolytic anemia [1]. In intravascular hemolytic anemia,
free Hb is released into the circulation, and hence Hp binds Hp is an a2-sialoglycoprotein endowed with Hb-binding
the Hb. This causes a decline in Hp levels. Conversely, in capacity and is characterized by molecular heterogeneity;
extravascular hemolysis, the reticuloendothelial system, this is due to the existence of three major genotypes, i.e.,
especially splenic monocytes, phagocytoses the erythro- HP*1/*1, HP*2/*1, and HP*2/*2 [1]. The main difference
cytes, and Hb is not released into the circulation; hence, the between the alleles HP*1 and HP*2 is the presence of a
Hp levels are normal. Thus, Hp is a potent antioxidant play- duplicated ~1.7 Kb DNA segment in HP*2, but not HP*1
ing a scavenging role for the toxic free Hb that accumulates (Fig. 8.1) [11]. Of note, HP*1 has two variants, HP*1F (fast)
during acute-phase inflammatory reactions [1]. and HP*1S (slow), which are correlated with the presence of
However, importantly, Hp also exerts a direct angio- amino acids Asp-Lys (version F) or Asn-Glu (version S) at
genic, antiinflammatory, and immunomodulatory function in amino acid positions 52 and 53 in the a1 chain. The HP*2
extravascular tissues and body fluids. In fact, in response to allele is supposed to originate from a breakage and reunion
various stimuli, Hp is able to migrate through vessel walls event at non-homologous positions within the fourth and the
and is expressed in different tissues [2]. Furthermore, Hp can second introns (unequal crossing over) in an individual who
be released from neutrophil granulocytes at sites of injury was heterozygous for HP*1F and HP*1S [12]. Having exons
or inflammation and locally dampens tissue damage [3]. Hp 3 and 4 in duplicate, the HP*2 monomer is bivalent and can
receptors include CD163 expressed on the monocyte-mac- associate with two different Hp monomers. Thus, homozy-
rophage system and CD11b (CR3) found on granulocytes, gous HP*1/*1 individuals express Hp protein as a single
natural killer cells, and in small lymphocyte subpopulations a1b homodimer of 86 kDa. Homozygous HP*2/*2 individu-
[4, 5]. Hp has also been shown to bind to the majority of CD4+ als express cyclic Hp oligomers containing three or more
and CD8+ T cells, directly inhibiting their proliferation and a2b subunits (170–900 kDa). The Hp synthesized by
modifying the balance of T helper (Th) 1 and 2 [6]. Notably, HP*2/*1 heterozygous subjects is assembled into linear
Hp inhibits the capacity of epidermal Langerhans cells to homodimers and multimers of variable numbers of a2b sub-
units flanked at each terminus by 1a1b subunits (86–
300 kDa). Thus, the HP*2/*1 phenotype is distinctly different
V. Napolioni, PhD
from the phenotypes of the HP*2 or HP*1 homozygotes
School of Biosciences and Biotechnologies,
University of Camerino, Camerino, Italy (Fig. 8.1). Since functional differences in the antioxidant,
e-mail: valerio.napolioni@unicam.it, napvale@gmail.com scavenging, and immune-regulatory properties of Hp occur

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 51

DOI 10.1007/978-1-4471-4429-8_8, © Springer-Verlag London 2013
52 V. Napolioni

1.7 kb gene duplication peripheral B-cell counts was also observed [14]. The number
in Hp*2
a of free CD22 binding sites on circulating B cells was esti-
Hp Hpr
mated to be higher in HP*2/*2 individuals, who display
lower serum Hp levels than those with HP*1/*1. Furthermore,
the concentrations of large, multimeric proteins such as IgM
1 2 3 4 5 6 7 1
and Hp 2–2 are considerably lower in extravascular fluids
b than in plasma, because diffusion of these macromolecules
Hp 1-1 Hp 2-1 Hp 2-2
into the interstitial compartment is limited. Thus, it is con-
ceivable that some interactions of B cells that are inhibited in
the blood stream are enabled within atherosclerotic plaque of
HP*2/*2 subjects.
However, it is not known whether and how the different
Hp phenotypes can influence the B-T cell dialogue and T
cell activation by interfering with CD22 function. Notably,
higher peripheral T helper lymphocyte counts are observed
in HP*2/*2 subjects [14]. However, Hp plays a direct effect
on T cells through a dose-dependent suppression of induced
T-cell proliferation [6]. Hp exhibits a strong inhibitory
effect on Th2 cytokine release, thus promoting a dominant
Th1 activation over Th2 activation and playing a modulating
role on the Th1/Th2 balance [6]. The majority of the T cells
in atherosclerotic lesions produce Th1cytokines, such as
Hp monomers IL-2, IL-12, interferon-g, TNF-a, and TNF-b, supporting
cell-mediated responses [15]. In contrast, human atheromas
contain only modest quantities of the Th2 cytokines IL-4,
α1 α2 β IL-5, and IL-10, which can promote humoral responses [15].
Whether and how the different polymorphic Hp forms can
Fig. 8.1 HP locus genetic structure and structural differences with
subunit arrangement of Hp phenotypes. (a) The physical map of the HP attenuate or enhance atherogenesis by direct modulation of
locus. HP exons are indicated by black boxes. The gene duplication Th1/Th2 balance requires further investigation. Some pro-
responsible for HP polymorphism is indicated by two vertical arrows. atherogenic properties related to Hb binding of Hp 2–2 can
(b) The three HP genotypes express entirely different molecular struc- have indirect effects on B- and T-cell responses as well as
tures at the protein level
antibody production against oxidized LDL. First, Hp 2–2
polymers are less efficient in the clearance of free Hb after
as a function of its polymorphism, the genetics of HP has intraplaque hemorrhage, causing higher susceptibility of
been associated with predisposition to infections and with LDL to Hb-driven oxidation [16]. Oxidatively modified
autoimmune, cardiovascular, and other diseases and disor- LDL epitopes are highly immunogenic and stimulate B-
ders [1]. In Caucasians, the phenotype frequencies are and T-cell responses that can promote humoral as well as
approximately 16 % (HP*1/*1), 48 % (HP*2/*1), and 36 % cellular immunity [17]. Second, Hb/Hp 2–2 complexes
(HP*2/*2), but marked geographical differences exist, with display higher affinity for CD163 on monocyte-mac-
Asians showing high HP*2/*2 frequencies (up to 55 %) [1]. rophages, leading to intracellular accumulation of
Hb-derived iron [18]. Such iron-loaded macrophages may,
in the arterial intima, expose LDL to reactive oxygen spe-
Haptoglobin Polymorphism and Its Role cies and thus generate an inflammatory stimulus [19].
in Inflammation and Atherosclerosis Finally, via CD163 binding, the Hb–Hp 1–1 complex stim-
ulates the macrophage to secrete the antiinflammatory
Beyond the conventional view of Hp as a marker of hemoly- cytokine IL-10 and heme oxygenase-1 to a markedly
sis, several findings point toward an immunomodulatory greater degree than the Hb–Hp 2–2 complex [19]. Release
effect of Hp in B-cell mediated progression of atherosclero- of IL-10 has been suggested to reduce inflammatory cell
sis [13]. It has been demonstrated that the HP*2/*2 pheno- infiltration and macrophage accumulation in atheroscle-
type is associated with markedly higher peripheral B-cell rotic plaques of Hp 1–1 mice [19]. IL-10 inhibits the Th1
counts than HP*1/*1 [14]. In contrast, B-cell percentages in response in atheroma. In contrast, macrophages activated
bone marrow are lowest in HP*2/*2 subjects [14]. A nega- by Hb–Hp 2–2 binding to CD163 shift the T helper
tive correlation between serum Hp 1–1 concentration and response towards Th1 cytokines [20].
8 Role of Haptoglobin in Abdominal Aortic Aneurysm 53

Haptoglobin and Its Role in Abdominal Aortic (mg/l) were significantly higher in patients with HP*2/*1
Aneurysm (7.2 [7.1]) than with HP*2/*2 [3.4 (3.1), P = 0.0058] and
HP*1/*1 [2.8 (4.1), P = 0.044]. In 2011, Pan et al. [35] con-
Inflammation with infiltrates of macrophages and lympho- ducted another study aiming to assess the association of the
cytes is an important feature of abdominal aortic aneurysms HP polymorphism with AAA in the Taiwanese population.
(AAA) [21, 22]. Elevated levels of various plasma markers Forty-five patients with AAA and 49 non-AAA subjects
of inflammation have been reported in patients with AAA as were included. They found that plasma Hp concentrations
compared with healthy controls or patients with cardiovascu- were significantly higher in AAA patients compared with
lar disease [23–25]. Positive correlations between non-AAA subjects (254 ± 158 vs. 186 ± 108 ng/ml; P = 0.017),
inflammatory markers and the degree of aortic dilatation in particular for HP*2/*2 carriers compared with corre-
have been reported in cross-sectional studies [26–29]. sponding non-AAA subjects (238 ± 144 vs. 163 ± 86 ng/ml;
In this context, Hp may play a crucial role in modulation P = 0.024).
the inflammatory response characterizing AAA, both as a Beside studies based on the HP genetic polymorphism,
susceptibility factor (by its genetic polymorphism) and three reports have been conducted only at the protein level.
as a prognostic marker. The first was performed on a large Swedish cohort, the
The first study on Hp’s role in AAA was performed in “Malmö Preventive Study,” including 6,075 men with infor-
early 1980, when Norrgärd and co-workers found that there mation on 5 inflammation-sensitive plasma proteins (ISPs;
was an increased frequency of the HP*2/*1 phenotype in fibrinogen, orosomucoid, a1-antitrypsin, haptoglobin, and
Northern Swedish individuals with AAA [30]. Following ceruloplasmin) [36]. A total of 63 men had AAA (0.49 per
this first report, Powell et al. [31] investigated whether the 1,000 person/years). Fifty were non-fatal cases whose aneu-
different Hp phenotypes influence the degradation of aortic rysm was repaired in an open vascular or endovascular surgi-
connective tissue. The HP*1 allele frequency was significantly cal procedure, and 13 of those 50 (26 %) were ruptured. The
increased in patients with aneurysms compared to control remaining 13 cases were fatal. The mean time from the base-
subjects (0.51 vs. 0.35, P <0.05). However, HP*2/*2 patients line examination to aneurysm repair or death from AAA was
had the highest mean age at aneurysm resection. Moreover, 18.8 ± 4.9 years (range 1.3–26.6). Age at the time of the AAA
they found that Hps containing an a1-chain accelerated the was 67.1 ± 5.3 years (range: 55–80 years). The Hp level (g/l)
degradation of aortic elastin by elastases two- to four-fold was significantly higher in men who subsequently had AAA
in vitro. as compared with the controls (1.69 ± 0.79 vs. 1.38 ± 0.68,
This preliminary evidence led Adamson et al. [32] to test p <0.001). Moreover, a higher Hp level conferred an increased
for the usefulness of the HP polymorphism as a family-based risk of fatal AAA compared with repaired AAA (O.R = 2.500,
informative genetic marker of AAA, without significant p <0.010). Another study examined the Hp level after post-
results. After this study, the role of Hp in AAA was almost operative surgery in elective repair of infrarenal aortic aneu-
ignored until 2001, when Wiernicki et al. [33] analyzed the rysm patients [37]; AAA patients had a significant
influence of Hp phenotypes on serum elastase activity, neu- postoperative rise in IL-10 levels and a significant decrease
trophil count, and elastin concentration in the aorta of Polish in plasma Hp levels. Lastly, very recently, Gamberi et al. [38]
AAA (N = 52) and aortoiliac atherosclerotic occlusive dis- performed a comprehensive plasma proteomic profiling on
ease (AOD; N = 37) patients. HP phenotype distribution did eight patients scheduled for AAA repair through elective
not differ between the two groups and the third control group aortic reconstructive surgery, identifying a significant Hp
of 37 subjects without atherosclerosis. Nevertheless, increase in plasma from AAA patients.
significant increases in serum elastase activity and neutrophil Overall, the emerging picture from these studies is a strik-
count were measured in the HP*2/*1 phenotype of AAA ing involvement of Hp in the pathophysiology of AAA. First,
patients, thus supporting the association of AAA susceptibil- the HP*2/*1 genotype seems to be an important predispos-
ity with the HP*2/*1 phenotype as postulated by Norrg rd ing factor of AAA liability, also influencing the prognosis.
et al. [30]. Nearly 10 years later, the same research group On the other side, the higher Hp level found in AAA patients
provided further evidence for the association of the HP*2/*1 is a clear demonstration of the proinflammatory nature of the
genotype with AAA [34]. They found that HP*2/*1 patients AAA phenomenon. Indeed, given the antiinflammatory
had a significantly higher growth rate [3.69 (2.40) mm/year] properties of Hp, it is conceivable that the rising of Hp level
of AAA compared with patients with HP*2/*2 [1.24 (0.79), is a counteracting response to the increased inflammation
P <0.00001] and HP*1/*1 [1.45 (0.68), P = 0.00004]. due to the presence of AAA. Concerning the role of the
Elevated elastase serum activity was also evident in AAA HP*2/*1 genotype in AAA liability, the molecular and
patients with HP*2/*1 [0.119 (0.084) arbitrary units] in con- genetic complexity of the HP polymorphism needs to be
trast to HP*2/*2 [0.064 (0.041), P <0.00001] and HP*1/*1 taken into account. Most of the authors failed to explain why
[0.071 (0.040), P = 0.0006] patients. CRP serum levels the HP*2/*1 heterozygous phenotype was different from
54 V. Napolioni

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of Hp 2–1. New functional studies are clearly needed to fur- subsets in bone marrow and peripheral blood is associated with
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nants of AAA, such as APOB [42, 43], APOE [43], and 16. Brouwers A, Langlois M, Delanghe J, et al. Oxidized low-density lipo-
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 Inflammatory Aortic Aneurysm
9
Guilherme Vieira Meirelles

Introduction Others, such as proteinase, plasminogen activator serum

elastase, and cathepsin, also contribute to aneurysmatic
The severity of aneurysmatic disease and its evolution were degeneration [6].
described long ago. Since that time, therapeutic strategies Atherosclerosis is still being investigated as a participatory
have been based on surgical procedures, which have been factor in degenerative aneurysmatic processes of the aorta.
modified according to scientific and technical developments Experimental studies including atherogenic diets for extended
in the medical fields. The Papyrus of Erbes, written in periods produced areas of lateral inclination of the middle
approximately 2,000 B.C., described peripheral aneurysms arterial layer, with aneurysm formation in primates (13 % in
and suggested surgical treatment with a glowing iron: “treat cynomolgus monkeys and 1 % in rhesus monkeys) [7].
with the knife and burn with fire …” [1,2]. Atherosclerotic plaques are usually more plentiful, pro-
The term inflammatory abdominal aortic aneurysm nounced, calcified, and complicated in the abdominal aorta
(AAA) was created in 1972 by Walker et al. [5] to describe compared with those in the thoracic segment. These changes
an AAA with an unusually thick wall surrounded by exten- are related to local differences in blood flow conditions, wall
sive fibrous adhesions involving adjoining tissues and struc- stress mechanisms, and the composition and nutrition of the
tures and treated as a different clinical entity from degenerative structures of the arterial layers.
aneurysms. This characteristic was found in 2.5–15 % of all In humans, the abdominal aorta expands with the progres-
AAAs with a 20:1 predominance in males and occurred in sion of atherosclerotic plaque. This is associated with the
patients an average of 10 years younger than those with narrowing and loss of structural architecture of the middle
noninflammatory AAAs [3–5]. layer, being particularly pronounced at its midpoint and at
The inflammatory AAA, once believed to have a different the fork of the iliac arteries [8].
etiology and pathogenesis, now seems to be the final result of Preliminary studies suggest cathepsin S and K as potent
the inflammatory process found in degenerative aneurysms. elastases, and the genes of this enzyme are expressed in
The etiology of the aortic aneurysm, attributed long ago to human atheroma plaque. Atheromas also have high activity
atherosclerosis, has not yet been fully defined. in destroying elastin, which is sensitive to the cysteine pro-
Aneurysmatic degeneration is the end result of a multifac- tease inhibitors. Levels of cysteine C, the most abundant of
torial process that leads to the destruction of the connective the cathepsin inhibitors, decreased in atherosclerosis arteries
tissues of the arterial wall. Evidence indicates that the most and in the walls of abdominal aortic aneurysms [6].
important structural elements of the aorta wall, the intersti- Evaluating the causal factors, elastin and collagen are the
tial collagen and elastin, are associated with the degradation most important components of the arterial wall and are asso-
of the extracellular matrix in AAA. Many of these findings ciated with smooth muscle cells and the middle layer of the
are related to matrix metalloproteinases (MMPs). Among abdominal aorta [9].
these are 72-kDa gelatinase (MMP-2), 92-kDa gelatinase Elastin is the arterial wall component responsible for
(MMP-9), matrilysn (MMP-7), and macrophage elastase elasticity of the artery, allowing physiological swelling and
(MMP-12), which are capable of degrading elastic fibers. shrinkage, determined by the heartbeat. Much evidence
exists concerning the participation of aortic dilatation in
elastin lesions.
G.V. Meirelles, MD
The presence of swelling occurs most often in the abdom-
Department of Vascular Surgery,
Celso Pierro Hospital and Maternity, inal aorta, where there are fewer elastic layers. Elastin is not
Campinas, SP, Brazil synthesized in the aorta of adult individuals, and the elastic

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 57

DOI 10.1007/978-1-4471-4429-8_9, © Springer-Verlag London 2013
58 G.V. Meirelles

capacity of the average 70 year old (period when AAAs transmural infiltrated mononuclear phagocytes, increased
appear most frequently) is three times less than that of a production of MMP, and progressive destruction of the
20 year old. The use of elastase in the arterial walls in animal protein matrix from the wall. The deletion of the degenera-
experiments produces dilatation, but without a relation to the tive process in vivo using nonselective antiinflammatory
proportions of the elastin lesion and the final diameter of the inhibitors of MMP (doxycycline) was also investigated.
aorta [10]. Elastin is responsible for 35 % of the weight of MMP-9 deficiency induced resistance to aneurysm forma-
the middle layer of normal aortas and is reduced up to 8 % in tion, but with a bone marrow transplant to correct this
aneurysmatic arteries. Comparing the quantity of elastin in deficiency, mice recovered the potential to develop aneu-
81 fragments of the AAA wall surgically removed from rysms. The administration of doxycycline resulted in a five-
corpses 82 with normal aortas, a reduction of approximately fold decrease in the expression of MMP-9 in the aortic wall
90 % was found and a total reduction of 50 % in amino 84 of patients undergoing elective treatment of AAA. In vitro, it
acid aneurysms [11–13]. suppressed expression of MMP-9 stimulated by forbol in
An additional finding was the elevated levels of elastase mononuclear THP1 phagocytes [6].
in these walls, suggesting an important participation of elas- In intermediate situations, increasing the process of recon-
tin in the genesis of aortic dilation in humans [14]. stitution of collagen (types I and III) can maintain stable lev-
Collagen types I and III are the main forms of this com- els, but with the continuous increase of degradation, this can
ponent of the aortic wall, which is characterized by tensile provide an unfavorable balance with rapid expansion and
strength and low distensibility in order to allow the increase rupture of the aneurysm. Collagenase-3 (MMP-13) is most
in arterial diameter. Different from elastin, collagen is pro- frequently found on the AAA wall [6].
duced throughout life (absorbed and reconstituted) and has In vitro studies suggest that reactive oxygen forms medi-
20 times the tensile strength of elastin. The collagen is laid ate activation of MMP-9 and MMP-8. Recent studies have
in such a way that, supported by elastin, it allows an shown that activated phagocytes produce oxygen, which then
increase in diameter (heartbeat) and upon reaching a par- forms hydrogen peroxide and myeloperoxidase in the pro-
ticular stretching point is used as a protective barrier con- cess of phagocytosis; the latter enables MMP-9 and MMP-8,
taining the arterial increase. Its concentration increases in creating the oxidative theory of aneurysm formation [6].
the AAA walls. A deficiency in type III collagen (the most An inflammatory infiltrate composed of T cells, mono-
frequent in the aortic wall) has been associated with the cytes/macrophages, B-lymphocytes, and plasma cells associ-
rupture of cerebral aneurysms and identified as an abnor- ated with the presence of HLA-DR + and antigenic markers
mality in Ehlers-Danlos syndrome type IV (arterial weak- on the wall of AAAs suggests an inflammatory component.
ness with formation of aneurysms) [13]. At the same time, This also indicates that purified immunoglobulin G in a seg-
the collagenolytic activity is increased in individuals with ment of the AAA wall in contact with the normal aorta wall
AAA ruptures [15]. Contrarily, metalloproteinase inhibi- will produce an immunoreaction [6,16].
tor (which decreases the activity of protease enzymes, Surveys on the presence of Chlamydia pneumoniae in
such as elastase, collagenase, and gelatinase) is found in aneurysmatic wall biopsies of the abdominal aorta proved to
decreased concentrations in the walls of dilated arteries be positive in 77 % of the cases, which highlights the rela-
[6,14]. tionship between infection and AAA [17]. The use of
RNA messenger expression of 92-kDa gelatinase plasma markers, such as IgA and IgG using ELISA or
(MMP-9) on the wall of the aorta has been correlated immunofluorescence, showed the presence of Chlamydia
with the presence and size of the aneurysm, being also pneumoniae in 36 % of aneurysms. A review showed their
associated with high levels of MMP-9 in the serum of these sensitivity and specificity for the need for surgery (expan-
individuals. These surveys suggest there is a change in the sion) for AAAs to be 80 % and 66 %, respectively [17,18].
ability to repair the arterial wall in case of an exaggerated Among the mechanisms that cause weakening of the aor-
expression of MMP-9, which results in the destruction of the tic wall, some are particularly crucial: genetics; smoking;
arrangement [6]. factors that increase the size of the artery, such as hyperten-
The enzyme 72-kDa gelatinase (MMP-2) appears at high sion, inflammatory, processes, and atherosclerosis.
levels in AAA walls, in its active form, next to the extracel- Family history is one of the background factors related to
lular matrix, suggesting a protease action. High-level mem- the prevalence of aneurysm and has special characteristics,
brane type I MMP (MMP-14), which constitutes the primary such as being most likely to be present in women or in indi-
activator Pro-MMP-2, was also found. Doxycycline inhibits viduals under the age of 65 years [19]. Although conditions
MMP-2, and this is an important factor in aneurysm forma- such as mutations in type III collagen, changes in MZ alpha-
tion [38]. 1-antitrypsin, and metalloproteinase inhibitors indicate a
A model of aortic wall lesion induction in rats, with genetic basis for AAAs, a genetic origin for the formation of
administration of elastase, demonstrated the presence of the aneurysm has not yet been established. Surveys suggest
9 Inflammatory Aortic Aneurysm 59

that 12–19 % of people with AAA features are related to one It is now accepted that AAAs are characterized by chronic
or more first-degree relatives with this disease [20,21]. The aortic wall inflammation, destructive remodeling of the
relative risk for relatives of people with AAA is 18 times extracellular matrix, and depletion of vascular smooth mus-
higher than for individuals without a family relationship [6]. cle cells, and the difference between inflammatory and
When searching for deficiency of type III collagen in 56 degenerative aneurysms is only the intensity of the
people with AAA, 16 (28.6 %) had a family history and 6 inflammatory reaction.
(10.7 %) a deficiency in type III collagen [21]. The herpes simplex virus and cytomegalovirus were more
Smoking is strongly associated with weakening of the frequently present in aneurysmal walls than in normal aortic
arterial wall. The products of combustion of tobacco inacti- walls. These viruses were more prevalent in inflammatory
vate alpha 1-antitrypsin, oxidizing methionine, increasing than in noninflammatory AAAs [31].
wall degradation, and contributing to the genesis of AAAs Risk factors that are associated with the development of
and an increase in their size, which entail an increased risk of inflammatory AAAs include cigarette smoking and a genetic
rupture [22,23]. The rupture rate in a study of small aneu- predisposition.
rysms in the UK (UK Small Aneurysm Trial) reached 1.9 %
per year in patients with high serum levels of nicotine com-
pared to 0.5 % in those with only trace amounts (AAAs of Clinical Features
4–5.5 cm diameter) [24].
It is still uncertain whether hypertension plays a role in Different from degenerative AAAs, the exacerbations of the
the formation of AAAs or exacerbates an already existing inflammatory process with fibrosis involving others struc-
situation. The fact is that hypertension is related to the pres- tures are typically symptomatic (65–90 % compared to
ence of AAAs and contributes to the increase in arterial 8–18 % in the noninflammatory form), with 80 % diagnosed
diameter [22] in the elderly (individuals aged 60 years or based on clinical symptom investigations. Abdominal or
more, according to the World Health Organization). As back pain, weight loss, and an elevated erythrocyte sedimen-
described earlier, age above 60 years is related to the pres- tation rate (raised in 70 % of cases) in AAA patients are very
ence of AAAs not only in association with atherosclerotic probably of the inflammatory variant. Chronic renal failure is
disease, but also with changes in the elastin and collagen associated in 10–20 % of patients, so serum electrolyte and
recruitment engine [25]. creatinine levels must be investigated. These AAAs are larger
Atherosclerosis is invariably associated with AAAs in than the atherosclerotic type, and an intensive inflammatory
spite of different risk factors. Hyperlipidemia and diabetes process is frequently observed with duodenum entrapment
are not related to AAAs, with great frequency observed in (100 %) and ureteral involvement (53 % with obstructive
atherosclerotic disease [26]. uropathy in 21 % of patients) in the retroperitoneal fibrotic
Local factors such as composition, biomechanical strength, process [4,32–34].
and nutrition are different in the abdominal and thoracic
aorta [6]. There is a decrease in the vasa vasorum in the
human abdominal aorta when compared with other arterial Diagnosis
segments considering the thickness of the wall. Thus, the
complement of this blood perfusion deficit is provided by Despite a pulsatile abdominal mass (present in 15–30 %) and
direct absorption through the aortic lumen. It is believed that the associated clinical features, a computer tomography (CT)
the presence of atherosclerotic plaques in the aorta or in the must be done to confirm the presence of a thickened aortic
nurturing artery (vasa vasorum) helps to create layers of wall wall surrounded by low-attenuation soft tissue enhancement
ischemia that can be related to the genesis of dilation. with iodine contrast creating a surrounding halo image. Other
The difference is basically the intense inflammatory pro- information, such as the diameter, proximal and distal colon,
cess involving fibroses and dense adhesions to the adjacent and involvement of the ureter or duodenum, is shown in this
abdominal viscera. exam and widely used in treatment planning. Ultrasound is
This condition was believed to be due to a retroperitoneal correct in establishing the diagnosis in 60 % compared to
leakage of blood from tiny subclinical perforations of the 90 % for CT
non-inflammatory wall. This theory was excluded because of
the absence of hemosiderin-laden macrophages in the peri-
aneurysmal tissue [5,27,28]. Surgical Management
Negative cultures for bacteria and syphilis show no rela-
tion between infectious and inflammatory AAA [3,5,27,28]. Inflammatory aneurysms’ natural history is one of enlarge-
A gradual progression of inflammation from degenerative ment and rupture, but they are less frequent than the non-
to inflammatory AAA has been described [29,30]. inflammatory type.
60 G.V. Meirelles

Table 9.1 Surgical mortality in elective abdominal aortic aneurysmectomy

Year Period Operations (n) Mortality (%)
Revisions
1992 1985–1991 3.130 3.5
2001 1985–1997 54.048 5.0
Multicenter studies
Canadian Aneurysm Study 1989 1986 666 4.8
Veterans Administration 1996 1991–1993 3.419 4.9
United Kingdom Small Aneurysm Trial 1998 1991–1993 563 5.8
State surveys
Michigan 1994 1980–1990 8.185 7.5
Maryland 1999 1990–1995 2.335 3.5
National Hospital Database (USA)
1999 1984–1994 32.389 8.4
2000 1979–1997 358.521 5.6
2001 1994–1996 16.450 4.2
Service survey
1984 1951–1980 94 7.4
2002 1989–1998 1.135 1.2

Clinical treatment using oral corticosteroids in an effort to (51.2 %) showed complete regression, 18 (41.8 %) remained
attenuate the inflammatory response has no scientific sup- unchanged, and 3 (7.0 %) showed progression after EVAR.
port. Actually, steroid therapy may increase the risk of AAA Renal impairment disappeared in 11 (45.8 %) of 24 patients.
rupture by a reduction of the protective fibrosis. Eight patients needed reinterventions. These results are compa-
Surgery remains the treatment of choice for inflammatory rable to those for open surgery and show that endovascular treat-
AAAs. The open surgical modality achieves mortality rates ment is an option for this disease [37].
of 3–4 %, matching those of noninflammatory aneurysms
(Table 9.1).
Due to the dissemination of the inflammatory process and References
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 Endovascular Treatment of Abdominal
Aortic Aneurysms: Current Approaches 10
and New Devices

Armando de Carvalho Lobato, Robert Guimarães do

Nascimento, and Ariele Milano de Oliveira

Introduction endovascular repair of AAAs are excellent, and the need for
conversions is less than 5 %, the cumulative risk of aneurysm
Abdominal aortic aneurysm (AAA) is a relatively common rupture is approximately 1 % per year, and the incidence of
disease among the elderly, often reaching a rate of up to 36.2 occlusion of the contralateral arm is less than 2.8 % in the
cases per 100,000 inhabitants, and it may be present in up to follow-up period [2].
5.9 % of the population aged more than 80 years. AAAs of This chapter discusses the technical aspects of the main
more than 5 cm in diameter are more prone to rupture and stents available on the market for endovascular treatment of
have a mortality of up to 63 % [1]. AAAs, enabling the reader to determine the best device for
Conventional surgical repair of AAA in patients with low or each patient, and describes the “sandwich technique.”
acceptable surgical risk is very effective, with morbidity and
mortality rates ranging from 0 to 8 %. However, mortality in
the population with moderate to high surgical risk ranges from Important Aspects of Stents
8 to 60 %. In view of the morbidity and mortality of conven-
tional surgical repair of AAAs, especially in the high-risk pop- Commercially available stent systems are designed with pre-
ulation, the development of a less invasive and potentially safer determined arterial diameters for implantation; therefore, the
technique is urgently needed. Stents have been developed in an applicability of these devices is limited. In these situations,
attempt to avoid conventional surgical repair of AAAs [1]. familiarity with the various devices and their correct applica-
The endovascular technique has gained wide acceptance tion is important. The major anatomical determinants of
for the treatment of patients with AAA. Short-term results of endovascular treatment are the diameter and tortuosity of the
arteries, the length and angulation of the proximal neck, and
A. de Carvalho Lobato, PhD (*) the presence of mural thrombus in the proximal neck [3].
Department of Vascular and Endovascular Surgery, Desired characteristics of stents for AAA are having a
Institute of Vascular and Endovascular Surgery of Sao Paulo (ICVE-SP),
low profile; having adequate flexibility, resistance to torsion,
Sao Paulo, Brazil
longitudinal force; being easy to deploy; having an accurate
Vascular and Endovascular Surgery,
system for determining safe and low stent permeability; and
Portuguese Beneficent Hospital of Sao Paulo,
Sao Paulo, Brazil having modularity for length customization. Obviously, no
ideal device is available at this time, not only because it is
Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
difficult to find all of these features in one device, but also
Brazilian Society of Angiology and Vascular Surgery (SBACV),
because most of the different features are protected by
Sao Paulo, Brazil
specific patents that are owned by different companies [1].
University Nove de Julho,Sao Paulo, Brazil
email: aclobato@icve.com.br
R.G. do Nascimento, MD
Department of Vascular and Endovascular Surgery,
Stents Available in Brazil
Institute of Vascular and Endovascular Surgery of Sao Paulo (ICVE-SP),
Sao Paulo, Brazil Up to December 2011, the NASV (National Agency for
Brazilian Society of Angiology and Vascular Surgery (SBACV), Sanitary Vigilance) listed 13 endoprostheses for the endovas-
Sao Paulo, Brazil cular treatment of AAA: Anaconda®, Aorfix®, Apollo®,
A.M. de Oliveira Braile®, Ella®, Endofit®, Endurant®, E-Evita®, Excluder®,
University Nove de Julho, Sao Paulo, Brazil Hercules®, Powerlink®, Talent®, and Zenith®.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 63

DOI 10.1007/978-1-4471-4429-8_10, © Springer-Verlag London 2013
64 A. de Carvalho Lobato et al.

Fig. 10.1 Anaconda® stent

The Anaconda® Stent branch ranges from 10 to 18 mm and the length from
60–140 mm.
The new Anaconda AAATM stent, manufactured by Vascutek, Importantly, the Anaconda® stent allows full redeploy-
a Terumo Company, was developed to correct aneurysms of ment after the first deployment, ensuring greater accuracy,
the infrarenal abdominal aorta. It represents a new genera- especially in tortuous anatomies (Fig. 10.1).
tion of AAA stent with a super-hydrophilic coating on the
introducer; it is called “Blu Glide” and provides greater sup-
port and flexibility. It has a proximal double ring generating Endoprótese Aorfix®
excellent sealing and four pairs of hooks that provide better
security against fixation and migration of the endoprosthesis. AORFIXTM has the most advanced stent technology on the
The introducer has a low profile, which helps to introduce market [9]. It is manufactured by Lombard Medical and mar-
the system, and the sheath has a radiopaque tip, allowing the keted in Europe and other countries [1].
accurate implantation of the device. The main body has an Because of its shape and high flexibility, it fits the anat-
intrinsic magnetic wire system that allows easy cannulation omy of the patients perfectly [12], optimizing operation per-
of the contralateral limb [8]. formance, also in the postoperative period. Its “fish mouth”
The main body has a diameter ranging from 19.5 to design allows optimal positioning in the proximal neck, with
34 mm with an area of 35 and 40 mm. The diameter of the the lower portions lateralized, allowing flow to the renal
conic iliac branch ranges from 12–15 to 17–23 mm and the arteries while keeping the highest parts oriented to the ante-
length from 80 to 130 mm. The diameter of the right iliac rior and posterior portions of the aorta, ensuring suprarenal
10 Endovascular Treatment of Abdominal Aortic Aneurysms: Current Approaches and New Devices 65

Endoprótese Apolo®

This is produced by Nano Endoluminal, a Florianópolis-

Santa Catarina company. It was the first Brazilian stent and
has been produced since 1998. It is available in monoiliac
and bifurcate formats, both with a woven metal structure
formed by a single nitinol wire and coated with high-strength
PTFE [14].
It is a modular, auto-expandable endoprosthesis designed
for vascular reconstruction of infrarenal abdominal aneu-
rysms. It presents a free proximal stent and barbs that
ensure excellent fixation and reduce the possibility of
device migration. It features gold radiopaque markers,
which help in the visualization and accurate positioning of
the stent [15].
The main body of the bifurcated Apollo® has diameters
of 25, 28, 31, and 34 mm, and the length of the covered
portion ranges from 130 to 180 mm. The monoiliac Apollo®
has the same diameters as the bifurcated one, but the length
ranges from 130 to 175 mm. Both have distal diameters of
12, 14, 16, and 18 mm. The straight distal iliac branches
have diameters from 12 to 18 mm and lengths ranging
from 60 to 115 mm. The conic iliac branches have proxi-
mal diameters of 12, 14, 16, and 18 mm and the distal ones
16, 18, 25, and 28 mm and lengths ranging from 80 to
130 mm. Proximal extensions are also offered with a length
of 45 mm. Occluders have diameters of 12, 14, 16, 18, 25,
Fig. 10.2 Endoprótese Aorfix®
and 28 mm and extension of 25 mm. Additionally, stents
can be customized, with the size and design set by the phy-
sician. Thus, one can include fenestrated and branched
fixation. It is made of nitinol, which has a circular framework stents [10].
covered with polyester fabric, ensuring perfect adaptation of
the graft, even after surgery. Radiopaque markers ensure cor-
rect positioning during the procedure, and fixing hooks Endoprótese Braile®
ensure safer fixation [9].
For aneurysms with significant angulation of the proximal The new generation of stents manufactured by Braile
neck (60–90°) and tortuous iliac arteries, the use of this stent Biomedica, a company from Sao Jose do Rio Preto-Sao
has proved to be extremely effective, resulting in low rates of Paulo, is composed of a metal frame coated with polyester.
type I endoleaks and iliac branch occlusion. Angles greater It has high flexibility and radial strength, and its release is
than 60° are a contraindication for the implantation of other caused by mobilization of the simple sheath. It also has
available devices. Therefore, the development of Aorfix ® proximal and distal radiopaque markers to facilitate stent
has enabled the extension of endovascular treatment to aneu- placement and location [3–16]. It is indicated for the correc-
rysms with complex anatomies [13]. tion of abdominal aortic aneurysms (AAA) and iliac
This device is available with proximal diameters of arteries.
24–31 mm, with a range of 1 mm. The length of the main Its main body has a proximal diameter from 24 to 36 mm
body, provided by the manufacturer, is the aortal portion and and a distal one of 14 mm, with lengths of 80, 130, 155, and
has a size range of 86, 96, 111, 126, and 142 mm. The diam- 170 mm. The free flow length ranges from 20 to 25 mm. It
eter of the distal ipsilateral branch can vary from 10 to has a low profile that varies from 18 to 20 F [17].
20 mm, increasing each 2 mm, and has lengths of 63, 80, and There is also an aortomonoiliac stent with diameters of
97 mm. The contralateral branch has a proximal diameter of 24, 26, 28, 30, 32, and 34 mm, length of 110 mm, and distal
12 mm, and the distal one, with the same variety of diameters diameter of 14 mm. Also, occluders are supplied with diam-
as the distal ipsilateral branch, has lengths of 56, 64, 73, 81, eters ranging from 14 to 22 mm and lengths ranging from 14
90, 98, and 105 mm [10] (Fig. 10.2). to 22 mm [10] (Fig. 10.3).
66 A. de Carvalho Lobato et al.

Fig. 10.3 Endoprótese Braile®

Endoprótese Ella®

Ella is manufactured by CS Ella in the Czech Republic.

Treatment of AAA with this stent is effective and safe. It has
been used in Brazil since 1998 with good results.
It has a resistant coating of polyester mesh attached to the Fig. 10.4 Endoprótese Ella®
stent by ultra-resistant polypropylene sutures and has two
rows of barbs for stabilization and fixation to prevent migra- from 6 to 20 mm and lengths from 22 to 120 mm. The iliac
tion of the stent, branches, and modular extensions that also occluder has diameters from 12 to 30 mm and lengths from
have barbs for better fixation. It has high radial force on a 35 to 60 mm (Fig. 10.4).
continuous metal skeleton, radiopaque markers indicating
the ends of the stent and the beginning of the coated portion,
and a smooth surface at any angle, without risk of pressure at Endoprótese Endofit®
any site (maximum angle of 60°) [1–10].
It is indicated for less invasive alternative treatment of This is produced by LeMaitre Vacular, Inc. (Burlington, MA,
aortic aneurysms (AA), anastomotic pseudoaneurysms, USA), and consists of a unique, safe, and effective aorto-
or aneurysms without signs of infection. It can also be monoiliac device [20]. Its nitinol structure has a conical
used to occlude the false lumen in case of dissection of shape and layers of PTFE, without sutures. Its attachment is
the aortal portion occurring in the descending thoracic positioned at the suprarenal level with a free 28 mm stent,
aorta and abdominal aorta or even to occlude the aorto- and radiopaque platinum markers indicate the initial site of
cava fistulas [19]. the device [1–12].
The main body has a bifurcated proximal diameter rang- Its delivery system is simple and can be positioned
ing from 14 to 38 mm and a distal one from 6 to 20 mm with above the place indicated as it does not have fixation
lengths from 110 to 220 mm. These measures also apply to barbs. One should retract the introducer and then adjust
the monoiliac model. The iliac branch has diameters ranging its position [22].
10 Endovascular Treatment of Abdominal Aortic Aneurysms: Current Approaches and New Devices 67

Fig. 10.5 Endoprótese Endofit®

The stent has proximal diameters of 26, 28, 30, 32, 34, or
36 mm, a distal one of 16 mm, and a length of 160 mm. There
is also an 180-mm-long stent with a proximal diameter of 34
and 36 mm [22].
Distal straight tubular iliac extension has a diameter of 16
or 18 mm with a length of 80 or 100 mm. The proximal aor-
tic extension stent is a free stent, is 50 mm long, and has the
same diameter as the main body. Also the proximal exten-
sion is 38 mm long, which is compatible with the 24 F intro-
ducer. The iliac occluder has diameters of 18, 20, 23, 24, and
26 mm and is 35 mm long, being compatible with the 20 F
introducer for 26 mm diameter and 18 F for other diameters
[10] (Fig. 10.5).

Endoprótese Endurant®

This device is produced by Medtronic Vascular (Santa

Rosa, CA). It is a last generation device designed to
expand the applicability of endovascular repair of the
aorta (EVAR) [24]. It was approved for use by the US
Fig. 10.6 Endoprótese Endurant®
Food and Drug Administration (FDA) on 16 December
2010. Its use is authorized for necks ³ 10 mm and up to
60° angulation [24]. The Endurant®device is safe and effective, with an excel-
The endoprosthesis is made of a metallic material lent rate of successful implementation and very low leakage
(nitinol) coated with polyester and fixed by polyethylene and reintervention rates [22].
sutures. It is auto-expandable, hydrophilic, and has a low The diameter of the main body is from 23 to 25 mm (intro-
profile. It has radiopaque markers that look like the letter ducer 18 F) and from 28 to 36 mm (introducer 20 F), and the
“e” in the proximal end, at the level of bifurcation, and in length ranges from 120 to 170 mm. The iliac branches have
the distal end, which allow adequate positioning. The upper distal diameters from 10 to 28 mm and lengths ranging from
end has a free-flow portion composed of a single filament of 80 to 120 mm. The iliac branches and extensions are also pro-
nitinol. Fixing is achieved by means of a free-flow portion, vided for by the “bell bottom” shape and by the distal diameter
which has barbs, and by the radial strength of the system being larger than the proximal one in order to treat dilated iliac
[10–23]. arteries. Aortouniiliac stents are available as well (Fig. 10.6).
68 A. de Carvalho Lobato et al.

Fig. 10.7 Endoprótese E-Evita®

Endoprótese E-Evita® self-expanding system with a spiral nitinol structure

covered with PTFE and sealed by heat. Its main body has
E-vita® is produced by Jotec (Hechingen, Germany). It is a angled wire barbs located at the proximal end of the main
relatively new infra-renal stent, having been approved for body to provide additional anchoring support against the
clinical use in Europe since 2008. It is a self-expandable mod- aortic wall [10].
ular device, and one of its features is supra-renal fixation The introducer system is composed of specific tube intro-
[2, 25]. It has low porosity, with minimal blood loss [2] and ducers for the Excluder® graft. The material is hydrophilic
high flexibility, being suited to the anatomy of aneurysms and has good navigability. The introducers allow safe tracking
with neck angulation or tortuous and dilated iliac arteries [2]. by the iliac artery, and placement is near the proximal neck.
It contains individual nitinol stents, coated with polyester One advantage of the introducers is the possibility to check
mesh in tubular or conical shapes. The first ring is not cov- out the system’s tracking on calcified or tortuous iliac arteries,
ered and is part of the local fixation [1]. preventing loss as the open stent has not gone forward [29].
Its delivery system is marked by a “squeeze-to-release” Controlled proximal release is also possible through the par-
approach, which allows the stent to be released in a tial opening of the proximal rings and gradual traction of the
controlled and constant manner by means of pressing a introducer sheath [30]. This technique requires training and
trigger [2]. experience of the surgical team. Remember that introducers
The catheter tip is long and flexible, allowing percutane- do not have radiopaque markers, and releasing is done by
ous introduction and easy tracking through vessels. The pulling the sheath up to the marked site [1].
marking ring on the catheter sheath provides information The main branch has proximal diameters of 23, 26, and
about the degree of stent release [2]. 28.5 mm with an 18 F sheath and a proximal diameter of
The main body is available in two different lengths (150 and 31.5 mm with a 20 F sheath. The diameter of the iliac branch is
170 mm) with trunk lengths of 50 and 70 mm, which can be from 12 to 14.5 mm. The length of the main trunk varies from
combined in any manner, allowing optimization of the treat- 140 to 180 mm. The contralateral branches have diameters of 12
ment. Its proximal diameter varies from 24 to 34 mm, and the and 14.5 mm and a 12 F sheath, diameters of 16, 18, and 20 mm
distal one is 14 mm for the short leg and from 12 to 22 mm for with an 18 F sheath, and lengths of 100, 120, and 140 mm [3].
the long leg. The contralateral branch presents a proximal diam- In January 2011, the FDA approved the use of the new C3
eter of 16 mm and distal one from 12 to 24 mm [26, 27, 28]. The device for implantation of the Excluder® graft. This device
length varies from 50 to 105 mm [12] (Fig. 10.7). consists of a significant technological advance in the endo-
vascular treatment of aortic aneurysms because its technol-
ogy gives doctors an opportunity for a second or even third
Endoprótese Excluder® attempt to get the best possible position for stent deploy-
ment. This fourth generation delivery system has the poten-
Excluder is a stent manufactured by W. L. Gore, approved tial to make endovascular repair easier for challenging
in 2002 by the FDA for clinical use. It has a modular and aneurysm anatomies [3] (Fig. 10.8).
10 Endovascular Treatment of Abdominal Aortic Aneurysms: Current Approaches and New Devices 69

It consists of a self-expandable cage of cobalt chrome

alloy, with a PTFE coating of low porosity and thin walls. It
is fixed proximally and distally to a metal cage with poly-
propylene sutures [33]. Its main body has a diameter of 28
or 25 mm and extension of 80 or 100 mm. The diameter of
the iliac branches is always 16 mm, and extension is 40 or
55 mm [1].
The 19 F introducer system, IntuiTrak, is disposable,
bifurcated, and integrated. The main body, branch cover-
ings, and introducer sheath restrict the self-expandable stent
in a compressed state. When the introducer sheath is
retracted, the coatings of the main body and branches are
exposed [33].
Complementing the main body, there are auxiliary devices
for proximal extension: one model with a 20 mm free stent
for suprarenal fixation and one with no stent. The models
have diameters of 25 and 28 mm and lengths of 55 and
75 mm or a diameter of 34 mm with a length of 80 mm.
Distal extension is available on the straight tube with 16 mm
diameter and a length of 55 or 88 mm and a diameter of
20 mm with 55 mm extension. It also has a distal extension
with 20 mm proximal diameter and a distal diameter of
25 mm with a length of 65 mm [1] (Fig. 10.9).

Fig. 10.8 Endoprótese Excluder®

Endoprótese Talent®

This device is manufactured by Medtronic, Inc. (Santa Rosa,

Endoprótese Hercules® CA). It is bifurcated, self-expanding, and indicated for infra-
renal AAA treatment [3].
Hercules B®, produced by the Chinese company Micro Port, It presents discontinuous stents attached to a column of
is a bifurcated stent graft that has a superelastic nitinol struc- nitinol. Its metal structure is composed of polyester, and
ture that ensures radial strength and support to the polyester. the upper end has a free-flow portion. Fixation is by means
It has suprarenal fixation through free stents, whose size var- of the proximal free stent and the radial strength of the
ies from 15 to 20 mm. The initial site of the nitinol top tissue system [1].
is viewed through 13 radiopaque markers that allow proper It has radiopaque markers to identify the beginning of the
positioning of the stent. proximal end devoid of covering [3].
The main body has a proximal diameter of 20, 22, 24, 26, The main body has a diameter ranging from 22 to 28 mm
and 28 with a 20 F profile, proximal diameters of 30, 32, and (22 F) and from 30 to 36 mm (24 F), and total length ranging
34 with a 22 F profile, and lengths ranging from 130 to from 155 to 185 mm. It has iliac branches with proximal
170 mm. The ipsilateral branch has a distal diameter of diameters of 10 to 22 mm and a distal one from 8 to 24 mm,
12–18 mm. The contralateral extension has a diameter with lengths ranging from 90 to 155 mm [3].
12–18 mm with an 18 F profile [32]. Aortic neck angulation of up to 60° has been approved, and
it can be used in short necks from 10 to15 mm length, allow-
ing aneurysm treatment for necks up to 34 mm diameter [34].
Endoprótese Powerlink® It has had excellent long-term clinical results [33].
A few points should be observed, such as the initial posi-
This stent is made by Endologix and was approved for clini- tioning, which must be just above the renal arteries as the
cal use by the FDA on 29 October 2004. It consists of a uni- system can be retracted caudally for the final release of
body bifurcated stent graft and stents with proximal cuff the free-flow portion. Besides, the radiopaque marker over
extensions, and accessories are available for limbs to adapt the stent edge must be aligned directly below the origin of the
to the specific anatomical needs of the patient [33]. renal artery [13] (Fig. 10.10).
70 A. de Carvalho Lobato et al.

Fig. 10.9 Endoprótese Powerlink®

Endoprótese Zenith®

This device is produced by Cook Inc., Zenith Flex®. It is a

modular system of primary and auxiliary components that are
combined to form multiple configurations of the endovascular
graft. Its Flexor introducer® has resistant technology and is a
PTFE-coated lumen to facilitate accurate delivery.
The main body is long and designed to bifurcate just
above the aortic bifurcation in order to obtain stability. It has
an uncovered stent with diameters from 22 to 36 mm and a
distal diameter of 12 mm. As an exception, a 22 mm prosthe-
sis has a diameter of 11 mm. It also contains anchorage barbs
for fixation with greater stability and reduced risk of leakage
or migration and a hemostatic valve, New Captor®, which
inhibits backflow [31].
Stent extension is identified by the contralateral short
branch, and the long ipsilateral branch is over 30 mm. The
branches have a diameter of 12 mm for connection to the
proximal body. The distal diameters range from 8 to 24 mm
and lengths from 3.7 to 12.2 mm.
It has radiopaque markers throughout the graft that pro-
Fig. 10.10 Endoprótese Talent® mote exact placement below the renal arteries [3]. Viewing
10 Endovascular Treatment of Abdominal Aortic Aneurysms: Current Approaches and New Devices 71

Fig. 10.11 Endoprótese Zenith®

of this distal marker indicates the position of the contralat- References

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 Endovascular Treatment of Ruptured
Abdominal Aortic Aneurysms 11
Frank J. Veith, Mario Lachat, Dieter Mayer, Zoran Rancic,
Todd L. Berland, and Neal S. Cayne

Ruptured abdominal aortic aneurysms (RAAAs) are being Strategies, Techniques, and Adjuncts: Top Tips
treated by endovascular aneurysm repair (EVAR) and other
endovascular techniques with increasing frequency. The Standard Approach or Protocol
endovascular procedures offer many potential advantages
over open repair. They are less invasive, eliminate damage to These allow the most effective decision-making and treat-
periaortic and abdominal structures, decrease bleeding from ment of these patients in what are often confusing and stress-
surgical dissection, minimize hypothermia, and lessen the ful circumstances [6, 7]. They are also important to facilitate
requirement for deep anesthesia. education in and recognition of RAAAs by generalists, emer-
Because of these advantages, EVAR has been used exten- gency room personnel, and others to enable early diagnosis
sively to treat RAAAs by several groups who have achieved and mobilization of the specialized caregivers best trained to
good results [1–8]. In contrast, some other groups have been optimize treatment.
unable to demonstrate superiority of EVAR over open repair
in the RAAA setting [9, 10]. This chapter describes some of
the strategies, techniques, and adjuncts that facilitate the Fluid Restriction (Hypotensive Hemostasis)
endovascular treatment of RAAAs. We believe that these all
contribute to improved outcomes in terms of enhanced sur- Fluid resuscitation should be restricted even if the patient
vival in this difficult group of patients. becomes hypotensive. Experience has shown that systolic
arterial pressures of 50–70 mmHg are well tolerated for short
periods and limit internal bleeding and its associated loss of
F.J. Veith, MD (*)
Department of Surgery, Division of Vascular Surgery, platelets and clotting factors [2, 3, 7, 11]. Whether or not
New York University Medical Center, 4455 Douglas Avenue, pharmacological lowering of blood pressure is beneficial
Riverdale, 10471 New York, NY, USA remains to be conclusively shown [3, 7].
Department of Surgery, Division of Vascular Surgery,
The Cleveland Clinic, Cleveland, OH, USA
Division of Cardiovascular Surgery, Clinic for Cardiovascular Treatment Site
Surgery, University Hospital Zurich, Zurich, Switzerland
e-mail: fjvmd@msn.com
EVAR procedures are optimally performed in a site equipped
M. Lachat, MD for excellent fluoroscopic imaging and open surgery since
Department of Vascular Surgery,
some patients will require OR or open adjuncts to their
University Hospital Zurich, Zurich, Switzerland
EVAR.
D. Mayer, MD
Departments for Vascular Surgery and Wound Care,
University Hospital Zurich, Zurich, Switzerland
Z. Rancic, MD
Anesthesia and Catheter Guidewire Placement
Department of Cardiovascular Surgery,
University Hospital of Zurich, Zurich, Switzerland The latter should be obtained percutaneously under local
Department of Surgery, University of Niš, Niš, Serbia anesthesia. This permits arteriography to define aortic and
arterial anatomy, facilitates large sheath and supraceliac
T.L. Berland, MD • N.S. Cayne, MD
Department of Surgery, New York University Medical Center, balloon placement if needed, and prevents circulatory col-
New York, NY, USA lapse caused by the induction of general anesthesia.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 73

DOI 10.1007/978-1-4471-4429-8_11, © Springer-Verlag London 2013
74 F.J. Veith et al.

Whether general anesthesia is used later to eliminate motion instability and profound circulatory collapse, a hostile abdo-
and improve fluoroscopic imaging to permit precise graft men, or those unable to receive transfusion would fall in this
deployment remains controversial. One group has success- category. If such patients, particularly those that are hemo-
fully used local anesthesia supplemented by sedation dynamically unstable, are excluded from EVAR, it is likely
throughout as an alternative [1, 3, 7]. that the improved survival that can accrue from this form of
treatment will be diminished [8].

Supraceliac Aortic Sheath Placement and Balloon

Control Discussion

Most experienced groups favor their use only when there is It is clear that several centers, in which the physicians and
severe circulatory collapse. In such cases, deflation of the surgeons are enthusiastic about EVAR treatment for RAAAs,
balloon before sealing of the rupture site will result in imme- have attempted to perform the procedure preferentially in
diate recurrence of the circulatory collapse. Therefore, tech- every AAA patients with suitable anatomy [8]. This includes
niques have been developed to maintain continuous aortic patients who are hypotensive and hemodynamically unstable
control until the endograft has sealed the leak [2, 3, 7, 12, as well as those with frank hemorrhagic shock. These centers
13]. These techniques use multiple balloons to minimize have achieved favorable results with EVAR for RAAAs in
renal and visceral ischemia by placing secondary balloons these unstable patients and believe that it is precisely these
within the endograft as the supraceliac balloon is deflated high-risk unstable hypotensive patients in whom EVAR
and removed though its supporting sheath. offers the greatest survival benefit over open repair. In these
centers, between 28 and 79 % (mean 49.1 %) of all RAAA
patients were treated by EVAR. In addition, the proportion of
Endograft Type and Configuration patients treated by EVAR increased with time as devices and
skills improved and enthusiasm for the procedure increased,
Both bifurcated and aortouni-iliac (or femoral) grafts can be and it is likely that the proportion will increase further as
used successfully, although some patients have unilateral iliac new devices and techniques are introduced. All these centers
disease, which mandates a unilateral configuration. Modular that are enthusiastic about EVAR treatment of RAAAs
and unibody grafts have been used successfully in both emphasize several key factors that are important in achieving
configurations. An appropriate inventory of suitable grafts and favorable outcomes in these patients. Proper use of aortic
accessories must be stocked sterile in the treatment site and be balloon control, adequate recognition and treatment of
available for the procedure and unexpected contingencies. abdominal compartment syndrome, and the establishment of
a structured system and protocol for the treatment of RAAA
patients all contribute importantly to improved survival out-
Abdominal Compartment Syndrome comes in patients with this diagnosis.
Although there may be other ways to deal with these and
This is a major cause of morbidity and mortality after EVAR other factors and still achieve good outcomes with EVAR in
for RAAA. It is advantageous to keep a high index of suspi- the RAAA setting, the strategies, techniques, and adjuncts
cion for this entity. Laparotomy and hematoma evacuation outlined in this chapter are one way of doing so that has
have alleviated the hypotension, high ventilatory compli- proven to be effective.
ance, and oliguria that occurs with the full blown syndrome.
Monitoring bladder pressure has been helpful in the early
detection of the syndrome [3, 7], and early laparotomy with
open abdomen treatment (OAT) and suction/sponge (VAC) References
dressings may decrease mortality and allow survival in oth-
1. Lachat ML, Pfammatter T, Witzke HJ, Bettex D, Dunzli A,
erwise hopeless circumstances when small bowel and mes- Wolfensberger U, et al. Endovascular repair with bifurcated stent-
enteric edema cause loss of domain for the abdominal viscera grafts under local anaesthesia to improve outcome of ruptured aor-
[7, 14]. toiliac aneurysms. Eur J Vasc Endovasc Surg. 2002;23(6):528–36.
2. Veith FJ, Ohki T. Endovascular approaches to ruptured infrarenal
aorto-iliac aneurysms. J Cardiovasc Surg. 2002;3:369–78.
3. Hechelhammer L, Lachat ML, Wildermuth S, Bettex D, Mayer D,
EVAR for Worst Risk Patients Pfammatter T. Midterm outcome of endovascular repair of ruptured
abdominal aortic aneurysms. J Vasc Surg. 2005;41(5):752–7.
4. Mehta M, Darling III RC, Roddy SP, Fecteau S, Ozsvath KJ,
It is probable that EVAR is most beneficial in augmenting
Kreienberg PB, et al. Factors associated with abdominal compart-
survival when it is used in the worst risk patients who are ment syndrome complicating endovascular repair of ruptured
unlikely to survive an OR. Patients with hemodynamic abdominal aortic aneurysms. J Vasc Surg. 2005;42(6):1047–51.
11 Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms 75

5. Coppi G, Silingardi R, Gennai S, Saitta G, Ciardullo AV. A single by EVAR protocol. Eur J Vasc Endovasc Surg. 2003;26(3):
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aortic aneurysms. J Vasc Surg. 2006;44(6):1140–7. domized trial of endovascular and open surgery for ruptured abdomi-
6. Moore R, Nutley M, Cina CS, Motamedi M, Faris P, Abuznadah W. nal aortic aneurysm – results of a pilot study and lessons learned for
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therapy protocol for ruptured abdominal aortic aneurysms. J Vasc 11. van der Vliet JA, van Aalst DL, Schultze Kool LJ, Wever JJ,
Surg. 2007;45(3):443–50. Blankensteijn JD. Hypotensive hemostasis (permissive hypoten-
7. Mayer D, Pfammatter T, Rancic Z, Hechelhammer L, Wilhelm M, sion) for ruptured abdominal aortic aneurysm: are we really in con-
Veith FJ, et al. 10 years of emergency endovascular aneurysm repair trol? Vascular. 2007;15(4):197–200.
for ruptured abdominal aortoiliac aneurysms – lessons learned. Ann 12. Malina M, Veith F, Ivancev K, Sonesson B. Balloon occlusion of
Surg. 2009;249(3):510–5. the aorta during endovascular repair of ruptured abdominal aortic
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Collected world and single center experience with endovascular 13. Larzon T, Lindgren R, Norgren L. Endovascular treatment of
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abdominal aortic aneurysm. Outcome of a prospective intent-to-treat tured abdominal aortic aneurysms. J Vasc Surg. 2009;50:1–7.
 Part IV
Critical Lower Limb Ischemia
 Thromboangiitis Obliterans
12
Otacílio de Camargo Júnior
and Juliana Lech de Camargo

Introduction 1. Often presents with inflammatory thrombus and preserva-

tion of the vessel wall
Thromboangiitis obliterans (TAO) was reported in the literature 2. Normal levels of markers even in the acute phase
for the first time in 1879 by Felix von Winiwarter [59], who 3. Normal immunoactivation markers
described a vascular syndrome that progressed to gangrene of TAO presenting as a result of smoking, usually cigarettes,
the lower limb, with extensive thrombosis of the arteries and has primarily been described in males, but the number of female
small veins and preservation of the internal elastic membrane. cases is increasing and is now already more than 20 %.
These pathological findings were in a 57-year-old male patient
presenting with foot pain that had begun 12 years earlier, turned
into gangrene, and resulted in amputation. Intimal proliferation Inflammatory and Histopathological Factors
with thrombosis, fibrosis, and endarteritis different from arte-
riosclerosis were demonstrated in a pathological specimen. Thrombotic involvement of all layers of the arterial and
This disease was called endarteritis obliterans until 1908 venous wall characterizes the acute phase of illness. In the
when Leo Buerger [59] published his classic study of 11 limbs acute phase of the disease, the inflammatory process has
that had been amputated because of ischemia with obstruction polymorphonuclear leukocytes around the thrombus, often
of the distal arteries and veins and preservation of entire vas- with multinucleated giant cells being the most common
cular wall; he called it TAO, reinforcing what had been inflammatory thrombotic lesion in the veins. This is more
described by von Winiwater, presenting clinical and patho- characteristic of superficial thrombophlebitis and is not
logical differences regarding arteriosclerosis. For his contribu- specific to TAO [38].
tions to our understanding of this disease, TAO is also known In TAO, the intensity of the periadventitial inflammatory
by the eponym Buerger’s disease. process can be quite variable in different segments of the
Arteriosclerotic inflammatory disease, characterized by the same vessel, showing segmental distribution, with healthy
occurrence of thrombotic occlusions, often affects the medium- vessel segments mixed with segments of diseased vessel. In
and small-caliber arteries and veins of the lower and upper the inflammatory process, lymphohistiocytic cells, granulo-
limbs, classified histopathologically as a vasculitis, but differ- cytic lymphocytes, and eosinophils, can be found, though
ing from most common vasculitises in three important ways: rarely in remarkable amounts [44]. In contrast, vasculitis
presents very disrupted elastic laminae; in TAO, they remain
intact.
O. de Camargo Júnior, MD (*) The histopathology of diseased vessels is variable depend-
Department of Vascular/Endovascular Surgery, ing on the chronological age of the disease from which mate-
Pontifical Catholic University of Campinas, rial was collected for examination. Positive histopathological
Celso Pierro Maternity Hospital, findings are more likely in the acute phase; however, in the
Sao Paulo, Brazil
subacute phase, because of the evolution of the pathological
Department of Vascular Surgery, changes, the histopathology is only suggestive. It is mostly not
Pontifical Catholic University of Campinas,
Sao Paulo, Brazil present in the chronic phase, when organized thrombus and
e-mail: otacamjr@terra.com.br fibrosis of vessels are detected (Figs. 12.1 and 12.2) [17, 39].
J.L. de Camargo, MD. Which vascular damage occurs first, thrombotic or
Department of Medicine, University of Taubate, inflammatory, is undetermined, but the intense inflammatory
São Paulo, Brazil infiltration and cell proliferation that are observed in lesions

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 79

DOI 10.1007/978-1-4471-4429-8_12, © Springer-Verlag London 2013
80 O. de Camargo Júnior and J.L. de Camargo

Fig. 12.1 Intimal thickening

with preservation of the medial
layer. Chronic inflammatory
process with recanalization
(Courtesy of the Study Group in
Correlation Anatomy-Clinic
PUCCAMP)

Fig. 12.2 Acute phase with

thrombosis (Courtesy of the
Study Group in Correlation
Anatomy-Clinic PUCCAMP)

during the acute phase are different, especially when veins phlebitis with thrombosis, and acute phlebitis with thrombus
are affected. Various stages of lesions may occur in different associated with microabscesses and giant cells (Figs. 12.3
segments of same vein when the biopsy is carried out in the and 12.4).
acute phase with phlebitis and thrombophlebitis. In these The intermediate stage is characterized by progres-
stages we can find acute phlebitis without thrombosis, acute sive organization of thrombus obstruction in arteries and
12 Thromboangiitis Obliterans 81

Fig. 12.3 Chronic phase with

intimal and medial layer
thickening (Courtesy of the
Study Group in Correlation
Anatomy-Clinic PUCCAMP)

Fig. 12.4 Acute phase: intimal

thickening caused by the
inflammatory process. Medial
layer with muscle fiber
hyperplasia. Inflammatory
process in the adventitia and
perineural area (Courtesy of the
Study Group in Correlation
Anatomy-Clinic PUCCAMP)

veins, often with an in fl ammatory cell in fi ltrate within adventitia characterize the chronic phase. These lesions
the thrombus with no expressive in fl ammation in the are least typical.
vascular wall. Obstructive thrombus organization with Rupture of the internal and medial elastic laminae, which
recanalization in various stages, prominent vasculariza- often occurs in arteriosclerosis and in systemic vasculitis,
tion of the medial layer, and perivascular fi brosis of the differs from TAO, in which the internal elastic lamina and
82 O. de Camargo Júnior and J.L. de Camargo

Fig. 12.5 Uniform intimal

thickening. Small area of
thrombosis with medial layer
preservation. Inflammatory
process in the adventitia and
perineural area (Coronary artery
courtesy of the Study Group in
Correlation Anatomy-Clinic
PUCCAMP)

entire vessel wall remain unchanged in the underlying loca- with an exuberant inflammatory process, with less intense cel-
tion of thrombus obstruction in three stages of the disease. lular activity in the vessel wall, preservation of the internal
There is no necrosis of the arterial wall in TAO as it pres- elastic lamina, and normal immunological markers.
ents with parietal architectural integrity, especially in the The etiology of TAO is unknown; however, an association
medial layer, which distinguishes it from other forms of with the smoking habit is recognized. However, the time
necrotizing arteritis. Also no calcifications or atheromatous course of the disease can vary [13, 40, 71]. The time of onset
plaques are observed, distinguishing it from arteriosclerosis. of signs and symptoms is also associated with smoking.
Endothelial dysfunction may also be involved in the Manifestations are more severe in individuals who smoke all
pathogenesis of disease as high levels of antiendothelial anti- day and have less time between each cigarette; major injuries
bodies were detected in diseased patients [22, 31]. are detected in those who started smoking before the age of
20 years or have smoked for over 10 years [66].
Continued use of tobacco is closely related to disease pro-
Thromboangiitis and Arteriosclerosis gression, being the main factor for this progression. All
researchers believe that tobacco use is a component of the
Despite histopathological differences, TAO can coexist with TAO diagnosis. In the literature, there are no clear cases of
arteriosclerosis, especially in patients over 40 years of age, this disease in non-tobacco-smoking patients.
creating an additional difficulty for diagnosis. Excessive use Several factors have been described about how smoking
of tobacco increases the risk of arteriosclerosis. affects the circulation, causing thrombosis, vasoconstriction,
The histological appearance of thrombus in TAO is the same vascular injury produced by the altered metabolism of cate-
as that of arteriosclerotic thrombosis, however with an exacer- cholamines, changes in the oxygen dissociation of hemoglo-
bated inflammatory process, with hypercellular thrombus with bin in the peripheral circulation, and direct action of
intense invasion of the smooth muscle cells from the medial tobacco-derived substances in the endothelium [40, 69].
layer and preservation of the internal elastic lamina (Fig. 12.5). Researchers have attempted to establish an autoimmune
etiology for TAO. A hypersensitivity reaction caused by
tobacco in the vascular endothelium has been verified by
Etiology, Pathogenesis, and Smoking significant amounts of active immune complexes in patients’
serum, which may compromise vessels. Endothelial lesions
TAO is a type of vasculitis [41], but with features that differen- changing the vessels’ features induce the formation of anti-
tiate it from other forms of vasculitis, presenting thrombosis arterial antibodies, which react with the already exposed
12 Thromboangiitis Obliterans 83

antigens to form circulating immune complexes, which are Disease incidence in females younger than 70 years is
partially removed from the circulation. There is a consequent low, in the range of 1–2 %, with a significant increase in the
increase in platelet aggregation in response to the formation 90s, by about 20 %, probably because of the increasing num-
of immune complexes [26]. ber of female smokers.
Hypotheses about an autoimmune mechanism haves been
considered in studies describing the presence of antinuclear
antibodies and increased specific antibodies in the arterial Vasodilation and Coagulation
wall [24, 25].
Often found in patients with TAO, hyperhomocysteine- Literature data indicate reduced endothelium-dependent
mia seems to play an important role in the pathogenesis of vasodilation in the peripheral circulation of patients with
the disease [70]. TAO. There is impaired vasodilation after infusion of the
High levels of anti-endothelial antibodies, which are endothelium-dependent vasodilator acetylcholine [45].
observed even before clinical manifestations of disease, In patients with TAO there is also increased platelet
cause endothelial dysfunction [61]. response to serotonin [65] and elevated plasma homocysteine
A higher occurrence of disease has been proven in coun- [8, 60].
tries with more significant consumption of tobacco, and an In the pathogenesis of TAO, prothrombotic factors play a
allergy or hypersensitivity to some component of tobacco is remarkable role as mutation of prothrombin gene 20210 and
suspected. This sensitivity would lead to inflammatory the presence of anticardiolipin antibodies are associated with
obstructive disease of the small blood vessels. increased risk and severity of disease [46, 57].
Literature reports indicate that chronic anaerobic peri- Patients with high levels of antibodies and TAO are
odontal infections may also play a role in the development younger and at greater risk for amputations than patients
of TAO as almost two-thirds of patients with this disease with normal antibody levels [46, 57].
also have severe periodontal disease. However, the preva-
lence of periodontal disease in smokers without TAO is also
high [9, 30]. Immunology
It is believed that other etiological factors with mecha-
nisms for triggering disease onset are present because Immunological factors have been the subject of several stud-
although tobacco use is predominant in the onset and pro- ies in patients with TAO, and several publications suggest
gression of disease, only a small number of tobacco users that immune responses may be important pathogenic factors
worldwide develop the disease. in the disease.
On one hand, more intense cellular sensitivity to collagen
types I and III has been observed in patients with TAO than
Epidemiology, Genetics, and Gender in healthy and arteriosclerotic patients [1, 2]. On the other
hand, samples analyzed histologically for many arteries were
Although the disease has worldwide distribution, it is most found to have preserved the general architecture of vessel
prevalent in the Mediterranean region, the Middle East, and walls, irrespective of disease stage, with significant cellular
Asia than in the West and North America. It occurs more infiltration in the thrombus and intima. In the acute phase,
frequently in countries where tobacco is widely used, espe- mainly macrophages and dendritic cells were identified in
cially where there is a habit of making cigarettes at home the intima, turning out to be TAO endarteritis caused by
[23, 37, 42]. T-cell- and humoral-mediated cellular immunity associated
Recently, the disease has decreased in Europe and the with B-cell activation of macrophages or dendritic cells in
United States because of the adoption of stricter criteria for the intima [34, 68].
diagnosis and also because of reducing the number of
smokers.
In Japan, a study conducted in 1976 by the Committee for Laboratory Aspects
Buerger’s Disease Research of the Ministry of Health and
Welfare in analyzed 3,034 patients with the disease, 2,930 There is no specific laboratory test for the diagnosis of TAO;
men and 104 women, finding an incidence of 5 per 100,000 however, all laboratory tests that contribute to the differential
people [10]. These results were similar to those of a statisti- diagnosis should be performed, such as:
cal study conducted by the Committee for Research on the Fasting glucose
Epidemiology of Untreatable Diseases from the Ministry of Urinalysis
Health and Welfare in 1986 [54]. Erythrocyte sedimentation rate
Although to date no gene has been identified, there may C-reactive protein
be a genetic predisposition to disease onset. Antinuclear factor
84 O. de Camargo Júnior and J.L. de Camargo

Rheumatoid factor
Hemogram
Coagulation
Liver function
Renal function
Protein C
Protein S
Antithrombin III
Factor V Leiden
Prothrombin gene mutation
Toxicology: cocaine, cannabis, amphetamines

Clinical Aspects

The classic description of TAO involves a young patient, about

40 years old, a smoker, male, and often having migratory
superficial thrombophlebitis and Raynaud’s phenomenon in
the upper and lower limbs. The usual initial involvement is
obstruction of the distal arteries and veins of the hands and
feet with consequent minor and asymptomatic arterial
insufficiency with frequent progression to the proximal ves-
sels, not rarely with involvement of the superficial femoral
artery. This progression of arterial lesions is accompanied by
worsening clinical symptoms presenting as intermittent clau-
dication. With disease progression, symptoms appear, such as
cooling of the extremities and superficial areas of ischemia Fig. 12.6 Female patient with involvement of all four limbs
that evolve into superficial ischemic ulcers on the feet, hands,
and fingers. Usually, the initial trophic lesion is periungual Microscopic pathological examination shows significant
and is often treated with excision of the nail, culminating in inflammation around the nerve fibers, which indicates isch-
finger necrosis. There is infrequent involvement of the bra- emic neuropathy.
chial artery, common iliac artery, and great vessels [4, 5, 72]. Rheumatological symptoms are frequent in patients with TAO,
Involvement of organs is also reported in the literature. and the classic Raynaud’s phenomenon is presented in approxi-
The histopathology of the vessels is the same as for the limbs, mately 50 % of patients, even asymmetrically in the limbs [21].
affecting the veins and arteries [27]. Recurrent arthralgia in the large joints with important
Although TAO affects the small and medium vessels of local inflammatory signs may indicate prodromal signs of
the extremities, the same histopathological findings have TAO years before the appearance of arterial occlusions [67].
been reported in cerebral, coronary, internal mammary, renal, Migratory thrombophlebitis can arise early, even before
and mesenteric arteries [20, 36]. Involvement of multiple arterial symptoms, and can distinguish TAO from other dis-
organs is rare [7, 49]. eases (Fig. 12.8). It may also be present in 50 % of cases and
At least two limbs are often affected, and published often demonstrates local disease activity; biopsies demon-
reports show involvement of four limbs in 43 % of cases, strate the classic histopathological aspects of TAO [62, 64].
three limbs in 41 % of cases, and two limbs in 16 % of cases It may present as a first symptom of TAO in approxi-
(Figs. 12.6 and 12.7) [32, 58, 71]. In radiological tests per- mately 25 % of patients with recurrent episodes in 60 % of
formed in patients with disease, arteriographic changes in cases. Palmar or plantar hyperhidrosis may appear in up to
limb segments that have not had symptoms are frequently 30 % of patients [13].
found.
Claudication in the legs is a common initial complaint
and less frequently in the upper limbs. Plantar claudication is Radiological Aspects
often an early symptom and can be confused with rheumato-
logic and orthopedic problems, resulting in delayed diagno- Doppler ultrasound can be useful to measure the pressoric
sis. With disease progression, the claudication becomes more indices and locate the occluded artery, but duplex ultrasound
proximal, often up to the calf. mapping is a non-invasive examination that can provide the
12 Thromboangiitis Obliterans 85

Fig. 12.7 Male patient with

involvement of all four limbs

Ultrasound can be important to rule out an embolic source

and aneurysmal disease. Parietal occlusive alterations can be
clearly seen on angiography and can confirm the diagnosis of
TAO.
There are no pathognomonic arteriographic aspects of
TAO, but aspects such as the classic sign of Martorell (cork-
screw-shaped collateral vessels) do exist (Fig. 12.9).
Arteriographic aspects of TAO are:
• No signs of atherosclerosis
• Involvement of vessels of small and medium caliber:
Radial, ulnar, and palmar digital arteries of the hands;
tibial, peroneal, and plantar digital arteries.
• Obstructive arterial lesions and spastic segmental mixed
with normal segments.
• Normal proximal circulation with intense distal
involvement.
• Corkscrew-shaped collateral vessels around sites of
obstruction.

Diagnosis and Differential Diagnosis

Many authors have proposed several major and minor diag-

nostic criteria for diagnosis, but others believe these diagnos-
tic criteria are not useful for diagnosis and treatment of the
disease. Association with other diseases should not exclude
the diagnosis. Diagnostic criteria proposed are clinical, path-
Fig. 12.8 Migratory thrombophlebitis ological, and arteriographic [50, 64].
Notable major factors are exacerbated smoking, distal
most data. It quantifies the distal flow of occluded arteries, ischemic symptoms before the age of 45 years, brachial and
even showing characteristics of the vessel wall and the loca- popliteal arteries without disease, arteriographic and/or his-
tion of the distal arterial occlusion. topathological signs of disease, absence of embolic sources,
86 O. de Camargo Júnior and J.L. de Camargo

Fig. 12.9 Corkscrew-shaped

collateral vessels

absence of autoimmune diseases, no change in coagulation, Ergotism, which can also cause ischemia of both the upper
and no arteriosclerosis. Notable minor factors are plantar and lower limbs, should be investigated and ruled out by
claudication, Raynaud’s phenomenon, disease in the upper detailed investigation.
extremities, and migratory thrombophlebitis. Shinoya’s Criteria [59]
The most important diseases to consider for the differen- Beginning before age 50
tial diagnosis, with signs and symptoms similar to athero- History of smoking
sclerosis, are embolisms and autoimmune diseases. Infrapopliteal arterial obstruction
Other vasculitises should also be excluded, such as Upper limb involvement or migratory phlebitis
Takayasu’s arteritis or giant cell arteritis, because of proximal Absence of risk factors for atherosclerosis except smoking
arterial involvement. Ischemic symptoms are extremely simi- Olin’s Criteria [59]
lar to TAO developed because of using cocaine, amphetamines, Beginning before age 45
and cannabis, with frequent reports in the literature [19, 55]. It Current or recent smoking
is necessary to exclude antiphospholipid antibody syndrome, Ischemia of the distal part of the upper and/or lower limbs
which leads to arterial and venous thrombosis, rheumatoid and claudication, rest pain, ischemic ulcers, and gangrene
arthritis, mixed connective tissue disease, and scleroderma. with documented with non-invasive tests
To rule out these diseases, serological marker tests are Laboratory tests to exclude autoimmune disease or con-
very important, and antiphospholipid antibody syndrome may nective tissue disease and diabetes mellitus
show a positive test for lupic anticoagulant and high levels of Determine the proximal source of emboli by echocardiog-
anticardiolipin antibodies. The histopathological examination raphy and angiography
of TAO thrombus shows an intense inflammatory process that Consistent arteriographic findings in the affected limbs
differs from those not showing an inflammatory process. and in those clinically free of disease
12 Thromboangiitis Obliterans 87

Medical and Surgical Treatment emic lesions. This medication can be used alone if there is no
indication for surgery [14, 15, 48]. The association of anxi-
Several published reports show that the only appropriate olytic and antidepressant medication has proven to be
treatment to stop the progression of TAO is to stop smoking beneficial in patients.
or any form of tobacco and/or cannabis use. It was also Surgical treatment can consist of minor surgery for devi-
shown that smoking at least one cigarette per day or chewing talized areas, debridement, drainage of abscesses, and major
tobacco can cause progression of disease and serious compli- amputations.
cations [12, 32, 43, 62]. Thoracic and/or lumbar sympathectomy by an open
Quitting smoking by patients with TAO is known to be approach or by thoracoscopy and laparoscopy can improve
difficult because of the chemical dependency and psycho- resting pain and healing of superficial ischemic ulcers. The
logical habit; frequently people are not able to quit smoking. results are better in more distal arterial obstructions. There is
To determine whether all forms of tobacco use have really no indication for sympathectomy in cases of plantar claudi-
been stopped, urinary levels of nicotine and cotinine can be cation or extensive gangrene of the hand and foot (Fig. 12.10)
measured [47]. [16, 33, 75, 76].
Providing analgesia and anesthetic blocks, facilitating Surgical revascularization is still an option when good
healing of ulcerations, and even preventing the patient from results have not been achieved by medical treatment and the
adopting an incorrect position of the limb, which can causes patient has pain at rest and/or ulcerations. Preoperatively,
severe edema with worsening of limb perfusion, are impor- angiography is the ideal examination for planning surgery.
tant for patients hospitalized with ischemic rest pain and/or Angiography is used to find at least one accessible distal ves-
ulcerations. Smoking cessation at the time of admission can sel, which is not a frequent disease characteristic, and its dis-
be beneficial; however, frequently the patient keeps smoking tal location. If there is an accessible distal artery, a
even when hospitalized. Keeping the patient in a proclive revascularization procedure should be performed, preferably
position can improve limb perfusion and alleviate pain. using the saphenous vein (Fig. 12.11). Despite arterial revas-
Patients with TAO exhibit reduced glucocorticoid recep- cularization, patients with TAO have a mean patency of 20 %
tors, which may cause variable responses to corticosteroid at 24 months, and the rate of limb salvage is considerable
treatment; the response varies according to the number of [18, 28, 50, 51, 53].
receptors [3, 6, 35]. When the treatment options have been exhausted in case
Vasodilator medication, such as cilostazol capsules and of unbearable pain at rest, carrying out neurotripsy may be
intravenous or oral prostaglandin, may also improve isch- advisable, which consists of crushing the nerves responsible

Fig. 12.10 Female patient with

good healing after lumbar
sympathectomy
88 O. de Camargo Júnior and J.L. de Camargo

Fig. 12.11 Patient with

femorofibular recanalization

for sensory innervation of the affected limb with subsequent Patients who quit smoking did not undergo major amputa-
anestesia in this segment, resulting in a better general condi- tions, and 19 % patients who continued smoking underwent
tion and quality of life for the patient. major amputations [56].
Neurotripsy can be performed selectively according to the In another study, 111 patients were followed for an average
injury site, although crushing of five nerves is recommended of 15 years with a major amputation rate of 11 % in 5 years,
when it is performed in the foot: the tibial, superficial per- 21 % in 10 years, and 23 % in 20 years. The risk of amputation
oneal, deep peroneal, sural, and saphenous nerves, with the was maintained in patients who did not stop smoking, and in
possibility of functional restoration in 6 months [52]. patients who did stop, the risk was reduced after 8 years. This
When medical treatment does not present clinical suc- study also demonstrated a decreased life expectancy in patients
cess and there is no possibility of surgical revasculariza- with TAO to a mean age of 52 years [11].
tion, implantable spinal cord stimulators can be used. There The patient profile of TAO is currently changing, with
have been several successful reports concerning this in the increasingly frequent involvement of the upper limbs and
literature, with its use for pain relief, healing ulcers, and more female and elderly patients.
even avoiding major complications, such as amputations Despite all clinical and surgical treatments, the only pre-
[10, 63, 73, 74]. dictor of good outcome with no symptoms, such as claudica-
Another method reported in the literature is stimulating tion, ulcers, and amputations, is absolute cessation of any
angiogenesis, in which a Kirschner wire was placed in the form of tobacco use.
medullary channel of the tibia in six patients with TAO, and
after 19 months, significant improvements were seen [29].
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 Inflammatory Markers and Mortality
in Critical Lower Limb Ischemia 13
Anders Gottsäter

Overview of Inflammatory Markers IL-6 is a cytokine with proinflammatory and proatherogenic

in Vascular Disease activity and is secreted from activated macrophages,
fibroblasts, lymphocytes, endothelial cells, and vascular
In atherosclerotic vascular disease, endothelial dysfunction smooth muscle cells [5]. Apparently healthy subjects with
is induced by risk factors such as arterial hypertension, high IL-6 levels have increased risk of death and cerebrovas-
hypercholesterolemia, and tobacco use. Inflammatory mech- cular events compared with those with low levels [12]. There
anisms and inflammatory cytokines play important roles in is also a close relationship between concentrations of
all of these mechanisms, and the different steps in atherogen- C-reactive protein (CRP), IL-6, and TNF-a and components
esis involve cytokines as inflammatory promoters, stimulat- of the insulin resistance syndrome [13].
ing the expression of proatherogenic genes in endothelial
cells [1, 2]. Important cytokines are, for example, tumor
necrosis factor a [3], neopterin [4], and interleukin-6 [3, 5]. Neopterin
Expression of the immune mediator CD40 ligand is increased
in atherogenesis [6, 7], and prostaglandin-like isoprostanes Increased plasma levels of the inflammatory mediator neop-
[8, 9] are markers of lipid peroxidation and believed to con- terin occur in atherosclerotic patients [4], reflecting increased
tribute to atherosclerosis and thrombosis [10]. activity of monocytes and macrophages [4, 14]. Among
patients with coronary atherosclerosis, S-neopterin and CRP
are both higher in patients with acute coronary syndrome
Tumor Necrosis Factor-a compared to those with stable angina [15]. Furthermore, sta-
tin treatment is associated with lower neopterin levels
TNF-a is a multifunctional proinflammatory cytokine pro- because of its antiinflammatory properties [16].
duced in lymphocytes, tissue macrophages, and myocardial
and vascular cells [11]. TNF-a mediates proatherogenic pro-
cesses, leading to altered endothelial function and enhanced C-Reactive Protein
expression of leukocyte adhesion molecules, which result in
foam cell and fatty streak formation [3]. CRP is the major acute phase reactant in humans and is
mainly synthesized by hepatocytes under control of IL-6,
IL-1, and TNF-a, but extrahepatic production of CRP occurs
Interleukin-6 in atherosclerotic plaques [17, 18]. CRP measured with high
sensitivity assays (hs-CRP) is a strong, independent predic-
Interleukins are cytokines responsible for signaling between tor of future cardiovascular events [19], such as myocardial
leukocytes. They mediate chemotaxis and proliferation of infarction, stroke, and peripheral arterial disease (PAD) [12,
different cell types in the pathogenesis of atherosclerosis [3]. 20–23].

A. Gottsäter, MD, PhD Isoprostanes

Department of Clinical Sciences, Vascular Center,
Lund University, Skåne University Hospital,
Södra Förstadsgatan 101, SE-205 02 Malmö, Sweden Isoprostanes are end products of lipid peroxidation, and
e-mail: anders.gottsater@med.lu.se 8-iso-prostaglandin F2a (8-iso-PGF2a) is an indicator of

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 91

DOI 10.1007/978-1-4471-4429-8_13, © Springer-Verlag London 2013
92 A. Gottsäter

oxidative stress [9], inducing platelet activation and smooth have also been shown to be related to the future development
muscle cell proliferation and contributing to atherosclerosis of PAD and CLI already in subjects without detectable dis-
and thrombosis [10]. Oxidative stress and lipid peroxidation ease. For example, being in the highest quartile of hs-CRP
are involved in the pathophysiology of atherosclerosis, and among healthy subjects increases the risk for the develop-
isoprostane levels are increased in high age, hypercholester- ment of PAD by a factor of 2.8 [22], and elevated levels of
olemia, diabetes mellitus, and smoking [9, 10, 24]. proteins such as fibrinogen, alpha 1-antitrypsin, haptoglobin,
ceruloplasmin, and orosomucoid measured in 5,619 healthy
men without symptoms suggestive of PAD have been associ-
Matrix Metalloproteinases ated with increased risk for the development of PAD requir-
ing revascularization during 16 years of follow-up, even after
Matrix metalloproteinases (MMPs), enzymes degrading the adjustment for other relevant risk factors [35]. Multisite ath-
extracellular matrix, are other important modulators of ath- erosclerotic disease is also reflected in more intensive
erosclerosis produced by inflammatory cells. MMPs play inflammatory activity; among 234 patients undergoing coro-
important roles in remodeling processes, plaque formation nary angiography, Brevetti and co-workers found that levels
and rupture, and aneurysm development [25]. of both hs-CRP and IL-6 were higher in patients with both
CAD and PAD or CAD alone or than in control subjects
without either disease. Furthermore, hs-CRP was higher in
CD40 Ligand/CD40 patients with both diseases than in those with only CAD
[34], indicating a more active inflammatory process in mul-
CD40 ligand (CD40L) is a potent immunomodulator, tisite disease.
whereas CD40 is an integral membrane protein [26]. CD40L Oxidative stress, as reflected by increased levels of 8-iso-
expressed on T lymphocytes, SMC, and macrophages trig- PGF2a, has also been related to PAD. In a study of 100 patients
gers inflammatory responses, expression of MMPs, adhesion with PAD and 100 control subjects without clinically relevant
molecules, secretion of proinflammatory cytokines, and atherosclerotic disease who were all non-smokers and not
chemokines, playing a role in plaque rupture and acute coro- taking any lipid-lowering drugs or vitamins to avoid possible
nary events [6, 27]. Increased levels and enhanced expres- effects on isoprostanes, 8-iso-PGF2a levels were 1.5-fold
sion of CD40L occur in patients with acute coronary higher among PAD patients than in controls [36]. Symptomatic
syndromes [27, 28]. Neutralization with anti-CD40L anti- PAD is also associated with increased levels of both IL-6 and
body inhibits these actions, and lipid-lowering therapy hs-CRP compared with subjects without PAD, even after
reduces levels and expression of CD40/CD40L [29]. adjustment for BMI, smoking, and cholesterol [37]. In vitro
culturing of whole blood and profiling of the production of
several different interleukins and other cytokines confirmed
Inflammatory Markers in Peripheral Arterial this inflammatory hyperresponsiveness related to associated
Disease and Critical Limb Ischemia leukocytosis in PAD patients [38]. Matrix metalloproteinases
have also been evaluated in relation to PAD, and increased
The importance of leukocytes and inflammatory reactions plasma levels of both MMP-2 and MMP-9 were found to be
for the pathophysiology of ischemic vascular disease [1, 2] correlated with development of both PAD and CLI [39].
has been studied predominantly in subjects with coronary Genetic studies have also confirmed the above-mentioned
artery disease (CAD). In peripheral arterial disease (PAD) connections between inflammatory markers and CLI. Gene
and critical limb ischemia (CLI), the role of inflammatory polymorphisms related to several markers for inflammation,
markers for pathophysiology is less well studied than in both both cytokines and matrix metalloproteinases, IL-6, E-selectin,
coronary and precerebral atherosclerosis. Furthermore, the ICAM-1, MCP-1, MMP-1, and MMP-3, are all independently
importance of inflammatory reactions may be especially associated with PAD, and the different risks for PAD and CLI
difficult to clarify in CLI, as patients with this condition by depend on the number of high-risk genotypes concomitantly
definition [30] often have ischemic leg ulcers (Fig. 13.1) fea- carried by the individual subject [40]. Furthermore, the IL-6
turing inflammatory processes affecting the levels of gene is upregulated in the hypoperfused musculature of CLI
inflammatory mediators. Circulating levels of inflammatory patients [41], corroborating the above-mentioned observation
mediators measured in CLI patients can therefore originate that IL-6 has been found to be increased in symptomatic
partly from ulcers and gangrene of the ischemic limb and peripheral artery disease [31]. It is important to note that all
partly from the general atherosclerotic process. study results have not shown uniform results; however, in a
Inflammatory markers have been evaluated among both small group of eight CLI patients including five with isch-
asymptomatic [31–33] and symptomatic [31–34] subjects emic lesions [42] neither TNF-a nor IL-6 differed from values
with PAD, however (Table 13.1). Furthermore, such markers in healthy controls.
13 Inflammatory Markers and Mortality in Critical Lower Limb Ischemia 93

Fig. 13.1 Critical limb ischaemia

with forefoot gangrene

Table 13.1 Some different markers and mediators of inflammation associated with peripheral arterial disease (PAD) and critical limb ischemia
(CLI) in different studies
Variable Feature of PAD References
a1-Antitrypsin PAD development [35]
a-Defensin PAD severity, cardiovascular mortality in PAD [52]
Amyloid A Adverse prognosis after intervention for PAD [43]
Ceruloplasmin PAD development [35]
Fibrinogen PAD development, mortality in CLI [35, 43]
Haptoglobin PAD development [35]
High sensitivity C-reactive PAD development, occurrence, progression, and severity, adverse [22, 34, 37, 43, 51–53]
protein prognosis after intervention for PAD, cardiovascular mortality in
PAD, mortality in CLI
Interleukin-6 PAD occurrence and progression, mortality in CLI [31, 34, 37, 41, 51, 53]
8-Isoprostane-PGF2a PAD occurrence [36]
Leukocyte count PAD occurrence, mortality in CLI [54]
Matrix metalloproteinases 2 and 9 PAD and CLI development [39, 40]
Neopterin Mortality in CLI [53]
Neutrophil/lymphocyte ratio Mortality in CLI [54]
Orosomucoid PAD development [35]
Tumor necrosis factor-a Mortality in CLI [53]

Inflammatory Markers During Invasive mechanisms are further activated. Such post-interventional
Treatment of PAD and CLI patterns have also mainly been investigated after interven-
tions in coronary vessels, however. For example, levels of
Potential relationships between inflammatory markers and P-selectin [44] mediating platelet-leukocyte binding [45]
invasive treatment of PAD and CLI have also been evalu- are increased, and leukocyte-platelet interactions are
ated (Table 13.1). Different markers such as high sensitiv- increased after percutaneous coronary interventions [46].
ity (hs)-CRP, fibrinogen, and serum amyloid A (SAA) In coronary blood, both expression of the activated platelet
measured preoperatively in patients planned for lower fibrinogen receptor [47] and release of chemoattractants
extremity bypass all correlate with an increased risk for affecting neutrophils [48] increase after endovascular cor-
later adverse graft-related or cardiovascular events [43]. onary interventions. Reports on patterns of inflammatory
For hs-CRP, this relationship persisted even in multivari- substances during and after invasive vascular interventions
able analysis. In the post-treatment period after both open for PAD are scarcer. In an observational study with repeated
and endovascular repair in different vascular segments, arterial sampling from 14 patients undergoing angiogra-
several of the above-mentioned platelet and leukocyte phy for aortoiliac atherosclerotic disease, 9 of whom
94 A. Gottsäter

underwent PTA, we could not demonstrate any definite A recent investigation showed that patients with CLI show
signs of leukocyte activation during or immediately after significantly higher a-defensin and hs-CRP levels compared
peripheral angiography [49]. The levels of inflammatory with patients with intermittent claudication (IC) [52].
mediators after peripheral vascular interventions are not Furthermore, within the IC group high concentrations of
clinically irrelevant, however, and the occurrence of rest- a-defensin and high hs-CRP conferred a five times higher
enosis after vascular injury, such as for example an episode risk for cardiovascular mortality during follow-up than in
of invasive treatment, also has inflammatory features. patients with either high a-defensin or high hs-CRP. The
A postischemic macrophage activation state evaluated in addition of a-defensin or hs-CRP to conventional risk fac-
an animal model has been suggested as a new potential tors thus improved risk prediction concerning cardiovascular
therapeutic approach to protect tissues from necrosis and mortality in patients with this manifestation of PAD [53].
promote tissue repair during CLI [50]. As no definite rela- The high 1-year mortality of around 20–25 % in patients
tionships have been reported between levels of inflammatory with CLI [7, 21, 22, 52] is mainly due to cardiovascular dis-
mediators and the efficacy of interventions, inflammatory ease. Furthermore, this already high mortality rate is increased
mediators cannot yet be used to determine the best treat- even more in patients with features of inflammation, such as
ment of a certain patient. increased leukocyte count and fibrinogen level [23], or an
elevated neutrophil/lymphocyte ratio and increased troponin
levels [54]. The inflammatory mediators IL-6, TNFa, neop-
Inflammatory Markers, Prognosis, terin, and hs-CRP have also been associated with 1-year
and Mortality in Critical Lower Limb Ischemia mortality in subjects with CLI [53]. For TNFa and neop-
terin, this association was independent of other variables,
Even if the prognostic importance of inflammatory activa- such as age, sex, gangrene, lipid-lowering therapy, leukocyte
tion is less well established in PAD and CLI than in patients count, renal function, and HDL cholesterol. As the relation-
with coronary or precerebral atherosclerosis, some observa- ships between inflammatory mediators and mortality per-
tions about the relevance of inflammatory activation for sisted after exclusion of patients with gangrene, these
prognosis have been presented also in PAD patients relationships may only partly be explained by the fact that
(Table 13.1). Elevated levels of inflammatory mediators patients with inflammatory processes such as gangrene of the
seem to be indicators of a more severe prognosis concerning extremities showed a high mortality [53]. Furthermore, when
both local progression of atherosclerosis in the affected limb the patient material was later analyzed concerning 5- and
and acute events occurring in other vascular territories. The 10-year mortality, the predictive value of TNFa at diagnosis
first mechanism is exemplified by the fact that both CRP and persisted (Fig. 13.2). Data are partly conflicting, however, as
IL-6 levels predict local progression of atherosclerosis in the no associations were found among a-defensin, hs-CRP, and
lower limb during 12 year follow-up of the ankle-brachial mortality in CLI patients in the above-mentioned study by
index (ABI) [51]. Urbonaviciene and co-workers [52].

10 10

1 1

Fig. 13.2 Tumor necrosis factor-a

(pg/ml, y-axis) at diagnosis in 259
patients [53] with critical limb ,1 ,1
ischaemia in relationship to 5- (left
panel, p < 0.001) and 10- (right panel, Dead after 5 years Alive after 5 years Dead after 10 years Alive after 10 years
p < 0.001) year survival
13 Inflammatory Markers and Mortality in Critical Lower Limb Ischemia 95

Conclusions 17. Yasojima K, Schwab C, McGeer EG, et al. Generation of C-reactive

protein and complement components in atherosclerotic plaques.
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 Arterial Wall Remodeling
and Restenosis Following Vascular 14
Reconstruction

Xue Ma and Randolph L. Geary

Simply defined, restenosis is a new lumen narrowing at the site clinical trials [32, 33]. In fact, the only systemic drugs
of a previous vascular reconstruction. Restenosis has been a that have improved PCI outcomes consistently are the
major limitation of surgical and endovascular reconstructions antithrombotic agents (e.g., platelet IIb and IIIa antagonists
since their inception, and while decades of research have and clopidogrel), largely by inhibiting thrombosis rather than
yielded vastly improved results for percutaneous coronary restenosis per se [34].
interventions, strategies to eliminate restenosis remain elusive. Parallel advances in device technology also met with
Increased application of endovascular therapy to extracoro- mixed results. The first major breakthrough came in the late
nary beds has been met with sobering rates of late failures. 1980s with the introduction of the bare metal stent (BMS).
This persistence of the problem reflects our incomplete under- BMSs countered elastic recoil and vasospasm that acutely
standing of its complex pathogenesis, and further research and decrease lumen diameter after angioplasty by 10–30 % [1,
novel approaches to prevention are needed before the full 2]. Stents were designed to hold lumen dimensions to those
potential of interventions can be realized. achieved at peak balloon inflation by providing radial strength
This chapter reviews the scope and progression of the in excess of inward radial forces exerted by the surrounding
clinical problem, the two primary structural mechanisms that vessel wall. This strategy worked, but the greatest impact of
contribute to restenosis, and their cellular and molecular BMSs has subsequently been recognized to be prevention of
pathogenesis. chronic arterial wall recoil, known as geometric remodeling
of the healing vessel wall, as will be discussed below.
Landmark PCI trials comparing BMSs to angioplasty reduced
Scope of the Problem absolute and relative restenosis by 10 and 30 %, respectively
[1, 2]. BMSs also improved PCI for chronic total occlusions,
After the introduction of coronary angioplasty in the 1970s, vein graft stenosis, and acute myocardial infarction.
widespread application was tempered by rates of restenosis Nonetheless, restensosis after BMS remains unacceptably
as high as 60 % within 2 years (Table 14.1) [1–28]. Patients high at 15–32 % [1, 2].
often returned with recurrent angina 3–9 months after percu- Another decade passed before the next major advance, a
taneous coronary intervention (PCI), leading to expensive period when exciting new approaches were embraced only to
and more complex repeat procedures with increased morbid- fade after disappointing results in randomized trials (e.g.,
ity [29–31]. This prompted major investments in research to atherectomy, gene therapy, and brachytherapy) [12, 13].
develop pharmacological inhibitors of restenosis, but drugs Drug-eluting stents (DESs) then emerged with startling results
effective in small animal models of balloon injury failed in phase I trials, reporting near 0 % restenosis with sirolimus-
repeatedly to reduce angioplasty restenosis in randomized eluting stents [9]. Subsequent trials in less selective “real-
world” populations have yielded slightly less favorable results
in PCI, but after a decade of iterative refinement (e.g., new
X. Ma, MD • R.L. Geary, MD, FACS (*) drugs and stent coatings), restenosis after DES is in the range
Department of Vascular and Endovascular Surgery, of 5–15 %, a significant improvement over BMSs [4]. Other
Wake Forest University School of Medicine,
trials have showed that DESs are superior to angioplasty in
Winston-Salem, NC 27104, USA
treating the difficult problem of in-stent restenosis [35].
Department of Pathology, Section on Comparative Medicine,
Restenosis in extracoronary vascular beds has received
Wake Forest University School of Medicine,
Winston-Salem, NC, USA more attention in recent years, and rightly so, as the num-
e-mail: rgeary@wakehealth.edu bers of failures at these sites can be remarkably high,

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 97

DOI 10.1007/978-1-4471-4429-8_14, © Springer-Verlag London 2013
98 X. Ma and R.L. Geary

Table 14.1 Representative restenosis rates by location and intervention

Location Procedure Restenosis (%) References
Coronary PTA 21–55 [1–3]
Coronary BMS 16–44 [1–3]
Coronary DES 10 [4–11]
Coronary Atherectomy 27–39 [12, 13]
Renal PTA 26–100 [14]
Renal BMS 17–60 [14–16]
Renal DES 18 [16]
Iliac PTA 22–34 [16]
Iliac BMS 10–26 [16]
Femoral popliteal PTA 39–62 [17–20]
Femoral popliteal BMS 34–47 [17–20]
Femoral popliteal DES 44 [21]
Femoral popliteal Covered stent 37 [22]
Carotid Endarterectomy 1.7–9.3 [23–25]
Carotid BMS 2.7–21 [24, 25]
Mesenteric celiac PTA 36–64 [26–28]
Mesenteric celiac BMS 40 [25–28]
PTA percutaneous transluminal angioplasty, BMS bare metal stent, DES drug-eluting stent

particularly for atherosclerotic lesions in the extremities repeat interventions measured in the billions of healthcare
(Table 14.1). For example, carotid revascularization carries dollars [38].
a relatively low (~6 %) risk of clinically significant resteno-
sis (>70 % diameter stenosis) for both endarterectomy and
stenting according to recent data from CREST (Lal et al. Structural Basis of Recurrent Lumen Narrowing
[36] International Stroke Conference 2012, New Orleans,
LA). Much higher rates have been reported in endarterec- Despite the steady push to reduce the invasiveness of vascu-
tomy trials using 50 % stenosis as the criteria for failure. lar reconstruction, virtually all methods are still mechanical
Restenosis after renal angioplasty for atherosclerosis is so in nature and cause trauma to the treated vessel wall, no matter
common that virtually all renal interventions done now how carefully applied. Surgery (bypass and endarterectomy)
employ primary stenting [14]. A meta-analysis of renal and endovascular approaches (angioplasty, atherectomy, and
stenting by Leertouwer [14] found a mean rate of in-stent stenting) all injure the vessel wall, and the response to injury
restenosis of 17 %, but late failures are probably much and subsequent healing are the common thread in the patho-
more common (Table 14.1). Large prospective renal stent genesis of restenosis.
trials have recently been completed, so the durability of Vessel wall trauma creates a thrombogenic lumen surface
BMSs will soon be characterized more accurately (e.g., by denuding the protective endothelium, fracturing inelastic
ASTRAL and CORAL). atherosclerotic plaque, and often wounding deep into the
Treatment of infrainguinal peripheral artery disease is surrounding tunica media and adventitia (Fig. 14.1). This
rapidly expanding as devices specifically tailored to the induces acute platelet and leukocyte adhesion and direct
extremities are being developed and public awareness is destruction of resident smooth muscle cells (SMC) and
increasing. However, the promise of less invasive options to extracellular matrix (ECM), setting into motion a prolifera-
replace high-risk open surgery has been slowed by rates of tive wound-healing response (termed “intimal hyperplasia”)
restenosis that often exceed 50 % at 2 years (Table 14.1). that is generally proportional to the extent of injury.
Moreover, the gains for the BMS and DES achieved in PCI Accumulation of new cells and ECM at sites of injury forms
have been far less consistent beyond the first few months in a “neointima” layer at the vessel lumen surface, a feature
the lower extremities (Table 14.1) [37]. common to virtually all forms of reconstruction and one of
Incremental improvements from better patient and lesion two major factors contributing to recurrent lumen encroach-
selection, enhanced anticoagulation and anti-platelet ment (Figs. 14.1, 14.2, and 14.3).
agents, and improved devices and imaging have each helped This observation led to an intense focus on the molecular
reduce restenosis, but despite these advances, millions of and cellular regulation of vascular SMC growth and migra-
persons are affected worldwide at an estimated cost for tion and ECM production and regrowth of a protective
14 Arterial Wall Remodeling and Restenosis Following Vascular Reconstruction 99

Fig. 14.1 Composite photomicrograph demonstrates a typical response plaque (p) and overlying media that have healed with neointimal
4 weeks after angioplasty and stenting in atherosclerotic primate. (a, b) ingrowth (n). (c) Shows a stented monkey iliac artery with a typical
Show the uninjured and injured common iliac arteries, respectively. neointimal lesion (n). (a, b) Verhoeff–van Gieson’s stain; (c) trichrome
Panel c shows stented iliac artery. Animals consumed an atherogenic stain; original magnification all panels, ×40 (Reproduced by permission
diet for 2.5 years to create complicated plaques (p). (b) Shows fractured of American Heart Association, Cherr et al. [73])

Fig. 14.2 Composite photomicrograph of the rat carotid after balloon 12 weeks (d). Note significant intimal hyperplasia at 2 and 12 weeks
injury. Histological cross-sections of normal rat carotid artery before with increasing contribution from ECM. Lumen is at top. Arrows indi-
injury (a), immediately after balloon injury (b), after 2 weeks (c), then cate IEL (Reproduced with permission from [44])

endothelial cell (EC) monolayer. Basic restenosis research developed (Figs. 14.1 and 14.2) and the time course of inti-
initially focused on vein graft arterialization and prosthetic mal hyperplasia carefully described.
graft anastomotic intimal hyperplasia and then intensely on Potent inhibitors of experimental neointima formation
neointima formation at sites of angioplasty and within BMS. were identified, but a series of clinical trials based on these
Animal models of angioplasty and bypass procedures were results failed miserably with no impact on restenosis. This
100 X. Ma and R.L. Geary

Fig. 14.3 Mechanisms of lumen Restenosis A

narrowing after angioplasty.
Diagram illustrates the early
concept of restenosis following
angioplasty due entirely to
neointimal formation (top) and L
more contemporary model,
which includes both intimal
A A N
hyperplasia and constrictive
remodeling (bottom). L lumen,
P plaque, A adventitia, P
N neointima Intimal hyperplasia
L PTA L

m
L

Constrictive remodeling

caused researchers and funding agencies to take a step back formation and inward shrinkage of the vessel wall merge to
in the early 1990s to explore possibilities for the failure of produce lumen narrowing at sites of angioplasty in the
animal models to predict clinical benefit. Three hypotheses absence of a stent (Fig. 14.3). While these two processes
emerged from this reappraisal. The first was the possibility occur together, conceptually it is easier to consider their
that species differences existed in the regulation of SMC pathogenesis separately.
growth, so that drugs effective in rodents were ineffective in
human beings. Data emerged to support this hypothesis as
results from studies in nonhuman primate models of rest- Intimal Hyperplasia
enosis mirrored those in clinical trials [39]. The second
hypothesis was that animal models did not accurately depict In practice, angioplasty is applied to stenoses surrounded by
the background of complex advanced atherosclerosis and its advanced atherosclerotic plaques. These lesions are inelas-
contribution to the injury response. Such lesions are present tic, in contrast to the normal arterial wall, and rupture rather
in the vast majority of vessels treated clinically. To this day, than stretch when dilated (Fig. 14.1) [39, 40]. New tissue for-
few models come close to developing plaques that mirror mation following the procedure is termed “neointima” as it
the complexity of human lesions. Perhaps the closest accumulates at the interface between the damaged vessel
approximation is the monkey model of diet-induced athero- wall and flowing blood (Fig. 14.1). As noted above, intimal
sclerosis [40]. When fed an atherogenic Western diet for hyperplasia is a generic response to virtually all forms of
2–5 years, macaques develop complex lesions in the coro- mechanical arterial wall injury (e.g., angioplasty, atherec-
nary, aortic, and iliac arteries (Fig. 14.1), but the expense tomy, endarterectomy, stenting, etc.). The time course and
and time required to work in this model have severely regulation of intimal hyperplasia following artery injury have
restricted its application. The third and perhaps most impor- been extensively characterized in the rat carotid balloon
tant hypothesis was that factors other than neointima were injury model by Clowes and others (Fig. 14.2) [44, 45].
contributing to lumen loss after angioplasty, and confirmatory Balloon injury denudes the endothelium and damages the
data soon emerged from BMS and IVUS trials. The concept surrounding wall by stretching, which if severe can rupture
of geometric arterial wall remodeling after angioplasty had the tunica media. In the rat model, a stretch injury standard-
been largely overlooked until serial imaging of human coro- ized to not rupture the IEL results in the immediate death of
nary lesions with IVUS demonstrated that changes in wall 25–30 % of medial SMCs. The loss of an endothelial barrier
diameter were even more important than new wall mass promotes platelet and leukocyte adhesion forming a thin
(neointima) in the loss of lumen caliber over time [41–43]. layer of mural thrombus and an acute wave of inflammation.
We now understand that the combination of neointima Adherent platelets release factors that promote cell growth
14 Arterial Wall Remodeling and Restenosis Following Vascular Reconstruction 101

and migration, including PDGFs, EGF, basic FGF, and constrictive process remodels the arterial wall to an even
TGF-b. Dead and injured SMCs release intracellular stores smaller caliber through a process with many parallels to
of basic FGF, and the damaged ECM releases matrix-bound wound contraction in healing cutaneous wounds.
growth factors as well as matrix fragments that have endog- If the reader has trouble visualizing the effects of remod-
enous mitogenic and inflammatory properties. A dramatic eling, the data from BMS studies may be helpful. When a
wave of replication ensues in which 30 % of medial SMCs BMS is used, the amount of neointma that forms within the
enter S-phase within 24 h. By day 4, both quiescent and rep- stent is generally worse, with a greater cross-sectional area
licating SMCs can be seen migrating from the media across than after angioplasty alone. Even so, stents reduce the fre-
the IEL to form a neointima (Fig. 14.2) [44–46]. Cells arriv- quency of restenosis compared to angioplasty alone because
ing in the neointima continue replicating until a quiescent they completely block acute and chronic recoil/remodeling/
state is reached by 4 weeks. The neointima continues to shrinkage of the arterial wall. So the initial lumen caliber
expand for ~6 weeks from accumulation of additional ECM, (the stent caliber) is large enough that moderate amounts of
and at 3 months ECM accounts for almost 80 % of the neointima have minimal impact on the lumen cross-sectional
neointimal area in the rat model (Fig. 14.2d) [44]. area. In contrast, an artery that constricts after angioplasty,
In the rat carotid balloon injury model, the endothelium remodeling pre-existing media and plaque area into a slightly
does not completely regenerate, but in other models, regrowth smaller diameter, will severely narrow the lumen even if the
of an intact endothelial monolayer serves to shut down repli- area of the wall stays constant (i.e., no additional neointima,
cation of the underlying SMC replication. This is due to Fig. 14.3). These concepts have been confirmed in studies
paracrine effects of growth inhibitors secreted by the endothe- using serial imaging of arterial segments after angioplasty
lium, including nitric oxide (NO) [47] and heparan sulfate and after BMS. IVUS of the cross-sectional vessel area
proteoglycans [48]. Endothelium also serves a barrier func- shows that after angioplasty 60–80 % of lumen loss was due
tion and excludes platelets, clotting proteins, and leukocytes to constrictive remodeling of the wall caliber, while only
from continuing to stimulate adjacent SMCs with their mito- 20–40 % was from a change in total wall cross-sectional area
genic, motogenic, and proinflammatory effects. These facts (neointima) [41–43].
have formed the basis of clinical trials designed to enhance Changes in wall caliber are generally measured histologi-
early endothelialization of prosthetic bypass grafts, BMS, cally by the area encompassed by the EEL [53]. The molecu-
and sites of angioplasty [49, 50]. lar mechanisms of constrictive reorganization of cells and
As noted above, many drugs have been identified that ECM material in the injured arterial wall remain poorly under-
inhibit intimal hyperplasia in the rat and other animal models stood, but attempts to explain it have drawn parallels to the
of vascular injury, including heparin [48], angiotensin-con- process of cutaneous wound healing, wound contraction, and
verting enzyme inhibitors [51, 52], and NO donors, but when fibrosis [54–57]. In cutaneous wounds left to heal by second-
applied in human angioplasty restenosis trials, their effects ary intent, the sequence of cellular events is similar in many
have all been disappointing [32, 33]. This is due in part to the ways to healing of the arterial wall after angioplasty. A platelet
fact that intimal hyperplasia (new wall mass) is only one and fibrin plug forms in the defect, which serves as provisional
variable in the angioplasty restenosis equation, the other matrix for the influx of leukocytes then fibroblasts from dam-
being constrictive arterial wall remodeling. aged wound edges as well as ingrowth of new microvessels.
Wound fibroblasts dedifferentiate into myofibroblasts, which
like SMCs express a-actin and are capable of contracting in
Arterial Wall Remodeling response to vasoconstrictors [56]. As leukocytes remove clot
and wound debris, myofibroblasts proliferate and lay down
Remodeling refers to changes in the arterial wall geometry new ECM rich in glycosaminoglycans and proteoglycans to
(intima, media, and adventitia) that can occur independent of form granulation tissue [57]. Fibroblasts then reorganize and
a change in the wall cross-sectional area. Normal adaptive apply traction to the newly synthesized matrix, and wound
vascular remodeling occurs when the vessel wall dilates and contraction occurs to bring wound edges together. Subsequent
thickens in response to chronic increases in flow and pres- ECM turnover leads to a change in matrix composition to a
sure, respectively. Compensatory outward remodeling is a more collagen-rich material. This results in fibrosis and even-
well-established response through which the media expands tually a mature scar after many months [55].
to accommodate the accumulation of atherosclerotic plaque, Parallels occur in atherosclerotic arteries injured by angio-
as described by Glagov and others. After angioplasty, the plasty [54]. This can be modeled in nonhuman primates with
arterial wall seldom dilates to a greater caliber than was complex pre-existing atherosclerosis. In this model, species
achieved when the balloon was inflated, but instead various differences in the regulation of SMC growth are minimized,
amounts of inward wall shrinkage occur over time. As noted and complex atherosclerotic lesions more closely depict the
above, acute recoil and spasm decreases wall caliber by human plaque prompting reconstruction (Fig. 14.1). Angio-
10–30 % within minutes. Over the next few weeks, another plasty increases lumen size by fracturing the atherosclerotic
102 X. Ma and R.L. Geary

plaque and stretching or tearing the surrounding media and arterial wall suggests an important interaction supported by
adventitia. Thus, the arterial wall “wound” is transmural. in vitro studies of collagen remodeling. Adventitial fibroblasts
The healing response is also transmural, and while new tis- and medial SMCs cultured from monkey aorta contract col-
sue is termed the neointima, it can develop in the media and lagen lattices using b1 integrins. Addition of HA significantly
adventitial layers if the fracture is deep. enhances collagen reorganization and peri-cellular collagen
Damage leads to acute inflammation where thrombus fiber condensation [69]. This effect is mediated in part by
forms within fractures, dissections, and clefts, providing pro- cell surface receptors for HA, including RHAMM and CD44.
visional scaffolding for the influx of leukocytes, initially Both are upregulated by arterial injury [69, 70]. Thus, these
neutrophils then monocytes after days 2–7 [40, 54]. Platelets data suggest HA could alter constrictive collagen remodeling
and the fibrin plug attract leukocytes to the denuded area in the healing arterial wall.
through a cascade of adhesion molecules including P-selectin, Matrix metalloproteinases (MMP) are important regula-
integrin Mac-1 and glycoprotein IIb/IIIa, and direct leuko- tors of matrix degradation that are critical in SMC migration
cyte attachment and migration [58, 59]. Mac-1 and platelet- in vitro, but their roles in constrictive remodeling are less
mediated leukocyte adhesion plays an important role in well established. Animal studies using MMP inhibitors
vascular inflammation and restenosis. Following a brief but showed conflicting results. In rat, rabbit, and pig models of
intense wave of proliferation, peaking at 4 days, SMC and arterial injury, MMP inhibition limited the injury response
other actin-positive cells (e.g., adventitial fibroblasts and cir- [71, 72]. In contrast, a continuous infusion of a broad-spec-
culating progenitor-derived SMCs) migrate to the lumen trum MMP inhibitor after angioplasty in atherosclerotic
interface into the area of injury to form neointima starting at monkeys had no effect on arterial wall remodeling or hyper-
day 7. Inflammation then resolves, and neointima replaces plasia [73]. Not surprisingly then, clinical trials of MMP
the thrombus and thickens substantially from further accu- inhibitors for PCI endpoints have been negative [74].
mulation of SMCs and ECM from days 14 to 28. Reactive oxygen species (ROS) have also been implicated
Constrictive remodeling of the arterial wall, probably from in constrictive remodeling. ROS are transiently increased
adhesive tension generated in reorganization of newly synthe- across the arterial wall after angioplasty. In rabbits undergo-
sized ECM, is often remarkable during this time period [53, ing iliac balloon injury, superoxide dismutase (SOD) activ-
54]. Despite the accumulation of neointima, restenosis in this ity, which maintains the redox balance by catalyzing the
model is not caused by increased lesion size alone. Rather, the reaction of O2- to H2O2, was decreased significantly as con-
change in overall arterial wall size or remodeling with wall strictive remodeling occurred [75]. Exogenous administra-
shrinkage is the major factor leading to lumen narrowing. tion of SOD to the endothelium increased lumen caliber,
Given that matrix accounts for more than 60 % of arterial wall inhibiting constrictive remodeling by 59 %. SOD also
volume, matrix reorganization is a key factor in wall remodel- improved nitrate levels, suggesting improved remodeling
ing and dependent on cell-matrix adhesive interactions, matrix was in part from increased NO production.
degradation by proteases, and new matrix synthesis. TGF-b and connective tissue growth factor (CTGF) are
As in healing wounds, the composition of the new ECM at induced at sites of injury where they regulate ECM turnover
sites of vascular injury is distinct from that in normal arterial and contraction during wound healing [76–78]. CTGF stim-
wall [54, 60–64]. The uninjured media is rich in types I and ulates SMC proliferation and migration and regulates
III collagen and elastin with lesser amounts of glycosamino- enhanced collagen remodeling by fibroblasts in vitro in
glycans and proteoglycans [61]. In contrast, ECM deposited response to TGF-b [76]. CTGF is significantly upregulated
by neointimal cells is rich in hyaluronan (HA) and versican. in monkey aortic after injury. Blocking TGF-b with neutral-
HA is a large hydrophilic disaccharide polymer associated izing antibodies or a soluble TGF receptor used as an inhibi-
with tissue remodeling in embryogenesis, wound healing, tor has been reported to reduce lumen narrowing by inhibiting
and tumor invasion. HA is important for scarless fetal wound constrictive remodeling following carotid artery ligation in
healing and improves collagen remodeling and re-epithelial- mice [79].
ization when applied exogenously to cutaneous wound in
adults [65–67]. Versican is a proteoglycan that binds to the
HA backbone and changes its physical-chemical properties, Clinical Progress in Treating Restenosis
increasing viscoelasticity, and together they provide hydrated
space favorable for cell motility, invasion, and replication The DES story elegantly merges therapies targeting the two
[68]. The relative ratio of HA and other stuctural matrix pro- major mechanisms underlying restenosis described above.
teins such as collagen and elastin alters ECM reorganization DESs overcome constrictive remodeling with the stent and
in culture and within the healing arterial wall [62, 69]. block intimal hyperplasia with an antiproliferative drug coat-
HA is expressed in all arterial wall layers after angio- ing that targets high-dose inhibitors to the site of injury, avoid-
plasty, most prominently the adventitia and neointima [54, ing systemic toxicity [6, 7]. DESs do not prevent the problem
64]. Co-localization with type-I collagen in the healing for all patients or in all vascular beds, but remarkable data
14 Arterial Wall Remodeling and Restenosis Following Vascular Reconstruction 103

from clinical studies of PCI show conclusive benefits (e.g., employed CD34 antibody-coated stents to capture circulat-
SIRIUS, RAVEL, TAXUS, and others) [3, 9]. New drugs ing CD34-positive EC progenitors to endothelialize BMSs
combined with new coating strategies have been studied in more rapidly to inhibit neointimal formation and in-stent
PCI. The SPIRIT-III, SPIRIT-IV, and the COMPARE trials restenosis [50, 87, 88].
studied everolimus DESs and found lower restenosis than for
pacitaxel DESs (2.3 % vs. 5.7 %) [10, 11].
In contrast to their efficacy in PCI, DESs in peripheral
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 Shear Stress and Endothelial Cell
Retention in Critical Lower Limb 15
Ischemia

Caroline Jadlowiec and Alan Dardik

The Molecular-Cellular Basis by the endothelium between blood and the surrounding ves-
for Critical Limb Ischemia sel wall allows it to function as a primary mediator in
response to shear stress alterations.
Endothelial Cell Physiology Studies have found that steady laminar shear stress is pro-
tective and, under such conditions, the endothelium is found
Progressive atherosclerotic stenosis of vessels commonly to occupy a quiescent state where it exhibits both low prolif-
leads to the development of critical limb and myocardial eration and apoptosis [6]. Perhaps the most extensively
ischemia. When possible and appropriate, surgical revascu- investigated subject to date has been the influence of fluid
larization is attempted, and it is here that we clinically shear stress applied to confluent monolayers of cultured
observe the pathological processes of ischemia and reperfu- endothelial cells [7]. Cellular morphology, under higher
sion and their complex effects [1]. Understanding of the role shear stress conditions, finds endothelial cells to have an
and function of the vascular endothelium has undergone elongated appearance and increased alignment, whereas low-
significant changes over the past several decades. In the flow, turbulent conditions produce rounded, nonaxially ori-
1960s Willms-Kretschmer and colleagues [2] and Pober [3] ented endothelial cells that possess a higher cell turnover.
referred to altered endothelial cells as being activated and, in The first in vivo documentation of flow-altered endothelial
doing so, implied a functional consequence to the altered cell cellular morphology was conducted in the early 1970s, and
morphology. This dynamic view of the endothelium, how- the findings from this study showed that, in uniform laminar
ever, did not ensue into the following decade when, again, it flow vessel segments, endothelial nuclei were oriented paral-
was believed that endothelial cells were nothing more than a lel to the axis of the blood vessel [8]. In contrast nonaxial,
passive barrier. It would not be until the 1980s that Bevilacqua less-ordered nuclear orientation was found at vessel branch
et al [4] would reexamine the scientific principle and ulti- points and bifurcations where flow is recognized to be turbu-
mately prove that the vascular endothelium is both dynamic lent [9]. Further studies have since confirmed the morpho-
and integral to vascular and systemic equilibrium. The logic observation that unidirectional laminar shear stress
scientific process to better understand the endothelium dates applied to cultured endothelial monolayers induces time- and
back to the 1800s when von Recklinghausen recognized that force-dependent cytoskeletal reorganization. This restructur-
vessels were not merely inert tunnels passing through tissue, ing produces changes in cell shape and alignment and is
but living entities lined by cells [5]. The endothelial mono- reversible with flow interruption [10].
layer comprises the entirety of the vascular system, and it is Current studies identify hemodynamic shear stress as an
now recognized that the diversity of these cells is not merely important, if not primary, determinant of endothelial func-
limited by cell type alone, but rather is a function of ana- tion and phenotype (Fig. 15.1). High shear stress, typically
tomic hemodynamic variation. The unique interface formed regarded as being greater than 15 dyn/cm2, such as is found
in arterial circulation, promotes endothelial cell quiescence
C. Jadlowiec, MD • A. Dardik, MD, PhD (*) and expression of atheroprotective genes. In contrast, low
Department of Surgery and the Interdepartmental Program in Vascular shear stress, defined as less than 4 dyn/cm2, stimulates an
Biology and Therapeutics, Yale University School of Medicine,
activated atherogenic endothelial phenotype [11]. Non-
10 Amistad Street, Room 437, P.O. Box 208089,
New Haven, CT 06520-8089, USA laminar flow correlates with endothelial cell activation and
the development of atherosclerosis and neointimal hyperpla-
VA Connecticut Healthcare System,
West Haven, CT, USA sia, and, in vitro, replication of disturbed flow has shown
e-mail: alan.dardik@yale.edu increased endothelial cell proliferation and apoptosis. With

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 107
DOI 10.1007/978-1-4471-4429-8_15, © Springer-Verlag London 2013
108 C. Jadlowiec and A. Dardik

a b
Turbula n t Flow
inar Flow
Lam

Shear Shear
Stress Shear Stress Shear Stress Stress

Coagulation Neointima Inflammation Coagulation Neointima Inflammation

PGI2 Cellular quiescence PG12 Cellular activation ICAM-1 expression

Endothelial ICAM-1 Endothelial proliferation Leukocyte adhesion
tPA Endothelial proliferation tPA
Leukocyte adhesion SMC proliferation
Platelet adhesion SMC proliferation Platelet Adhesion
Apoptosis Apoptosis
Endothelial alignment Endothelial alignment

Fig. 15.1 Alterations in endothelial cell function and phenotype as determined by environmental hemodynamics. (a) Endothelial cell responses
to high shear stress. (b) Endothelial cell responses to low shear stress

regard to anticoagulant properties, activated endothelium expression, and the conversion from aerobic metabolism to
displays increased intercellular adhesion molecule expres- anaerobic alternative pathways [16]. The vascular endothe-
sion and platelet aggregation as well as reduced production lium is responsible for regulating membrane permeability,
of antithrombogenic substances, such as prostacyclin (PGI1) vascular tone, coagulation, and inflammation, and it does so
and tissue plasminogen activator (tPA) [7]. These qualities by dynamically responding to any systemic alterations, such
are in stark contrast to quiescent endothelium where leuko- as hypoxia, within the vascular environment [17]. Yet, despite
cyte adhesion is diminished, PGI1 and tPA production is its wide range of adaptability, the vascular endothelium like-
increased, and platelet aggregation is reduced [7, 12]. wise remains very sensitive to hypoxic insults, inflammatory
Normal laminar shear stress is critical in maintaining nor- stimuli, and physical injury from surgical manipulation or
mal physiologic vascular function including thromboresis- hemodynamic stress, and it is this interplay between adapta-
tance, barrier function, and vascular tone. In contrast, low or tion and injury that makes cardiovascular surgery a challeng-
oscillary shear stress results in disturbed flow conditions and ing paradox [16] (Fig. 15.2).
plays an important role in atherogenesis and bypass failure In contrast to other cell types, the vascular endothelium
[13] (Fig. 15.1). Work done by Gimbrone and colleagues has is comparatively resistant to decreases in oxygen content
demonstrated the relationship between decreased shear stress [17]. Under ischemic conditions, aerobic cellular energy
and atherogenesis [14]. Decreases in shear stress are accom- depletion leads to an atypical accumulation of cytoplasmic
panied by disturbances in normal endothelial cell function, metabolites and failure of oxygen-dependent membrane
and repair mechanisms within the endothelium are reduced transport systems. Of most significance is the documented
along with the production of endothelial nitric oxide synthase intracellular increase in calcium ion concentration and the
(eNOS). Moreover, systemic risk factors such as hypertension upregulation of xanthine oxidase (XO) transcription and
and hyperlipidemia exacerbate endothelial intrinsic dysfunc- synthesis. Although restoration of blood flow after pro-
tion. On a cellular level, this results in increased production longed ischemia is essential for possible physiologic sal-
of reactive oxygen species (ROS), altered lipoprotein perme- vage, reperfusion itself exacerbates endothelial cell injury.
ability, leukocyte adhesion, and cellular proliferation [15]. XO, an endothelial cell-associated enzyme, increases under
hypoxic conditions and, with the restoration of blood flow
and oxygen, leads to the intracellular buildup of reactive
Hypoxic Physiology oxygen species (ROS) [18]. Once produced, ROS cause
localized and systemic cellular damage through both direct
Hypoxia, depletion of the circulating oxygen content, is rec- injury to membranes and proteins and indirectly through
ognized as the driving force behind ischemic injury and, on activation of proapoptotic pathways [19]. This reperfusion
a cellular level, endothelial cells respond to this insult by damage is further augmented as damaged cellular mem-
undergoing the phenotypic change now universally recog- branes are exposed to a replenished intravascular supply of
nized as endothelial cell activation. This results in a series of calcium. Acting as a second messenger, calcium triggers
alterations including the release of stored inflammatory activation of various enzymes crucial to the production of
mediators, changes in endothelial cell surface protein proinflammatory mediators [20].
15 Shear Stress and Endothelial Cell Retention in Critical Lower Limb Ischemia 109

a Ischemia b Reperfusion

O2 O2
O2 Permeability O2

O2

O2
MMPs

Matrix remodeling
MMPs ROS
Proliferation -1
Vasodilation VEGF AM
IC
NOS PDGF
ROS
Proliferation
VEGF ATP
XO
Hypoxanthine + H2O + 2O2 Xanthine + 2O–2 + 2H+
Ca2+
XO
HIF-1 HIF-1 ROS
Hypoxanthine
Tight junctions Permeability
Barrier function Edema

Fig. 15.2 Endothelial cell responses to ischemia. (a) Endothelial cell hypoxic physiology. (b) Endothelial cell responses to reperfusion

Under normal conditions endothelial cells form an over- Shear Stress and Arteriogenesis
lapping monolayer that permits only controlled passage of
molecules. This monolayer is further enhanced through the Study of arteriogenesis, the enlargement of preexisting arte-
presence of tight junctions that reinforce endothelial cell bar- rial connections into true collateral arteries, began in the
rier function. Hypoxic conditions lead to alterations in 1700s with the work of Albrecht von Haller, a Swiss anato-
endothelial cell barrier function and vessel permeability. In mist, who dissected human hearts and found that coronary
response to decreased oxygen content, there is loss of tight arteries provide a system of interarterially connected vessels
junctions between adjacent endothelial cells leading to gap on the side of high arterial pressure. His findings suggested
formation and increased permeability between cells. These that these conduits were functional arteries, larger in size
changes are likewise accompanied by decreases in intracel- than capillaries [26]. Today, this process is recognized as
lular cyclic AMP, which is essential for maintenance of the arteriogenesis, and, unlike angiogenesis, which is primarily
actin-based cytoskeletal architecture and normal barrier mediated by hypoxia, initiation of collateral artery growth
function [4, 21]. This increased permeability results in what and remodeling is dependent on alterations in hemodynamic
is clinically observed as ischemia reperfusion edema. forces. Circumferential wall stress and fluid shear stress are
Hypoxic adaptation in endothelium leads to the transcrip- recognized and the two primary forces responsible for this
tional induction of a series of genes that participate in complex process; however, uncertainties continue with
angiogenesis, metabolism, and cell proliferation, and the pri- regard to the specific contributions and overall importance of
mary mediator of this response is hypoxia-inducible factor-1 either toward arteriogenesis. Some uncertainty comes from
(HIF-1), an oxygen-sensitive transcriptional activator [22]. the observation that fluid shear stress, with a typical range of
The HIF-1 heterodimeric protein consists of two subunits, a 20–30 dyn/cm2, is a weak force when compared with cir-
beta subunit that is constitutively expressed (HIF-1b) and an cumferential wall stress, which is 106 times greater [27].
oxygen-regulated alpha unit (HIF-1a). The stability and In the early 1920s, Murray proposed that the vascular sys-
activity of the alpha subunit are regulated by its post- tem’s branching configuration exists so as to minimize the
translational modifications, and, under normoxic conditions, amount of mechanical and metabolic work to provide ade-
this subunit is degraded. Conversely, in hypoxia, the beta sub- quate blood flow. Using this model, it can be surmised that
unit becomes stable resulting in the regulation of target gene fluid shear stress remains constant throughout the vasculature
expression [22]. Previous studies have demonstrated that and that blood flow is proportional to the cube of each indi-
HIF-1 plays a critical role in endothelial angiogenesis through vidual vessel’s diameter. Additionally, shear stress remains
both paracrine and autocrine mechanisms [23, 24]. Recent proportional to blood flow and inversely related to the cube of
discoveries have shown that hypoxia-activated HIFs induce the radius [27, 28]. Accordingly, it is hypothesized that shear
endothelial expression of several critical angiogenic factors, stress regulates the acute early phase of arteriogenesis where
including vascular endothelial growth factor (VEGF), nitric small increases in collateral artery diameter result in significant
oxide synthase (NOS), platelet-derived growth factor (PDGF), decreases in shear stress [29]. The formation of collateral cir-
Ang2, and others [25]. HIFs have also been found to be medi- culation after an arterial occlusion correlates well with the
ators of endothelial survival pathways where hypoxic upregu- observed increase in shear stress where increased collateral
lation results in cellular proliferation. Clinically, this can flow is caused by the pressure redistribution from pre-existent,
result in a wide spectrum of remodeling, including angiogen- now occluded, vessels [30]. It is also recognized that increases
esis and neointimal hyperplasia (Fig. 15.2). in collateral diameter end once shear stress normalizes.
110 C. Jadlowiec and A. Dardik

Interestingly, despite early and abrupt normalization, cellular compliant than arteries at low pressures, but less compliant
remodeling of collaterals persists beyond this acute period, than arteries when subjected to arterial pressures.
and a shift from quiescence toward proliferation is observed in Low pressure and low flow are the dominant hemodynamic
both endothelial and vascular smooth muscle cells [31]. As a entities in the normal venous environment, and, unlike the
result, it has been proposed that circumferential wall stress, physiology observed in arterial circulation, veins are not sub-
which remains elevated, is the more dominant force in this jected to pulsatility, high flow, or high pressures. All vessels,
later stage of arteriogenesis. Regardless of the dominant venous and arterial, are subject to mechanical forces in the
mediators, collateral remodeling frequently reaches a plateau, form of shear and circumferential wall stress. Effects of cir-
at which point hemodynamic alterations are unable to com- cumferential strain directly correlate with blood pressure, and
pensate for progressive atherogenesis. Indeed, when these in the venous system, these maximal pressures are understand-
compensatory systems fail or are overwhelmed, what follows ably reduced. The circumferential venous forces that remain
next is the clinical entity of critical limb ischemia. go on to be counteracted by the entirety of the vessel wall, and
the cellular components in the intima, media, and adventitia
are uniformly affected. Conversely, shear stress, the frictional
Surgical Solutions for CLI force of blood along the intima is distinctive in that it exerts its
force primarily on endothelial cells. Fluid shear stress likewise
Autologous Vein Grafts displays significant variation between venous and arterial sys-
tems, and prior studies have found 1–6 dyn/cm2 to be typical
Today, autologous vein grafting is the recognized standard for of venous shear stress. This is in large contrast to arterial vas-
infrainguinal arterial revascularization, yet prior to the pioneer- culature where anywhere from 10 to 70 dyn/cm2 is the prevail-
ing work done in the early 1900s, the predominating belief was ing norm [11]. This abrupt hemodynamic alteration has been
that repair of major vasculature was beyond the capacity of implicated as the mechanism responsible for initial endothelial
surgical technique. Unconvinced that the 1894 penetrating por- desquamation, which is observed to occur in the first week of
tal venous injury of French president Carnot was not treatable, graft placement. In such situations, graft endothelium regen-
Carrel would undertake the task of refining vessel anastomosis. eration appears to occur quickly with complete healing
He would go on to establish the modern fundamentals of bypass observed in some veins at 48 h [34]. Nonetheless, concerns
surgery with his combined techniques of delicate vessel han- regarding the long-term effects of acute arterial disruption of
dling, fine suture material, and triangulation [21]. The future of venous endothelium remain with respect to graft patency.
bypass surgery would then be further progressed by Kunlin, Indeed, long-term patency for autologous bypass is largely
who in 1948 would be the first to successfully use a reversed dependent on how successfully venous conduits adapt to
saphenous vein graft in the treatment of lower extremity isch- arterialization. As first suggested by Owens et al., the pro-
emia [32]. In 1962, Sabiston would then go on to use a cess of successful vein graft adaptation appears to involve at
modification of this technique in what we recognize today as least two distinct temporal phases: early outward remodeling
the modern coronary bypass. Interestingly, although much has of the lumen and delayed acquisition of wall stiffness [35].
changed from the pioneering days of surgical vascular research, In 2006, in a prospective human study, the authors showed
what remains is that the conduit of choice for lower extremity that 72 % of venous grafts dilate during the first post-surgical
bypass continues to be the greater saphenous vein. month and that no appreciable changes occur beyond this
time. During the first 6 months, a nearly 40 % increase in
conduit stiffness was found with the greatest relative increase
Physiology of Vein Graft Adaptation occurring during the initial first 3 postoperative months.
Clinically, grafts that demonstrated early positive remodel-
Venous anatomy echoes arterial, and the intima, media, and ing in the form of lumen dilatation appeared to have increased
adventitia are easily identified as the major anatomic vessel wall primary patency, and a trend toward greater wall stiffness at
components. It is well known that, unlike arteries, veins have 1 month was noted in grafts that failed [35]. Further work
a reduced medial component, which results in a thinner vessel done by the same authors in 2008 underscored the critical
wall and typically allows for increased compliance. From prior role of systemic inflammation in vein graft remodeling. In
work, it is known that vein compliance is not a static prop- this study, there was positive correlation noted between vein
erty, but rather dependent on its environment. Although it is graft diameter and initial shear stress. This shear-dependent
commonly assumed that native veins are more compliant than response, however, was disrupted in patients with an elevated
arteries, in actuality, this increased compliance only remains baseline high-sensitivity C-reactive protein (hsCRP).
present up to pressures of 35–50 mmHg [33]. Under typical Moreover, despite similar vein diameter and shear stress at
arterial pressures, vein grafts become stiff and lose compli- implantation, grafts in the elevated hsCRP group demon-
ance, while matched arteries remain moderately distensible. strated less positive remodeling within the first month and
Accordingly, a more accurate description is that veins are more likewise had a propensity to be stiffer [36]. Accordingly,
15 Shear Stress and Endothelial Cell Retention in Critical Lower Limb Ischemia 111

although intricacies and specific mediators remain to be and venous circulation, with a comparative shear stress of
identified, early positive adaptation of vein grafts lends itself 33.4 ± 1.1 dyn/cm2 in the high-flow carotid versus 1.4 ± 0.2 dyn/
to successful long-term patency, and the importance of con- cm2 in the ligated, low-flow complement [41]. These correla-
trolling systemic inflammation deserves emphasis. tions between shear stress and neointimal remodeling provide
insight into the mechanisms involved in venous bypass and
likewise demonstrate the paradoxical effects that high flow
Responses of Venous Endothelial Cells and shear stress can exert on endothelial homeostasis.
to Shear Stress

Hemodynamic shear stress, possibly the most influential Graft Characteristics and Long-Term Patency
component of vascular remodeling and pathology, is the fric-
tional force created by the flow of blood in relation to the Using the best available autologous conduit is universally
luminal vessel wall and endothelial surface. It is in this regard accepted as the fitting approach for peripheral bypass sur-
that the creation of a surgical bypass, using a venous conduit, gery, and the conduit of choice is the ipsilateral, single-
becomes one of the most dynamic processes responsible for -segment greater saphenous vein secondary to its documented
endothelial remodeling. Although the technicalities of per- patency in lower extremity bypass [42]. Other characteristics
forming a successful bypass are well established, much of the that define the best autologous conduit however continue to
final outcome hinges on how successful the venous conduit be debated, and much of the data available comes from sin-
will be in adapting to the high-pressure pulsatile flow arterial gle-institution retrospective studies that attempted to define
circulation where it is acutely placed [37]. Much remains to meaningful graft characteristics in regard to long-term pat-
be learned about the underlying mechanisms responsible for ency. Traditionally, three surgical configurations, reversed,
both successful as well as pathologic endothelial adaptation. nonreversed, and in situ, have been accepted for use in
At present, the majority of our insight into endothelial infrainguinal vascular bypass work, and each is believed to
response to hemodynamics comes from animal experiments confer different effects on endothelial cells.
in which shear stress is acutely or chronically altered [11].
Classically, increases in shear stress, both acute and Reversed Vein Grafts
chronic, are observed to result in upregulation of endothelial Vein excision with reversal of anatomical orientation and
nitric oxide synthase (eNOS) mRNA and protein production maintenance of intact valves is the essence of a reversed vein
[38]. Such increases in eNOS activity result in vessel lumen grafting technique. Considered to be somewhat basic, usage
dilation. Studies investigating this role for nitric oxide (NO) of reversed vein grafts is typically well adapted for most sur-
have shown that through the use of L-NAME, a nitric oxide gical bypass settings. The reversed technique eliminates the
synthase inhibitor, flow-induced vessel dilation is inhibited need for valve lysis and thus limits intraluminal manipula-
[39]. In 1997, Clowes and colleagues demonstrated an tion. Concerns with regard to the altered flow dynamic in
important relationship between shear stress and neointimal reversed vein grafts have come from studies showing intralu-
hyperplasia. Using a primate model, the authors inserted minal turbulence secondary to retained valves. The surgical
PTFE grafts into aortoiliac circulation bilaterally. A neointima creation of a reversed vein graft introduces valves into the
was allowed to develop for 2 months, and, at that time, half arterial system and, by doing so, adds a potential source of
of the animals were killed. For the remaining group, graft turbulence. Such deviations from laminar flow hold the
flow was increased through the creation of a femoral arterio- potential to initiate pathological endothelial cell activation.
venous fistula. These animals were then killed 2 months Despite having a reversed anatomy, venous valves do not lie
post-fistula creation. The findings from this study showed flush with the graft wall, and once subjected to pulsatile arte-
regression of the neointima in those grafts exposed to the rial flow, these valves are observed to close during diastole
additional 2 months of high shear stress. From prior work, [43]. Coupled with the cardiac cycle, valves have the poten-
using this same model, the authors were also able to show tial to modify flow dynamics by becoming active and pre-
that high shear stress inhibits neointimal growth [39]. venting the natural arterial backflow, and it has been
Work examining the effects of high and low flow on graft speculated that midgraft stenotic lesions occur secondary to
adaptation have shown increased smooth muscle cell prolif- retained valve leaflets [44]. Other surgical concerns arise
eration in grafts exposed to low shear stress, and similar from the stasis observed within the valve cusps and the
findings have also been observed in endothelial cells [40]. In a potential for them to function as a thrombogenic nidus [43].
rat model, where unilateral ligation of the internal and external
carotid arteries results in the creation of high- and low-flow Nonreversed Vein Grafts
arteries, increased endothelial cell proliferation is seen at 24, In nonreversed technique, the vein is excised, its valves are
48, and 72 h post-ligation in the reduced flow carotids. With subjected to mechanical lysis, and it is then oriented in its
this model, the achieved alteration in flow reflected true arterial original nonreversed configuration. Observed advantages
112 C. Jadlowiec and A. Dardik

come from the preservation of a nonreversed orientation, thus data available come from the 2006 Project of Ex-Vivo Vein
improving the circumferential accord of the arterial graft Graft Engineering via Transfection III (PREVENT III)
anastomosis. Intraluminal valve lysis, however, is a requisite Study, which was a randomized, double-blinded, placebo-
and results in endothelial cell trauma and denudation. Venous controlled trial of edifoligide for prevention of vein graft
valve lysis results in significant endothelial trauma, and, from failure in patients undergoing lower extremity revasculariza-
prior work, it is known that the preservation of endothelial tion for critical limb ischemia. Although the primary and
cell integrity in venous grafts prevents subsequent morpho- secondary endpoints for PREVENT III did little to modify
logic changes, namely thickening of the venous intima and current medical strategies for limb revascularization, the
media in response to arterial dynamics [45]. Remarkably, study was able to provide perhaps the most comprehensive
despite the inherent need for more manipulation and handling multicenter data available to date with regard to long-debated
with nonreversed grafts, improved hemodynamic flow is the conduit and technique characteristics, such as vessel diame-
resulting outcome following valve lysis. Studies have shown ter, graft type, and conduit orientation [52, 53].
that lysis of valves increases graft flow rates anywhere from Results for early 30-day graft failure identified several
30 to 60 % as compared to grafts with intact valves [46, 47]. significant technical predictors of early loss of primary pat-
Clinically, the improved bypass hemodynamics, shown ency. Small-conduit diameter was identified as one such tech-
through higher shear stress and flow velocity, are atheropro- nical factor, and primary patency in grafts greater than 3.5 mm
tective and correlate with increased long-term graft patency. was observed to be 93.2 % vs. 85.7 % in grafts with diameters
less than 3.0 mm. Not surprisingly, composite grafts showed
In Situ Vein Grafts worse outcomes when compared to single-segment grafts
The initial concept of utilizing an autologous vein graft with a primary patency of 84.1 % vs. 92.2 % in non-spliced
while minimizing surgical manipulation is attributed to greater saphenous vein. Bypasses originating from a more
the work of both Rob and Hall in the early 1960s. At that distal location showed improved short-term outcomes. Grafts
time, advanced valvulotomes had yet to be developed, and that originated from the popliteal artery had primary patency
valve lysis was achieved through serial transverse venoto- rates of 93.9 % as compared to those with more proximal
mies and individual valve excision [48]. The modern in situ anastomoses, such as the common or superficial femoral
vein graft is created through limited mobilization of both the arteries, where rates were 91.7 % and 87.7 %, respectively.
proximal and distal vein segments, thus allowing them to be Graft length and the site of distal anastomosis were not found
used in arterial bypass but simultaneously reducing total vein to be predictors of primary patency loss. Although a slight
manipulation and damage to the outer vessel layers, includ- difference was observed between the early failure rates of
ing the vasa vasorum, during harvesting. Some studies have reversed and nonreversed grafts, 91.6 % patency as compared
suggested improved patency outcomes in vein bypasses har- to 93.3 %, this finding was not statistically significant [53]. At
vested en-bloc with surrounding tissue where venous spasm 1 year, graft patency was again found to be detrimentally
is believed to be reduced [49]. Prior studies have also dem- affected by small conduit diameter with primary patency
onstrated that the disruption of the vasa vasorum results in observed to be 68.4 % in grafts with diameters greater than
an acute decrease in vessel distensibility as well as long-term 3.5 mm vs. 42.4 % for those less than 3.0 mm. Poorer out-
structural changes and delayed deterioration of vessel elastic comes were observed in bypasses composed of composite
properties [50]. Based on such evidence, it has been proposed spliced vein, those greater than 60 cm in length, and more
that by diminishing spasm, the need for high pressure disten- proximal bypass origination. Moreover, at 1 year, the primary
tion, a known mediator of vein wall and endothelial damage, patency rates for reversed (65.0 %) and nonreversed (63.3 %)
is reduced [49]. There is also evidence to suggest an inverse orientation grafts were equivalent and not statistically
relationship between vasa vasorum preservation and neointi- significant. From these data, significant identifiable technical
mal hyperplasia. Findings by Gossl et al. showed that vessel predictors of early and late graft failure include use of a small
areas with diminished vasa vasorum density were more sus- conduit diameter or a composite vein; however, surgical vari-
ceptible to hypoxia, oxidative stress, and microinflammation, ation with the reversed and nonreversed technique does not
all factors known to potentiate early atherogenesis [51]. appear to be a primary factor in bypass success [53].
Accordingly, there is modest evidence present that the use
of atraumatic techniques, which minimize damage to the
adventitia and the vasa vasorum, improve bypass patency. Prosthetic
Although there have been many studies, mainly single
center and retrospective, that have attempted to address While the saphenous vein continues to be the superior unri-
aspects of surgical technique in relation to lower extremity valed arterial substitute for lower extremity bypass, a
bypass outcomes, the exact contribution of specific technical significant portion of patients with critical limb ischemia
factors remains to be fully defined. The most comprehensive does not possess an autologous vein that is usable. It is in
15 Shear Stress and Endothelial Cell Retention in Critical Lower Limb Ischemia 113

such difficult situations that an alternative arterial conduit is adherence is not inhibited, and the overall host response has
frequently employed. The history regarding synthetic con- been found to be similar to that of Dacron [60]. More recently,
duits, like much of surgical history, is long and much indebted heparin-bonded ePTFE grafts have become available for
to research pioneers. In 1952, Voorhees and Blakemore pub- clinical use. Early data have suggested that these grafts
lished a preliminary report describing the successful use of decrease platelet adherence and acute thrombus formation
Vinyon “N” cloth prostheses in the infrarenal aorta of mon- surface [61]. Animal models have also shown a reduction in
grel dogs [54]. Despite these limited successes, long-term anastomotic myointimal hyperplasia [62]. In 2009, The
durability would remain limited until the successful use of Propaten European Product Evaluation (PEPE II) study
the modern polymers polytetrafluoroethylene (PTFE) and showed that heparin-bonded ePTFE grafts yield patency
polyethylene terephthalate (Dacron). rates that are comparable to those obtained with other graft
material in infrainguinal bypass surgery [63]. At present,
Dacron however, improvements to graft patency remain to be dem-
Within the same time period of the early 1950s, DeBakey onstrated, and further clinical data will be required to ade-
went on to create the first Dacron tube graft for aortic recon- quately determine this. Despite such fundamental differences
struction [55]. Unlike the preceding experiments using nylon, in material composition, prospective randomized trials have
Dacron, a synthetic multifilament yarn, proved to be both a found PTFE and Dacron to be equally suitable for infraingui-
durable and suitable material for vascular reconstruction. nal bypass. Results from a trial published in 2001 showed no
Traditionally, Dacron grafts have either been woven or knit- differences between Dacron and PTFE with regard to pri-
ted, and modern grafts of both varieties continue to be manu- mary and secondary patency or limb salvage [64].
factured and used. Woven grafts do not rely on the looping of Consequently, the surgeon’s choice of PTFE versus Dacron
yarn around a needle, and because of this the resulting mate- for infrainguinal bypass in the operating room is truly based
rial has a decreased porosity [56]. The more compact nature on preference and not on clinical differences in graft perfor-
of woven grafts results in stronger fabric, but comes at the mance and patency.
cost of decreased compliance. The stiffness of the woven
graft is believed to make it more difficult to handle and
suture, and the fiber orientation enhances the potential of Endothelial Cell Seeding
fraying when cut in the operating room [56]. Conversely,
knitted Dacron results in a softer, more compliant material Early work with Dacron from the 1960s raised excitement
that likewise is more porous. The increased porosity of these over the finding of a complete endothelial lining present in
grafts makes them more susceptible to bleeding, and tradi- prosthetic grafts implanted into various animal species [65].
tionally knitted tube grafts were subjected to preclotting In stark contrast to this mature endothelium found within the
where the patient’s blood was passed through the graft prior arterial prostheses of baboons and pigs, however, was the
to surgical interposition so as to coat the pores with fibrin realization that humans grafts fail to achieve this re-endothe-
and minimize operative bleeding [57]. Modern knitted grafts lialization [66]. Knowledge that endothelial cells possess
are now manufactured with precoated materials, such as gel- anti-thrombotic properties and function to limit intimal
atin or collagen. hyperplasia, both primary obstacles to graft patency, led to
research investigating the potential role for endothelial cell
PTFE transplantation onto synthetic vascular grafts. In 1978,
Polytetrafluoroethylene (PTFE) first came into production in Herring et al. published their work using a canine model on
the 1930s, and by the early 1970s, an expanded form, ePTFE, arterial prostheses seeded with autogenous vascular endothe-
began to be used in animal models as an alternative to Dacron lium. The authors achieved this result by harvesting endothe-
in arterial reconstruction [58]. The first successful reported lial cells from saphenous vein using steel wool pledgets and
clinical use followed soon after in 1976 when Campbell et al. using the admixture to preclot Dacron grafts [67]. These
published their experience in using ePTFE in infrainguinal results were promising, and over the ensuing decade much
bypass [59]. Today, PTFE it is predominantly processed into effort would be placed into endothelial cell harvest optimiza-
expanded PTFE (ePTFE), and the extrusion process results tion and transplant, a process that came to be referred to as
in a porous morphology that microscopically is character- cell seeding.
ized by interconnected nodes and fibrils. Unlike the woven Further enthusiasm toward cell seeding would come from
or knitted characteristics of Dacron, ePTFE is a single seam- later animal studies demonstrating that ex-vivo endothelial
less structure. Despite being microporous, ePTFE has a low cell incorporation into synthetic grafts enhanced patency
friction coefficient making its surface smooth and hydropho- [68]. These results only further reinforced the belief that
bic. Although ePTFE’s hydrophobic property prevents development of mature endothelial cell surface was the miss-
hematogenous graft permeation, plasma and platelet surface ing link to maintaining long-term patency in synthetic arterial
114 C. Jadlowiec and A. Dardik

substitutes [68]. Concerns that remained to be reconciled, been less successful in providing similar insight and prog-
however, included whether any of the benefits ascribed to cell ress. The first report of human cell seeding came from
seeding in animal models actually conferred analogous Herring et al. in 1984. Using seeded and unseeded ePTFE,
human benefit [69]. In 1985, Rosenman et al. published the authors documented a 100 % patency for seeded femoral-
important work relating to the kinetics of endothelial cell popliteal bypasses at 18 months in comparison to 60 % in
adhesion to synthetic graft materials. Using carotid interposi- unseeded grafts [76]. Overall, however, results from further
tion ePTFE seeded grafts with 111indium oxide-labeled human clinical trials have been mixed, with many investiga-
endothelial cells, the authors were able to examine cell reten- tors finding no benefit [77]. The most promising long-term
tion following arterial implantation. Immediately following clinical cell seeding data come from work done by Zilla and
implantation, only 19.8 % of the originally seeded cells were colleagues. In a study published in 1999, the authors showed
found to be present, and, at 30 min, 70.2 % of these remain- a notable primary 9-year patency rate of 65 % in endothelial-
ing cells desquamated. Cell loss continued over the next 24 h, ized PTFE grafts versus 16 % in control non-seeded PTFE
at which time only 4.4 % of originally seeded cells remained grafts [78]. More recently in 2009, the same authors pub-
present [70]. These results were obviously unfavorable, and lished their long-term results using autologous in vitro
for much of the next decade, experimental work would focus endothelialization of infrainguinal ePTFE grafts. Over a span
on methods to improve endothelial cell adhesion. of 15 years, and inclusive of 341 infrainguinal endothelial-
The findings of poor endothelial cell retention coupled ized ePTFE grafts, the authors showed an overall femorop-
with, at best, modest improvements in graft patency greatly opliteal primary patency rate of 69 % at 5 years and 61 % at
diminished the surgical community’s enthusiasm for cell 10 years [79]. Unexpectedly, examination of retrieved ePTFE
seeding. As noted by Zilla, those who continued work with samples from this cohort revealed the presence of an endothe-
endothelial cell transplant were prepared to accept both a long lium on all samples after 38.9 ± 17.8 months, thus challeng-
and arduous route with the knowledge that their contribution ing prior cell seeding outcomes where long-term cell
would be a quiet one [71]. Not surprisingly, research using retention appeared difficult, if not impossible, to achieve
collagen or fibronectin pretreatment to synthetic grafts found [79]. The results of this group go on to suggest that in vitro
that endothelial cells adhered poorly to and did not grow on long-term endothelialization of synthetic grafts is not only
untreated Dacron and PTFE, while protein-treated materials clinically feasible, but that it also provides a patency benefit
facilitated cellular retention [72]. Differences were also noted in challenging patients without suitable autogenous vein.
between pre-treated Dacron and PTFE. Cells seeded onto
protein-treated PTFE were noted to form a confluent mono-
layer within 9 days, while the more irregular surface of
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 Arterial Transplantation for Limb
Salvage 16
Thomas Hölzenbein, Nina Mader, Manuela Aspalter,
Sophina Trubel, and Klaus Linni

Introduction and surgeon preference seem to be the main reasoning for

decision-making [5, 6]. The bypass procedure can be altered
Distal arterial bypass, despite being challenged by endovas- by using only short segments of vein connecting various
cular therapy, remains the cornerstone of distal revascular- distal target arteries, feeding this graft with an artificial
ization for peripheral arterial disease. The autologous graft: the bridge graft concept [8]. Yet, although technically
saphenous vein is regarded as the graft of choice for these feasible, the results of bypass in these circumstances do not
interventions [1]. It has proven its usefulness and durability match the results using the saphenous vein. In addition, it is
for short bypass grafts to the popliteal artery above and below difficult to compare the results of alternative autologous
the knee as well as for long distal reconstructions to tibial vein to bridge graft revascularization because many of these
and pedal target arteries [2]. Although there are reports advo- procedures are secondary or tertiary procedures done for
cating prosthetic grafts for primary bypass, the saphenous failed or failing distal bypass grafts. In these circumstances,
vein is unrivalled with regard to its versatility, infection resis- the target arteries are located at more distal sites, usually at
tance, and long-term performance. the tibial level, and the graft material is barely sufficient to
There are circumstances in which no saphenous vein is reach the distal target artery sites, even with a distal origin
available because of previous vein harvesting for coronary bypass grafts [9, 10].
bypass, previous leg revascularization, creation of an arte- When no autologous graft is available, only a few options
riovenous fistula for hemodialysis, or other procedures are possible. The surgeon may choose a prosthetic graft
requiring vascular graft material or after removal of the material such as expanded polytetrafluoroethylene (ePTFE)
vein for venous insufficiency. The vein can be of inferior or Dacron for bypass reconstruction. However, these grafts
quality because of inadequate size or postthrombotic have shown inferior long-term results with regard to infec-
changes. In these circumstances, the surgeon is forced to tion resistance and mid-term patency in infrapopliteal recon-
change the operative strategy and look for alternative graft structions [11].
material. The bypass surgery can be performed using alter- Homografts have been used since the beginning of recon-
native sources of autologous vein, such as the short saphen- structive vascular surgery, mainly for aortic and iliac recon-
ous vein [3], the arm veins [4, 5], or even the deep femoral struction. Initially, grafts were stored in chilled sterile saline
vein. Currently, there is no recommendation available about solution without any adjuncts. These grafts often failed because
the sequence in which these veins should be harvested for of aneurysmal degeneration and secondary rupture [12].
distal bypass, and the literature in that regard is not conclu- Improvements in preservation and cryopreservation tech-
sive [5–7]. There are no prospective comparisons of the niques have enhanced results of homograft reconstructions.
autologous alternative vein grafts available. Local policies However, the availability of artificial grafts and the develop-
ment of the all autologous vein policy have reduced the need
for homografts for distal revascularization [13, 14]. New inter-
est in homograft revascularization, especially in distal revas-
T. Hölzenbein, MD, PhD (*) • N. Mader, MD
M. Aspalter, MD • S. Trubel, MD • K. Linni, MD cularization, was driven by the need for a solution in patients
Department of Vascular and Endovascular Surgery, requiring extension of limb salvage after several failed previ-
PMU Salzburg, Müllner Hauptstrasse 48, ous revascularizations [15, 16]. In these patients, bypass with
Salzburg 5020, Austria
cryopreserved arterial or venous homografts (self-prepared or
e-mail: t.hoelzenbein@salk.at; n.mader@salk.at;
m.aspalter@salk.at; s.trubel@salk.at; commercially available) or fresh homografts (“transplanta-
k.linni@salk.at tion”) with or without subsequent immunosuppression can be

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 117
DOI 10.1007/978-1-4471-4429-8_16, © Springer-Verlag London 2013
118 T. Hölzenbein et al.

performed [17–19]. The concept of transplantation derived arteries are harvested under sterile conditions. In organ donor
from the observation that arteries in solid organ transplanta- procedures, both legs are prepped down to the proximal calf.
tion, except for cardiac grafts [20], virtually never occlude or For fresh homograft preparation, the artery is used from the
become aneurysmal, even after long-term follow-up. common iliac artery down to the tibioperoneal trunk.
Although technically possible, graft harvesting becomes
increasingly difficult more distally because of the depth of
Patient Selection the arteries and tibial artery side branches. With regard to
graft length, this corresponds to the saphenous vein taken
In our series, only patients with extensive limb-threatening from the groin down to the ankle. The hypogastric and pro-
arterial disease after exhaustion of all autologous vein sources funda femoris arteries are also harvested together for histo-
and no option for an intertibial or tibiopedal vein bridge graft logical purposes, viability tests, angiographic access, and
as outflow for a femerodistal ePTFE graft were selected for possible patch plasties in the recipient. Usually the right-
this procedure. Usually patients require bypass to a single sided artery is harvested. The organ harvest procedure has to
distal tibial or pedal artery. Patients are asked to sign a con- be slightly changed for the additional procurement of the
sent form in which the experimental nature of this procedure iliac arteries. As arterial homografts are usually harvested in
is explicitly mentioned. They have to be willing to undergo younger organ donors usually serving as multiorgan donors,
immunosuppressive therapy and a strict follow-up regimen. other arterial segments will be harvested from the transplant
After informed consent has been obtained, patients undergo teams. Usually both iliac bifurcations are taken for the liver
tissue typing, and all national transplant centers are informed and the pancreatic graft to serve as conduits. Arterial cannu-
to look for potential organ donors within their respective lation for organ perfusion, which is commonly performed
regional responsibility. through the right common iliac artery, should be carried out
through either an aortic access or preferably the contralateral
groin. This preserves the entire right iliofemoral arterial sys-
Organ Donor Selection tem for homograft procurement and allows harvest of the left
femoral artery as a conduit for the liver graft. The procure-
Younger individuals without peripheral arterial disease or ment can be done either simultaneously with the transplant
major trauma to the legs may serve as donors for bypass teams or after harvest of the solid organs, depending upon
grafts. Otherwise, the same criteria as for solid organ donors the time and availability of surgical teams.
apply. These donors usually serve as multiorgan donors, and The artery is harvested by leaving the entire artery in its
several solid organs and other tissues can be harvested. bed and just ligating the side branches is situ. As most vasa
Arteries as well as veins can be harvested. Whereas the vasorum of the femoral artery initiates at the origin of side
saphenous vein is relatively easy to harvest and can be taken branches, side branch flush ligation must be avoided, and
from the groin to the ankle, the vein is often damaged because side branches should be ligated 1 or 2 mm from the main
of lack of surgical experience, time constraints, or judgment, stem in order to preserve these arteries. It is important to
yielding only short segments of usable vein. These segments determine the length of the graft before excision of the artery.
may well serve as hemodialysis grafts, but seldom as single- After systemic heparinization, the artery is removed and
segment distal bypass grafts. Arteries are more difficult to rinsed thoroughly with the organ perfusion solution used for
harvest, requiring more advanced surgical skills, and greater the respective organ donor. We have used Eurocollins solu-
care has to be taken during procurement. The probable graft tion, HTK solution, and UW solution and found no differ-
length should be known before harvest, and a body height ence with regard to graft patency or infection. The graft is
match between the donor and recipient is desirable, avoiding then stored in a small batch of perfusate and packed in sev-
problems with graft length at implantation. ABO compatibil- eral sterile bags, similar to an organ transplant graft, and pre-
ity between the donor and recipient should be observed. HLA pared for further transport on ice in an insulation bag.
matching may be of importance for later graft rejection, but
HLA mismatch or a positive crossmatch is not an exclusion
criterion for fresh arterial homograft transplantation [21]. Graft Description and Documentation

If the organ procurement team is different from the implanta-

Graft Procurement tion team, it is necessary to submit a detailed description of
the graft harvested. This is similar to solid organ transplanta-
Homografts can be obtained from either heart-beating organ tion and includes basic details of the organ donor (sex, blood
donors or post mortem, depending on whether one has cho- group, previous medical history, basic laboratory tests, viral
sen fresh or cryopreserved homografts. In both cases, the antibodies, location of the explantation, and exact time of
16 Arterial Transplantation for Limb Salvage 119

excision), a vial of peripheral blood or a small piece of spleen A blood levels are determined at every visit. Duplex is car-
or lymph node for crossmatching with the recipient, infor- ried out every 6 months to look for aneurysms or signs of
mation on the perfusate, length of the graft before removal, rejection. Antithrombotic therapy is carried out with oral
description of the graft anatomy, presence of major side anticoagulation with phenprocoumon (Marcoumar®) up to
branches (hypogastric artery, profunda femoris artery), and an INR of 2.5 and 100 mg of salicylic acid (ThromboASS®).
areas of inferior quality or injuries. This is continued until definite graft failure.

Cold Ischemia Time Immunosuppressive Therapy

There are no reports on the limits of the cold ischemia time of Several of our patients are already on immunosuppres-
these grafts. Although it is probable that arteries and veins sive therapy for a solid organ transplant (cardiac trans-
can tolerate extended cold ischemia up to 48 h, we have never plant, kidney transplant) [22]. All other patients receive a
tested these limits and have implanted the grafts as soon as mild immunosuppressive regimen with low-dose cortisone,
possible in order to assure viability of the transplanted graft. cyclosporin A (Sandimmun®) [23], and mycophenolate
mofetil (Cellcept®) [24]. Immunosuppressive therapy is con-
tinued until definite graft failure. Cyclosporin A levels are
Graft Implantation adjusted to 80–110 ng/ml. Immunosuppressive therapy in
these patients is a challenge because of their poor functional
Graft implantation follows standard surgical principles of status and medical comorbidities. Many of the patients pres-
bypass surgery. Usually sufficient graft length is available, so ent with moderate renal insufficiency, making therapy with
proximal and distal anastomotic sites can be chosen at conve- cyclosporin A difficult even with moderate blood levels. As
nient locations to avoid extremely scarred regions, such as the most of the patients are diabetic, a cortisone-free immuno-
groin. The graft is then removed from the sterile bag, swabs suppressive therapy would be of advantage [25].
are taken from the transport solution for bacteriology, and the
graft is rinsed with cold heparinized saline solution. Clips are
removed and exchanged for ligatures. After proper heparini- Graft Rejection
zation of the recipient patient and a single shot of 120 mg
prednisolone-21-sodium-hydrosuccinate (Solu-Dacortine®), Graft rejection is difficult to determine in these patients and
the proximal anastomosis is performed first with standard can only be proven by the presence of antibodies [26] or his-
suturing techniques. The graft is then perfused with blood. tology of a perfused segment of artery [27]. Initially, we
The artery will distend considerably and lengthen back almost hoped that the long large branches of the donor profunda and
to its initial configuration. The graft is then tunneled as donor hypogastric artery would remain patent for some time
desired and placed into the tunnel with some tension. The to allow for histological evaluation in case of suspected graft
graft is then trimmed, and the distal anastomosis is performed rejection. However, these side branches tend to thrombose
with standard suturing techniques. After flushing, the anasto- within the first months of bypass function. Graft samples can
mosis is opened. The trimmed graft segment is then sent to be obtained, but always after graft thrombosis. There have
the laboratory for viability tests and histology. A completion been some signs of lymphocyte accumulation in the graft
angiogram is then performed using the hypogastric artery or arterial wall in some cases, but clear signs of structural
the deep femoral artery of the graft as access site. The arteries destruction as a sign of severe rejection have not been seen in
are then tied off, leaving some extra length, which may serve our experience. Often reversible intimal thickening can be
as a biopsy site for confirmation of rejection or an access site observed in these grafts, which could be reduced by elevat-
for later thrombectomy. In order to have easy access to the ing the level of cyclosporin A. Although this could possibly
grafts routinely, we choose the subcutaneous space. be a sign of graft rejection, we cannot prove this to date; The
usefulness of duplex surveillance in these patients is cur-
rently under further investigation.
Postoperative Follow-up

Patients receive a postoperative MR angiogram before dis- Late Problems

charge. Patients are seen weekly until their wounds heal
completely and every 6 weeks thereafter. Healing of the Fresh arterial homografts need intense medical attention to
wound seems somewhat slower than expected, and this is keep them going on a long-term basis. We have performed
attributed to the immunosuppressive therapy. Cyclosporin repeated thrombectomies and patch plasties at the site of
120 T. Hölzenbein et al.

Fig. 16.1 Pre- and postoperative angiogram of a patient undergoing artery. Panel b shows a postoperative follow-up angiogram 2 years
arterial transplantation. The patient had undergone eight pervious after the procedure with moderate aneurysmal degeneration of
vascular procedures on the left leg after varicose vein surgery the graft
35 years ago. Panel a shows distal runoff via the posterior tibial

pseudoaneurysms. We could not determine whether these procedures are performed with autologous vein. The
pseudoaneurysms were at the sites of side branches, sites of remainder of the bypass procedures comprises bridge grafts,
early donor atherosclerosis, or randomly distributed within and only 1.5 % of all infrainguinal bypass procedures are
the graft. These small patch plasties have been performed performed with arterial homografts. This is not because of
with remnants of vein, such as the lesser saphenous vein or a shortage of these grafts. Austria has very liberal organ
arm vein. donation legislation in which every patient experiencing
irreversible brain death may become a potential organ
donor. Despite increasing donor age, the average waiting
Results time for a fresh arterial homograft is 2 weeks. This proce-
dure, although not entirely experimental, is reserved for
Our patients undergoing fresh arterial homograft transplan- patients in whom no other option is available (Fig. 16.2) or
tations usually have undergone multiple previous vascular who are under immunosuppressive therapy for a solid organ
surgeries, and all of them have been operated on for limb transplant.
salvage. Under these difficult circumstances, we have
achieved a 1 year limb salvage of 75 %, which otherwise
would be impossible [28]. Life quality was acceptable in Conclusion
these patients despite several follow-up interventions because Fresh arterial homograft for distal bypass with moderate
open as well as endovascular interventions [29] could be immunosuppressive therapy seems to be a promising
done under local anesthesia, with short hospital stays way to go in selected patients with distal arterial disease
(Fig. 16.1). who are difficult to manage. It is unclear whether fresh
or cryopreserved homografts are the way to go or if arte-
rial or venous homografts perform better. Careful graft
Frequency procurement by surgeons with vascular surgery experi-
ence is of great advantage. Patient and donor selection
Fresh arterial homograft implantation is an infrequent pro- together with careful follow-up is a key for success in
cedure. We are trying hard to follow an all autologous vein these patients and will lead to gratifying results [18, 19,
bypass policy, and about 95 % of all infrainguinal bypass 22, 28, 30].
16 Arterial Transplantation for Limb Salvage 121

a c

Fig. 16.2 Pre.- and postoperative view of the same patient as shown in skin graft heals nicely. Panel c: The lesion is completely healed 3 years
Fig. 16.1. Panel a: Extensive gangrene on the anterior aspect of the calf after the procedure, and the patient is essentially symptom free.
prevented artificial graft use. Patient was MRSA positive. Panel b: After Nevertheless, occasional thrombectomies are necessary to maintain
revascularization, debridement, and vacuum therapy, a split thickness graft function

8. Deutsch M, Meinhart J, Howanietz N, Fröschl A, Heine B, Moidl

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 Part V
Vascular Trauma
 Disseminated Intravascular
Coagulation in Vascular Trauma 17
Ramyar Gilani, Peter I. Tsai, Matthew J. Wall Jr.,
and Kenneth L. Mattox

Introduction Coagulation and Fibrinolysis

A principal function of the vascular system is to maintain In a normal state, a continuous equilibrium between the
structural integrity to allow for normal physiologic activity. blood vessels and blood is maintained among endothelium,
Insults to this delicate framework due to various forms of blood cells, and coagulation proteins. This balance allows
traumatic injury severely disrupt the dynamic homeostatic for blood to remain fluid and flow while preparedness for
environment of the vascular and hematologic systems, result- desired hemostasis is assured. Once a source of trauma is
ing in physiologic derangements – not only within the local introduced and vessel architecture is disrupted, a normal
setting, but also within the global host environment. physiologic response designed to achieve hemostasis is initi-
Disruption of vessel architecture often manifests as either ated. This response seems to be advantageous for the cessa-
hemorrhage or thrombosis, which leads to subsequent shock tion of hemorrhage; however, excessive coagulation can lead
and ischemia. The resulting shift in homeostasis places phys- to undesired thrombosis and ischemia.
iologic stress on nearly every organ system in the body, The endothelium within vessels is a critical component of
including the system of coagulation. Corrective maneuvers the balance between fluid state and coagulation. Functionally,
employed by clinicians addressing hemorrhage and coagul- vascular endothelium regulates blood flow, cellular adhe-
opathy intend to restore normal function of coagulation and sion, and coagulation. Normal endothelium is a non-throm-
while doing so can often simultaneously lead to undesired bogenic coating that is metabolically active with both
deleterious effects. This chapter discusses the normal bal- antithrombotic and prothrombotic properties. The antithrom-
ance of the vascular and hematologic systems, describe the botic activity of endothelium is modulated through its struc-
local and systemic sequelae of vascular trauma in reference ture and synthesis of anticoagulants. The continuous layer
to coagulation, and review the therapies utilized for treating prevents circulating platelets and plasma proteins to contact
disturbances in coagulation. the highly thrombogenic subendothelial matrix [1].
Endothelial cells produce prostacyclin, nitric oxide, and ade-
nosine phosphatase, which are known to inhibit platelet
aggregation. They also synthesize tissue plasminogen activa-
R. Gilani, MD tor (t-PA), which plays a key role in fibrinolysis [2]. Further,
Division of Vascular Surgery and Endovascular Therapy of Michael E.
anticoagulants depend on membrane expression of heparin-
DeBakey, Department of Surgery, Baylor College of Medicine,
Houston, TX, USA like molecules and thrombomodulin by endothelial cells for
activity [3]. In addition to their antithrombotic activities,
P.I. Tsai, MD
Cardiothoracic Surgery, Ben Taub General Hospital, endothelial cells have synthetic functions that are prothrom-
Houston, TX, USA botic. These cells secrete a highly thrombogenic subendothe-
M.J. Wall Jr., MD lial extracellular matrix that binds platelets [1]. Other
Cardiothoracic Surgery, Trauma and Critical Care, prothrombotic synthesis products of endothelial cells include
Baylor College of Medicine, von Willebrand factor (vWF), tissue factor, and plasminogen
Houston, TX, USA
activator inhibitors (PAIs) [4].
K.L. Mattox, MD (*) Circulating platelets play a key role in maintaining coagu-
Michael E. DeBakey Department of Surgery,
lation readiness. Normally, platelets are sequestered from
Baylor College of Medicine,
Houston, TX, USA contact with the extracellular matrix by the endothelium,
e-mail: kmattox@aol.com; plisa@aol.com; redstart@aol.com thus preventing activation. These circulating platelets contain

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 125
DOI 10.1007/978-1-4471-4429-8_17, © Springer-Verlag London 2013
126 R. Gilani et al.

Fig. 17.1 Contemporary TF + FVII

Kallikrein
depiction of the blood coagula- HMWK
tion cascade FXlI FXlIa
TFPI
Ca++
FX FIX FXl

TF-FVIIa complex
FV
FXla FVIII

FXa FIXa FVIIIa

FIXa-FVIIIa-Ca++-PL
complex

Prothrombin Thrombin

Fibrinogen Fibrin

Ca++
FXIII
Stable fibrin clot

TF : Tissue factor TFPI : Tissue factor pathway inhibitor

PL : Phospholipid : Negative effect
HMWK : High-molecular weight : Positive effect
kininogen Williams-Fitzgerald
Flaujaec factor

numerous granules containing a myriad of modulating cytok- that are normally quiescent within the circulation until a trig-
ines and chemokines. In the setting of vascular injury, plate- gering mechanism is encountered. The overall schema is best
lets contact the extracellular matrix, which sets off a sequence represented by two activating pathways, the intrinsic and
of platelet-mediated activity that is essential to normal hemo- extrinsic pathways, converging into a common pathway lead-
stasis [5]. Initially, platelets undergo adhesion to the extra- ing to the formation of thrombin.
cellular matrix, which is dependent upon interaction between The intrinsic pathway does not require interaction with
vWF and platelet surface receptors such as glycoprotein Ib the injured vessel wall, but rather a negatively charged sur-
[6]. After adhesion, platelet activation and subsequent secre- face. In the laboratory, this surface can be glass or kaolin;
tion of secretory granules occur. This then leads to further however, the physiologic surface is unknown [7]. Regardless,
platelet activation and aggregation, and the coagulation the initiating step occurs with the activation of factor XII. It
intrinsic pathway is prompted. The enlarging mass of aggre- is not clear what role the intrinsic pathway plays in vivo,
gating platelets forms what is known as the primary hemo- despite understanding that deficiencies in the pathway can
static plug, the first step in achieving hemostasis. At this lead to severe bleeding disorders, such as hemophilia.
point, platelet aggregation is reversible; however, ongoing Activation of the extrinsic pathway is initiated through
activation of coagulation ultimately leads to fibrin deposition the release of tissue factor from the subendothelium due to
within the plug, becoming irreversible and creating the more injury. The released tissue factor then comes into contact
stable secondary hemostatic plug. with factor VII, thus beginning the cascade. There is evi-
The final step in achieving hemostasis involves activation dence to suggest that the tissue factor-factor VII pathway is
of the clotting cascade, ultimately resulting in the formation the predominant mechanism for in vivo coagulation [8]. Both
of stable fibrin clot. This process occurs through a sequence of routes lead to the activation of factor X, thus initiating the
enzymatic reactions leading up to the formation of fibrin common pathway leading to fibrin formation and deposition
(Fig. 17.1) and involving activation of coagulation factors resulting in a stabilized clot and secondary hemostasis.
17 Disseminated Intravascular Coagulation in Vascular Trauma 127

Also within the coagulation cascade are mechanisms exert- active hemorrhage of whole blood, shock, and systemic
ing anti-thrombotic control. Antithrombin III (ATIII) is inflammatory response. Damage to the layers of the vessel
thought to be the principal inhibitor of coagulation factors [9]. wall may cause cessation of blood flow, thrombosis, and dis-
It targets most factors, notably factors IIa and Xa, and requires tal shock. Often times, there is overlap between both path-
heparin as a cofactor to increase efficiency. Protein C is another ways, creating local and systemic responses affecting
naturally occurring anticoagulant, the effects of which stem coagulation [13].
from its ability to inactivate factors Va and VIIIa [10]. Activity Ongoing hemorrhage begins to produce signs of hemor-
of protein C requires the presence of cofactor protein S. Low rhagic shock once 15 % of blood volume is lost. As hemor-
levels of both protein C and S are risk factors for thrombo- rhage continues, signs of hypotension, tachycardia, and
philia [11]. malperfusion intensify. Blood volume loss beyond 40 % is
Opposing the processes of primary and secondary hemo- immediately life-threatening [14]. With the onset of hemor-
stasis in a state of equilibrium is the system of fibrinolysis. rhagic shock, a variety of changes begin to take place in a
Objectively, fibrinolysis serves to break down fibrin and pro- cascade of closely involved events.
vide control measures on excessive or undesired thrombosis. Shock, specifically hemorrhagic shock, is a known trigger
However, excessive or unopposed fibrinolysis can lead to for a systemic inflammatory response, resulting in the release
coagulopathy and hemorrhage. The principle component in of inflammatory mediators secondary to injury. One of the
the fibrinolysis system is the activation of plasminogen to first mediators is tumor necrosis alpha (TNF-a), and once
plasmin by t-PA. Once a vessel sustains injury, t-PA, located released, it triggers the release of other mediators, such as
within the endothelium, is released at the site of injury, which interleukin-1 (IL-1) and IL-6. On its own, TNF-a causes
then initiates the pathway resulting in plasmin degradation of vasodilation and has procoagulant activity [15]. TNF-a,
fibrin into fibrin split products. This process is kept local- IL-1, and IL-6 all invoke endothelial cells to release tissue
ized, partly because of the specificity of t-PA for plasmino- factor (TF) and thus trigger the coagulation cascade
gen bound to fibrin. Also, within the circulation, systemically.
alpha2-antiplasmin binds circulating plasmin, thus inhibiting As expected, normal coagulation commences locally at
it and preventing systemic fibrinolysis [12]. the site of injury. However, this may not be adequate to arrest
Further inhibition of fibrinolysis is provided by mediators hemorrhage, and continued bleeding ensues until surgical
known as plasminogen activator inhibitors (PAIs). PAIs are correction. Activated clotting at sites of injury leads to con-
contained within platelets and endothelium, and as their sumption of platelets and coagulation factors as well as fibrin
name implies, they bind and inhibit t-PA. Activated platelets deposition. With ongoing consumption exceeding reserves,
and an injured endothelium release PAIs in high concentra- thrombocytopenia and hypofibrinogenemia occur, leading to
tion. Fibrinolysis is therefore paramount. The balance a consumptive coagulopathy. The balance between coagula-
between coagulation and fibrinolysis exists in a dynamic tion and fibrinolysis shifts to favor clot dissolution and also
state involving many participants to achieve the desired explains the late observed fibrinolysis.
hemostasis and prevent unwanted thrombosis. During the Bleeding trauma patients often experience hypothermia,
maintenance phase of these processes, appropriate amounts which has known deleterious effects on coagulation. As body
of substrate are present with normal metabolic activity. temperature declines, potential energy for enzymatic activity
However, the stress of vascular trauma quickly alters system dissipates. The reactions of coagulation require enzymatic
requirements, resulting in shifts to the dynamic state in an activity and are therefore slowed with decreases in body tem-
attempt to maintain homeostasis. Unfortunately, demand on perature. Beyond 34 °C, impairment of coagulation becomes
the system often exceeds capability, which requires external significant [16]. The level of derangement is not evident on
forces to reestablish the delicate balance. routine laboratory tests as the samples are warmed to 37 °C
prior to testing. Platelet function is also impacted by hypo-
thermia. In addition to reduction in platelet enzymatic func-
Impact of Vascular Trauma tion, production of thromboxane A2 is reduced, which results
in vasodilation and reduced platelet aggregation, leading to
Trauma to the vascular system can cause significant disrup- microvascular bleeding [17].
tion in the flow of blood, leading to hemorrhage and throm-
bosis, thus initiating a complex sequence of events designed
to maintain homeostasis in the setting of injury. Injuries may Mechanisms of DIC
be penetrating or blunt trauma, with penetrating injuries
being more common. Once a vessel sustains an insult, two Disseminated intravascular coagulation is a syndrome
pathophysiologic pathways are responsible for the resulting describing systemic observances due to derangements in
sequelae acutely. Disruption of the vessel wall can lead to activated coagulation and fibrinolysis and occurs because
128 R. Gilani et al.

of some underlying etiology [18]. Trauma is a known ini- Management Strategies for DIC in Vascular
tiator of DIC, which is found in 50–70 % of trauma Trauma
patients [19]. DIC can be variable, from mild to life-
threatening, and has identifiable stages indicating constant Treatment principles for managing DIC focus on first cor-
progression. Clinically, manifestations include thrombo- recting the underlying cause and then attempting to reestab-
sis, coagulopathy, hemorrhage, and multiorgan system lish homeostasis. Attempts at halting the progression of DIC,
failure. Once initiated, coagulation derangements can once the systemic cascade has been initiated, are ineffective
become severe, and goal of therapy is to treat the underly- until the impetus has been removed. In vascular trauma,
ing cause and restore the normal balance between coagu- focus should also be placed on prevention, as once DIC
lation and fibrinolysis. begins to progress, the deleterious effects can be quite devas-
The precipitating event in DIC is tissue factor (TF) activa- tating. Therefore, triggering mechanisms associated with
tion of the coagulation cascade leading to fibrin deposition. vascular trauma should be avoided or mitigated through con-
Mediators, such interleukin-1 (IL-1), IL-6, and tumor necro- scious efforts, recognizing the consequences of ignoring
sis factor alpha (TNF-a), play a key role in the release of TF them.
from the subendothelium [20]. The subsequent activation of Hemorrhage control is paramount in vascular trauma, not
the extrinsic pathway via factor VIIa ultimately leads to gen- only because uncontrolled bleeding is eventually lethal, but
eration of factor Xa and extensive thrombin formation and also because it places severe stress on physiologic reserves,
fibrin deposition [21]. In addition, the resulting endothelial and corrections have additional negative effects. Therefore,
damage results in platelet activation and aggregation, caus- without expeditious vascular control, all other maneuvers are
ing platelet consumption. futile. While attempting to stop hemorrhage, however, other
Normal opposing mechanisms to thrombosis are also maneuvers intended to lessen the impact of blood loss should
impaired in DIC. Levels of antithrombin III are found to be not be ignored. A damage control strategy designed to lessen
low in DIC. Normal levels of protein C and S are also the physiologic impact of surgery should be considered even
decreased [20]. Furthermore, fibrinolysis activity is depressed before the onset of operation. During the initial damage con-
secondary to increased levels of plasminogen activator inhib- trol strategy, there is little role for complex vascular recon-
itor (PAI) [22]. This systemic coagulation=exaggerated acti- structions, and simple, expeditious, and efficacious techniques
vation leads to consumption of substrate for coagulation and should be all that are utilized.
defines phase I of DIC [23]. Microthrombi also form within While ongoing hemorrhage ensues, consumption of coag-
organ system vascular beds, causing thrombosis and organ ulation components occurs, which can lead to exhaustion of
ischemia, which lead to organ dysfunction. reserves. Targeted blood component therapy should be initi-
As phase I continues, consumption ultimately exceeds ated once large-volume blood loss is anticipated. Routine
available reserves, and the system of coagulation begins laboratory evaluations often offer delayed results in the anal-
to decompensate, defining phase II of DIC. At this point, ysis of the current status of coagulation and are unreliable.
laboratory evaluation demonstrates increased prothrom- The thromboelastogram (TEG) has a role in trauma, as
bin time (PT) and partial thromboplastin time (PTT). results can be generated and acted upon rapidly. However,
However, thrombin time (TT) may still be normal because waiting for laboratory evaluation of coagulation status should
of the remaining normal levels of fibrinogen. Further not delay blood component therapy. A transfusion strategy
ongoing consumption eventually exhausts the system using a 1:1:1 ratio of packed red blood cells (pRBCs), fresh
completely, resulting in phase III of DIC [23]. Once reach- frozen plasma (FFP), and platelets (PLTs) is utilized and
ing this point, laboratory clotting times are markedly adjusted according to need. Effective transfusion practice is
increased, platelet counts have dropped, and fibrinogen facilitated by prior arrangements of protocols for use in situ-
levels are now also low, as are levels of other coagulation ations of massive transfusion.
factors. With extreme systemic coagulation insufficiency, With active ongoing hemorrhage and fluid resuscitation,
generalized hemorrhage is an associated clinical finding hypothermia is almost inevitable. Also, with large areas of
with phase III DIC. skin exposure, maintenance of body temperature and correc-
Ongoing fibrin deposition generates increasing levels of tion of hypothermia are quite difficult. Therefore, the sur-
plasmin, which has a protective role in lysing the generated rounding environment must be maintained in order to maintain
microthrombi and restoring the microcirculation within the core body temperature. Utilization of active warming
organs, and should not be inhibited [24]. As plasmin produc- maneuvers should be initiated early to prevent hypothermia
tion continues in combination with coagulation exhaustion, from occurring. Keeping operative times to a minimum will
secondary thrombolysis ensues. Although partly protective, also help to reduce heat loss and its consequences.
this secondary thrombolysis forces the balance further toward Ischemia and the resulting acidosis from shock, thrombo-
coagulopathy and undesirable hemorrhage. sis, and even vascular control have a definite impact on
17 Disseminated Intravascular Coagulation in Vascular Trauma 129

coagulation, so attempts should be made to minimize the 4. Lijnen HR, Collen D. Mechanisms of physiological fibrinolysis.
impact of ischemia and acidosis on coagulation. The hemo- Baillieres Clin Haematol. 1995;8(2):277–90.
5. Packham MA. Role of platelets in thrombosis and hemostasis. Can
dynamic status needs constant attention to optimize end organ J Physiol Pharmacol. 1994;72(3):278–84.
perfusion through volume additions or inotropic support. In 6. Cruz MA, Yuan H, Lee JR, Wise RJ, Handin RI. Interaction of the
the setting of thrombosis, rapid restoration of blood flow von Willebrand factor (vWF) with collagen. Localization of the pri-
helps decrease the ischemic time and subsequent acidosis. mary collagen-binding site by analysis of recombinant vWF a
domain polypeptides. J Biol Chem. 1995;270(18):10822–7.
Cross-clamping for vascular control must be recognized as 7. Scully MF. The biochemistry of blood clotting: the digestion of a
acidosis provoking. Furthermore, supra-celiac clamping and liquid to form a solid. Essays Biochem. 1992;27:17–36.
the resulting hepatic ischemic time in addition to other vital 8. Broze Jr GJ. The role of tissue factor pathway inhibitor in a revised
abdominal organs have implications of further worsening coagulation cascade. Semin Hematol. 1992;29(3):159–69.
9. Pratt CW, Church FC. Antithrombin: structure and function. Semin
coagulopathy, and clamp times must be kept to a minimum. Hematol. 1991;28(1):3–9.
Despite incorporating all possible preventable maneuvers, 10. Esmon CT. Molecular events that control the protein C anticoagu-
DIC can be unavoidable. Once surgical hemorrhage control lant pathway. Thromb Haemost. 1993;70(1):29–35.
has been achieved, treatment must focus on returning the 11. Dahlbäck B. The protein C anticoagulant system: inherited defects
as basis for venous thrombosis. Thromb Res. 1995;77(1):1–43.
balance of coagulation. Frequent laboratory assessment of 12. Müllertz S, Clemmensen I. The primary inhibitor of plasmin in
clotting should be performed, with targeted therapy employed human plasma. Biochem J. 1976;159(3):545–53.
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Although it may be counterintuitive, anti-thrombolytic ther- characterization of an inhibitor of plasminogen activator in human
platelets. J Clin Invest. 1984;74(4):1465–72.
apy should not be incorporated, as the observed fibrinolysis 14. American College of Surgeons Committee on Trauma. Advanced
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15. Akira S, Hirano T, Taga T, Kishimoto T. Biology of multifunctional
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Vascular trauma and its subsequent effects have a profound hypothermia on enzyme speed, platelet function, and fibrinolytic
activity. J Trauma. 1998;44(5):846–54.
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 Temporary Intravascular Shunt
in Complex Vascular Injury 18
Ding Wei-wei and Li Jie-shou

Despite the decline in the overall amputation rate associated the management of arterial injuries. The shunts were irrigated
with lower limb vascular injury, complex vascular injuries of with heparin to maintain patency at that time. Later, surgeons
the extremities accompanied by skeletal fractures or soft tis- extended the use of shunts to arterial injuries associated with
sue destruction still result in a high rate of limb loss of up to fractures and dislocations and supported the utility of this
20 % [5]. The austere environment, limited instrumentation rational approach in selected civilian patients with complex
and operating room (OR) availability, large number of wounds upper and lower limb vascular injuries [7, 11–15] and recently
encountered, (with many of them being relatively severe), and as a component of damage control management in patients
the front-line surgical team’s paucity of experience with vas- with severe multisystem trauma [16].
cular anastomosis complicate the performance of definitive Temporary intravascular shunting of major vascular inju-
vascular repairs [6]. Ligation, balloon occlusion, or clamping ries requiring complex repair has the potential advantage of
of an injured blood vessel in an extremity may prevent exsan- facilitating rapid control of hemorrhage and restoring flow
guination; however, irreversible tissue loss will occur if too distally while permitting deferment of definitive repair to
much time elapses while other injuries are treated [7]. higher echelons of care where more resources and expertise
Complex repairs including end-to-end anastomosis, saphen- are available. Typically, these temporary intravascular shunts
ous vein grafts, and vascular prosthesis transplantation are are used in combined orthopedic and vascular injuries or
time-consuming, and in the cold, a coagulopathic, exsan- damage control surgery (DCS). Temporary shunts interrupt
guinating patient may develop disastrous outcomes, such as the warm ischemic time, providing a time window in which
infection, amputation, thrombosis, and death. The front-line to carry out other tests or treatments and allowing eventual
surgical team needs an easy and reliable hemostasis facility return to the vascular injury [7]. Similarly, use of these vas-
so that distal perfusion can be maintained. cular shunts may reduce the risk of amputation of potentially
The concept of temporarily bridging the vessel gap or salvageable extremities.
intravascular shunting to maintain distal blood flow is not The evidence for the value of temporary intravascular
new. Silver tubes were first used in 1915 [8], and encouraging shunts as a DCS adjunct technique mainly depends on per-
results were reported in 1922 during World War I [6]. Glass sonal experiences. This systemic review first summarize the
[9] and plastic [2] tubes were then used during World War I1 type, configuration, duration, indications, and complications
to maintain perfusion of the injured limb while collaterals of the temporary intravascular shunts used as an adjunct to
developed. After that, shunts were abandoned because of the DCS in severe vascular injuries.
long evacuation times and the high incidence of shunt throm-
bosis. In 1971, Eger et al. [10] was the first documented
author to pioneer the use of temporary intravascular shunts in What Can Be Used As Temporary
Intravascular Shunts?
D. Wei-wei, MD, PhD (*)
Department of General Surgery, Nanjing General Hospital of Nanjing How to choose the shunt material and configuration presum-
Military Command, Institute of People’s Liberation Army for General ably depends on the experience and preference of the trauma
Surgery, The Clinical College of the Nanjing University Medical
surgeon. The use of commercial and self-made tubes of dif-
School, Nanjing, Jiangsu, China
e-mail: dingwei_nju@hotmail.com ferent diameters for intravascular shunts has been reported
(listed in Table 18.1).
Li Jie-shou
Department of Surgery, Jinling Hospital, Medical School of Nanjing Commercially available shunts (i.e., Javid, Sundt, Argyle,
University, Nanjing, Jiangsu 210002, China and Pruitt-Inahara carotid shunts) are first designed to provide

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 131
DOI 10.1007/978-1-4471-4429-8_18, © Springer-Verlag London 2013
 132

Table 18.1 Cumulative review of temporary intravascular shunts used as damage control surgery adjuncts for treating complex vascular injuries
Year Author Type Configuration N Duration Patency rate Distribution Systemic anticoagulation
1971 Eger PVC tube T-shaped 36 ND ND ULAV Yes
1979 Majeski Javid Looped 2 210 min 100 % (2/2) ULAV ND
1981 Nunley Sundt Straight 8 ND 100 % (8/8) ULAV ND
Ventriculoperitoneal shunts Straight
1984 Eggink ND T-shaped ND ND ND ND ND
1986 Khalil Javid Straight 5 2–6 h 100 % (5/5) LEAV No
Balloon-type shunts Straight
Nasogastric tube Straight
1986 Nichols Javid and Sundt Looped 13 127 min 100 % (13/13) ULAV No
1989 Johansen PVC intravenous tube Looped 1 16 h 100 % (1/1) LEAV No
1992 Husain PVC Suction catheter ND 5 3–6 h 100 % (5/5) LEA No
1995 Reilly Javid Straight 1 36 h 100 % (1/1) SMA No
1996 Starr ND ND 3 ND 100 % (3/3) LEA No
1999 Reber Heyer-Schulte carotid shunt T-shaped 7 90–390 min 100 % (7/7) ULAV No
2000 Granchi Argyle Straight 19 47–3,130 min 100 % (19/19) ULAV No
2002 Sriussadaporn PVC intravenous and extension Looped 7 60–180 min 100 % (7/7) LEAV No
tube
2003 Parry Argyle Straight 18 22 h 100 % (18/18) LEA No
thoracostomy tube Straight
Pruitt-Inahara T-shaped
2003 Rozycki Chest tube Straight 13 24–54 h 83 % (15/18) ULAV No
Angiocatheter Straight
Argyle Straight
Pruitt-Inahara T-shaped
2004 Hossny PVC Suction catheter Straight 7 ND 100 % (7/7) LEAV No
2004 Nalbandian ND Looped 1 24 h 100 % (1/1) LEAV No
2006 Rasmussen Javid Straight 30 2h 86 %a(19/22) ULAV No
Argyle Straight 12 %b(1/8)
2006 Chambers Javid and Sundt Straight 20 <6 h 78 % (21/27) ULAV No
Abbreviations: ND not determined, SMA superior mesenteric artery, PVC polyvinylchloride, ULAV upper and lower extremity artery and vein, LEAV lower extremity artery and vein, LEA lower
extremity artery, LEV lower extremity venous
a
Proximal shunt
b
Distal shunt
D. Wei-wei and L. Jie-shou
18 Temporary Intravascular Shunt in Complex Vascular Injury 133

temporary carotid bypasses for cerebral circulation during Chambers et al. [6] suggested to avoid looping of the shunts
carotid endarterectomy procedures, and now they are widely to help minimize both the resistance to flow and likelihood of
used as an adjunct to DCS in severe vascular injuries. dislodgment as both complications occurred intraoperatively
The Sundt shunt (internal and external) is constructed of sili- early in their military experience. They advocated ensuring
cone elastomer with stainless steel spring reinforcement to min- the shunt lies straight; they needed a significant length to lie
imize kinking and occlusion of the cannula lumen and to aid in within the vessel lumen above and below the site of injury.
the ease of insertion of the proximal and distal ends [17]. The
ends of the shunt have cone-shaped bulbs to facilitate fixation of
the shunt in the vessel. The bulb fits so firmly against the wall of How Long Can the Shunt Stay Patent?
the vessel that there is no bleeding around the distal bulb.
The Javid shunt has fusiform swellings at each end and is The success rate of arterial revascularization is inversely pro-
held in place by external clamps [18]. It is most commonly portional to the duration of the ischemic time. According to
used in the superficial femoral artery and vein [19]. Argyle the histological studies of Malan [26], the critical warm isch-
shunts are usually used in the tibial and brachial arteries. emic time for striated muscle is 6–8 h. Blood flow must be
Both the Argyle and Javid are in-line shunts, while the few reestablished within this time to avoid irreversible muscle and
Sundt shunts are either in-line or looped. However, in the nerve damage. The presence of soft tissue loss, disruption of
military experiences in Iraq, Rasmussen et al. [19] did not arterial and venous collateral vessels, or hypotension may
see any differences in patency rates among the Javid, Sundt, further decrease the length of this critical period. After vascu-
and Argyle shunts, although the patient number was small. lar shunts have been inserted, potentially life-threatening
The Pruitt-Inahara shunt is the same length as the Javid, injuries to the head, chest, or abdomen can be diagnosed and
but is held in place by incorporated inflatable balloons at treated in a more orderly fashion. Similarly, use of these vas-
each end. They are dual-lumen devices with balloons at both cular shunts can prevent the need for the amputation of poten-
the distal and proximal ends of the shunt with a T-piece. The tially salvageable extremities because of the prolonged
balloons, when inflated independently, act as a stabilization ischemic time during other operative procedures. Therefore,
mechanism to maintain the position of the shunt when it is the amount of time the intravascular shunt can maintain pat-
placed within the arteries. An external safety balloon located ency is of importance to the trauma surgeon.
on the inflation arm leading to the distal balloon acts as a The reported shunt times in the literature ranged from a
mechanism to relieve pressure on the distal balloon in the couple of minutes to as long as several days. The longest
event it inflates above maximum stated volume. The external shunt time of up to 10 days occurred in a civilian case (David
safety balloon feature reduces the possibility of balloon V. Feliciano, Atlanta, GA, 2009 personal communication).
overinflation and resultant vessel damage [18, 20]. The But the longest dwell time recorded in the literature was
Pruitt-Inahara carotid shunt instantly verifies pulsatile flow, reported by Granchi [25], who demonstrated that shunts could
and an arteriogram can be performed to verify flow to the be left in place and maintained distal perfusion for up to 52 h
hand or foot. Its occlusion balloons eliminate the need for without systemic anticoagulation in complex extremity inju-
clamps, thereby reducing vessel trauma, using a small inci- ries. Although Rozycki et al. [24] reported a dwell time of 54
sion, minimal dissection, and a short arteriotomy [21]. h for a Pruitt-Inahara shunt left in the brachial artery, this
Self-made shunts such as the endotracheal suction cathe- shunt was occluded at reoperation, resulting amputation in
ter [13, 22], nasogastric tube [15], ventriculoperitoneal shunt the end. Intravascular shunts have been used to maintain the
[23], thoracostomy tube [21, 24], and angiocatheter [24] are vascular patency of the extremities, with times ranging from
readily available in various sizes, inexpensive, and non-toxic. 12 to 17 h in three patients undergoing air transfer to a level I
The Indian surgeon Husain et al. [13] reported the inexpen- trauma center for definitive care [27]. No evidence of shunt
sive and easily available polyvinylchloride (PVC) disposable thrombosis or distal emboli was observed. However,
endotracheal suction catheters, which were successfully used Rasmussen et al. [19] argued that in war time maintaining the
as temporary intravascular shunts in five popliteal artery shunt patency for 2 h is sufficient because of fast evacuation
trauma patients during the delay between the time of injury patterns and relatively fewer shunt-related complications.
or presentation and the vascular repair. The shunts provided Experimentally, Ding compared four different shunt
good outcomes with all limbs viable without complications. indwelling times in previously established superior mesen-
Choosing the right shunt diameter size is critical. However, teric artery (SMA) injury models [28] and aimed to deter-
the surgeon selects the shunt size mostly based on clinical mine the safest duration in the setting of DCS. Their study
experience and estimation of vessel size [25]. One principle suggested that TIVS can be used as an important DCS adjunct
is that it is essential to never have an oversized shunt in order to maintain patency safely for 6 h (Fig 18.1); however,
to minimize endothelium dysfunction. Many authors prefer prolonged duration of an indwelling vascular shunt (over
to loop the shunt while securing it in vessel. However, 9 h) caused endothelial injury in such SMA injuries in the
134 D. Wei-wei and L. Jie-shou

a b

Fig 18.1 After re-establishment of intestinal circulation with a tempo- intravascular shunt in situ, which was inserted to the proximal and distal
rary intravascular shunt, the entire small bowel regained normal color end of transected SMA
and vigorous peristaltic activity (a). (b) A close view of the temporary

setting of DCS [29]. Their recent study [30] showed that pro- angulation of the extremity [6], and periodical distal detec-
longed indwelling time of temporary vascular shunts is asso- tion using an ultrasound machine [32].
ciated with increased endothelial injury, and, when possible,
vascular reconstruction following the use of shunts should
include an interposition graft after debridement of the arte- Must Systemic Anticoagulation
rial edges that interfaced with the shunt. Finally, to minimize Be Administered?
intimal injury to the native vessel, this model suggests that
the indwell times of shunts should be <9 h. Trauma surgeons may expect the shunt to stay patent as long
Aldridge et al. [31] found that heparin-bonded polyvinyl- as possible so that they do not need to hurry when carrying
chloride intravascular shunts remained patent in the iliac cir- out difficult and uncontrollable surgery on dying patients.
culation for a 24-h period. They noted no distal embolization Another issue is that the shunt may clot without anticoagula-
from the arterial shunts during the observation period and no tion therapy during the recovery period [34].
increase in coagulation factor, platelet consumption, or red Despite administration of systemic heparin to their
blood cell destruction. Dawson et al [32] demonstrated in a patients, Wagner et al. [35] reported a limb salvage rate of
swine model that a temporary arterial shunt could maintain 85 % after blunt popliteal trauma, which is close to the sal-
patency with adequate distal perfusion for up to 24 h without vage rate of 84 % reported by Hafez et al. [36], although they
systemic anticoagulation. did not use systemic heparin. Daugherty et al. [37] have used
Duration of patency is affected by multiple technical and systemic anticoagulation in all popliteal artery trauma
physiologic factors. Several technical considerations appear patients without untoward effects; it would perhaps be more
to be beneficial in minimizing shunt occlusion: performance prudent to withhold systemic heparinization in such patients,
of distal fasciotomy [6], reestablishment of major venous particularly those with multiple injuries.
outflow before arterial shunt in cases of concurrent arterial Massive transfusions with possible hypothermia and dilu-
and venous injuries [12, 14, 32, 33], avoiding looping of the tional coagulopathy often complicate making the decision
shunts [6], appropriate shunt diameter [24], avoiding external about anticoagulation. As shown in Table 18.1, most authors
18 Temporary Intravascular Shunt in Complex Vascular Injury 135

don’t agree about administering systemic anticoagulation. arterial repair is performed as the initial step and none of the
Administering systemic anticoagulation may increase wound non-arterial injuries take priority.
bleeding and thwart attempts at hemostasis [32].
Hypothetically, the patency of the shunt and perfusion of the
limb might be jeopardized if anticoagulation is withheld, but Complex Vascular Extremity Injuries
the patient’s life is threatened by renewed or continued bleed-
ing if anticoagulation is given. This approach raises a variety Vascular injuries of the upper and lower extremities associ-
of questions regarding shunt application in devastating vas- ated with fracture dislocation, neurovascular disruption,
cular injury. In particular, the timing of reoperation and the multiple systemic injuries, and extensive soft tissue crushing
need for controlled therapeutic anticoagulation once the ini- injuries are considered to be the indications for temporary
tial coagulopathy has been corrected are unclear. Instead, intravascular shunts. Vascular injuries of the upper and lower
according to many authors’ experiences [13, 15, 19, 25, 32], limbs in the presence of extensive soft tissue loss, fractures,
local irrigation of the proximal and distal arterial segments or other life-threatening injuries are associated with a high
with heparinized saline is performed to effect some local amputation rate [15]. Rapid reperfusion of the extremity via
anticoagulation. They advocated avoiding systemic antico- such shunts permits more comprehensive evaluation and
agulation because of the risks of bleeding or worsening of management of the other associated injuries than would be
existing coagulopathy. The coagulopathic state that damage possible in the presence of prolonged ischemia.
control patients exhibited would lend itself to shunt patency Several studies have demonstrated the safety and utility of
rather than thrombosis. temporary arterial shunts for combined arterial and orthope-
With the development of heparin-bonded shunts, it seems dic injuries. Majeski et al. [41] in 1979 recommended a stan-
likely that these patients may better tolerate temporary intra- dard Javid shunt for early revascularization of limbs with
vascular shunting while damage control part II (recovering) arterial injuries to minimize the ischemic time. According to
is being undertaken without systemic anticoagulation. Reber et al. [12], using an initial temporary intravascular
Ultimately, it may improve both morbidity and mortality in shunt in selected patients with combined skeletal and vascular
this difficult patient population. injury of the upper or lower limbs may reduce the number of
complications resulting from prolonged ischemia and permits
an unhurried and reasonable sequence of treatment. In 1982,
Indications Johansen et al. defined the criteria for “complex vascular inju-
ries” and advocated the routine use of shunts in their manage-
There has been debate concerning the order of management in ment [27]. Hossny et al. [22] recommended routine use of
combined skeletal and vascular trauma with proponents argu- shunts in patients with complete lower limb ischemia caused
ing in favor of performing arterial repair first [38, 39] and oth- by blunt popliteal artery trauma in their clinical observation.
ers favoring skeletal fixation as the initial mode of therapy [16, They compared the benefits of routine use of a temporary
40]. However, the crucial denominator in these injuries that intraluminal shunt in 8 shunt patients with 13 no-shunt
heralds an adverse outcome is the relentless progression of patients with complete limb ischemia caused by blunt
warm ischemia and its unforgiving effect on striated muscle. popliteal trauma. Insertion of a shunt succeeded in maintain-
Temporary intravascular shunting eliminated the dilemma. ing the total ischemic time within the same preoperative isch-
Definitely, temporary intravascular shunting should not be emic interval in all eight patients, whereas the total ischemic
used in all major limb vascular injuries, and in clean sharp ampu- time was within the time interval after the preoperative inter-
tation patients who arrive in the operating room within 2 or 3 h of val in all but two patients in the non-shunt group. The shunt
injury, its use by the trauma surgeon is not recommended [23]. patients had a lower fasciotomy rate (14.3 vs. 70 %), a smaller
The use of shunts in patients with severe vascular injury mean number of repeat operations (0.8 vs. 1.9), shorter mean
can improve the overall outcome by reducing the intraopera- hospital stay (14.4 vs. 23 days), and an obviously lower
tive ischemic time and hence shortening the total ischemic amputation rate (0 vs. 40 %). Rasmussen et al. [19] described
time. The time that can be saved with shunting is the time the largest series from the central level III echelon facility in
needed to harvest the saphenous vein, fashion the graft, con- the Iraq conflict. In this article, 30 of 53 (57 %) patients who
struct the anastomosis, repair other life-threatening injuries, were transferred from the front line to the central trauma cen-
and correct the lethal triangle (hypothermia, acidosis, and ter had temporary shunts in place. Chambers et al. [6] sum-
coagulopathy) before definitive vascular repair. These proce- marized their experiences from a 6-month rotation during
dures prolong the intraoperative ischemic time, and conse- Operation Iraqi Freedom (OIF) and supported the use of the
quently the total ischemic time, in the non-shunt patients. TVS option by front-line surgical teams as an effective means
Shunting is more effective in minimizing the intraoperative of obtaining rapid control of extremity hemorrhages while
ischemic time than in the situation in which rapid definitive simultaneously re-establishing distal flow.
136 D. Wei-wei and L. Jie-shou

Damage Control Surgery for Severe the injury, can replace the shunt quickly without significant
Visceral Vascular Injuries blood loss or interruption of perfusion.
Shunt occlusion occurs relatively more frequent. It is usu-
Using damage control surgery, firstly advocated by Rotondo ally not a problem during the first few hours postoperatively
[16], survival rates in patients with major vascular and mul- because the patient is coagulopathic. However, after the
tiple visceral injuries can be greatly improved [42–44]. patient is rewarmed and coagulation has been restored, it is
Though we cannot predict with certainty who will die after not uncommon to encounter sudden occlusion of the shunt.
DCS, shunt placement offers a direct benefit to the surgeon This usually manifests as a difference in color, temperature,
who must choose between a protracted and dangerous arte- or capillary filling between the two extremities and occasion-
rial reconstruction or a precipitous amputation [45]. The ally the absence of a distal Doppler signal, which has been
temporary arterial shunt provides another option that allows documented previously. Consideration should then be given
the surgeon to abbreviate the operation without sacrificing to the feasibility of a vascular reconstructive procedure. This
the limb. would preferably occur at a second operation, but can be per-
The use of an intravascular shunt in the visceral circula- formed in the SICU if early shunt occlusion occurs in a patient
tion is rare [21]. Reilly et al. [16] described the first and the [45]. Thrombosis may also occur because the vessels that are
unique clinical application of an intraluminal shunt to a small at baseline are prone to significant spasm in injured
patient to maintain temporary vascular continuity of the patients who are cold and in shock, which limits outflow and
superior mesenteric artery during rewarming and correction patency [19]. Thrombectomy should be performed in this
of coagulopathy in the intensive care unit following a gun- situation. Intimal disruption while inserting the shunt and
shot wound to the abdomen. The patient died because of securing it in the vascular lumen greatly influences the early
aspiration pneumonia on day 63 after injury; however, the patency of the anastomosis. Generally, the shunts should not
autopsy of the intestines showed no evidence of ischemic be oversized in case of endothelial denaturation [25].
changes, and the SMA graft was patent. Although shunt-related complications have been noted by
surgeons [12] and some refuse to use them because of the
complications [46], the actual rate is low. Hossny [22]
Shunt Used During Transfer to a Higher reported no technical complications in shunt insertions and
Trauma Center no shunt-related complications such as shunt dislodgement
or distal embolization in their eight shunt patients. More than
Temporary intravascular shunts can be used while transfer- 90 % of shunt patients reported in literature did not develop
ring patients to a higher or more experienced trauma center. any complications (listed in Table 18.1).
Johansen et al. [27] described the use of a polyethylene shunt Long-term follow-up of shunt patients seems too difficult.
inserted into the ends of a lacerated superficial femoral artery An attempt to contact all patients for return visits was imprac-
before a 950-mile air evacuation. Anticoagulation was not tical. More detailed research is needed to evaluate the long-
used. This shunt remained patent for over 16 h during the term complications of intravascular shunts. Further
transfer, and arterial repair was able to be performed, although experience is needed to more definitively determine the use-
development of compartment syndrome led to later amputa- fulness of temporary intravascular shunts in trauma patients
tion. Surgeons in remote locations or practicing outside of a in both military and civilian conditions. Expanded use of
trauma center, especially those without significant vascular shunts in other unligatable arteries or veins, such as the supe-
surgery experience, should consider shunt insertion as a sim- rior mesenteric artery, portal vein, and iliac vessels, is worth
pler alternative to surgical reconstruction when faced with a considering in further research. The optimal shunt type or
patient with a complex limb injury. material, the most appropriate dwell time, the safest proce-
dures for inserting shunts, and the right time to carry out
shunting are unclear.
Complications

Dislodgment, occlusion, infection, and hemorrhaging may References

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 Part VI
Venous Diseases
 Metalloproteinases in Acute
Venous Occlusion 19
Anita C. Thomas

Abbreviations Introduction

AP Antiplasmin Acute venous thrombosis is a life-threatening event proceed-

AT Antithrombin ing from altered blood flow, abnormalities in the vessel wall,
col Collagen and changes in blood components (Virchow’s triad).
DVT Deep vein thrombosis Aberrations in the coagulatory and fibrinolytic pathways
ECM Extracellular matrix contribute to the altered blood components, but other blood
F Factor proteases also have roles to play [1].
GF Growth factor
IFN Interferon
IL Interleukin Matrix Metalloproteinases
LDL Low density lipoprotein
LPS Lipopolysaccharide Matrix metalloproteinases (MMPs, matrixins) are a family
LRP Low density lipoprotein receptor-related protein of highly conserved, neutral, zinc-dependent peptidases, of
MG Macroglobulin which at least 14 are to be found in the vasculature [2, 3].
MMP Matrix metalloproteinase They are known to play major roles in embryology, morpho-
PAI Plasminogen activator inhibitor genesis, reproduction, disease, and wound repair [4, 5] as the
PDGF Platelet-derived growth factor major regulators of extracellular matrix (ECM), but their
ROS Reactive oxygen species activity is not restricted to matrix turnover. They are also
TF Tissue factor involved in cell communication and the activation and release
TFPI Tissue factor pathway inhibitor of growth factors (GFs) and other bioactive molecules from
TGF Transforming growth factor the matrix; they also have nonmatrix substrates [2–7]. There
TIMP Tissue inhibitor of metalloproteinase are many interactions between the thrombotic, fibrinolytic,
TLR Toll-like receptor and MMP pathways. For example, MMPs are known to pre-
TM Thrombomodulin vent the activity of two of the important anticoagulant path-
TNF Tissue necrosis factor way regulators, tissue factor pathway inhibitor (TFPI) and
tPA Tissue plasminogen activator antithrombin (AT), and to be activated by a third pathway
uPA Urokinase plasminogen activator regulator, protein C; smooth muscle cell migration (which
vWF von Willebrand factor requires matrix remodelling) is facilitated by urokinase and
tissue plasminogen activators (uPAs and tPAs, respectively);
several MMPs are capable of degrading plasminogen; the
plasma proteases plasmin, thrombin, uPA, and activated fac-
tor Xa may activate pro-MMP-1, -2, -3, -7, -9, -10, and -13
[2, 5–13]. The use of MMP-10 as a thrombolytic treatment
has also been the subject of a patent (US application
A.C. Thomas, PhD 20110091436). The particular focus of this chapter is the
Department of Cardiovascular Surgery - Bristol Heart Institute,
strong links between venous thrombosis and MMP produc-
7th Floor, Queens Building, Bristol Royal Infirmary,
Bristol BS2 8HW, UK tion and activation, with MMP activity a requirement for
e-mail: a.thomas@bristol.ac.uk thrombus resolution [2, 12, 14, 15]. Figure 19.1 outlines

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 141
DOI 10.1007/978-1-4471-4429-8_19, © Springer-Verlag London 2013
142 A.C. Thomas

Fig. 19.1 Diagram outlining the MMP-12, -13, -14

Collagen Vessel injury MMP-1, -7, -9, -12
considerable overlap between the
coagulatory, fibrinolytic, and
matrix metalloproteinase (MMP) FXII TFPI
systems Neutrophil elastase
ECM
(versican)
FXI FVII-TF α2-MG

ECM
(heparan sulphate)
FX TM + thrombin

vWF FVIII-FIX AT Protein C

Heparin MMP11
cofactor II
TIMP-2
MMP-2
TM
ECM
(dermatan sulphate)

Thrombin Prothrombin
MMP-1, -2, -3, -7, Neutrophil elastase
-8, -9, -12, -13, -14

Fibrinogen Fibrin FXIII, FVIII

XLF Fibrin degradation products
(including D-dimer)

uPA α1-AT
MMP-9
Plasmin MMP-3
MMP-1, -8
tPA

MMP-11 PAI
MMP-3
MMP-9
MMP-2, -3, -7, -9, -12 MMP-2
α2-AP MMP-11

Plasminogen
FXII Plasmin α2-MG
MMP-14 (Mini-plasmin)
(Neutrophil elastase) MMP-15
MMP-16 TIMP-3

GF ECM ECM degradation products

MMP-1
vWF
MMP-3
MMP-7
MMP-9
MMP-10 MMP-9
MMP-12
MMP-13 TIMPs Nitric oxide
MMP-2 + ROS

Activates/permits
Deactivates/prevents
19 Metalloproteinases in Acute Venous Occlusion 143

many of the complex relationships between the coagulatory, Origin of MMPs in the Blood and Vasculature
fibrinolytic, and MMP systems, while the various activities
of MMPs are expanded in Table 19.1. Platelets contain the gelatinases MMP-2 and -9 in their cyto-
MMP activity is regulated at several levels: gene induc- plasm and within platelet granules [21], but these MMPs can
tion, vesicle trafficking, secretion (not all MMPs), and pro- exhibit contradictory effects in thrombus formation. MMP-2
form activation. MMPs are also regulated by their stimulates platelet aggregation, with maximal release at
differential temporal and spatial expression. They can form maximum platelet aggregation. MMP-9, however, opposes
complexes with their specific inhibitors, the tissue inhibi- the MMP-2 effect by inhibiting aggregation. Its release from
tors of MMPs (TIMPs), but plasma proteases, including platelets is maximal at 30 % aggregation [22]. MMP-1 and
a2-macroglobulin (a2-MG), can also inhibit MMPs [2, 4, -3 have also been identified in platelets, as have TIMP-1 and
11, 12]. While many MMPs are expressed as inactive pre- -4; the presence of MMP-1 is thought to prime the platelets
proforms, the membrane-type MMPs (MMP-14, -15, -16, for aggregation, while MMP-3 has no effect on aggregation
-17) and MMP-11, -21, -23, and -27 are activated during [21, 23]. Platelet adhesion results in the release of MMP-1
processing along the endosomal pathway [2, 11]. Pro- and -2, with possible activation of the pro-MMP-1 by the
MMPs can be activated by many processes, including platelets [21, 23]. During the onset of thrombosis, platelets
chemical (via reactive oxygen species or nitric oxide, for release tissue factor (TF) from their a-granules to complex
example) and biological means (e.g., GFs, MMPs, or with FVIIa and initiate coagulation. However, platelets also
plasma proteinases) [2–4, 11]. secrete TFPI, which antagonizes the initiation of coagulation
(Fig. 19.1). MMP-1, -7, -9, -13, and neutrophil surface pro-
teases are all capable of degrading TFPI, thus allowing coag-
MMPs in Peripheral Blood ulation progression [2, 8, 13, 19].
Neutrophils secrete MMP-2, -8, and -9 from various stor-
Most of the components of blood and the vessel wall are age granules, as well as cathepsins and other matrix proteases
capable of producing or interacting with MMPs. Culture [2, 13, 19, 24]. MMP-2 and -9 are released from gelatinase
studies suggest that MMP-1 expression may be increased granules within neutrophils [19] to become activated and
during hyperglycemia, while diabetes is also associated influence coagulation and fibrinolysis (Fig. 19.1). MMP-2,
with altered MMP gene expression [16, 17]. Patients with -3, -7, -9, and -12 can cleave plasminogen to produce
type 2 diabetes have elevated levels of MMP-2 and TIMP-1 angiostatin, an angiogenesis inhibitor, while further angio-
protein, but not MMP-9, with MMP expression indepen- genesis inhibitors are produced from cleaved collagens.
dent of age, duration of diabetes, blood pressure, or serum Other matrix components, released from the ECM after pro-
lipid concentration [16], while both MMP-2 and -9 are tease activity, can contribute to the inhibition of coagulation
elevated in serum from patients with type 1 diabetes [17]. [4, 25, 26]. Neutrophil elastase, a serine protease, is also
Several studies have measured MMP levels in plasma and important in thrombus formation and resolution. It has the
serum, but since the absolute concentration of various capacity to control fibrin generation (altering clot stability by
MMPs is now known to be dependent on how the blood inactivating TFPI) and to degrade fibrin (both directly and
sample was collected and stored [18], the accuracy of indirectly via its effect on plasminogen activation) [19, 24].
many measurements is uncertain. Nevertheless, it seems Neutrophil elastase cleaves plasminogen to form mini-
that there are localized differences in MMP levels in plasminogen, which is readily activated to form mini-plasmin,
plasma due to differences in the secretion of MMPs from without need of any cofactors. Mini-plasmin is more efficient
the cells of the blood (predominantly platelets, neutrophils, at degrading cross-linked fibrin than normal plasmin and is
monocytes) and the artery wall (endothelial cells, smooth considerably less sensitive to a2-antiplasmin (a2-AP) inhibi-
muscle cells, macrophages, fibroblasts). These different tion [19], but many MMPs can degrade fibrinogen indepen-
concentrations of proteases, in conjunction with the differ- dently of plasmin [4]. Plasmin-degraded clots disassemble
ing numbers of platelets, neutrophils, and erythrocytes, abruptly, releasing large particles into the circulation, possi-
result in differential lysis of the clot. Platelet-rich (“arte- bly resulting in thromboemboli. Elastase-degraded clots
rial” or “white”) clots contain fibrin fiber that are more release soluble (not particulate) products into the blood [19,
resistant to fibrinolysis and retract more strongly than 20]. These differences in thrombus stability and plasmin
platelet-poor (“venous” or “red”) clots [19]. Both platelet- activity will have a significant influence on thrombus resolu-
rich and platelet-poor clots can be found in veins [1]. Thus, tion in blood vessels.
fibrinolysis in venous thrombi may be heterogeneous, leav- Monocytes rapidly upregulate their production of
ing channels in the clot (“recanalization”) through the MMP-9 on contact with endothelial cells, matrix compo-
platelet-poor regions [19, 20]. nents (including collagen), fibrinogen, or inflammatory
Table 19.1 MMP production and activation and substrates
144

MMP Alternative name Produced by Activated by Substrate – vessel wall Substrate – blood Other References
MMP-1 Collagenase-1, Smooth muscle cells, MMP-3, -7, -12, Col1, col2, col3, col7, TFPI, fibrin(ogen), (Pro-)IL-1b, pro-MMP-1, -2, [2–5, 7, 8, 11, 28,
interstitial collagenase endothelial cells, plasmin, activated col8, col10, col11, a1-AT, a2-MG pro-TNF-a, Complement 1q 33]
macrophages, mono- platelets gelatin, laminin,
cytes, platelets vitronectin, aggrecan,
tenascin, fibronectin,
perlican
MMP-2 Gelatinase-A Smooth muscle cells, MMP-11, -14, -15, Col1, col3 col4,col5, Fibrin(ogen), thrombin, (Pro)-IL-1b, IL-2 receptor-a, [2–7, 11, 12, 16,
endothelial cells, -16, ROS, thrombin, col7, col10, col11, a1-AT, plasminogen endothelin, adrenomedullin, 19, 22, 23, 28,
macrophages, mono- FXa, uPA, tPA, laminin, elastin, gelatin, platelet integrins, pro-TGF-b, 33, 41, 50, 51]
cytes, neutrophils, neutrophil elastase fibronectin, chondroitin pro-TNF-a, pro-MMP-1, -2, -13,
fibroblasts, platelets, sulphate, decorin, Complement 1q, monocyte
cardiomyocytes osteonectin, aggrecan, chemoattractant protein-3,
vitronectin fibroblast GF receptor
MMP-3 Stromelysin-1 Smooth muscle cells, Plasmin, cathepsins, Broad range Fibrin(ogen), PAI-1, Pro-MMP-1, -3, -7, -8, -9, -13, [2–4, 6, 7, 9, 11,
endothelial cells, mast cell proteases a2-AP, uPA, plasmino- E-cadherin, pro-IL-1b, pro-hepa- 33, 41, 50, 51]
macrophages, mono- gen, a1-AT rin-binding EGF-like GF,
cytes, cardiomyocytes pro-TNF-a, Complement 1q
MMP-7 Matrilysin-1, PUMP-1 Macrophages, mono- Plasmin, cathepsins, Broad range Fibrin(ogen), TFPI, Pro-a-defensin, Fas ligand, [2, 3, 6, 8, 10, 11,
cytes, fibroblasts mast cell proteases plasminogen, a1-AT pro-TNF-a, E-cadherin, RANK 28]
epithelial cells ligand, heparin-binding EGF-like
GF
MMP-8 Collaginase-2, Smooth muscle cells, Col1, col2, col3, col7, Fibrinogen, a1-AT, Pro-MMP-8, complement 1q [2, 5, 6, 28, 51]
neutrophil collagenase endothelial cells, col10, gelatin, tenascin, a2-MG
macrophages, mono- aggrecan
cytes, neutrophils
MMP-9 Gelatinase-B Smooth muscle cells, Plasmin MMP-3, -7, Col1, col4, col5, col7, TFPI, fibrin(ogen), Angiogenic fragments, (pro)-IL- [2–4, 7, 8, 11, 12,
endothelial cells, -11, -12, tissue col10, col11, col14, a1-AT, plasminogen, 1b, IL-2 receptor-a, IL-10, 22, 28]
macrophages, mono- kallikrein, nitric laminin, elastin, gelatin, other serpins, a2-MG vascular endothelial GF, (pro-)
cytes, neutrophils, oxide, ROS, osteonectin, galactin-3, TGF-b, intercellular adhesion
platelets cathepsins, mast cell fibronectin, aggrecan, molecule-1, pro-TNF-a,
proteases, uPA, tPA vitronectin Complement 1q, IL-2 receptor-a
MMP- Stromelysin-2 Endothelial cells, MMP-11, plasmin, Broad range Fibrinogen Pro-MMP-1, -7, -8, -9 [2, 4, 5, 7, 11,
10 monocytes, fibroblasts, plasma kallikrein, 28]
NK-cells, T-cells, trypsin, neutrophil
chondrocytes elastase
MMP- Stromelysin-3 Smooth muscle cells, Activated Very weak PAI, a2-AP, a2-MG, [2, 29, 51]
11 endothelial cells, intracellularly AT, other serpins
macrophagesa,
carcinomas, placenta,
uterus
A.C. Thomas
 19
MMP- Macrophage Macrophages, mono- Plasmin, cathepsins, Col1, col4, elastin, FXII, fibrinogen, TFPI, Pro-TNF-a [2–6, 8, 11, 19,
12 metalloelastase cytes, chondrocytes, mast cell proteases fibronectin, laminin, plasminogen, a2-MG, 28, 33, 51]
osteocytes aggrecan, gelatin a1-AT
MMP- Collagenase-3 Smooth muscle cells, MMP-2, -14, -15, Col1, col2, col3, col6, FXII, fibrinogen, Pro-MMP-9, -13, complement 1q [2–7, 11, 41, 51]
13 endothelial cells, -16, plasmin, trypsin col7, col9, col10, col14, a2-MG
macrophages, osteonectin, perlican,
fibroblasts, fibronectin, gelatin,
cardiomyocytes aggrecan, tenascin
MMP- MT1-MMP Endothelial cells, Activated Col1, col2, col3, laminin, FXII, fibrin(ogen), Pro-MMP-2, -13 [2–5, 10, 11, 28,
14 macrophages, intracellularly gelatin, fibronectin, a2-MG, a1-AT 51]
monocytes vitronectin, aggrecan
MMP- MT2-MMP Smooth muscle cells, Activated Gelatin, fibronectin, Transglutaminase Pro-MMP-2, (pro-)TNF-a, LRP [2, 5]
15 endothelial cells, T-cells, intracellularly vitronectin, collagen,
NK-cells aggrecan, tenascin,
perlican
MMP- MT3-MMP Smooth muscle cells, Activated Col3, gelatin, fibronectin, a2-MG, a1-AT, LRP Pro-MMP-2 [2, 4, 5]
16 endothelial cells, intracellularly vitronectin, collagen,
Metalloproteinases in Acute Venous Occlusion

macrophages, T-cells aggrecan

MMP- MT4-MMP Endothelial cells, Activated Gelatin Fibrin(ogen), LRP Pro-MMP-2 [2]
17 macrophages, mono- intracellularly
cytes, B-cells
MMP- RASI (rheumatoid Smooth muscle cells, Col1, col4, laminin, Fibrin(ogen) [3–5, 28]
19 arthritis synovial endothelial cells, basement membrane,
inflammation) macrophages, mono- fibronectin, aggrecan,
cytes, activated cartilage oligomeric
lymphocytes, matrix protein, gelatin
keratinocytes
MMP- Enamelysin Tooth enamel Amelogenin, aggrecan, [5, 11]
20 cartilage oligomeric
matrix protein
MMP- Cysteine array Monocytes, foam cells, Laminin, gelatin [5, 11, 28],
23 (CA)-MMP fibroblasts, epithelial personal
cells, chondrocytes observation
MMP- MT5-MMP Brain specific Activated Gelatin, fibronectin, pro-MMP-2 [3, 5, 11]
24 intracellularly vitronectin, collagen,
aggrecan
MMP- MT6-MMP Peripheral blood Activated Col4, gelatin, laminin, Fibrin Pro-MMP-2 [5, 11]
25 leukocytes intracellularly fibronectin
MMP- Matrilysin-2, Endometrium Col4, fibronectin, gelatin a1-AT, fibrinogen MMP-9 [5, 11]
26 endometase
MMP- C-MMP, MMP-22 Fibroblasts Gelatin, casein Autolysis [11]
27
a
Not produced in monocytes
145
146 A.C. Thomas

mediators [such as tissue necrosis factor-a (TNF-a), Role of MMPs in Coagulation, Thrombosis
lipopolysaccharide (LPS), or oxidised low-density lipopro- Formation, and Fibrinolysis
tein (LDL)] [2, 27, 28]. MMP-12, -14, and -16 (but not
MMP-1 or -3) production in monocytes is also upregulated Every member of the MMP family is capable of degrading
by inflammatory cytokines, while contact with CD40 ligand components of the vascular ECM, but their substrates are not
upregulates MMP-1, -3, -8, -9, and -11 expression [2, 29]. limited to matrix. Many MMPs are active in the propagation
Interestingly, monocytes treated with an MMP-9 inhibitor and resolution of thrombosis (Table 19.1).
lose the ability to aggregate upon contact with fibrinogen
(despite fibrinogen’s ability to activate proinflammatory
pathways in monocytes), suggesting the presence of an MMPs in Haemorrhage
autocrine mechanism in this process [27]. Monocytes also
express MMP-10, -19, and -23 [2, 28]. These changes in The gelatinases, MMP-2 and MMP-9, have been implicated
monocyte MMP production are thought to facilitate entry in aneurysm formation, acute neurovascular events, and
of these cells into the vessel wall, where they can become unstable atherosclerotic plaque structure [40]. Elevated
macrophages. Tissue macrophages express MMP-13, -14, MMP-9 levels in plasma have also been associated with cere-
and -16, while foamy macrophages (macrophages that have bral haemorrhage and perihaematomal oedema, with a nega-
migrated into the vessel wall and have become lipid-laden) tive association of the MMP-9 inhibitor TIMP-1 [41]. Patients
have upregulated production of MMP-1, -3, -8, -9, -13, and with acute intracerebral haemorrhage also have more MMP-
-23. Both foamy and non-foamy macrophages constitu- 3, which is associated with increased mortality [41]. This
tively secrete TIMP-1, -2, and -3 [2, 29–34] (also personal increase in MMP-3 production may occur through the inter-
observations). action of tPA and low-density lipoprotein receptor-related
The vessel wall is lined by thrombo-resistant endothe- protein (LRP) on endothelial cells [42]. Animal studies sup-
lial cells, which have constitutive MMP-2 expression. port these findings, as MMP-9 null mice also have increased
MMP-1, -3, -8, -9, and -11 levels are upregulated by incidence of cerebral haemorrhage and oedema, with
inflammatory cytokines, or exposure to macrophages, oxi- increased mortality [43]. There is at least partial compensa-
dised LDL, or CD40 ligand [2, 29]. MMP-1 and -2 expres- tion for the missing MMP-9 in knockout animals by an
sion may also be upregulated by high glucose levels [2]. increase in MMP-2 and MMP-3 levels in areas of cerebral
These results suggest that inflammation and immune haemorrhage. A similar compensatory increase in MMP-2
mechanisms are associated with MMP production by expression has also been observed in vein grafts in MMP-9
endothelial cells. Endothelial cells also express MMP-13 null mice [44].
and the inhibitors TIMP-1 and -2, which are not responsive
to oxidised LDL. TIMP-2, however, may be upregulated in
response to CD40 ligand [2, 35], while TIMP-1 is induced MMPs in DVT Resolution
by prostaglandins and a wide variety of cytokines, includ-
ing transforming GF (TGF)-β and platelet-derived growth Venous thromboembolism [deep vein thrombosis (DVT) and
factor (PDGF) [36]. pulmonary embolism] is a common cause of cardiovascular-
Vascular smooth muscle cells constitutively express associated mortality and is associated with thrombi that are
MMP-2, production of which is further upregulated by stretch rich in fibrin [1]. DVT resolution often involves re-canalisa-
and reactive oxygen species; MMP-9 expression can also be tion (clot retraction, fibrinolysis, and angiogenesis) and
upregulated [2, 37, 38]. Smooth muscle cells appear to be infiltration by leukocytes and other cells [45, 46]. The first
subject to immune activation, as the presence of inflammatory leukocytes to appear in the thrombi are neutrophils and
cytokines such as interleukin-1 (IL-1), IL-4, and TNF-a, or monocytes, both which can express high levels of MMPs
contact with activated T-cell membranes (or CD40 ligand) (particularly after activation) [12, 28]. Recently, a study was
induce the smooth muscle cells to produce MMP-1, -3, -8, performed examining patients presenting with DVTs, with
and -9 [2, 29]. Smooth muscle cell expression of MMP-11 blood samples being taken immediately and 6 months later.
and TIMP-1, -2, and -3 appear to be upregulated by fibrogenic Compared with healthy controls, patients with DVTs had
cytokines such as TGF-b and PDGF [2, 39]. four to fivefold more MMP in their blood, with an increase in
There are several further cell types found in blood or inflammation (as indicated by increased Toll-like receptor-4
the vasculature that are capable of secreting MMPs, includ- gene expression in leukocytes) [47]. Unsurprisingly, patients
ing T-cells (MMP-1, -2, -3, -9), mast cells (MMP-2, -9, with thrombi also had more fibrin D-dimer (an indicator of
TIMP-1), and adventitial fibroblasts (MMP-2, -9, TIMP- ongoing thrombosis and fibrinolysis [46, 48]) and P-selectin
1, -2) [2, 3]. (an indicator of endothelial cell activation [46]) in the initial
19 Metalloproteinases in Acute Venous Occlusion 147

blood sample [47]. In vivo studies suggest that DVT resolu- thrombus [52]. An elevated venous pressure (resulting in
tion involves the production of fresh matrix, requiring MMP reduced shear stress) is known to induce elevated enzymic
production and activation and production of pro-fibrotic GF activity, including MMP-2 and -9 activity, which in turn pro-
by invading leukocytes (from the blood) and smooth muscle duces venous dilation and further increases in venous pres-
cells and fibroblasts (from the vessel wall) [45, 46]. These sure [52, 53]. In the rat, acute venous occlusion is immediately
results support two hypotheses: that thrombosis is linked to accompanied by an upregulation of MMP-1, -8, -9, and
inflammation, and that DVT resolution, like wound healing, TIMP-1 and -2, with no early differences in MMP-2, -3, -9,
requires remodelling [12, 46]. While venous thrombolysis is and -12. The changes in blood pressure due to the thrombotic
predominantly mediated by plasminogen activation, at least occlusion result in vein wall expansion, with upregulation of
part of the efficacy of plasmin is due to its ability to activate the expression and activity of the proteases [53].
many MMPs [9, 12]. Thus, successful thrombus resolution is
associated with active matrix remodelling consisting of early
collagenolysis, elastolysis, and gelatinolysis (predominantly MMPs in Varicose Veins
due to MMP-2, -8, -9, and -14 being produced by cells within
the thrombus rather than from the circulation), followed by Varicose veins are dilated, elongated, and tortuous, often
fibrosis [12, 45, 46]. having areas of vein wall thickening or thinning and throm-
Studies using genetically modified mice can give insight bosis, possibly due to changes in ECM content and altered
into the varying contributions of the various proteases. DVTs levels of MMPs and plasminogen activators [13, 54, 55].
in uPA null mice have fewer neutrophils and monocytes than Varicose veins tend to have altered elastin content and struc-
wild-type controls, even though the thrombi are similar in ture, with increased collagen type I (col1) and laminin, and
size. The thrombi have significantly more interferon-g (IFNg) reduced col3, with altered collagen bundle orientation [13,
(an inducer of MMP-2), plasminogen activator inhibitor-1 55]. They also have elevated levels of MMP-1, -3, -7, -12,
(PAI-1), and active MMP-2 and -14, with reduced plasmin and -13 and TIMP-1 and -3 and less TIMP-2 compared with
activity. The thrombi also have less fibrinogen, possibly normal veins [13, 36, 54–56]. The expression and activity of
because of the increased MMP-2 production [49]. MMP-2 is gelatinases is not clear, however. Some researchers have
known to inactivate fibrinogen, effectively limiting its avail- reported that varicose veins have less pro- and active MMP-
ability for participation in the coagulation cascade [50]. 2, pro-MMP-9, and PAI-1, but no difference in TIMP-2
MMP-8, -12, -13, and -14 can also inactivate fibrinogen [45, levels [36, 54]. Others report that the expression of MMP-2
51]. Interestingly, the efficiency of the enzymic action of and -9 is elevated in varicose veins and that there are regions
MMP-2 on fibrinogen is similar to that of plasmin, both of increased pro-MMP-9 in the plasma in these vessels [13,
being lower than that of thrombin [50]. The ability of MMP-2 55, 56]. As varicose veins also have reduced levels of uPA
to inactivate fibrinogen is probably the reason for the large and tPA [54], this may indeed result in regions of reduced
thrombi found in MMP-2 null mice, as there was no change activation of the gelatinases. These changes in fibrinolytic
in plasmin expression [49]. MMP-14 is the major cell sur- and matrix proteases will influence thrombosis and thrombus
face activator of MMP-2, but MMP-2 may also be activated clearance within the vein, as demonstrated by the occurrence
by proteases within the thrombus, including activated protein of regions of blood stagnation and thrombophlebitis in vari-
C and factor Xa [45]. MMP-2 reporter mice have more cose veins [13, 56].
MMP-2 activity and increased MMP-14 expression in resolv-
ing DVTs, possibly mediated by an endothelial cell response
to thrombin [45]. When uPA was inhibited using aprotinin MMPs in Acute Vein Graft Thrombosis
rather than a genetic deletion, the size of the thrombus was
increased, as was MMP-9 activity [14]. Taken together, these The saphenous vein is commonly used for surgically bypass-
studies indicate that MMPs are important early thrombolytic ing blocked areas of coronary and peripheral arteries because
agents, able to compensate for a reduction in plasmin or lack of the use of multiple grafting procedures, technical ease of
of uPA [14, 49]. use, and increasing need of repeat surgery [57]. Although
The proportion of different MMP-positive cells within the these surgical procedures have improved both patient mortal-
DVT may give insight into the age of the DVT. Recently ity and quality of life, their success is limited by graft thick-
formed (1–5 day old) experimental DVTs produced in mice ening resulting in partial or complete closure of the vessel in
had a MMP-9/MMP-2 cell ratio of >2.0, while thrombi older up to 50 % of cases by 10 years after the procedure [57–59].
than 7 days had a ratio of <2.0 [15], but it remains to be seen Saphenous vein grafts have been used to bypass blockages in
whether this method can be used clinically. The changes in coronary arteries for almost 50 years, with the engraftment
MMP levels may be due to the altered venous pressure in the operation being performed over 500,000 times each year
148 A.C. Thomas

worldwide [57, 60]. However, vein grafts are subject to early been found on arteries as early as 10 min after injury [65],
closure due to thrombus formation and longer term occlusion and it is likely that veins placed into the arterial environment
as a consequence of neointimal formation and accelerated would similarly be subject to very early fibrin deposition and
atherosclerosis, often with further thrombotic events [57– thrombosis. By 1 week after engraftment, 12–13 % of exper-
59]. Failure of the graft may result in angina, myocardial imental vein grafts in mice have thrombi (Fig. 19.2a), but
infarction, or gangrene of the extremities, and often leads to there is no evidence of a link between thrombus formation
repeat revascularisation procedures with their associated and a lack of MMP-9. Some grafts rupture, and others
morbidity and costs [60]. become thrombosed at later time points (Fig. 19.2b–d). Many
Up to 18 % of vein grafts occlude in the first few days occluded grafts are re-canalised, ensuring that circulation is
because of acute thrombosis. This thrombosis is caused by re-established after the thrombotic event [44]. Compensatory
harvesting, surgical trauma, mechanical stress, and exposure graft remodelling is found earlier in MMP-9 null mice than
of the graft to the arterial environment [57, 60]. Vein prepara- in wild-type mice, possibly because of an increase in MMP-2
tion prior to implantation results in increased degradative [44], but graft thickening may be reduced by limiting
enzymic activity, including MMPs and other matrix-degrading endothelial loss and early thrombus formation using a loca-
proteases [2, 37, 61]. Gross damage also occurs when the lised aspirin treatment [63].
graft is suddenly exposed to pulsatile and high-pressure flow, One way to prevent the serious complications associated
increased wall tension, and shear stress, resulting in increased with systemic anti-coagulatory and thrombolyic regimes is
MMP activity and a loss of thrombomodulin (TM). The to target drugs specifically to the vein graft. A model of
endothelium is sloughed away and individual cells damaged, saphenous vein-carotid artery engraftment in the pig has
allowing platelets and leukocytes to adhere to the vessel. been recently adapted to assess the effectiveness of treat-
Medial and adventitial ECM fractures and any remaining ments for targeted acute vein graft thrombosis [70]. To mini-
vasa vasorum thromboses. TF and von Willebrand factor mise systemic effects, the vein was exposed to local tPA
(vWF) within the vessel wall, normally protected by the gene therapy prior to implantation. After implantation, blood
endothelium, are thus exposed to circulating fibrin(ogen) and flow in the graft was continuously measured using transit
platelets, allowing rapid formation of thrombi [19, 61–63]. time ultrasonography to determine blood flow and the fre-
Early thrombosis particularly affects grafts in arteries with quency of production and resolution of flow-restricting
a small diameter or poor distal runoff [57, 64] and is caused thrombi (cyclic flow reductions). Even as early as the day
by alterations in the graft wall, changes in blood rheology, after engraftment, endothelial cells (when present) and
and altered flow caused by sudden exposure to the arterial underlying smooth muscle cells in the graft expressed ele-
environment. Anti-thrombotic treatments are used to reduce vated levels of tPA (Fig. 19.2e–f). Blood flow was increased
the risk of early thrombosis, but these can be associated with in the graft, and the cyclic flow reductions were less severe,
increased postoperative bleeding and do not completely pre- indicating the efficacy of the treatment [70]. This model
vent graft failure [57, 60, 64]. Many of the components of the could also be of use in investigating the effects of altering
thrombus contribute to the development of a neointimal thick- local levels of MMP production either directly or by using
ening, either by becoming absorbed into the vessel wall or by tPA to influence plasminogen activation, thus affecting MMP
contributing factors that stimulate cells to proliferate and pro- activation.
duce matrix, thus promoting the longer term complications of
vein graft disease [2, 65]. Monocyte adhesion and infiltration
into the graft also occur early after graft implantation. These Conclusion
cells transform to become macrophages and take up lipid to Acute venous thrombosis can be a life-threatening event and
become ‘foam cells’. Both foamy and non-foamy mac- may in part be due to factors in the blood other than coagula-
rophages alter their ECM environment by producing pro- tory or fibrinolytic enzymes. It is now known that inflammation
teases, such as fibrinolytic enzymes, cathepsins, heparanase, and thrombosis are intimately connected, with considerable
and MMPs, which degrade the ECM, thus allowing graft reciprocal activation of the coagulatory, fibrinolytic, and
remodelling [2, 34, 61, 66, 67]. MMP systems. While each pathway has been studied exten-
The specific role of MMP-9 has been examined in experi- sively, details concerning how the pathways interact are lim-
mental vein grafts. MMP-2 and -9 are not present in normal ited and require further examination. This would allow
vein (or are present in very low amounts), but their expres- personalised novel therapies to be investigated, possibly
sion is increased upon engraftment. Other MMPs, including involving effective prophylaxis based on circulating factor
MMP-1 and MMP-3, are also upregulated [37, 44, 68]. In assessment. Alternatively, the use of combination therapies,
mouse vein grafts over 70 % of the graft endothelium is common to two or three of the pathways, may enable the
removed in the first 24 h, and both thrombus and neointimal design of treatments to prevent coagulation without promot-
formation is observed within a few days [44, 63, 69]. ing bleeding. These investigations may give insight into pro-
Microthrombi are present on the graft by the day after surgery viding an integrated approach for the study and prevention of
[63], but probably occur even earlier. Fibrin formation has acute venous thrombosis and other thrombotic diseases.
19 Metalloproteinases in Acute Venous Occlusion 149

a b

lumen
lumen

c d

lumen
lumen

e f

lumen lumen

Fig. 19.2 Acute thrombosis in experimental vein grafts (a) Vena cava- showing that acute thrombotic events can occur as late as 8 weeks after
carotid artery interposition graft in a MMP-9 null mouse 1 week after engraftment. (Haematoxylin and eosin stain, ×200.) (e) Propagation of
engraftment. The lumen is almost completely blocked by a fresh throm- a thrombus 1 day after engraftment of a control saphenous vein into the
bus. (Elastin van Gieson stain, ×40.) (b) Vena cava-carotid artery inter- carotid artery of a pig. Thrombus caused by crush injury of the graft.
position graft in a control mouse 4 weeks after engraftment, showing a (Elastin van Gieson stain, ×200.) (f) Pig saphenous vein-carotid artery
recently formed thrombus on the luminal surface of the graft. interposition graft. The vein has been treated with tPA gene therapy
(Haematoxylin and eosin stain, ×200.) (c) Vena cava-carotid artery prior to engraftment. tPA (green; anti-human tPA, no. 385R American
interposition graft in a control mouse 5 weeks after engraftment. Acute Diagnostica, Inc., USA) is deposited along the luminal surface (arrow)
rupture of the graft with infiltration of blood cells into the graft wall. or is found in cells within the graft, and its presence reduces the inci-
The graft has relatively few cells. (Haematoxylin and eosin stain, ×200.) dence and severity of thrombus formation, even after crush injury.
(d) Vena cava-carotid artery interposition graft in a MMP-9 null mouse, (×1,000). (Nuclei appear blue (DAPI)).
150 A.C. Thomas

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 Idiopathic Venous Thromboembolism
20
Crina Sinescu

Abbreviations any VTE in the absence of an identifiable predisposing factor.

The International Cooperative Pulmonary Registry evaluated
APLAS Antiphospholipid antibody syndrome the incidence of unprovoked PE at about 20 % of all VTEs [1].
CUS Compression ultrasonography Of patients diagnosed with proximal DVT, around 50 %
DVT Deep vein thrombosis have an associated PE; 70 % of patients with PE have a posi-
HDL High density lipoprotein tive diagnosis for DVT. PE can be diagnosed 3–7 days after
IL Interleukin the occurrence of a DVT, can be fatal in 10 % of cases, and
LDL Low density lipoprotein presents with shock or hypotension in 5–10 % of cases; 50 %
LMWH Low molecular weight heparin of the remaining patients present with signs of right ventricu-
MDCT Multi-detector computer tomography lar (RV) dysfunction. Chronic complications such as throm-
PE Pulmonary embolism boembolic pulmonary hypertension can occur in 0.5–5 % of
RV Right ventricle patients treated for PE. The complete list of factors that pre-
RVT Residual vein thrombosis dispose to VTE is presented in Table 20.1.
SDCT Single-detector computer tomography
VKAs Vitamin K antagonists
VT Venous thromboembolism Risk Factors for VTE
VTE Venous thrombotic event
Apart from traditional risk factors (Table 20.1), it worth
mentioning less usual risk factors for VTE, which corre-
Introduction spond to the classic atherosclerotic cascade. Many risk fac-
tors for VTE, such as dyslipidemia, obesity, hypertension,
Venous thromboembolism is a manifest disease that includes diabetes, and smoking, overlap with those for atherothrom-
deep vein thrombosis (DVT) and pulmonary embolism (PE). bosis. As a consequence, VTE is starting to be considered a
It is the third most common cardiovascular disorder after “full-time member” of the cardiovascular syndrome “club”
coronary artery disease and stroke. that includes coronary artery disease, peripheral artery dis-
ease, and cerebrovascular disease.
More evidence describing the continuum between VTE
Definition and arterial disease has appeared in past years [3]. Stein et al.
[4] found a 2.5 increased risk for VTE in obese patients. In a
Annual incidence of venous thrombotic events (VTEs) is prospective study of 250 women, the authors investigated
approximately 0.1 % among persons in early adulthood and which factors predispose to VTE. They found an increase in
increases to nearly 1 % among those who are at least 60 years risk of 2.9-fold for obese subjects (body mass index >29 kg/
old. Idiopathic or unprovoked venous thrombosis is defined as m2), 1.9-fold for smokers, and 1.9-fold for those with hyper-
tension [5]. Pradoni et al. [6] suggested a link between ath-
erosclerosis and VTE; they discovered that patients with
C. Sinescu, MD, PhD, FESC spontaneous veinous thrombosis had a higher incidence of
Department of Cardiology,
carotid plaques than controls, translating into a 2.3-fold risk
Carol Davila University of Medicine,
Bucharest, Romania increase for VTE vs. controls. Subsequently, Spencer et al.
e-mail: crinasinescu@gmail.com [7] showed that idiopathic VTE is associated with increased

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 153
DOI 10.1007/978-1-4471-4429-8_20, © Springer-Verlag London 2013
154 C. Sinescu

Table 20.1 Predisposing factors for VTE Diet also influences the occurrence of thrombotic events.
Strong (risk increased by more than tenfold) A total of 14,962 middle-aged adults participated in a pro-
Fracture (hip or leg) spective trial to evaluate the role of dietary intake in the
Hip or knee prosthesis development of DVT or PE [12]. Surprisingly, a diet includ-
Major surgery (general) ing more plant food and fish and less red and processed meat
Major trauma was associated with a lower incidence of VTE.
Spinal cord injury Hormonal replacement therapy and contraception have
Moderate (risk increased by two to ninefold) been linked to atherothrombotic events and venous throm-
Arthroscopic knee surgery botic disease. Contraceptives, especially those that contain
Central venous lines third-generation progestins, increase the risk of VTE [13].
Chemotherapy
The Women’s Health Initiative randomized trial enrolled
Chronic heart or respiratory failure
subjects receiving estrogen-plus-progestin hormone replace-
Hormone replacement therapy
ment therapy and showed a twofold increase in the risk of
Malignancy
Oral contraceptive therapy
VTE compared with those in the placebo group [14].
Paralytic stroke An interesting question, that of whether venous throm-
VTE in antecedents boembolism is related to psychosocial factors, was answered
Thrombophilia in a study dating from 2008 [15]. The authors found that per-
Weak (odds ratio < 2) sistent stress and low occupational class were independently
Bed rest >3 days related to future PE but not to DVT.
Immobility due to sitting (e.g., prolonged travel)
Advanced age
Laparoscopic surgery Pathophysiology
Obesity or overweight
Pregnancy/postpartum The three keywords that describe both venous thrombosis
Varicose veins and atherothrombosis are inflammation, systemic/local
Modified from [2, 3] hypercoagulability, and endothelial dysfunction.
Inflammation plays an important role in the pathogenesis of
risk of acute myocardial infarction among younger patient this entity; elevated C-reactive protein (a sensitive marker of
populations (ages 20–64 years). In addition, the risk of myo- systemic inflammation) has been linked to an increased risk
cardial infarction and stroke was evaluated in a large popula- of VTE. A total of 10,505 patients enrolled in the ARIC
tion that included 25,199 patients with DVT, 16,925 patients (Atherosclerosis Risk in Communities) study showed that
with PE, and 163,566 controls [8]. During the subsequent elevated C-reactive protein is independently associated with
20 years of follow-up, presence of VTE was associated with increased risk of VTE [16]. Increased values of systemic
a 20–40 % increase in risk for arterial cardiovascular events inflammatory markers (C-reactive protein, fibrinogen, and
(for patients with DVT, the relative risks was 1.60 for myo- factor VIII) are especially found in patients who had an
cardial infarction to 2.19 for stroke in the first year after the unprovoked DVT or PE compared with those with secondary
thrombotic event; for patients with PE, the relative risk was VTE [17]. Genetic anomalies of interleukin (IL)-1β and
2.60 for myocardial infarction and 2.93 for stroke). The fact IL-10 genes also influence the risk of idiopathic VTE [18].
that VTE and atherosclerosis are two analogous entities has The JUPITER (Justification for the Use of statins in
recently been shown in a meta-analysis: patients with VTE Prevention: an Intervention Trial Evaluating Rosuvastatin)
have more asymptomatic atherosclerosis and more cardio- trial showed that 20 mg/day of rosuvastatin reduced the rate
vascular events than control subjects [9]. The risk of having of symptomatic VTE by 43 % in patients with elevated
a future VTE was 2.33 greater for obesity, 1.51 for hyperten- C-reactive protein and low-density lipoprotein (LDL) cho-
sion, 1.42 for diabetes mellitus, 1.18 for smokers, and 1.16 lesterol levels <130 mg/dl compared with placebo [19].
for hypercholesterolemia. High-density lipoprotein (HDL) Hypercoagulability anomalies (which together with
cholesterol was lower in subjects with events. Both low lev- endothelial lesions and venous stasis form Virchow’s triad)
els of HDL cholesterol and elevated fasting glucose have include inherited thrombophilias (activated protein C resis-
been found to double the risk of VTE in a cohort of 208 tance due to factor V Leiden mutation; prothrombin gene
patients [10]. A large study of 20,374 middle-aged and mutation; congenital dysfibrinogenemia; deficiencies of pro-
elderly adults were followed for more than 12 years for inci- tein C, protein S, and antithrombin III), hyperhomocysteinemia
dent VTE, and results showed that metabolic syndrome was (most often acquired because of dietary folate deficiency but
associated with an 1.84-fold increased risk for VTE, a result also can be inherited because of a deficiency in methylenetet-
largely attributable to abdominal obesity [11]. rahydrofolate reductase; has been associated with both VTE
20 Idiopathic Venous Thromboembolism 155

and atherothrombosis), and antiphospholipid antibody syn- Table 20.2 Wells score for DVT diagnosis
drome (APLAS; an acquired thrombophilia that increases Clinical characteristics Score
the risk for both VTE and arterial thromboembolism). Active cancer +1
Endothelial injury and dysfunction expressed as a trau- Paralysis or plaster immobilization +1
matic injury of the vessel wall may also result in VTE [20]. Bed rest >3 days or major surgery in the last 4 weeks +1
For example, local endothelial injury from pacemaker leads Localized tenderness along the distribution of the deep +1
and long-term indwelling venous catheters increases the risk venous system
of VTE [21]. Entire leg swollen +1
Calf swelling >3 cm when compared with asymptomatic leg +1
Pitting edema +1
Collateral superficial veins (nonvaricose) +1
Diagnosis Previously documented deep vein thrombosis +1
Alternative diagnosis at least as likely as deep vein −2
The initial assessment for determination of DVT is the clinical thrombosis
probability assessment. For suspected DVT, the Wells score Clinical probability
has been validated and has well-established criteria (Table 20.2). Unlikely <2
A score ³2 indicates that the probability of DVT is likely, and Likely ³2
a score of <2 indicates that the probability of DVT is unlikely. Modified from [22, 23]
For PE, a Wells score >4 indicates PE is likely, and a score of
£4 indicates PE is unlikely (Table 20.3). We can also use the
simplified or revised Geneva score (Table 20.4). Table 20.3 Well’s score for PE diagnosis
Symptoms such as dyspnea, cough, or chest pain are pres- Clinical characteristics Score
ent in the majority of patients with PE. Additional symptoms Hemoptysis +1
include hemoptysis and syncope. Specific signs for PE are Cancer +1
tachypnea (>20 respiratory cycles/min), tachycardia (>100 Previous pulmonary embolism or deep venous thrombosis +1.5
beats/min), signs of DVT, fever (>38.5 °C), and cyanosis. Heart rate >100/min +1.5
Chest x-rays are nonspecific but can exclude other causes Recent surgery or immobilization +1.5
of dyspnea and chest pain. Electrocardiographic findings Clinical signs of deep venous thrombosis +3
Alternative diagnosis less likely than that of pulmonary +3
could show signs of RV overload such as inversion of T waves
embolism
in V1-V4, QR pattern in V1, complete or incomplete right Clinical probability
bundle branch block, or the classic S1Q3T3. Low <2
Negative highly sensitive D-dimer assays can exclude PE Intermediate 2–6
in patients with low or moderate clinical probability, whereas High >6
moderately sensitive arrays can exclude PE only in patients Modified from [24]
with a low clinical probability.
Compression ultrasonography (CUS) can be used either
as a backup procedure to reduce a false-negative result when Table 20.4 Revised and simplified revised Geneva scores for PE
using single-detector computer tomography (SDCT) or can diagnosis
be used in patients that have contraindications to contrast Clinical characteristics Revised score Simplified score
dye or radiations (Fig. 20.1). Age >65 years +1 +1
Ventilation-perfusion scintigraphy is very safe for excluding a Active malignant condition +2 +1
PE if it is normal. A high probability of PE establishes the diag- Surgery or fracture within 1 month +2 +1
nosis with a high degree of probability; additional tests may be Hemoptysis +2 +1
considered in selected patients with a low clinical probability. Previous deep vein thrombosis or +3 +1
pulmonary embolism
Single-detector computer tomography (SDCT) and multi-
Unilateral lower-limb pain +3 +1
detector CT (MDCT) are diagnostic if a thrombus is evident
Heart rate 75–94/min +3 +1
at least at a segmental level, whereas incertitude exists Pain on lower deep venous +4 +1
regarding treatment of a sub-segmental defect (Figs. 20.2 palpation and unilateral edema
and 20.3). Patients with non-high clinical probability can Heart rate >94/min +5 +1
have only MDCT or combined SDCT plus CUS for diagnos- Clinical probability
tic purposes. Further testing is needed in patients with nega- Low 0–3 0–1
tive MDCT and high clinical probability. Intermediate 4–10 2–4
Among invasive diagnostic exams, even though pulmo- High >10 ³5
nary angiography is the gold standard in the diagnosis of PE, Modified from [25, 26]
156 C. Sinescu

Fig. 20.3 Computer tomography plane showing a thrombosed

proximal right pulmonary artery

Fig. 20.1 Compression ultrasonography showing a thrombosed

femural vein (middle plane) and patent femural artery (right side)

Fig. 20.2 Computer tomography plane showing a thrombosed

proximal right pulmonary artery

it is rarely used because of its invasive nature. Diagnostic

criteria for PE include direct evidence of a thrombus, visible
filling defect, and other indirect signs (slow flow contrast, Fig. 20.4 Venography of the left thigh showing thrombosed great
regional hypoperfusion, and delayed or diminished pulmo- saphenous vein
20 Idiopathic Venous Thromboembolism 157

nary venous flow). Venography is also less used today

(Figs. 20.4 and 20.5).
Echocardiography is especially useful in emergency man-
agement decisions. The absence of RV overload/dysfunction
excludes PE as a cause of hemodynamic instability in a
patient with hypotension or shock (Figs. 20.6, 20.7, 20.8,
20.9, 20.10, and 20.11). It has a very important role in strati-
fying patients with non-high risk PE into intermediate and
low-risk categories. Echocardiographic criteria of RV dys-
function include RV hypokinesis and dilatation, RV size
>30 mm at annulus, tricuspid insufficiency of >2.8 m/s, a
ratio of RV/left ventricle >1, paradoxical septal systolic
motion, and a pulmonary acceleration time <90 ms.

Complications

(a) Complications of DVT include the post-thrombotic syn-

drome (Figs. 20.12 and 20.13) (evolves in 20–50 % of
patients and could result in lifelong limb pain, swelling,
heaviness, edema, and leg ulcers) [27] and PE.
(b) Complications of PE include RV dysfunction, hemody-
namic instability, and chronic thromboembolic hyper-
tension. In the acute phase, stratification of PE includes
high-risk PE and non-high-risk PE.
High-risk PE is a life-threatening condition in which
short-term mortality exceeds 15 %. It includes PE in associa-
tion with shock or hypotension (systolic blood pressure

Fig. 20.5 Venography of an extended thrombosed iliac vein

Fig. 20.6 Subcostal view

of a dilated right ventricle
in the context of chronic
thromboembolic pulmonary
hypertension
158 C. Sinescu

Fig. 20.7 CW Doppler on the

tricuspid valve showing elevated
right ventricle-right atrium
gradient

Fig. 20.8 Parasternal short-axis

view at mitral valve level
showing a dilated right ventricle
in the context of a hemodinamic
unstable pulmonary embolism
20 Idiopathic Venous Thromboembolism 159

Fig. 20.9 Preserved systolic

function using pulsed tissue
doppler of the right ventricle free
wall in the context of pulmonary
embolism

Fig. 20.10 Subcostal view

showing a dilated right ventricle
in the setting of a hemodinamic
unstable pulmonary embolism
160 C. Sinescu

Fig. 20.11 Preserved systolic

function using the tricuspid
annular plane systolic motion
(TAPSE) of the right ventricle
free wall in the context of
chronic thromboembolic disease

Fig. 20.12 Post-thrombotic syndrome associated with oedema and

cutaneous trophic disorder (left leg)

Fig. 20.13 Post-thrombotic syndrome associated with cutaneous

trophic disorder
20 Idiopathic Venous Thromboembolism 161

<90 mmHg or a pressure drop >40 mmHg for >15 min if not Table 20.5 Curative doses of LMWH and fondaparinux for PE
caused by new-onset arrhythmia, hypovolemia, or sepsis). treatment
Non-high-risk PE is further categorized into intermediate Dose Interval
(3–15 % short-term risk of mortality) and low-risk PE (<1 % Enoxaparin 1.0 mg/kg Every 12 h
short-term mortality). Intermediate-risk PE is defined by the or 1.5 mg/kga Once dailya
presence of RV dysfunction defined by the presence of at Tinzaparin 175 U/kg Once daily
least one of the following: echocardiographic findings (pre- Fondaparinux 5 mg (body weight Once daily
<50)
viously mentioned), RV dilatation at CT, BNP or NT-proBNP
7.5 mg (body weight
elevation, increased right heart pressure at right heart cathe- 50–100 kg)
terization, and positive cardiac troponin T or I. 10 mg (body
weight >100 kg)
Modified from [3]
Treatment a
Approved for inpatient treatment of PE in the United States and in
some European countries
Once DVT has been diagnosed, treatment goals are: symp-
tom relief, prevention of embolization and recurrence, con- Table 20.6 Thrombolytic doses for pulmonary embolism
trol of thrombus progression during the acute phase in order Streptokinase [28] 250,000 IU as a loading dose over 30 min,
to clear away the risk of an immediate, possibly fatal pulmo- followed by 100,000 IU/h over 12–24 h.
nary embolism, control of acute and chronic pulmonary and Accelerated regimen: 1.5 million IU over
2h
peripheral venous hypertension, and control of relapsing dis-
Urokinase [29] 4,400 IU/kg as a loading dose over 10 min,
ease in the intermediate and long-term course. Treatment of followed by IU/kg/h over 12–24 h
VTE is composed of three periods: the acute phase (days), Recombinant tissue Accelerated regimen: 3 million IU over
the intermediate phase (weeks or months), and the long-term plasminogen activator 2,100 mg over 2 h or 0.6 mg/kg over
period (months or years). [28–30] 15 min (maximum dose 50 mg)

Acute Treatment Table 20.7 Contraindications to fibrinolytic therapy

Absolute contraindicationsa
In patients with DVT or stable PE, either unfractionated hep- Hemorrhagic stroke
arin or low-molecular-weight heparin (LMWH) can be used Stoke of unknown origin at any time
safely (except in case of severe renal impairment for LWMH Ischemic stroke in preceding 6 months
use). Monitoring anti-Xa activity is useful in patients with Central nervous system damage or neoplasms
severe renal failure, in pregnancy, and in obese patients (to Recent major trauma/surgery/head injury (within preceding
be done 4 h after the morning injection). Monitoring of 3 weeks)
unfractionated heparin is done 4–6 h after the bolus injection Gastrointestinal bleeding within the last month
Known bleeding
and 3 h after each adjustment, aiming for an activated partial
Relative contraindications
thromboplastin time of 70–90 s. Table 20.5 shows standard
Transient ischemic attack in preceding 6 months
doses of LMWH. There is no benefit of immobilization for
Oral anticoagulant therapy
the clinical outcome of patients with PE. Wearing stockings
Pregnancy or within 1 week postpartum
markedly reduces the incidence of post-thrombotic Non-compressible punctures
syndrome. Traumatic resuscitation
In patients with hemodynamic unstable PE, intrave- Refractory hypertension (systolic blood pressure >180 mmHg)
nous thrombolysis is mandatory, followed by unfraction- Severe liver disease
ated heparin (bolus of 80 U/kg and subsequent infusion of Infective endocarditis
15–18 U/kg/h). The most used thrombolytic protocols are Active peptic ulcer
shown in Table 20.6 [28–30]. Contraindications to throm- Modified from [3, 31]
bolysis are shown in Table 20.7. Thrombolysis could be used a
Absolute contraindications might become relative in a patient with
in patients with intermediate-risk PE after thorough consid- life-threatening unstable PE
eration of conditions that increase bleeding risk. Surgical
pulmonary embolectomy can be performed in patients who foramen ovale and intracardiac thrombi. Hemodynamic sup-
may need cardiopulmonary resuscitation, in patients with port including vasopressors, and mechanical ventilation may
contraindications to thrombolysis, and in those with a patent be needed in severe cases.
162 C. Sinescu

Table 20.8 Comparative properties of thrombin and factor Xa inhibitors in comparison to warfarin
Warfarin Rivaroxaban Apixaban Dabigatran Edoxaban
Target Vitamin K Factor Xa Factor Xa Factor IIa Factor Xa
Prodrug No No No Yes No
Bioavailability (%) >95 >57–86 >49 6.5 50
T (max) (h) 72–96 2–4 1–4 1.25–3 1–2
Half-life (h) 40 9–13 8–15 12–14 9–11
Monitoring INR-adjusted Not needed Not needed Not needed Not needed
Administration in VTE Once daily 15 mg bid for 3 weeks 10 mg bid for 1 week followed 150 mg bid 60 mg od
followed by 20 mg od by 5 mg bid
Metabolism and CYP 2C9, 3A4, CYP3A4; 33 % renal, 66 % CYP3A4; 75 % fecal, 25 % 80 % renal, 20 % 35 % renal
elimination 1A2 fecal renal fecal
Drug interactions CYP 2C9, 1A2, and CYP 3A4 inhibitor CYP 3A inhibitor P-GP inhibitor P-GP inhibitor
3A4 P-GP inhibitor P-GP inhibitor
Modified from [32]
T(max) indicates peak plasma levels, h hours, P-gp P-glycoprotein, od once daily, bid twice daily

Intermediate Phase Treatment and Chronic Table 20.9 Factors that increase recurrence risk in idiopathic VTE
Treatment Immobilization
Cancer
After the acute phase, oral anticoagulation is mandatory. It Chronic obstructive pulmonary disease
can be done either by vitamin K antagonists (VKAs) or by Family history
newer anticoagulants. VKAs such as warfarin have several Male gendera
limitations, such as a slow onset of action, frequent monitor- Overweight, obesitya
ing of INR because of the limited therapeutic index, food and Low levels of apolipoprotein AI and high-density lipoprotein
cholesterola
drug interactions, inter-individual dosing differences, and
Proximal DVTa
warfarin resistance. The only apparent advantages of VKAs
Symptomatic PEa
over newer anticoagulants are the possibility to administer
Elevated D-dimer levels after discontinuing anticoagulationa
an antidote in case of overdose and its use independent of Failure to recanalize leg veins after anticoagulation for DVTa
renal failure.
Modified after [44]
Newer anticoagulants are available and are ready to use in a
Validated for idiopathic VTE
VTE (Table 20.8). The main advantages over VKAs include:
fixed-dose administration, no INR testing, and no interac-
tions with food or drugs. in patients who have undergone elective total hip or knee
Rivaroxaban is an oral direct inhibitor of factor Xa [33] replacement surgery [42, 43].
that inhibits factor Xa in a concentration-dependent manner Oral anticoagulants should be started as soon as possible,
via a rapid and reversible binding. It reduces the rate of preferably on the first day if a stable PE has been diagnosed,
development of VTE in patients after total hip or knee arthro- and should aim for a target INR (international normalized
plasty vs. LMWH with no significant differences in risk of ratio) of 2–3 when VKAs are used.
bleeding [34–37]. Compared with enoxaparin, it reduces the Oral anticoagulants should be continued for 3 months if a
costs associated with drug administration for prophylaxis reversible factor has been identified (surgery, trauma, medical
and treatment of VTE events. Also it reduces the incidence illness, estrogen therapy, pregnancy, etc.; see Table 20.1).
of symptomatic VTE [38]. Patients with thrombophilia (deficit of protein C or S, lupus
Apixaban is a reversible active direct inhibitor of factor anticoagulant, homozygous for factor V Leyden, or homozy-
Xa that can also be administered orally (fixed oral dose may gous for PTG 20210A) are candidates for chronic oral antico-
replace LMWH combined with vitamin K antagonists in the agulant treatment as recurrence is high. At this time, there is
treatment of DVT) [39]. Compared with LMWH, apixaban no clear benefit of chronic VKA treatment in patients heterozy-
was more effective for prevention of VTE as compared with gous for factor V Leyden or heterozygous for PTG 20210A.
LMWH without enhancing bleeding risk after knee and hip Patients with provoked or apparently unprovoked VTE
replacement [40, 41]. should benefit from chronic oral anticoagulants treatment,
Dabigatran etexilate is a competitive reversible oral anti- especially if any of the factors in Table 20.9 are present.
coagulant that inhibits thrombin directly. It has the potential Also, if the bleeding risk is low, lifelong anticoagulation is
to replace traditional anticoagulants for prevention of VTE advised.
20 Idiopathic Venous Thromboembolism 163

Table 20.10 The HASBLED score

Letter Clinical characteristicsa Points awarded
H Hypertension 1
A Abnormal renal and liver function (I 1 or 2
point each)
S Stroke 1
B Bleeding 1
L Labile INRs 1
E Elderly (e.g., age >65 years) 1
D Drugs or alcohol (1 point each) 1 or 2
Maximum 9 points
Modified from [45, 46]
a
Hypertension – systolic blood pressure >160 mmHg, Abnormal kidney
function – the presence of chronic dialysis or renal transplantation or
serum creatinine ³mmol/l, Abnormal liver function – chronic hepatic
disease (e.g.. cirrhosis) or biochemical evidence of significant hepatic
derangement (e.g., bilirubin >2× the upper limit of normal, in associa-
tion with aspartame aminotransferase/alanine aminotransferase/alka-
line phosphatase >3× the upper limit normal, etc.), Bleeding – history
and/or predisposition to bleeding, e.g., bleeding diathesis, anemia, etc,
Labile INRs unstable/high INRs or poor time therapeutic range (e.g.,
<60 %), Drugs/alcohol – concomitant use of drugs, such as antiplatelet
agents, non-steroidal antiinflammatory drugs, or alcohol abuse, etc.,
INR – international normalized ratio

patients with pulmonary hypertension. As soon as oral anti-

coagulants can be introduced, they should be removed
because of increased complication rates (insertion site
thrombosis in 10 % of cases, recurrent DVT in 20 % of
cases, post-thrombotic syndrome in 40 %, and occlusion of
the inferior vena cava in 22 % of patients at 5 years).
Fig. 20.14 Caval filter (mid-plane)
Whatever the reason for filter insertion, temporary filters
should be favored over permanent filters.
In pregnancy, VKAs are not advised in the first and the
Treatment for chronic thromboembolic hypertension is third trimester, and they should be considered with caution in
pulmonary endarterectomy and should be advised when the second trimester. LMWHs are safe.
severe symptoms and RV failure occur. Thrombectomy in DVT may be indicated when the anti-
For cancer patients, LMWH and especially dalteparin are coagulation therapy is inefficient or contraindicated. It is
indicated for the first 3–6 months of a proximal DVT and/or rarely used nowadays in iliofemoral massive thrombosis
PE at an initial dose of 200 U/kg subcutaneously once daily; (afterwards the caval vein must be interrupted for prevention
afterwards oral anticoagulants should be continued of pulmonary embolism).
indefinitely or until cancer is cured. As with the catheter-guided approach, surgery is a
The rationale for caval filter insertion (Fig. 20.14) is to treatment concept for descending iliac DVT or recent
lower the chance of pulmonary embolism originating from onset in young and otherwise healthy individuals, and it is
a proven proximal DVT (usually with dimensions more rarely used.
than 4 mm). According to the latest American Heart
Association guidelines on VTE (2011), venous filters are
indicated when there is an absolute contraindication to anti- Risk of Bleeding
coagulation and when there is a high risk of VTE recur-
rence while on anticoagulation and evidence of active Multiple parameters have been integrated into the HAS-
bleeding complications requiring termination of anticoagu- BLED risk score [45] and have been validated on a popula-
lation therapy. Relative contraindications include large, tion of 3,978 European subjects with atrial fibrillation from
free-floating iliofemoral thrombus in high-risk patients, the EuroHeart Survey (Table 20.10). A score of ³3 indicates
propagating iliofemoral thrombus while on anticoagula- high risk for bleeding; thus, anticoagulation should not be
tion, patients with significant fall risk, and chronic PE in advised.
164 C. Sinescu

Recurrence of VTE Searching for Hereditary Thrombophilia

General Considerations Among patients with thrombophilia, certain populations,

such as those who test positive for lupus anticoagulant, have
During 25 years of follow-up, Heit et al. [47] reported prob- a deficit of antithrombin, protein C, or S [50, 51], are homozy-
able/definite cumulative percentages of VTE recurrence at 1 gous for factor V Leyden (FVL), and are homozygous for
and 10 years of 12.9 %/5.6 % and 30.4 %/17.6 %. Independent PTG20210A [52, 53], should be provided with indefinite
predictors of first overall VTE recurrence included increas- anticoagulation as recurrence is high. Deficiencies of anti-
ing age and body mass index, neurologic disease with pare- thrombin, protein C, or protein S are observed in fewer than
sis, malignant neoplasm, and neurosurgery. Independent 5 % of patients presenting with a first unprovoked VTE; if
predictors of a first probable/definite recurrence included the patient is under the age of 50 and has a positive family
the presence of a clear diagnostic and the presence of neuro- history, the incidence increases up to about 15 %. The pos-
logic disease in patients with hospital-acquired VTE. sibility of identifying more than one hereditary defect in
Recurrence risk was increased by malignant neoplasm but patients presenting with an unprovoked VTE with a negative
varied with concomitant chemotherapy, patient age and sex, family history is between 1 and 3 %.
and study year. Regarding those heterozygous for FVL and heterozygous
Follow-up was also performed in 355 consecutive for PTG20210A, there is little evidence that prolonged anti-
patients with a first episode of symptomatic DVT [48]. coagulation would be of benefit. In a recent review [52],
After 8 years, the cumulative incidence of recurrent being heterozygous for FVL was associated with a 1.56-fold
venous thromboembolism was 30.3 %. Survival after increased risk and being homozygous with a 2.65-fold
8 years was 70.2 %. The presence of cancer and impaired increased risk compared with individuals without FVL.
coagulation inhibition increased the risk for recurrent Being heterozygous for prothrombin G20210A was not pre-
venous thromboembolism [hazard ratios, 1.72 (CI, 1.31– dictive of recurrent VTE in probands compared with indi-
2.25) and 1.44 (CI, 1.02–2.01), respectively), and the viduals without this anomaly. An older meta-analysis stated
cumulative incidence of the post-thrombotic syndrome that heterozygous FVL and prothrombin G20210A are each
was 29.1 % after 8 years (CI, 23.4–34.7 %). The develop- associated with a significantly increased risk of recurrent
ment of ipsilateral recurrent deep venous thrombosis was VTE after a first event, but the magnitude of the increase in
strongly associated with the risk for the post-thrombotic risk is modest and by itself is unlikely to merit extended-
syndrome (hazard ratio, 6.4; CI, 3.1–13.3). The presence duration anticoagulation [53].
of cancer increased the risk for death (hazard ratio, 8.1; Some hemostatic abnormalities have been associated with
CI, 3.6–18.1). increased VTE, such as homocysteine and increased factor
In the largest cohort with long-term follow-up, compris- VIII and VII. A study from 1995 [54] underlined that high
ing 1,626 patients with either idiopathic or provoked throm- factor VIII concentrations are common and represent a clear
bosis in whom anticoagulation had been stopped, follow-up increase in the risk of thrombosis, similar to the risks con-
was performed 10 years after the first event [49]. The cumu- ferred by deficiencies of the coagulation-inhibiting proteins
lative incidence of recurrent VTE at 10 years was 39.9 % (if and activated protein C resistance. Another paper [55]
the population was dichotomized into idiopathic versus showed that the relative risk of recurrent venous thrombosis
provoked initial events, the 10-year recurrence rate was was 1.08 for each increase of 10 IU per deciliter in the plasma
52 % for idiopathic DVT versus 22 % for provoked DVT). level of factor VII. Regarding hyperhomocysteine, it has
The adjusted hazard ratio for recurrent VTE was 2.02 been shown that treatment with vitamin B supplements did
(1.52–2.69) in those with thrombophilia, 2.30 (95 % CI, not reduce the risk of VTE in two clinical trials, even though
1.82–2.90) in patients whose first VTE was unprovoked, it did reduce homocysteine levels [56, 57]. Because the
1.14 (1.06–1.12) for every 10-year increase of age, 1.44 results of these tests should not affect patient management,
(1.03–2.03) in those presenting with primary DVT, and testing for these abnormalities is discouraged.
1.39 (1.08–1.80) for patients who received a shorter (up to APLAS consists of the occurrence of venous or arterial
6 months) duration of anticoagulation. When the analysis thrombosis or recurrent fetal loss in association with a posi-
was confined to patients with unprovoked VTE, the results tive lupus anticoagulant or elevated b2-glycoprotein I anti-
did not change. body or cardiolipin levels. To conclude that APLAS is
Clear evidence shows that a high rate of recurrence after positive, these tests must remain persistently positive for a
provoked and especially unprovoked VTE exists. The minimum of several months following the initial thrombotic
numbers previously presented should change our habits in event. Typically, an unexplained prolongation of the aPTT
treating and preventing recurrences of this complex is found in approximately two-thirds of patients. APLAS
disease. is frequently identified in patients with systemic lupus
20 Idiopathic Venous Thromboembolism 165

erythematous in the context of certain drug intakes [63]. The authors prospectively enrolled 929 patients with a
(i.e., thorazine, hydralazine). Other etiologies are infections, first unprovoked VTE who had been treated with oral antico-
underlying malignancy, or idiopathic status. agulants for at least 3 months, excluding patients with VTE
In summary, hereditary hemophilia should be investigated provoked by surgery, trauma, pregnancy, female hormone
in the following subgroups of population: patients with intake, deficiency of antithrombin, protein C or protein S,
venous thromboembolism before the age of 40–45 years, and presence of the lupus anticoagulant or cancer. Patients
recurrent VTE, patients with arterial thrombosis younger entered the study at the time of discontinuation of oral anti-
than 30 years old, idiopathic prolongation of the activated coagulation. The study end point was recurrent symptomatic
partial thromboplastin time, systemic lupus erythematous, deep vein thrombosis confirmed by venography or color
repeated fetal loss, neonatal thrombosis, unusual site for duplex sonography (in case of proximal thrombosis of the
thrombosis (e.g., mesenteric vein, cerebral sinus), idiopathic contralateral leg) or recurrent symptomatic pulmonary embo-
thrombocytopenic purpura, thrombophilic abnormalities in lism confirmed by ventilation-perfusion scanning and/or spi-
the same family, and family history of VTE. ral computed tomography. Follow-up had a median of
43.3 months after discontinuation of anticoagulation. Of the
patients, 18.9 % had recurrent VTE, and the following fac-
Idiopathic VTE tors were related to a higher recurrence risk: male sex (haz-
ard ratio versus female sex 1.90, 95 % confidence interval
Risk Factors for Recurrence (see also Table 20.9) 1.31–2.75), proximal DVT (hazard ratio versus distal 2.08,
95 % confidence interval 1.16–3.74), PE (hazard ratio versus
In 2007, Nijkeuter et al. [58] proved in their study that risk distal thrombosis 2.60, 95 % confidence interval 1.49–4.53),
factors for recurrent VTE in secondary and idiopathic throm- and elevated levels of D-dimer determined by ELISA (haz-
bosis were immobilization for >3 days and being an inpa- ard ratio per doubling 1.27, 95 % confidence interval 1.08–
tient; COPD or malignancies were risk factors for bleeding. 1.51). Subsequently, the authors developed a normogram
Malignancy, higher age and immobilization, and being an that can be used to calculate risk scores and to estimate the
inpatient were risk factors for mortality. cumulative probability of recurrence (Fig. 20.15).
Another paper showed that men have a 3.6-fold higher D-dimers have been largely utilized to predict the rate of
relative risk of recurrence of VTE compared to women [59]. recurrence after an unprovoked venous embolic event. It is
Very interestingly, overweight seemed to predict the rate suggested that the results of quantitative D-dimer assays,
of VTE recurrence. A total of 1,107 patients were followed measured at the end of warfarin therapy (3 or 6 months) and
for an average of 46 months after a first unprovoked venous then 1 month after its discontinuation, can help stratify such
thromboembolism and withdrawal of anticoagulant therapy patients with respect to recurrence risk. Seven studies total-
[60]. The authors excluded pregnant patients, those requiring ing 1,888 patients with a first unprovoked VTE were included
long-term antithrombotic treatment, and those who had a in a meta-analysis to clarify whether the D-dimer value is a
previous or secondary thrombosis, natural coagulation inhib- predictor of recurrent disease in patients who have stopped
itor deficiency, lupus anticoagulant, or cancer. Four years anticoagulant therapy after a first unprovoked VTE.
after discontinuation of anticoagulant therapy, the probabil- A D-dimer level of less than 500 ng/ml (a “negative test”)
ity of recurrence was 9.3 % among patients of normal weight was associated with a 3.5 % annual risk of recurrence,
and 17 % among patients with increased body mass index whereas a D-dimer over this level (a “positive test”) was
(overweight and obese patients). associated with an 8.9 % risk in each of the first 2 years
Proof that patients with high levels of apolipoprotein AI (Table 20.11). As there is no D-dimer “standard” worldwide,
and HDL have a decreased risk of recurrent venous throm- practitioners have to rely on the manufacturer’s cutoof point
boembolism comes from a study conducted in 772 patients for a positive or negative D-dimer test to assess recurrence
after a first spontaneous venous thromboembolism (average risk. In another landmark trial [65], D-dimer testing was per-
follow-up 48 months) [61]. formed 1 month after the discontinuation of anticoagulation
The same author investigated the risk of recurrence among in patients with a first unprovoked proximal deep-vein throm-
patients with spontaneous symptomatic PE and those with bosis or pulmonary embolism who had received a vitamin K
DVT without symptoms of PE. He found that subjects with a antagonist for at least 3 months. Patients were divided in
first symptomatic PE not only have a higher risk of recurrent three groups and followed up for 1.4 years: those who had
VTE than those with DVT without symptoms of PE, but are normal D-dimer values stopped the treatment and had a VTE
also at increased risk of symptomatic PE at recurrence [62]. recurrence of 6.2 %, those who had abnormal D-dimer val-
A landmark trial that deserves special attention assessed ues and continued treatment had a VTE recurrence of 2.9 %,
the risk of recurrence in patients with unprovoked DVT or and those who had abnormal D-dimer values but discontin-
PE using a prediction model (the Vienna prediction model) ued treatment had a VTE recurrence of 15 %. The authors
166 C. Sinescu

Fig. 20.15 The Vienna 0 10 20 30 40 50 60 70 80 90 100

prediction model for VTE
recurrence. Values of D-dimer, Points
sex, and VTE location corre-
spond to points on upper panel
line. Value of total points (lower Male
line) are assigned a VTE Sex
recurrence risk at 12 and Female
60 months (Modified from [62]) Proximal DVT
Location
Distal DVT Pulmonary embolism

100 150 200 250 400 500 750 1000 1500 2000
D-Dimer (µg/I)

0 50 100 150 200 250 300 350

Total points

[sex+location+d-dimer]

Low risk of recurrence High risk of recurrence

12 months cumulative recurrence rate

0.02 0.04 0.06 0.08 0.1 0.12 0.15

60 months cumulative recurrence rate

0.1 0.2 0.3 0.4 0.5

Table 20.11 D-Dimer values and VTE recurrence rate overview from the same authors stated that measurement of
Author/year/D-dimer Actualized VTE rate
D-dimer in conjunction with clinical variables shows prom-
assay D-dimer level (ng/ml) (95 % CI) ise in being able to identify individuals at particularly low
Palareti, 2003, Vidas >500 7.3 (4.3–10.3) risk of recurrence, as women younger than age 65 with a
(ELISA) £500 2.8 (1.0–4.5) normal D-dimer 1 month after stopping anticoagulation had
Eichinger, 2003, ³250 4.5 (3.4–5.6) a very low risk of recurrence (0.4 % per year) [66].
Asserachrom (ELISA) <250 3.0 (1.5–4.4)
Paraleti, 2006, Simply Pos (>500) 10.9 (5.9–15.9) Residual Venous Thrombus on CUS
Red( Qualitative) Neg (£500) 4.4 (2.6–6.1) One of the advantages of obtaining an ultrasound at the com-
Shrivastava, 2006, ³500 11.3 (0.0–24.1) pletion of anticoagulation is to establish a baseline for distin-
Liatest (Stago) <500 3.7 (0.0–8.7) guishing new from old thrombus in case the patient develops
Tait, 2007, Vidas ³500 14.4 (7.7–21.1) symptoms of a recurrent DVT. However, if thrombus is still
(ELISA) <500 3.7 (0.1–7.6) present, there is an increased risk for recurrence if the treat-
Baglin, 2006, MDA, ³500 8.8 (5.2–12.2) ment is stopped. In the “DACUS” study [67], subjects with a
(Liatest) <500 4.8 (1.5–8.1) first episode of DVT, treated with anticoagulation for
Poli, 2008, IL- Test ³250 10.8 (5.6–15.9)
3 months were randomized to either stop or continue antico-
(Liatest) <250 3.8 (1.4–6.1)
agulants for 9 additional months if there was residual vein
Modified from [52, 64] thrombosis (RVT) at echo, whereas in those without RVT,
anticoagulation was stopped. Recurrent events occurred in
concluded that in patients with abnormal D-dimer values, 27.2 % of those who discontinued and 19.3 % of those who
anticoagulation should be continued, whereas in patients continued anticoagulation and in 1.3 % in those without
with a normal D-dimer level, the optimal course of antico- RVT. Major bleeding occurred in 1.1 % patients who stopped
agulation is not clearly established. However, a more recent and in 2.3 % in those who continued anticoagulation.
20 Idiopathic Venous Thromboembolism 167

Prandoni et al. [68] enrolled 538 consecutive outpatients 2003 [72] showed controversial results: after 3 months of
with a first episode of acute proximal DVT at completion of conventional warfarin therapy for unprovoked venous throm-
an uneventful 3-month period of anticoagulation and ran- boembolism, patients were randomized similarly to the pre-
domized them to fixed-duration anticoagulation (no further vious study; however, the study started at 3 months after the
anticoagulation for secondary thrombosis and an extra initial event. At 2.4 years, the low-intensity warfarin regimen
3 months for unprovoked thrombosis) or flexible-duration did not reduce the risk of clinically important bleeding and
ultrasonography-guided anticoagulation (no further antico- was not efficient in reducing recurrences. A new generation
agulation in patients with recanalized veins and continued of anticoagulants might bring huge benefits in treating this
anticoagulation in all other patients for up to 9 months for entity.
secondary DVT and up to 21 months for unprovoked throm-
bosis); 17.2 % of patients allocated to fixed-duration antico-
agulation and 11.9 % of patients allocated to flexible-duration Cancer-Related Consideration
anticoagulation developed recurrent VTE. For patients with
unprovoked DVT, the adjusted HR was 0.61 (CI, 0.36–1.02) The majority of patients diagnosed with unprovoked VTE
and 0.81 (CI, 0.32–2.06) for those with secondary DVT. are found to have a hereditary or acquired risk factor if
Major bleeding occurred in 0.7 % of patients in the fixed- detailed questionnaire and biology tests are performed.
duration group and 1.5 % of patients in the flexible-duration Around 10–20 % of patients aged over 50 will be diagnosed
group. The authors suggested that tailored anticoagulation with an occult malignancy within 1–2 years from the initial
therapy conducted by residual thrombosis at echo should be VTE. We must keep in mind however that 66 % of these
integrated into clinical practice. A Canadian study [69] ana- patients already have a diagnosis of cancer when they ini-
lyzed the outcome of 646 participants with a first, unpro- tially present with VTE [73].
voked major VTE over a 4-year period. If women had none At this time, there is insufficient evidence to recommend
or one of the following characteristics of hyper-pigmenta- an aggressive investigation (for example, screening with
tion, edema or redness of either leg, D-dimer ³ 250 mg/l computed tomography of the abdomen and pelvis) unless the
while taking warfarin, body mass index ³30 kg/m2, or age patient is symptomatic (for example, bowel habits, weight
³65 years, then they had a low annual risk of recurrence loss, cough, etc.) or presents with objective findings that sug-
(1.6 %) and could safely abort anticoagulation, whereas gest the presence of an underlying malignancy. Even if an
women with two or more of these risk factors had an increased extensive etiological workup is made, up to one-third of can-
annual risk for recurrence (14.1 %). Conflicting results come cers are missed. A thorough history questionnaire, physical
from a study conducted by Cosmi et al. [70], which stated examination, chest x-ray, and routine blood work (including
that RVO at the time of anticoagulation withdrawal is not a a complete blood count, basic chemistries, liver function,
risk factor for recurrence of VTE. and lactate dehydrogenase) accompanied by age-appropriate
Limitations in tailoring such a strategy include the stan- cancer screening along with ongoing clinical surveillance
dardization of ultrasound protocols and criteria for assessing have been proved to be the best strategy.
residual thrombus. A list with the most important papers regarding the inci-
dence of occult malignancy detected with screening and dur-
ing follow-up in patients with VTE is presented in
Other Anticoagulation Strategies Used Table 20.12.
in the Treatment of Idiopathic VTE

Ridker et al. [71] recently analyzed outcomes of patients Algorithm for the Treatment of Idiopathic VTE
with idiopathic venous thromboembolisms who had received
full-dose anticoagulation therapy for a median of 6.5 months Several treatment algorithms exist for current decision-mak-
and who were randomly assigned to placebo or low-intensity ing [3, 44, 75].
warfarin (target INR, 1.5–2.0). Follow-up at 4.3 years showed After reviewing all available data, we propose a new
that low-intensity warfarin therapy was associated with a improved algorithm that could ease the risk stratification in
reduction in the risk of recurrent venous thromboembolism VTE (Figs. 20.16 and 20.17).
between 76 and 81 % (risk reductions were similar for all The two ends of the VTE spectrum are secondary VTE
subgroups, including those with and those without inherited without risk factors for recurrence (for which anticoagu-
thrombophilia). Major hemorrhage occurred in two patients lation is mandated for 3–6 month) and idiopathic VTE
assigned to placebo and five assigned to low-intensity warfa- (for which anticoagulation is mandated indefinitely if the
rin. Eight patients in the placebo group and four in the group bleeding score is low or medium). In between the two
assigned to low-intensity warfarin died. Another paper from sit secondary VTE with temporary risk factors for
Table 20.12 Incidence of occult malignancy detected with screening and during follow-up in patients with venous thrombotic events
168

Patient no. and Cancer diagnosed with

Author/year/study type pathology Duration of FU Investigations done screening/during FU Comments
Monreal et al./1991/ 113 pts with DVT Mean Initial screen: Hx, exam, CBC, LFTs, 11 pts (9.7 %)/1 pt (1.0 %) Cancer was more commonly found in pts with
prospective of lower limbs 12–15 month ESR, LDH, SPEP, CXR, blood smear, idiopathic DVT compared to pts with known risk
CEA, and abdo/pelvic US factors for DVT (7 of 31 pts vs. 5 of 82 pts;
p = 0.0127) and in those pts with abnormal LDH
levels (6 of 23 vs. 6 of 90; P = 0.007). the
majority of cancers were identified with a CBC,
LDH, CEA, CXR, and abdo US or CT
Monreal et al./1993/ 78 pts with PE Mean Initial screen : Hx, exam, ESR, CBC, 7 pts (9 %)/2 pts (2.6 %) Cancer was more commonly found in pts with
prospective 9–21 month blood smear, LFTs, LDH, SPEP, CXR, idiopathic PE as compared with pts with known
CEA, and abdo/pelvic US risk factors for PE (6 of 27 pts vs. 3 of 51 pts;
Additional test if pt agreed or abnormali- p < 0.05)
ties found: UGI endoscopy, thoracic CT
(if abnormal CXR), BM biopsy (if
abnormal SPEP), colonoscopy (if
abnormal CEA), and prostate biopsy (if
abnormal node)
Bastounis et al./1996/ 293 pts with 1st 2 years A II pts underwent screening: Hx, exam, 22 pts (7.5 %)/7 pts (2.4 %) Cancer was diagnosed in 25 % pts with
prospective episode of DVT CBC, ESR, LFTs, creat, SPEP, UA, CXR, idiopathic DVT as compared with 4 % pts with
CEA, and in 222 pts, abdo/pelvic CT secondary DVT
Cailleux et al./1997/ 148 pts with DVT 3–6 months A II pts underwent screening: Hx, exam, 6 pts (4.1 %)/not reported US was abnormal in 8 pts (5.4 %) but detected
prospective or PE laboratory tests, CXR, and abdo/pelvic US only 6 cancers. In 5 of the 6 cases, clinical exam
and lab test suggested presence of underlying
cancer
Enguidanos 48 pts with 1 year A II pts underwent screening: Hx, exam, 6 pts (12.5 %)/2 pts (4.2 %) Cancer was diagnosed in 8 pts (16 %) and a
et al./2002/prospective unprovoked DVT laboratory tests, AFP, CEA, CA19-9, CA positive tumor marker was identified in 23 pts
125, SCA, NSE, beta2-microglobulin, (48 %). This yielded a sensitivity of 12 %, a
PSA (for men), and CA 15–3 (for women) specificity of 52 %, a PPV of 5 %, and an NPV
of 75 %. Pts who had negative tumor marker and
were asymptomatic during admission had no
subsequent cancer diagnosis
Monreal et al./2004/ 864 pts with DVT 1 year Routine screen: Hx, exam, ESR, CBC, 34 pts (3.9 %) with routine The routine screen identified almost half of the
prospective or PE and no prior LFTs, creat, UA, SPEP, and CXR screen, 13 pts (1.6 %) with malignancies. Logistic regression analysis
VTE within 2 years If routine screen neg, pts underwent additional screening/14 pts showed a statistically significant association with
additional limited w/u: Abdo/pelvic US, (out of 817 for FU = 1.7 %) occult malignancies for idiopathic VTE (OR, 3.3;
CEA, PSA, and CA 125 P <0.002), as well as age above 70 years (OR,
If routine screen or limited w/u abnormal, 4.0; P <0.001)
pts underwent additional extensive w/u:
UGI endoscopy, colonoscopy, BM biopsy,
abdo/pelvic CT, thoracic CT, bronchos-
copy, and prostate US
C. Sinescu
Piccioli et al./2004/ 201 pts with 2 years Limited screen: Hx, exam, CBC, LFTs, Limited 0 pts (0 %), Extensive screen had short delay in diagnosis of
randomized controlled unprovoked and 1st calcium, UA and CXR Extensive: 13 pts (13.1 %) / cancer (1 vs. 11.6 months, [P < 0.001]) and
trial episode of DVT or Extensive screen: abdo/pelvis US, abdo/ Limited: 10 pts (9.8 %), cancer detection at earlier stages. Lower
PE pelvis CT, gastroscopy or barium swallow, Extensive : 1 pt (1 %) cancer-related mortality was not statistically
colonoscopy or sigmoidoscopy plus BE, significant (2.0 % vs. 3.9 %; [absolute difference,
stool guaiac, sputum cytology, tumors 1.9 % (95 % CI, -5.5-10.9)]). Trial was stopped
markers (CEA, AFP, CA 125), mammo- prematurely because of recruitment issues
gram and Pap smear for women, and
transabdominal US of the prostate and
PSA for men
Van Doormaal 630 pts with Median Limited screen: Hx, exam, laboratory Limited: 7 pts (2.4 %) No differences in cancer detection or deaths
et al./2009/center unprovoked VTE 30 months tests, and CXR. Extensive: 12pts (3.5 %)/ during the study (8.3 % in limited screen vs.
controlled study Extensive screen: limited screen plus Limited: 15 pts (5.3 %) 7.6 % in extensive screen) were observed
thoracic CT, abdo Ct, and mammogram
20 Idiopathic Venous Thromboembolism

(in women)
Jara–Palomares 107 pts with PE 2 years All patients underwent initial screen: Hx, 5 pts (4.7 %)/4 pts (3.9 %) Overall sensitivity of screening program was
et al./2010/prospective exam, routine blood chemistries, CBC, 55.5 % in pts with idiopathic PE. Number needed
cohort tumor markers (CEA, AFP, CA 19-9, CA to screen was 12.1 (6.1 in idiopathic PE, 58 in
125, and in men, PSA),CXR, and abdo/ secondary PE)
pelvic US. If any abnormalities found, Idiopathic PE (OR: 12.82; p = 0.03) was an
appropriate diagnostic procedures independent risk factor for occult cancer in these
performed pts with logistic regression analysis
Modified from [74]
Abdo abdomen, AFP alpha-fetoprotein, BE barium enema, BM bone marrow, CA carbohydrate antigen, CEA carcinoembryonic antigen, CBC complete blood count, CI confidence interval, creat
creatinine, CRP C-reactive protein, CXR chest radiography, DVT deep vein thrombosis, ESR erythrocyte sedimentation rate, FU follow-up, Hx history, LDH lactic dehydrogenase, LFTs liver func-
tion tests, LN lymph node, mos months, neg negative, No. number, NSE neuron-specific enolase, OR odds ratio, PE pulmonary embolus, NPV negative predictive value, PPV positive predictive
value, PSA prostate-specific antigen, pt patient, pts patients, SCC squamous-cell antigen, SPEP serum protein electrophoresis, UA urinanalysis, UGI upper gastrointestinal, US ultrasound, vs.
versus, VTE venous thromboembolism, w/u work up, yrs years
169
170 C. Sinescu

Fig. 20.16 Treatment algorithm

for secondary VTE. RF risk
factors for recurrence of VTE, * Secondary VTE
validated for idiopathic VTE
(RF-risk factors)
Anticoagulation: 3-6 months

Temporary or treatable RF present

after 3-6 months? Persistent RF after 3-6 months?

Immobilization (temporary)
Cancer (in remission, treatable) Immobilization (chronic condition)
Overweight, obesity* Cancer (metastasis, non treatable)
Low levels of apo-lipoprotein AI and Chronic obstructive pulmonary disease
high density lipoprotein cholesterol* Family history
Elevated D-dimer levels after Male gender*
discontinuing anticoagulation* Symptomatic PE*
Failure recanalize leg veins
after anticoagulation for DVT*

RF managed or treated?

Consider long-term
Yes No anticoagulation if
bleeding risk low to
moderate

Stop Continue anticoagulation until RF

Anticoagulation managed or treated (6 months-years)

recurrence and secondary VTE with permanent risk fac- Nonetheless, we should not forget that patient preference is
tors for recurrence. In the first case, anticoagulation is crucial for tailoring anticoagulation therapy. This being said, we
mandatory until the risk factor disappears or has been strongly recommend the algorithm from Figs. 20.16 and 20.17
cured (3–6 months to several years). In the latter situa- for medical decisions, even though in selected cases the most
tion, long-term anticoagulation is mandatory for low or effective treatment protocol could be decided on a case-by-case
medium bleeding risk. basis, accounting for the risk-benefit ratio in each situation.
20 Idiopathic Venous Thromboembolism 171

Fig. 20.17 Treatment algorithm

for idiopathic VTE. RF risk
factors for recurrence of VTE, *
validated for idiopathic VTE Idiopathic VTE
(RF-risk factors)

Persistent RF?

Immobilization

Cancer

Chronic obstructive pulmonary disease

Family history

Male gender*

Overweight, obesity*

Low levels of apolipoprotein AI and high-density lipoprotein

cholesterol*

Symptomatic PE*

Elevated D-dimer levels after discontinuing anticoagulation*

Failure to recanalize leg veins after anticoagualation for DVT*

Chronic anticoatulation if bleeding score low or moderate and patient

compliant, ESPECIALLY if any of the validated RF is PRESENT.
172 C. Sinescu

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 Inflammation, Thrombogenesis,
Fibrinolysis, and Vein Wall Remodeling 21
After Deep Venous Thrombosis

Jose Antonio Diaz and Daniel Durant Myers Jr.

Introduction The overall mortality associated with VTE is 30 % [4]. Of

note, the annual number of PE-related deaths in the USA
Venous thromboembolism and its sequelae, postthrombotic may exceed myocardial infarction–related and stroke-related
syndrome and chronic thromboembolic pulmonary hyper- deaths [4]. Almost 60 % of PE is diagnosed postmortem, and
tension, affect millions of people worldwide. The purpose of sudden death after symptomatic PE occurs in approximately
this chapter is to present recent and current research focused 35 % of patients [4]. Thus, it is not surprising that PE is an
on defining the mechanism that drives vein wall remodeling independent risk factor for poor outcome at 3-month follow-
after venous thrombosis. up [4].
The factors that could lead to or interact with one another
to lead to VTE were first described by Rudolph Virchow in
Epidemiology 1856 [5] and include: (1) endothelial injury, (2) blood stasis
or turbulent flow, and (3) and blood hypercoagulability.
VTE includes both deep vein thrombosis (DVT) and pulmo- Vessel wall endothelial damage initiates a local inflammatory
nary embolism (PE). After acute coronary syndrome and response, which promotes a prothrombotic state driven by
stroke, VTE is the third most common cardiovascular dis- tissue factor, adhesion molecules, and proinflammatory
ease. VTE occurs worldwide, in any age group and all socio- cytokines [5]. Stewart et al. [6] in 1974 first established the
economic groups in North America and Western Europe [1]. link between vascular inflammation and veinous thrombosis
In a recent study by Silverstein et al. [2] the estimated total (VT). This process promotes thrombosis via rolling, adher-
annual number of VTE events in the United States exceeded ence, and migration of the activated leukocytes [6]. Current
900,000. Symptomatic VTE accounted for two-thirds of the research in vascular biology supports this hypothesis.
cases reported. Interestingly, no changes in the incidence of Multiple independent risk factors for VTE have been
VTE were noted during the 25-year cohort study. identified, including advanced patient age, surgery, trauma,
The incidence of VTE varies among ethnic groups, with a prolonged bed confinement or immobility, active malignancy
higher incidence among Whites and African Americans com- with or without concurrent chemotherapy, central vein cath-
pared with Asians and Native Americans [2]. VTE is more eterization or transvenous pacemaker, history of superficial
frequent among women during childbearing years and men vein thrombosis, varicose veins, and neurological disease
after the age of 45 [2]. However, the incidence rates increase with leg paresis [1].
exponentially with age for both men and women and for both The genetic predisposition to VTE has been demon-
DVT and PE. The overall age-adjusted incidence rate is higher strated in association with deficiencies or abnormalities of
for men (114 per 100,000 person-years) than women (105 per specific plasma proteins such as protein S and protein C, or
100,000 person-years); the male:female ratio is 1.2:1 [2, 3]. downregulation of the anticoagulant system (activated pro-
tein C [APC] resistance, factor V Leiden), and increased
plasma concentrations of procoagulant factors (fibrinogen,
prothrombin; factors VIII, IX, and XI). More recently,
J.A. Diaz, MD (*) • D.D. Myers Jr., DVM, MPH, DACLAM increased basal innate immunity activity and reactivity have
Section of Vascular Surgery, Department of Surgery, added new paradigms to the list of inherited or acquired dis-
School of Medicine, University of Michigan,
orders predisposing to thrombosis [7].
2800 Plymouth Rd, North Campus Research Complex,
B26, Room 251N, 48105 Ann Arbor, MI, USA Approximately 30 % of the time, VTE will recur within
e-mail: josediaz@med.umich.edu; ddmyers@med.umich.edu 10 years of the initial episode, with most recurrences

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 175
DOI 10.1007/978-1-4471-4429-8_21, © Springer-Verlag London 2013
176 J.A. Diaz and D.D. Myers Jr.

occurring within the first 6–12 months [8]. Independent Inflammation and Thrombogenesis
predictors of recurrence include male gender [9], increas-
ing patient age and body mass index, neurological disease There is evidence to suggest that inflammation and throm-
with leg paresis, and active cancer [10]. Other predictors bosis interact and have mechanisms in common. Selectins
include idiopathic VTE; a lupus anticoagulant or antiphos- are glycoproteins that are expressed by leukocytes, activated
pholipid antibody; deficiencies of antithrombin, protein C, endothelial cells, and platelets. The role of selectins is to
or protein S; and, as recently reported, persistently mediate the initial adhesion interactions of leukocytes stim-
increased plasma fibrin D-dimer and residual venous ulated by physiological changes in blood flow at sites of
thrombosis [4]. vascular endothelial injury. Three selectins have currently
The two major complications associated with VTE are been identified: P-selectin, E-selectin, and L-selectin [14].
post-thrombotic syndrome and chronic thromboembolic pul- P- and E-selectins are cell adhesion molecules with critical
monary hypertension [8]. Approximately 12 % of all cases roles in thrombogenesis. Animal studies using rat and mouse
of post-thrombotic syndrome in the community are related to venous thrombosis models demonstrated upregulation of
VTE [8]. P-selectin and E-selectin in the vein wall 6 h and 6 days
after thrombus induction, respectively [14] (Fig. 21.1).
P-selectin is involved in leukocyte rolling and adhesion, an
Pathophysiology early inflammatory mechanism that facilitates leukocyte
transmigration. The P-selectin receptor, P-selectin glyco-
Endothelium protein ligand 1 (PSGL-1), is a glycoprotein expressed on
the surface of leukocytes and platelets that plays a critical
The endothelium forms the inner cell lining of all blood role in the recruitment of leukocytes and platelets into
vessels in the body and is a spatially distributed organ. On inflamed tissue. The interaction of PSGL-1 with P-selectin
average, the total endothelium in a person weighs approxi- (the endothelial cell P-selectin: PSGL-1-leukocyte complex)
mately 1 kg and covers a total surface area of 4,000–7,000 promotes rolling and adhesion of leukocytes and platelets,
square meters [1]. The endothelium is involved in most if which ultimately result in increased vein wall cell infiltration
not all disease processes, either as a primary determinant [15] (Fig. 21.1).
of pathophysiology or as a target of collateral damage [1]. A study by Wagner et al. showed that the increase in the
Endothelial cells play a critical role in hemostasis. In a number of P-selectin molecules present on the endothelial
healthy individual, there is a balance between procoagulant cell surface is due to the release from the Weibel-Palade
and anticoagulant mechanisms. The anticoagulant effect body (WPB). WPBs are the endothelial-specific storage
involves the endothelial cells supporting local fibrinolysis organelle for regulated secretion of von Willebrand factor
in which coagulation (platelet adhesion and activation) and (vWF) and P-selectin onto its membrane [15]. Thus, the
inflammation (leukocyte activation) remain suppressed exocytosis of WPB initiates a rapid translocation of
[11] (Fig. 21.1). In contrast, a procoagulant effect is P-selectin to the endothelial surface, resulting in augmented
observed during states of endothelial disturbance, e.g., endothelial adhesiveness for leukocytes and platelets.
physical (vascular trauma) or functional (sepsis) [11] Soluble P-selectin (sP-sel) is released from activated plate-
(Fig. 21.1). lets and endothelial cells, and levels rise significantly during
It is widely known that, under normal conditions, cellular pathologic conditions. The function of sP-sel has been
blood components interact with the vessel wall in order to shown to be an endogenous activator of coagulation via
promote normal vascular repair. generation of plasma microparticles in addition to its ability
The effect of the thrombus on the cellular components of to bind to PSGL-1, leading to leukocyte recruitment and
the vein wall is not well defined; however, post thrombosis, rolling [16].
the vein wall increases in stiffness and thickness and loses Circulating cell-derived microparticles (MP) contribute to
compliance [13]. The non-injured vein wall at rest is the coagulation and amplification of thrombosis (Fig. 21.1).
characterized by a continuous endothelium, a thin and com- They are present in the blood of healthy individuals. These
pliant structure with scattered vascular smooth muscle cells MPs are small vesicles (less than 1 mm) consisting of a
(VSMCs) (Fig. 21.2). In contrast, the post-thrombotic vein plasma membrane surrounding a small amount of cytoplasm
wall is thickened, with loss of endothelium (early) and dis- with cell-specific surface molecules [17]. Endothelial cells,
rupted matrix and proliferative VSMC. The longer an occlu- leukocytes, and platelets have a very well-structured plasma
sive or partially occlusive thrombus is in contact with the membrane characterized by a controlled transverse lipid
vein wall, the greater the inflammatory response and damage distribution termed “rafts.” The activation of these cells pro-
to the vein wall as defined in a recent review by DeRoo et al. motes a general membrane content redistribution during
[13] (Fig. 21.2). which rafts concentrate in areas of the cell that will ultimately
21 Inflammation, Thrombogenesis, Fibrinolysis, and Vein Wall Remodeling After Deep Venous Thrombosis 177

Inflammatory stimulus

P-selectin; PSGL-1; E-selectin; ESL-1 Interactions

leukocytes; Platelets; Endothelium

Monocyte Neutrophil

MPs
Tissue factor
PSGL-1 PSGL-1 ESL-1
=TF

Injury

P-selectin

Activation of extrinsic pathway

Red blood Platelet (PLT)

Monocyte
cells (RBC)
Neutrophil

MPs
Endothelium

Fibrin strands E-selectin

Fibrin deposition and thrombus amplification

Neutrophil
Monocyte TF
PLT
MPs
Binding

P-sel; PSGL-1 E-sel; ESL-1

Fig. 21.1 Hypothesized mechanisms of acute venous thrombosis post ticles lead to thrombus formation and amplification (From Stanley et al.
activation of the venous endothelium. The activation of tissue factor, [12] with permission)
P-selectin and E-selectin, platelets, inflammatory cells, and micropar-
178 J.A. Diaz and D.D. Myers Jr.

Normal vein wall

Red blood Platelet (PLT)

cells (RBC)

Neutrophil
Monocyte

Continuous endothelium
Few scattered contratileVSMC
ECM of collagen fibrils, dispersed
Primarily collagen I
Undisturbed basement membrane
Primarily collagen IV

Post thrombotic vein wall

Monocyte Neutrophil

Few VSMC, synthetic transformation

Fracture of normal ECM
Depostition of new ECM
Collagen type I and III
Disturbed basement membrane
Loss of Collagen IV

Fig. 21.2 Vein wall matrix changes post venous thrombosis (Modified from DeRoo et al. [13] with permission)
21 Inflammation, Thrombogenesis, Fibrinolysis, and Vein Wall Remodeling After Deep Venous Thrombosis 179

derive in MP. Therefore, the MP membrane is rich in lipid by the liver. Plasma protein C is a two-chain molecule,
rafts. These MPs concentrate tissue factor (TF) in caveolae consisting of a light and heavy chain. Its half-life is 6–7 h.
where it is stored with the tissue factor pathway inhibitor Once protein C binds to its receptor, endothelial protein C
(TFPI). The fusion of MP with activated platelets promotes receptor, it is cleaved (activated) by the thrombin-thrombo-
thrombus formation in a TF-dependent manner. In addition modulin complex on the endothelial surface, resulting in
to TF, the expression of prothrombinase activity on the mem- activated protein C (APC). In the presence of calcium and
brane [18] and PSGL-1 [11] are involved in the procoagulant protein S, APC inactivates factor Va and factor VIIIa of the
activity of MPs (Fig. 21.1). “protein C anticoagulant pathway.”
During inflammation, activation of endothelial cells Protein S, a vitamin K-dependent plasma glycoprotein, is
upregulates surface expression of P-selectin, leading to for- synthesized by the liver, the endothelial cells, and the mega-
mation of the endothelial cell-P-selectin: PSGL-1-leukocyte karyocytes. Protein S is a cofactor of APC in the protein C
complexes. These complexes stimulate the production of anticoagulant pathway. In addition, protein S exhibits APC-
MPs from leukocytes, particularly monocytes, along with independent anticoagulant activity by binding to factors Va,
platelets and endothelial cells. In addition, the accumulation VIIIa and Xa [1]. In serum, protein S is found in two forms:
of leukocyte markers expressed on the surface of MPs in the free (active) and protein bound (inactive). Almost 70 % of
growing thrombus is mediated by the P-selectin-PSGL-1 circulating protein S is bound to a complement protein (C4b-
complex [11]. Therefore, MP concentration increases dra- binding protein). The remaining 30 % circulates as “free pro-
matically at the area of vein wall injury and inflammation tein S,” which has a half-life of 96 h. It is the free protein S
[19]. MPs also possess a phosphatidylserine-rich anionic that acts as a cofactor for protein C [1].
surface capable of assembling complexes of the coagulation TFPI is a single-chain plasma polypeptide that inhibits
cascade. Another molecule expressed on the MP membrane factor Xa and TF-factor VIIa complex catalytic activity.
surface is PSGL-1, which then can bind to upregulated Plasma only contains 20–30 % of the intravascular minor
P-selectin on platelet surfaces in the thrombus. There is even fraction of TFPI, and it is largely bound to lipoproteins. The
evidence that macrophage-1 (Mac-1) on leukocyte-derived majority of TFPI (60–70 %) is normally bound to the vascu-
MPs can allow interactions between MPs and inactivated lar endothelium. This pool of TFPI is released into circula-
platelets using glycoprotein 1b alpha (GP1ba), resulting in tion after heparin injection [1].
further platelet activation with P-selectin upregulation [20, Prostacyclin and nitric oxide (NO) are secreted by
21]. All these events occurring in the area of thrombus for- endothelial cells. These compounds synergistically contrib-
mation lead to thrombus amplification. The increase of cir- ute to vessel homeostasis by reducing vascular smooth mus-
culating MPs with the onset of inflammation adds to the cle cells tone and growth, platelet aggregation, leukocyte
proposed mechanisms linking vein wall inflammation and adhesion to endothelium, and susceptibility to thrombosis.
thrombogenesis (Fig. 21.1). Interestingly, Osanai et al. demonstrated that vessel homeo-
Circulating inhibitory mechanisms regulating the process stasis might be maintained through an increase in prostacy-
of thrombogenesis include anti-thrombin III (ATIII), protein clin production in vascular endothelial cells when NO
C, protein S, TFPI, and glycocalyx-associated glycosamino- synthesis is impaired [22].
glycans, such as heparin sulfate, endothelial protein C recep- We recently used our mouse inferior vena cava (IVC)
tor, and thrombomodulin (TM), which facilitates inhibitory ligation model to generate venous thrombosis in order to
activity of thrombin by anti-thrombin III and APC by TM. study the role of interleukin-6 (IL-6) in thrombus develop-
Anti-thrombin III, a plasma glycoprotein synthesized ment. Specifically, an antibody (anti-IL-6) was administered
in the liver, is a serine protease inhibitor (SERPIN) struc- to mice pre-thrombus induction that leads to in vivo neutral-
turally related to other plasma protease inhibitors, such as ization [23]. We found that IL-6 had an acute and a chronic
alpha 1-antichymotrypsin, alpha 2-antiplasmin, and heparin effect. During the acute phase (2 days post-thrombosis), C-C
cofactor II. Anti-thrombin III acts as a pseudo-substrate for motif chemokine ligand 2 or CCL-2 (the mouse equivalent to
the inhibition of the intrinsic pathway (factors IIa [throm- human monocyte chemotactic protein-1 [MCP-1]) was
bin], IXa, Xa, XIa, XIIa) and the extrinsic pathway (factor significantly decreased in the group where circulating IL-6
VII), kallikrein, and plasmin. Other targets of anti-thrombin was blocked. This was demonstrated by the gene expression
III include trypsin and the C1s subunit, which are involved and protein level [23]. The decrease in CCL-2 caused a
in the classical complement pathway. The anti-thrombin III reduction in the number of monocytes recruited into the
plasma half-life is 60–70 h, while the thrombin-antithrom- injured area at an intermediate time point (6 days post throm-
bin (TAT) complex is cleared by the liver, and its inhibitory bosis), indicating a dynamic and linked process. At the
activity is increased by heparin [1]. chronic time point (14 days post thrombosis), a statistically
Protein C, a vitamin K-dependent plasma glycoprotein, is significant decrease in fibrosis was observed in the group
synthesized as a single chain and cleaved prior to secretion treated with anti-IL6 vs. control [23]. This was demonstrated
180 J.A. Diaz and D.D. Myers Jr.

using several methods, including Masson’s stain quantification in a healthy individual [1]. Thrombolysis depends on
of fibrosis. In summary, we have shown a relationship multiple physiological processes, including fibrinolysis.
between IL-6/CCL-2/monocyte recruitment and fibrosis for In response to thrombus formation, natural anticoagulants
the first time in the context of VT, exhibiting a potential path- such as protein C and protein S have roles in thrombolysis.
way that started early on in venous thrombosis (VT) and con- Similarly, circulating plasminogen is activated to plasmin,
tinued to have an impact on chronic VT as well [23]. This is which is the main fibrinolytic enzyme [11]. Plasmin’s
an important step in understanding the link between main substrates include fibrin, fibrinogen, and other coag-
inflammation and thrombosis in the context of VT and indeed ulation factors. In addition, plasmin interferes with vWF-
a recent insight into the molecular and cellular contributions mediated platelet adhesion by proteolysis of GpIb receptor
to venous thrombosis. complex [32].
The role of neutrophil extracellular traps (NETs) in acute Plasminogen activators are serine proteases that activate
inflammation was recently described. In addition to their plasminogen by the proteolytic cleavage of a single argin-
phagocytic and bactericidal functions, activated neutrophils ine-valine peptide bond. Plasminogen activator inhibitor
have been shown to release chromatin deoxyribonucleic acid type 1 (PAI-1) is the primary inhibitor of the plasminogen
(DNA) and histone containing granular antimicrobial pro- activators, both tissue type plasminogen activator (t-PA) and
teins, which form extracellular matrices or traps [24]. The urokinase type plasminogen activator (u-PA), and hence
mechanisms regarding neutrophil cell death and the forma- fibrinolysis [11]. PAI-1 is produced by the endothelium but
tion of NETs appear to be separate from apoptosis and necro- is also secreted in an active form by the liver and adipose
sis and appear to rely upon the formation of intracellular tissue. Increased PAI-1 levels are found in various disease
reactive oxygen species [25]. NETs have been shown to kill states such as cancer, obesity and metabolic syndrome.
bacteria while forming a microbial containment barrier [26, Thus, the increased occurrence of thrombosis in patients
27]. In addition, NETS have been reported to form during with these conditions has been suggested to be associated
sepsis and in inflammatory non-infectious disease states such with elevated PAI-1 levels. PAI-1 elevation appears to syn-
as small-vessel vasculitis [28, 29]. ergize with factor V Leiden genetic abnormalities [11]. It is
It was demonstrated that NETs were associated with DVT possible that elevated PAI-1 levels could suppress fibrinolysis
when using an experimental baboon model of occlusive bal- and increase thrombosis, hence increasing the clinical mani-
loon-induced iliac deep vein thrombosis [30]. Plasma DNA festations of DVT. However, studies on the role of elevated
samples collected at baseline were significantly lower than levels of PAI-1 to venous thrombosis have been contradic-
plasma DNA samples collected at 2 and 6 days post-DVT tory [33].
(p < 0.01) [30]. Furthermore, the rise in plasma DNA kinetics Polymorphism in the PAI-1 gene has been suggested to be
was similar to our previous findings of plasma D-dimers in associated with an increased risk of VTE. Human studies
the same experimental model [31]. In addition to plasma have evaluated the role of genetic polymorphisms, particu-
DNA, histologic samples of iliac veins (6 days post-DVT) larly the 4 G/5 G insertion/deletion in the promoter region,
and controls were stained using an antibody directed toward which affects transcription rates. The highest levels of PAI-1
DNA histone complexes (nuclear origin) and evaluated for have been noted in those individuals carrying the 4 G/4 G
the presence of DNA nuclei and extracellular DNA or NETs. polymorphism. Akar et al. reported an increased risk of DVT
Affected vessels demonstrated punctate staining of nuclear (odds ratio 5.5) in individuals with the 4 G allele polymor-
DNA and diffuse staining of extracellular DNA compared to phism. This risk of DVT was even greater when the 4 G
controls. Furthermore, immunocolocalization of VWF polymorphism coexisted with factor-V-Leiden deficiency
strings were dispersed within the DNA core and between the [34]. Another study by Zoller et al., showed an increased risk
DNA core and the vessel wall [30]. These are the first of PAI-1 elevation (odds ratio 8.14) in individuals carrying
reported results demonstrating that markers of NETs were the 4 G polymorphism in combination with other thrombo-
present in both the plasma and thrombus in experimental philic markers. The risk of PE development was increased in
DVT. These results provide early evidence regarding the individuals with the 4 G/4 G polymorphism and protein S
interactions and roles of NETs (DNA and histones), vWF, deficiency (odds ratio 4.5) [35].
and platelet binding in venous thrombosis. Fibrin degradation products (FDPs) result from the action
of plasmin on deposited fibrin. FDPs include fragments E
and fragment D, which, during physiological thrombolysis,
Plasminogen Activators and Thrombolysis are released as a covalently linked dimer, the D-dimer [11].
Clinically, testing of circulating D-dimer is used as a surro-
Venous thrombosis is a dynamic process with thrombus gate maker for diagnosis of ongoing DVT and/or PE. In addi-
formation (thrombogenesis) and dissolution (thrombolysis) tion, the presence of elevated D-dimer levels after successful
occurring almost simultaneously under normal conditions treatment of DVT has a high positive predictive value for
21 Inflammation, Thrombogenesis, Fibrinolysis, and Vein Wall Remodeling After Deep Venous Thrombosis 181

recurrent DVT [11]. In patients with suspected disseminated MMP-2 and MMP-9 activities without an increase in
intravascular coagulation, D-dimer levels may also aid in the thrombus monocyte influx [39].
diagnosis. Thrombus resolution involves a number of proinflam-
Platelet-activating factor (PAF) and endothelin-1 matory factors that are released into the local environ-
(ET-1) play a role in thrombogenesis. PAF, also known as ment. These factors include IL-1 beta (IL-1b) and tumor
PAF-acether or acetyl-glyceryl-ether-phosphorylcholine necrosis factor (TNF)-alpha [11]. It has been suggested
(AGEPC), is a potent phospholipid activator and mediator that these mediators are released by leukocytes and smooth
of many leukocyte functions, including platelet aggrega- muscle cells found within the resolving thrombus,
tion, inflammation, and anaphylaxis. In addition, ET-1 is although the specific mechanisms involved in this process
a 21-amino-acid peptide produced in a variety of tissues are yet to be elucidated [13]. Henke et al. observed that
including endothelial and smooth muscle cells. Functions elastinolysis occurred at early time points in a mouse
of ET-1 include binding to ET-1 receptors on the vascular model of stasis-induced DVT. In this model, the occur-
smooth muscle, which are Gq-proteins, inducing increased rence of elastinolysis was determined by an increase in
inositol 1,4,5 phosphate levels, leading to calcium release vein wall stiffness. Elastinolysis persisted for 14 days,
and subsequent muscle contraction. Although an association along with elevated MMP-2 and MMP-9 activities. In the
between ET-1 and platelet activation has been suggested, the same model, early vein wall collagenolysis was observed
data remain unclear [36]. within the first 7 days, representing an acute response to
injury [39].
The elevation of profibrotic mediators, including trans-
Thrombus Resolution and Vein Wall Remodeling forming growth factor (TGF)-beta, IL-13, and MCP-1, has
been associated with early biomechanical injury during DVT.
DVT resolution is a fibrotic process that mimics wound These mediators are present in the vein wall and thrombus
healing. This process involves profibrotic growth factors, and may drive the fibrotic response. Exogenous MCP-1 may
collagen deposition, and matrix metalloproteinase (MMP) accelerate DVT resolution, but it also promotes organ fibrosis
expression and activation [13, 37]. The kinetics of the leu- in vivo. TGFb is also present in the thrombus and is activated
kocyte in the vein wall follows the same pattern of that during thrombolysis. This factor appears to be a key mecha-
observed in the thrombus. Thus, immediately after throm- nism promoting vein wall fibrosis. In mice, late fibrosis has
bus formation, an early influx of polymorphonuclear (PMN) been associated with a significant increase in vein wall col-
cells is followed by monocyte migration. Leukocyte migra- lagen after stasis thrombogenesis [40]. Increased gene
tion from the vein lumen into the wall and into the thrombus expression and activity of collagen I and III, MMP-2, and
follows a specific sequence of events leading to thrombus MMP-9 have also been observed. Thus, vein wall injury is
resolution [11]. associated with active matrix remodeling, which seems to
The first cell type that migrates into the thrombus is the promote net fibrosis [40].
PMN leukocyte. PMNs are essential for early thrombus reso- We demonstrated that inhibition of the inflammatory
lution as they promote both fibrinolysis and collagenolysis response can decrease vein wall fibrosis [23]. These data
[11]. In support of this concept, a study using a rat model add to the evidence of the close interaction between
of stasis DVT showed that neutropenia was associated with inflammation and fibrosis [23]. In another study using an
increased thrombus size at 2 and 7 days, increased intrathrom- IVC stenosis model in rats, animals were treated with either
bus collagen deposition, and significantly low intrathrombus low-molecular-weight heparin or an oral P-selectin inhibitor
levels of both uPA and MMP-9 [38]. 2 days after thrombus initiation. In this study, the P-selectin
The second cell type observed in the thrombus is the inhibitor significantly decreased vein wall injury (indepen-
monocyte. Monocytes are important cells in later thrombus dent of thrombus size), which was assessed by vein wall
resolution. Monocyte influx into the thrombus is detected at tensiometry (stiffness), intimal thickness score, IL-13 levels,
day 8 after thrombus generation and correlates with elevated MCP-1 levels, and platelet-derived growth factor-b (PDGFb)
MCP-1 levels, a CC chemokine that promotes monocyte levels [41].
chemotaxis and activation. MCP-1 has been associated with In addition, we recently demonstrated a link between
DVT resolution [11]. In a study using a mouse model of sta- hyperlipidemia and DVT and its effects in both fibrinolysis
sis-induced thrombosis, late thrombus resolution was tested and vein wall remodeling [37]. An association was found
using target-deleted CC receptor-2 (CCR-2 KO) mice. In this between hyperlipidemia and high levels of PAI-1 in ApoE
study, late impairment of thrombus resolution appeared to be KO mice, leading to the production of a larger thrombus
due to impaired MMP-2 and MMP-9 activity [11]. This situ- compared to controls [37]. Also, decreased levels of uPA
ation was reversible with the administration of exogenous production in ApoE KO mice was noted, leading to
interferon gamma (INF-g), in part attributable to recovery of decreased levels of MMP-2 and 9, MCP-1 and monocyte
182 J.A. Diaz and D.D. Myers Jr.

recruitment, which are all key participants in vein wall 11. Wakefield TW, Myers DD, Henke PK. Mechanisms of venous
remodeling [37]. These results are the first to demonstrate thrombosis and resolution. Arterioscler Thromb Vasc Biol. 2008;
28(3):387–91.
that hyperlipidemia and DVT are linked and, in the context 12. Stanley JC, Veith FJ, Wakefield TW (editors) Current Therapy
of hyperlipidemia, both fibrinolysis and vein wall remodel- in Vascular and Endovascular Surgery, 5th edition. Elsevier (in press).
ing are impaired [37]. 13. Deroo S, Deatrick KB, Henke PK. The vessel wall: a forgotten
Furthermore, we found that levels of PAI-1 (circulating player in post thrombotic syndrome. Thromb Haemost. 2010;104(4):
681–92.
PAI-1, vein wall PAI-1 and Liver PAI-1) were significantly 14. Myers Jr D, Farris D, Hawley A, Wrobleski S, Chapman A,
decreased in ApoE KO hylperlipidemic mice treated with Stoolman L, et al. Selectins influence thrombosis in a mouse model
rosuvastatin compared to controls, suggesting a profi- of experimental deep venous thrombosis. J Surg Res. 2002;108(2):
brinolytic effect of rosuvastatin [42] and might be responsi- 212–21.
15. Wagner DD, Frenette PS. The vessel wall and its interactions.
ble for the protective effect of rosuvastatin on DVT positive Blood. 2008;111(11):5271–81.
patients [43]. 16. Andre P, Hartwell D, Hrachovinova I, Saffaripour S, Wagner DD.
In summary, thrombus resolution and vein wall remodel- Pro-coagulant state resulting from high levels of soluble P-selectin
ing are complex processes that vary with the degree of throm- in blood. Proc Natl Acad Sci USA. 2000;97(25):13835–40.
17. Ahn ER, Lander G, Jy W, Bidot CJ, Jimenez JJ, Horstman LL, et al.
bus burden and age (chronicity). Novel therapeutic approaches Differences of soluble CD40L in sera and plasma: implications on
aimed at alleviating post-thrombotic cell wall damage will CD40L assay as a marker of thrombotic risk. Thromb Res. 2004;
need to be directed at the sequence of events occurring at the 114(2):143–8.
vein wall:thrombus interface over time. 18. Satta N, Toti F, Feugeas O, Bohbot A, Dachary-Prigent J, Eschwege
V, et al. Monocyte vesiculation is a possible mechanism for dissemi-
nation of membrane-associated procoagulant activities and adhe-
Acknowledgments The author’s would like to thank Dr. Katherine sion molecules after stimulation by lipopolysaccharide. J Immunol.
Shuster for her careful edits of this book chapter. Financial support was 1994;153(7):3245–55.
obtained from the Jobst Foundation Grant (to JAD and DDM). 19. Myers DD, Wakefield TW. Inflammation-dependent thrombosis.
Front Biosci. 2005;10:2750–7.
Conflicts of Interest The authors have no conflicts of interest to 20. Pluskota E, Woody NM, Szpak D, Ballantyne CM, Soloviev DA,
disclose. Simon DI, et al. Expression, activation, and function of integrin
alphaMbeta2 (Mac-1) on neutrophil-derived microparticles. Blood.
2008;112(6):2327–35.
21. Andrews RK, Berndt MC. Microparticles facilitate neutrophil/
platelet crosstalk. Blood. 2008;112(6):2174–5.
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Kunkel SL, et al. Deep vein thrombosis resolution is not accelerated 1851–1861.
 Varicose Veins: Venous Wall Changes,
Inflammation, and Matrix 22
Metalloproteinases

Joseph D. Raffetto

Introduction to the same segment of vein containing the varicose vein, and
they compared the varicose vein to normal control saphenous
Varicose veins are superficial vessels that are abnormally veins. The study found an increase in collagen, a significant
twisted, lengthened, or dilated, and they are usually caused decrease in elastin, and an increased collagen:elastin ratio in
by inefficient or defective valves within the vein. Varicose both varicose veins and competent “normal” saphenous vein
veins are part of the spectrum of chronic venous diseases segments that were adjacent to the varicosities compared with
(CVDs), which affect millions of people throughout Western the normal control saphenous vein. This study demonstrated
populations [1]. There is significant evidence in the litera- that in patients with varicose veins, collagen and elastin changes
ture that wall dysfunction consisting of alterations in the were present, but, importantly, normal-appearing saphenous
endothelium and smooth muscle cells (SMCs) are a princi- veins in proximity to varicose veins also demonstrated connec-
pal cause for varicose veins [2]. In addition, matrix metal- tive tissue changes in the venous wall. These findings support
loproteinases (MMPs) are present in varicose veins and can the notion that vein wall changes precede valvular insufficiency
be found in the endothelium, smooth muscle, and adventi- [4]. Other human studies have corroborated these findings. In
tial layers of the vein wall [3]. However, it is unclear whether an interesting study using duplex ultrasound-evaluated seg-
the presence of MMPs is a result of chronic inflammation ments of varicose veins of the greater saphenous vein, saphen-
and venous wall remodeling or whether MMPs actually ous vein segments had a dilated varicosity that was proximal to
functional in veins, causing biochemical changes in the a competent venous valve and adjacent to a normal-appearing
venous wall leading to early dilation and chronic irrevers- distal vein segment. The study evaluated the rigidity of the vein
ible changes typified by varicose veins [2]. Furthermore, wall, matrix fibers, and elastin in the varicose vein and com-
the role of venous wall dysfunction appears to precede valve pared it to the continuous normal-appearing vein. It was dem-
dysfunction, is linked to MMPs [2], and is tightly regulated onstrated that the rigidity was the same in both the proximal
by hypoxia inducible factor. varicose vein and normal distal saphenous vein, and both vein
segments had increased matrix fibers and fragmented elastin. It
was concluded that the role of the venous valve dysfunction
Basic Scientific Evidence for Primary leading to reflux in varicose veins is secondary to the primary
Vein Wall Changes changes that occur in the wall [5]. The same investigators
evaluated the matrix proteins in the wall of varicose veins in
In an early study, investigators evaluated the collagen and elas- 372 specimens and compared them to normal control veins in
tin content of the nonthrombophlebitic greater saphenous vari- 36 specimens. The varicose veins demonstrated a significant
cose vein and normal-appearing saphenous vein in proximity increase in wall matrix proteins, including collagen, laminin,
and tenascin, and a nearly significant increase in fibronectin
(Table 22.1). Importantly, in patients with varicose vein, the
normal-appearing segments of vein just inferior to the varicose
J.D. Raffetto, MD, MS, FACS, FSVM vein had the same biochemical profile as the adjacent varicose
Division of Vascular and Endovascular Surgery,
vein [6]. This study provided further evidence that alterations
Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA of structural proteins in the vein wall occur in normal-
appearing veins taken from contiguous segments of a varicose
Department of Surgery, 112, VA Boston Healthcare System,
1400 VFW Parkway, West Roxbury, MA 02132, USA vein and precede the changes of venous valve reflux during
e-mail: joseph.raffetto@med.va.gov varicose vein formation.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 185
DOI 10.1007/978-1-4471-4429-8_22, © Springer-Verlag London 2013
186 J.D. Raffetto

Table 22.1 Structural protein alterations in varicose vein wall and in control veins, although the transcriptional products (same
the smooth muscle cells (SMC) of varicose veins amount of mRNA product) of these two proteins were not
Protein Varicose veina dissimilar in varicose veins versus control vein. In addition,
Vein wall collagen Increased the synthesis and deposition of collagen type III but not type
Vein wall elastin Decreased I were significantly lower in varicose veins. When matrix
Vein wall laminin Increased metalloproteinases (MMPs) -1, -2, and -9 and the natural tis-
Vein wall tenascin Increased sue inhibitors of MMPs (TIMPs) -1 and -2 were analyzed
Vein wall fibronectin Similar from the supernatant of confluent SMC, no differences were
SMC collagen type I Increased
observed. These data suggested that the regulation as well as
SMC collagen type III Decreased
changes for both collagen type III and fibronectin in SMC
SMC collagen type IV Similar
was a post-transcriptional event [10]. Although there was no
SMC fibronectin Decreased
a
difference in MMP and TIMP in the supernatant tested, this
Indicates relative to normal control veins
did not exclude the possibility that altered expression, activ-
ity and other types of MMPs exist in whole tissues including
Vein Wall Inflammation, SMC Dysfunction, TIMP. Further work in this area demonstrated that varicose
MMP Expression, and Venous Dilation greater saphenous vein had a smaller spiraled collagen distri-
bution specifically in the intima and media. To investigate
A significant finding in varicose veins is the role of the latter findings, the same investigators demonstrated that
inflammation as a consequence of inflammatory cell infiltrate. inhibition of MMP with marimastat (BB-2516, non-selective
Several studies have evaluated inflammatory cells and activa- MMP inhibitor) resulted in partial restoration in the produc-
tion in varicose veins and normal control veins. In human tion of collagen type III in smooth muscle cells from vari-
saphenous vein specimens from patients with CVD, an cose veins. In addition, MMP-3, which degrades fibronectin,
increased number of monocytes/macrophage infiltration in was elevated in both its transcription product and protein
the venous wall and valves was demonstrated. The expression. It was concluded that the mechanism involved in
inflammatory invasion is an important step in the events lead- collagen type III and fibronectin degradation in the smooth
ing to inflammation, cytokine and proteinase production, and muscle cells cultured from varicose veins is likely linked to
structural changes in the vein wall architecture. Elevated the expression of MMP-3 and its proteinase activity [11].
intercellular adhesion molecule-1 (ICAM-1), a marker of The important properties of type III collagen in blood vessels
activation of leukocytes to adhere to the endothelium, has is the ability to provide elasticity and distensibility. The
also been detected in CVD vein specimens, but not in normal abnormal production of type III collagen in both SMC cul-
veins [7]. This would suggest that certain predisposing fac- tured from varicose veins and fibroblasts cultured from der-
tors and/or stimuli cause the vein endothelium to express mal biopsies of patients with CVD raises the possibility that
ICAM-1, leading to leukocyte activation and infiltration, with varicose veins’ pathology may arise from abnormal matrix
further inflammatory responses that initiate the release of collagen deposition and is likely a systemic disease [12].
cytokines and MMPs. In fact, a study evaluating patients with Furthermore, to identify factors involved in abnormal elas-
venous hypertension demonstrated that there was sequestra- ticity and distensibility in varicose veins, a study evaluated
tion of activated neutrophils and monocytes in the microcir- the content of hydroxyproline and quantified collagen types
culation. This persisted even after elevating the limbs and I, III, and V. It was found that in both SMC and fibroblast of
decreasing the venous hypertension, which indicated that leu- patients with varicose veins, as compared to control, had an
kocytes were adhering to the endothelium [8]. In another increase in hydroxyproline content, indicating increased col-
interesting study, plasma collected from patients with CVD lagen; however, the proportion of collagen type III was
caused significant granulocyte activation, which was more significantly reduced despite normal mRNA transcript. These
prominent in advanced stages of CVD (skin changes and data were consistent with previous reports and offered an
ulcer). In addition, there was increased hydrogen peroxide explanation for the loss of distensibility and elasticity in vari-
production from activated granulocytes in the patient’s plasma cose veins; they suggested that the defect is generalized, sup-
than the control patient plasma [9]. These data suggested the porting a genetic basis for the alterations observed in patients’
presence of a circulating activating factor in the plasma of varicose veins [13]. Taken together, these findings suggest
patients with CVD, which could activate the ICAM-1 on that at least in cultured SMC from varicose vein, there is an
endothelium, initiating the early events that may be important imbalance of collagen production with dysregulation and
in the pathophysiology of CVD and varicose veins. increased type I collagen but reduced type III collagen pro-
Immunohistochemical studies of SMC cultured from var- duction. Because of normal expression of mRNA for type III
icose veins were found to have a decreased number of cells collagen, the reduction in synthesis is related to post-
staining for collagen type III and fibronectin compared to transcriptional events. The inhibition of type III collagen
22 Varicose Veins: Venous Wall Changes, Inflammation, and Matrix Metalloproteinases 187

synthesis could be a result of degradation/inhibition by inflammation on the vein wall to maintain valve function and
MMP-3 and may explain changes in the mechanical proper- reduced venous wall destruction.
ties of the vein wall leading to inappropriate elasticity and
distensibility, which results in varicose vein formation.
Finally, the similar abnormalities found in dermal cultured MMPs and Effects on Endothelial
fibroblasts indicate that the problem of varicose veins is a and SMC Venous Function
systemic disease, likely with genetic factors involved.
It is possible that MMPs may have acute and chronic effects
on the vein wall. Early changes may cause functional and met-
Localization of MMPs and Significance, abolic changes to the vein wall, while the later effects of
Models of Venous Hypertension and MMP MMPs may alter wall matrix composition to such an extent
Activation, MMP Modulation by Flavonoids that dilation and tortuousity becomes the prominent morpho-
logical feature [2]. In recent studies, evidence for how MMPs
A possible explanation for venous dilation and tortuosity acutely influence venous wall dilation was determined. In a rat
may be the influences of MMPs and TIMPs, which lead to inferior vena cava (IVC) model where exogenous MMP-2 was
venous wall remodeling and subsequent dilatation and valve added, changes in vein wall contraction resulting in relaxation
incompetence. Several authors have found an increased was recorded. MMP-2 caused time-dependent venous relax-
expression, localization, and activity of MMPs in the venous ation in phenylephrine-contracted IVC. However, MMP-
segments of varicose veins and in veins with thrombophlebi- 2-induced venous relaxation was essentially abolished in
tis compared to control veins [3, 14, 15]. It is unclear whether 96 mmol/l KCl depolarizing solution, which prevents outward
MMPs are present because of a secondary process due to cel- movement of K+ ions from the cell through K+ channels, which
lular inflammatory infiltration and wall remodeling or is necessary during venous relaxation in hyperpolarized vas-
directly involved in the formation of varicose veins. The cular tissue. In order to define which K+ channels were
question is how MMPs cause venous dilation and varicose involved, the investigators tested the effects of K+ channel ago-
vein formation. The role of MMPs in varicose vein has nists and antagonists on MMP-2-induced venous relaxation.
largely been attributed to their proteolytic effects on extra- MMP-2 caused further relaxation of vein segments in the pres-
cellular matrix (ECM), degradation of the valve leaflets, and ence of activators of the ATP-sensitive potassium (KATP) chan-
weakening of vein wall structure [16, 17]. The localization of nel, indicating that MMP-2 was not working through the KATP
MMPs in the varicose vein wall adventitia and fibroblast is channel during cell hyperpolarization (a condition of negative
consistent with a role in ECM degradation [15]. However, in membrane potential caused by outward potassium ion move-
varicose veins, MMPs have also been localized in the vicin- ment leading to smooth muscle cell relaxation and resulting in
ity of the endothelium and SMC [15, 18], raising the possi- venous relaxation). In contrast, blockade of the large conduc-
bility of additional effects of MMPs on these cell types. tance Ca2+-dependent K+ channels (BKCa) with iberiotoxin
Other studies have investigated the ratio of TIMP-1/MMP-2 significantly inhibited the MMP-2 effect on venous relaxation,
and found a threefold ratio increase in varicose veins com- suggesting that MMP-2 actions in part involve hyperpolariza-
pared to normal veins, concluding that proteolytic inhibition tion by activation of BKCa. MMP-2 induced activation of K+
and ECM accumulation may account for the pathogenesis of channels likely causes SMC hyperpolarization and leads to
varicose veins [19]. decreased Ca2+ influx through voltage-gated channels [22]. In
Animal models of venous hypertension utilizing a femo- addition, it was determined that nitric oxide (NO) was abun-
ral artery and vein fistula in the rat have demonstrated an dant in acetylcholine-stimulated IVC. However, in the pres-
increased sustained venous pressure above 90 mmHg with ence of MMP-2, there was no measurable increase of NO,
significant abnormal structural changes in the vein valve and indicating that the NO-cGMP pathway was not stimulated by
wall. In addition, there was significant expression of MMP-2 MMP-2-induced relaxation. In addition, using inhibitors of
and MMP-9 at 6 weeks [20]. In a similar animal model, the NO-cGMP (L-NAME) and PGI2-cAMP (indomethicin)
untreated veins developed venous hypertension with reflux pathways did not cause inhibition of MMP-2-induced relax-
and morphologic changes in the vein wall and valve, but in ation of phenylephrine-contracted IVC, indicating that the
veins treated with the flavonoid Dalfon, which reduces MMP-2 mechanism likely involves hyperpolarization, result-
inflammation by modulating inflammatory cells, there were ing in venous dilation [22, 23]. Taken together, these data
reduced physiologic and anatomic changes in the vein wall demonstrated a novel effect of MMPs on venous tissue func-
and valves as a response to venous hypertension [21]. tion and suggest that protracted MMP-2 induced venous relax-
Importantly, these two latter studies demonstrated the feasi- ation could lead to progressive venous dilatation, possibly
bility of a venous hypertensive model, the implications of influencing the venous wall before changes in the valve occur,
MMPs, and how certain drugs may alter the effects of and leading to varicose vein formation [22].
188 J.D. Raffetto

In the same rat IVC and venous isometric contraction Venous hypertension, mechanical stretch, and
increased tension
apparatus, it was determined that MMP-2 attenuates [Ca2+]e-
dependent vascular smooth muscle (VSM) contraction (by
inhibiting Ca2+ entry into the smooth muscle) without affect- HIF upregulation HIF inhibitory drugs
ing Ca2+ release from intracellular Ca2+ stores. In addition, in
an effort to determine the mechanism of MMP-2 induced
vasorelaxation, it was found that MMP-2 induced VSM MMP-2 and MMP-9 overexpression MMP inhibitory drugs
relaxation does not involve the generation of RGD or activa-
tion of avb3 integrin receptor (RGD contains the Arg-
Venous relaxation Hyperpolarization inhibitory drugs
Gly-Asp tripeptide known to activate integrin receptors and
lead to membrane hyperpolarization). From this study, it was
concluded that MMP-2-induced inhibition of the Ca2+ entry Progressive varicose veins formation
mechanism of VSM contraction may play a role in the venous
dilation associated with varicose vein formation [24]. Fig. 22.1 Progressive venous hypertension causing increased
From previous data, it is known that MMPs are found in mechanical stretch and tension on the vein wall induces overexpression
of HIF-1a and HIF-2a. HIF molecule via non-hypoxic conditions pro-
the wall of varicose vein [3, 14, 15] and that MMP-2 can motes MMP-2 and MMP-9 mRNA and protein levels to increase.
cause venous relaxation by hyperpolarization [2]. However, MMP-2 causes venous relaxation via hyperpolarization. At different
the relation among venous pressure, MMP expression, and stages of the venous-hypertension cascade, a variety of inhibitors (|—)
venous dysfunction is unclear. A study to test the hypothesis are available that may have potential as therapeutic targets for prevent-
ing varicose vein formation
that prolonged increases in vein wall tension cause overex-
pression of MMPs and decreased contractility, which in turn
promote venous dilation, was performed in rat IVC. The prolonged 2-g tension, and the overexpression was reversed
results demonstrated that increases in the magnitude and by the inhibitors (UO126, echinomycin, and 17-DMAG) of
duration (2-g for 24 h) of wall tension were associated with HIF. In addition, the overexpression of HIF-1a and HIF-2a
reduced contraction and overexpression of MMP-2 and -9. stretched IVC was associated with increased MMP-2 and
There was a direct correlation between the expression of MMP-9 mRNA and protein in IVC subjected to prolonged
MMP-2 and -9 with a decrease vein contractile function. 2-g wall tension, but was reversed by the inhibitors (UO126,
These responses were partially reversible with MMP inhibi- echinomycin, and 17-DMAG) of HIF, with a decrease in
tors. Importantly, the key factor was the amount of tension expression of MMP-2 and MMP-9. The authors concluded
applied since tissues exposed to 0-g tension for 24 h had nor- from the study that prolonged increases in vein wall tension
mal contraction. Taken together, MMP-2 (as well as MMP-9) are associated with overexpression of HIF-1a and HIF-2a,
promotes IVC relaxation, indicating that protracted increases increased MMP-2 and MMP-9 expression, and reduced
in venous pressure and wall tension increase MMPs expres- venous contraction in rat IVCs (Fig. 22.1). This study eluci-
sion, which in turn reduces venous contraction and leads to dated the mechanism and relation of HIF and MMPs, indi-
progressive venous dilation (Fig. 22.1) [25]. cating that increased vein wall tension induces HIF
An important question is what regulates the induction of overexpression and causes an increase in MMP expression
MMPs during venous stretch and dilation. A possible mech- and reduction of venous contraction, leading to progressive
anism may involve hypoxia-inducible factors (HIF), which venous dilation, and it may be a cause in varicose vein for-
are nuclear transcriptional factors of heterodimeric protein mation. As with targeting MMPs and hyperpolarization-
consisting of a and b subunits. HIF expression may be oxy- induced relaxation, specific inhibitors aiming at HIF
gen or non-oxygen dependent including mechanical stretch. regulation may be important in the future study of varicose
The importance of HIFs is that they regulate the transcription veins [28].
of several target genes of oxygen homeostasis including
remodeling of the ECM [26, 27]. In a recently published
study evaluating rat IVC and an ex-vivo model of stretch and Drugs for the Treatment of Varicose Veins
the induction of HIF and MMPs, the main study findings
were that phenylephrine-induced and KCl-induced contrac- Because MMPs and the HIF pathway are linked to the patho-
tion was restored in IVCs exposed to prolonged 2-g tension genesis of varicose veins, interest in modulating drugs for
plus the HIF inhibitor (UO126 and echinomycin). However, possible clinical treatment is an area of research. There are a
treatment with DMOG, which stabilizes the HIF molecule, number of selective and non-selective inhibitory drugs
further reduced phenylephrine-induced and KCl-induced against MMPs. The drugs classes consists of tissue inhibitors
contraction in veins subjected to prolonged 2-g tension. HIF- of MMPs (TIMP-1,2,3,4), hydroxamates (Batimastat [BB-
1a and HIF-2a mRNA was overexpressed in IVC exposed to 94], Marimastat [BB-2516]), carboxylates (BAY12-9566,
22 Varicose Veins: Venous Wall Changes, Inflammation, and Matrix Metalloproteinases 189

compound 12c,d, compound 22, PGE-2909492), thiols venous wall. These events have been studied in an AV-fistula
(compound 4a–k, compound 5a–c, compound 36a,b), amin- rat model with important findings of venous wall and valve
omethyl benzimidazole analogs, tetraclyclines (doxycycline, degeneration, with expression of both MMP-2 and MMP-
minocycline), monoclonal antibodies (REGA-3G12, 9. Flavonoids may offer therapeutic benefit with decreas-
REGA-2D9, REGA-2F9, REGA-1G8), siRNA, and other ing venous wall changes, but further investigation is
synthetic drugs (Ro 28-2653, Ro 32-3555 [Trocade]). The necessary to evaluate long-term use of these drugs. MMPs
affinity of these drugs to substrate are moderate/high (tetra- play a critical role in ECM turnover, but also have variable
cylines, hydroxamates, thiols) to very high (TIMPs), and the functions both early and late in the venous wall vasodila-
effective dose concentrations are in the micromolar to pico- tory effects and degradation of venous wall, respectively.
molar range, respectively. The major limitations of these Basic scientific study has elucidated one possible mecha-
drugs is broad-spectrum inhibition, low specificity, toxicity, nism involving MMP-2 in venous dilation, which involves
and cross reactivity with other proteins [29]. Many of these hyperpolarization. The distension of veins is associated
drugs are used in the laboratory for research purposes, and with the overexpression of MMPs and is tightly regulated
very few have been tried clinically (tretracycline in venous by HIF molecules. The understanding of the molecular
ulcer treatment) given their limitations. Although sapono- mechanism involving MMPs and venous wall dilation pro-
sides (horse chestnut seed extract, escin) and flavonoids vides an avenue for new pharmacologic therapies. Future
(Daflon), which have anti-inflammatory properties, have studies to define preventative drugs in patients at risk for
been used clinically to treat patients with active venous dis- varicose vein formation, progression, and recurrences will
orders, to date no studies evaluating these drugs have been offer important advantages in the treatment of a disease
carried out with the intention to actually prevent de-novo, that affects millions of people worldwide.
progression, or recurrent varicose veins [29].
Inhibitors of HIF (U0126, 17-[2-(dimethylamino)ethyl]
amino-17-desmethoxygeldanamycin [17-DMAG], or echino- References
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and smooth muscle relaxation have been used to treat hyper- valve dysfunction and wall dilation. Phlebology. 2008;23:85–98.
tension both experimentally and clinically [30]. However, 3. Kowalewski R, Sobolewski K, Wolanska M, Gacko M. Matrix met-
alloproteinases in the vein wall. Int Angiol. 2004;23:164–9.
the spectrum of K+ channels is found in both arteries and
4. Gandhi RH, Irizarry E, Neckman GB, Halpern VJ, Mulcare RJ,
veins, and given that we want to reverse the process of venous Tilson MD. Analysis of the connective tissue matrix and proteolytic
relaxation, non-selective K+ channel inhibitors would affect activity of primary varicose veins. J Vasc Surg. 1993;20:814–20.
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2000;71:300–5.
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before treatment of varicose veins can occur clinically.
molecules and cytokines on saphenous veins in chronic venous
insufficiency. Ann Vasc Surg. 2000;14:427–35.
Conclusions 8. Saharay M, Shields DA, Porter JB, Scurr JH, Coleridge Smith PD.
Varicose vein SMCs have an important abnormality in col- Leukocyte activity in the microcirculation of the leg in patients with
chronic venous disease. J Vasc Surg. 1997;26:265–73.
lagen type III and fibronectin protein production, and the
9. Takase S, Schmid-Shonbein GW, Bergan JJ. Leukocyte activation in
events are related to post-transcription events involving patients with venous insufficiency. J Vasc Surg. 1999;30:148–56.
MMP-3. Importantly, patients with varicose veins have a 10. Sansilvestri-Morel P, Nonotte I, Fournet-Bourguignon MP, et al.
systemic abnormality in collagen synthesis that not only Abnormal deposition of extracellular matrix proteins by cultured
smooth muscle cells from human varicose veins. J Vasc Res.
affects the SMC of the vein but also the fibroblast from
1998;35:115–23.
dermis. These findings suggest a genetic cause for varicose 11. Sansilvestri-Morel P, Rupin A, Jullien ND, et al. Decreased produc-
vein development and certainly are consistent with cross- tion of collagen type III in cultured smooth muscle cells from vari-
sectional population based studies suggesting that varicose cose vein patients is due to a degradation my MMPs: possible
implication of MMP-3. J Vasc Res. 2005;42:388–98.
veins have an underlying yet unidentified genetic cause
12. Sansilvestri-Morel P, Rupin A, Jaisson S, Fabiani JN, Verbeuren TJ,
[31]. The endothelium plays an important part and likely Vanhoutte PM. Synthesis of collagen is dysregulated in cultured
initiates the early events with inflammation and expression fibroblasts derived from skin of subjects with varicose veins as it is
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190 J.D. Raffetto

13. Sansilvestri-Morel P, Rupin A, Badier-Commander C, Fabiani JN, K + channels. Relevance to varicose vein formation. J Vasc Surg.
Verbeuren TJ. Chronic venous insufficiency: dysregulation of col- 2007;45:373–80.
lagen synthesis. Angiology. 2003;54 Suppl 1:S3–8. 23. Feletou M, Vanhoutte PM. Endothelium-derived hyperpolarizing
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variation in MMP-1 and MMP-13. J Surg Res. 2002;106:233–8. 24. Raffetto JD, Khalil RA. MMP-2 induced vein relaxation via inhibi-
15. Woodside KJ, Hu M, Burke A, et al. Morphologic characteristics of tion of [Ca2+]e dependent mechanisms of venous smooth muscle
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16. Pascarella L, Penn A, Schmid-Schonbein GW. Venous hyperten- in vein wall tension increase matrix metalloproteinases and decrease
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19. Badier-Commander C, Verbeuren T, Lebard C, Michel JB, Jacob Prolonged mechanical stretch is associated with upregulation of
MP. Increased TIMP/MMP ratio in varicose veins: a possible expla- hypoxia-inducible factors and reduced contraction in rat inferior
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2000;192:105–12. 29. Raffetto JD, Khalil RA. Matrix metalloproteinases in venous tissue
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Hypertension-induced venous valve remodeling. J Vasc Surg. 2008;6:158–72.
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 Part VII
Visceral Vasculopathy
 Management of Aneurysms
in Takayasu’s Arteritis 23
Christian Espinoza Silva, Diego Soto Valdés,
and Vania Rozas Almeida

Introduction Epidemiology

Takayasu’s arteritis (TA) is a chronic inflammatory vascular TA is an uncommon chronic inflammatory vasculitis, with an
disease of unknown etiology that affects the aorta, proximal incidence of 2–3 cases per million population. It mostly
parts of its major branches, and the pulmonary arteries. It is young women, with a 9:1 female predominance [3, 5–7],
a typical “large-vessel” nonatherosclerotic vasculitis, which usually Asian women [8]. In fact, TA is responsible for about
can produce vascular stenosis, aneurysm formation, and 5 % of all vascular diseases in India and Japan [9].
other presentations in the aorta or affected vessels. Although TA was first described in Asia and is undoubt-
edly more prevalent among patients in India, Africa, and
South America, this disease has a worldwide distribution,
History with an increasing incidence in Western countries [10].

Dr. Mikito Takayasu (1860–1938) was the first to describe reti-

nal vascular abnormalities in association with aortitis in 1905 Pathophysiology
(Fig. 23.1) [1]. The original work, presented by Takayasu at
the Annual Meeting of the Japan Ophthalmology Society [2], TA most commonly involves the aortic arch and its major
showed peculiar vessels in the retinal fundus characterized by branches, but may involve any segment of the aorta. This
arteriovenous anastomosis around the papilla in a 22-year-old condition affects the vessel walls, producing medial destruc-
woman. The curious thing is that Takayasu did not describe the tion of the aortic wall with stenosis, occlusion, or aneurysm
absence of a radial pulse. This sign was described at the same formation. Although TA usually produces obstructive
meeting by two other ophthalmologists, Onishi and Kagoshima, lesions, it may have a dilative component in 15 % of cases
who also described patients with ocular findings similar to [11], and it is usually associated with disease elsewhere.
those of Takayasu, adding that their patients had no radial However, different reports suggest a wide spectrum of
pulses [3]. In 1761, Morgagni described a 40-year-old woman prevalence, with aneurysm formation varying from 0 to
with multiple stenoses and aneurysms of the great vessels, also 87.5 % [12, 13].
reporting the absence of a radial pulse [4]. Although TA is widely known as a chronic vasculitis
that affects large vessels, the intimate processes of the
pathophysiology in this clinical picture remain only par-
C.E. Silva, MD, PhD (*)
tially explained because they have not been completely
Cardiovascular and Heart Transplant Surgeon,
Servicio Cardiovascular, National Institute of Thorax, elucidated. For this reason, TA is considered to be a multi-
José Manuel Infante 717, Providencia, factorial disease, with autoimmune mechanisms undoubt-
Santiago, Chile edly involved. In 2004, Seko et al. [14] postulated an
e-mail: cardiocirugia@gmail.com
interesting pathogenic sequence, which we will analyze in
D.S. Valdés more depth. This pathologic sequence may implicate the
Resident of General Surgery, Department of Surgery,
stimulation from an antigen of unknown nature, possibly
University of Santiago of Chile,
Santiago, Chile infectious, that triggers heat shock protein 65 expression
in aortic tissue. This, in turn, would induce the human
V.R. Almeida
Servicio Cardiovascular, National Institute of Thorax, major histocompatibility complex class I chain-related
José Manuel Infante 717, Providencia, Santiago, Chile gene A (MICA) [15].

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 193
DOI 10.1007/978-1-4471-4429-8_23, © Springer-Verlag London 2013
194 C.E. Silva et al.

Fig. 23.1 Juzenkai Zasshi, vol. 50, 1908, photograph courtesy of the Collections of the Department of Ophthalmology, Kanazawa University

As a response to this process, inflammatory cells, such inflammatory response, recruiting especially mononuclear
as T-cells and natural killer (NK) cells, which express cells.
NKG2D receptors, could recognize MICA, resulting in acute Immature dendritic cells (DCs) are vastly distributed
inflammation. This process is increased and self- migratory cells in charge of sampling the antigens in the
perpetuated. environment. Once activated, the profile of their chemokine
receptor is modified, migrating to lymphoid tissues. Here
they express a mature chemokine-producing DC profile and
Cellular Immunity costimulatory molecules that interact with antigen-specific
T cells.
TA clearly seem to be an autoimmune disease in which cel- In giant cell arteritis (also called Horton’s arteritis), DCs
lular immunity plays a major role and humoral immunity are activated and produce chemokines (CCL18, CCL19, and
participates in a form that still remains to be clarified. In CCL21) that bind the chemokine receptor (CCR7) they
fact, immunohistochemical studies have shown different cell express, leading to the entrapment of DC within the vascular
strains involved in the aortoarteritis process, suggesting a wall [17]. The co-localization of DC near T-cells indicates
critical role in the onset of the disease. Gamma-delta T cells, that they are probably involved in the physiopathology of the
NK cells, cytotoxic T cells, T-helper cells, and macrophages TA by a similar mechanism.
are some of the cells found in the aortic wall. This process Study of the cellular composition within the adventitia
does not seem to start in the endothelium of the aortic wall. in Takayasu’s arteritis has shown inflammatory infiltrates
The pathogenesis implies the stimulation of an antigen of containing T-cells colocalizing with dendritic cells (DC)
unknown nature. T cells, NK cells, and cytotoxic T cells [18, 19]. This fact is essential in the development and main-
express and release massive amounts perforin (a membrane- tenance of inflammation in the vascular wall.
disrupting protein) through the recognition of MICA, which The antigens (of unknown nature) are presented to killer
is directly placed on the surface of arterial vascular cells [14]. T-cells by an epitope associated with the major histocom-
This way, the endothelial cells of the vasa vasorum are acti- patibility complex (MHC) on the activated DCs, which
vated to allow the lymphocytes to gain access to the media facilitates the cytotoxic reaction present within the vascular
and adventitia of the arterial wall [16], thus amplifying the wall.
23 Management of Aneurysms in Takayasu’s Arteritis 195

Humoral Immunity of TNF-alpha, IFN-gamma, IL-2, IL-3, and IL-4 and higher
expression of IL-12 mRNA after stimulation of cells with
Although the existence of a humoral role is not known, lipopolysaccharide and lower mRNA expression of IL-10
specific immunologic markers for aortoarteritis, rheumatoid than in controls. These results suggest a chronic establishment
factor, and antinuclear antibodies have been identified, sup- of the inflammatory response in Takayasu’s arteritis [42].
porting the role of an autoimmune component [20, 21] in the In conclusion, notwithstanding numerous studies, the
establishment of the disease. physiopathology of TA remains unknown and is probably
The presence of immune complexes in the sera and recep- multifactorial, involving several actors.
tors of lymphocytes has been reported, but the results differ The data strongly implicate of autoimmune processes,
among authors [22]. mainly led by cellular immunity, whose role remains to be
Anti-aorta antibodies have long been reported in TA elucidated. The 2004 study by Seko et al. linked some of the
[23–28], but in the study by Baltazares [29], reactive anti- previously discussed data [43]. Therefore, the model pro-
bodies against a total human aorta extract were searched for, posed in Fig. 23.2 is valid for the understanding the patho-
including their main protein components, elastin, fibronectin, genesis of the disease. The pathologic sequence may
and collagen, but no difference was found compared with implicate the stimulation from an unknown antigen, trigger-
controls. However, in the same trial, the immunoblot tech- ing the expression of heat shock protein 65 in the aortic wall,
nique showed an immunoprecipitate of a 45 kDa protein in which in turn would induce the expression of MICA.
the sera of TA patients significantly more frequently than in Inflammatory cells recognize MICA and secrete perforin,
the sera of the control group [29]. In the same line of research, disrupting the endothelial membrane of the vasa vasorum
Eichhorn [30] suggested that an antigen to these antibodies and gaining access to the arterial wall.
was stored within the cytoplasm when they found that healthy Inflammatory mediators, such as cytokines and chemok-
cells exposed to sera from patients with TA had a bright, ines, are released, allowing inflammatory cells to amplify the
homogeneous, and specific immunofluorescent cytoplasm process and entrap DCs within the arterial wall.
stain and weak membrane stain. Alpha-beta T-cells would specifically recognize one or a
There are reports about the presence of antiphospholipid few autoantigens presented by a shared epitope associated
antibodies in a significant proportion of patients with TA with a specific MHC on the DCs. These DC could
[31–33], anticardiolipin antibodies and antimonocyte anti- simultaneously cooperate to some extent with the B-cells and
bodies [34]. These were correlated with disease activity, sug- determine a humoral immunity mainly consisting of anti-
gesting a pathogenic role in TA. Finally, alpha-beta T-cells endothelial cell autoantibodies that could trigger comple-
would then infiltrate the arterial wall and specifically recog- ment-dependent cytotoxicity against endothelial cells (though
nize one or a few autoantigens presented by a shared epitope this last pathogenic mechanism remains very controversial).
associated with a specific MHC on the DCs. This condition would produce medial destruction of the aor-
The participation of other proinflammatory mediators, tic wall with stenosis, occlusion, or aneurysm formation.
such as interleukin (IL)-6, mainly synthesized by mac-
rophages and T-cells, is also known. Functions of the IL-6
are to activate B-cells, enhance T-cell cytotoxicity [35] and Clinical Presentation
NK cell activity [36], stimulate fibroblast proliferation, and
induce acute-phase protein synthesis. Other proinflammatory The clinical presentation of Takayasu’s arteritis is varied and
molecules, such as RANTES chemokine (regulated on acti- not specific. In fact, it usually develops in a very insidious
vation, normal T-cell-expressed and secreted) and IL-8 way, leading the physician to consider other diagnoses, espe-
cytokine, are potent chemoattractants for most mononuclear cially when the disease develops in children. Classically, this
cells, including those that constitute the majority of the condition has two distinguishable phases, acute and chronic,
inflammatory infiltrate of the vascular wall in TA. and recent studies have also divided it into early (prepulse-
Interleukin-6 and RANTES can also induce the production less) and late (pulseless) phases [44].
of metalloproteinases (MMP) in the matrix from mononu- In the acute phase, the symptoms are related to the sever-
clear cells and smooth muscle cells. These proteolytic ity of the vascular inflammation. It can cause constitutional
enzymes degrade elastin and collagen, which are structural symptoms, such as weight loss, fatigue, night sweats,
components of the arterial wall [37]. anorexia, malaise [45], and fever (which is more frequent in
These findings have been reinforced by several studies in pediatric patients).
patients with TA that showed higher serum concentrations of Children can present also joint pain or arthritis and
IL-6 [38], RANTES [39], IL-8 [40], MMP-2, MMP-3, and extremities pain. When these symptoms are present, the dif-
MMP-9. The levels of these latter two MMPs are correlated ferential diagnosis must be performed considering other
with disease activity [41]. However, studies of mRNA of autoimmune diseases, such as rheumatic fever and juvenile
proinflammatory cytokines showed increased gene expression rheumatoid arthritis [46].
196 C.E. Silva et al.

Arterial well

T
COR
B
RT
DC
Ag
DC CO

H
CCL18

LA
1 CCL19 CD86
CD CCL21

HLA
HSP65 86 Anti-endothelial
5 cell antibodies

RT
3

CO
63GLU 7 ?
67SER
DC HLA
FAS/FASL
Perforin
CD86 T4
Tgd NKG2D MICA
CD28
2 Cells in the
vascular wall Ttox 6

HLA ICAMI
Pro-inflammatory T4
T and chemoattactant
cytokines B
Tgd 4

Mo Ttox
Vasa vasorum

Fig. 23.2 Overview of the physiopathology of TA (brief explanation vascular cells and thus recruiting more mononuclear cells. (4) One or a
of different immunological interactions proposed by Seko’s investiga- few (auto)antigens are presented to killer T-cells by a shared epitope
tions published by Arnaud in 2006) [1]. (1) Stimulation by an antigen associated with specific MHC on the activated dendritic cells trapped
of unknown nature triggers heat shock protein 65 expression, which in within the vascular wall. (5) This leads to a cytotoxic reaction of the
turn induces MICA. (2) Infiltrating gamma-delta T cells and NK cells cells within the vascular wall. (6) These dendritic cells simultaneously
expressing NKG2D receptors recognize MICA and release perforin. (3) cooperate with B lymphocytes and induce anti-endothelial cell autoan-
Proinflammatory cytokines amplify the inflammatory response, induc- tibodies, whose role is controversial
ing more MHC antigen and costimulatory molecule expression on

In the chronic phase, patients report symptoms referable present, although, like the other markers, they are very
to the organs involved. In a large published experience, nonspecific variables [48].
more than half of all patients experienced upper extremity
claudication, 50 % presented symptoms associated with
cerebrovascular insufficiency (vision loss, lightheadedness, Imaging Study
stroke), and a third reported carotid artery pain [13]. Less
frequently, other symptoms have been reported, such as For decades, angiography was considered the “gold standard”
instability, vertigo, orthostatism, syncope [4], and hyperten- to confirm the diagnosis of Takayasu’s arteritis (Fig. 23.3).
sion (as a result of renal artery involvement, which was the Although this technique can show the location and grade of the
most common presenting sign in an Indian trial) [47]. stenotic or aneurysmatic lesion [49], it is an invasive method
with several limitations (radiation exposure, adverse reactions
to contrast media, and arterial damage [50]). Therefore, it will
Laboratory Tests probably be replaced by multiple less invasive techniques that
also provide information about changes in the wall, such as
Markers of inflammation, such as C reactive protein levels and ultrasonography, contrast CT scan, and MRI.
the erythrocyte sedimentation rate, are elevated, which may Ultrasonographic study can show the stenotic or aneurys-
help make the diagnosis, despite being very nonspecific. matic lesions and may contribute to the diagnostic process as
Multiple studies indicate that C-reactive protein levels and the well as to the evaluation of the grade and progress of the disease
erythrocyte sedimentation rate are elevated in approximately [51]. Patients with Takayasu’s arteritis can present an homoge-
70 % of patients in the acute phase and 50 % in the chronic neous, midechoic, circumferential wall thickening with luminal
phase of disease [4]. Leukocytosis and anemia may also be stenosis on carotid echo-Doppler imaging [52]. These findings
23 Management of Aneurysms in Takayasu’s Arteritis 197

have been described as pathognomonic of Takayasu’s arteritis patients), ionizing radiation is not used, and soft-tissue dif-
and have been called the “macaroni sign” (Fig. 23.4) [53]. ferentiation is better [55]. However, some disadvantages of
The CT scan may have some advantages over angiogra- MRI are that it is less available, costs more, and has more
phy, allowing demonstration of the mural changes of the technical difficulties than CT scans.
affected vessels, such as wall thickening, calcification, or Another diagnostic advantage of MRI compared to the CT
thrombus, which are not seen with conventional angiography scan is an increased sensitivity in detecting mural edema, a
[54], but in order to determine the degree and extension of finding that is present in almost all acute-phase patients.
the damage to the vessels more accurately, the use of mag- However, some studies question the use of MRI as a single fol-
netic resonance imaging (MRI) may be more helpful than low-up imaging technique because of the contradictory findings
CT scans. MRI has other technical advantages: paramagnetic of disease activity in patients with Takayasu’s arteritis [56].
contrast media rarely cause anaphylactic reactions and are The use of 18F-FDG PET and enhanced CT has also been
non-nephrotoxic (which can be a determinant in the pediatric described to determine the inflammatory status of the ves-
sels. Parallel studies show that these tests can show the dis-
tribution of the inflammation in the aorta, its branches, and
the pulmonary artery, suggesting that the 18F-FDG accumu-
lation observed in Takayasu’s arteritis patients directly indi-
cates the inflammation in the vascular wall [57].

Diagnostic Criteria and Classification

Several diagnostic criteria models have been proposed in the

literature [58, 59]. In 1988, Ishikawa [60] published his clini-
cal criteria to establish the diagnosis of Takayasu’s arteritis.
These proposed criteria were based on clinical and angio-
graphic data from 96 patients with Takayasu’s disease.
• One obligatory criterion: age £40 years.
• Two major criteria: left and right mid-subclavian artery
lesions.
• Nine minor criteria: high erythrocyte sedimentation rate,
common carotid artery tenderness, hypertension, aortic
regurgitation, annuloaortic ectasia, lesions of the pulmo-
Fig. 23.3 Angiographic imaging: aneurysmal dilations of the right nary artery, left mid common carotid artery, distal bra-
common artery and left intrathoracic subclavian artery chiocephalic trunk, thoracic aorta, and abdominal aorta.

a b

Fig. 23.4 Ultrasound B-mode (a) and color-duplex (b) flow imaging luminal stenosis. CCSX indicates the left common carotid artery.
of the left common carotid artery (longitudinal section): homogeneous, Intima-media thickness is 0.20–0.22 cm (the maximal normal value is
midechoic, circumferential wall thickening (“macaroni sign”) with 0.06 cm) [1]
198 C.E. Silva et al.

Fig. 23.5 Classification of Takayasu’s arteritis

according to the anatomic site of involvement

I IIa IIb III IV V

In addition to the obligatory criteria, the presence of two Type IIB. Type IIA vessels plus descending aorta
major criteria, one major plus two or more minor criteria, Type III. Descending and abdominal aorta and/or renal artery
or four or more minor criteria suggests a high probability Type IV. Abdominal aorta and renal artery
of the presence of Takayasu’s disease. The criteria had Type V. Combination of types IIB and IV (Fig. 23.5)
84 % sensitivity in 96 patients with this disease.
In 1990, The American College of Rheumatology [61]
established the current and most widely used diagnostic cri- Aneurysmal Disease of Takayasu’s Arteritis
teria. They proposed that three or more criteria must be pres-
ent to make the diagnosis: The specific incidence of aneurysmal presentation is not
1. Age of onset of illness 40 years or less. Development of known, but it is more frequent in Japan, India, Thailand,
symptoms or findings related to Takayasu’s arteritis at age Mexico, and Africa [64, 65], compared with occlusive dis-
40 or less. ease, which is more prevalent in the United States and
2. Claudication of extremities. Development and worsening Europe. It is not quite clear why there is such a difference.
of fatigue and discomfort in the muscles of one or more Frequently, aneurysm formation develops in the descending
limbs with activity, especially the upper extremities. aorta, followed by the abdominal aorta, and, less frequently,
3. Decreased brachial artery pulse. Decreased pulsation of the ascending aortic segments.
one or both brachial arteries. Aneurysm formation is considered one of the main com-
4. Differential blood pressure greater than 10 mmHg. plications in Takayasu’s arteritis and is an extreme marker of
Differential pressure greater than 10 mmHg systolic disease activity, usually present in patients with a long his-
between arms. tory of disease, implying a poor prognosis. Miyata published
5. Murmur over subclavian arteries or aorta. Audible mur- a comparison of survival rates of patients with Takayasu’s
mur on auscultation on one or both subclavian arteries or arteritis based on the presence or absence of aneurysms,
abdominal aorta. showing a 66.5 % survival rate in patients with aneurysms
6. Abnormal arteriography. Arteriographic narrowing or versus a 79.5 % survival rate in patients without them [66] in
occlusion of all primary aortic branches or large arteries 15 years of follow-up.
in the proximal upper and lower extremities not due to Although the incidence of aneurysmal presentation of
arteriosclerosis, fibromuscular dysplasia, or similar Takayasu’s disease is unknown, some authors have provided
causes: changes usually focal or segmental. information on small groups of patients. These studies show
Three or more criteria provide a sensitivity and specificity a moderately high incidence of aneurysms.
for diagnosis of 90.5 % and 97.8 %, respectively [13]. Matsumura in 1991 showed an incidence of saccular or
Concerning the classification of TA, in 1996 Hata et al. fusiform aneurysms in 31.9 % (36/113) of patients with
[62] published the classification currently used, which Takayasu’s arteritis. Multiple aneurysms were found in 15
grouped the different presentations into five types depending patients. In their study, most patients were over 40 years old,
on the affected segments, adding two subtypes depending on and most of the aneurisms were located in the ascending
the involvement of the pulmonary or coronary artery. aorta [65]. In 1994, Kerr et al. [45] published a series of 60
In 2004, Nastri [63] published a diagram of this new patients with Takayasu’s arteritis from the National Institute
classification. of Health. Twenty-three percent had aortic aneurysm forma-
Type I. Aortic arch vessels tion. In 2000, Sueyoshi, from Omura Hospital, showed 17
Type IIA. Ascending Aorta, aortic arch, and branches aortic aneurysms in 14 (45.2 %) of 31 patients [67].
23 Management of Aneurysms in Takayasu’s Arteritis 199

It’ is curious that Nakao [25], in his series of 84 patients,

revealed no cases of aneurysmal dilatation of the aorta,
describing only 6 cases of moderate post-stenotic dilata-
tion in the angiographic findings. In Chile, Krämer reported
that the incidence of aneurysm formation was less than
10 % [68].

Thoracic and Abdominal Aortic Aneurysms

Thoracic and abdominal aneurysms are the most common

aneurysm presentations in Takayasu’s arteritis [69].
Matsumura showed a markedly high frequency in the tho-
racic area (29 thoracic and 7 abdominal, respectively) [65].
However, Sueyoshi [13] showed a proportional distribution
between the thorax and abdomen (9 and 8 patients, respec-
tively). In 2004, Kieffer et al. in Paris [70] published a series
of 27 years’ experience, including 10 thoracic and 23 thora-
coabdominal aneurysms. Six patients had associated aneu-
rysms of the proximal aorta.

Extracranial Supraaortic Aneurysm

Fig 23.6 Bilateral common carotid artery aneurysm in Takayasu’’s
Aneurysms also occur in the subclavian [71], innominate, arteritis: Tochii M. Asian Cardiovasc Thorac Ann. 2008;16:185–186
and carotid arteries (Regina et al., 1998 [72]), but extracra-
nial carotid aneurysms caused by Takayasu’s arteritis are
extremely rare [73]. Tabata et al. [74] reported six cases of reported 45 % of coronary lesions, of which 73 % are occlu-
extracranial carotid aneurysm among 106 cases in sive coronary lesions localized around the coronary ostia as
50 years. a result of the extension of inflammation-induced intimal
These anatomical presentations may have surgical proliferation and fibrous contraction from the ascending
difficulties in the resection and replacement of the arteries, aorta.
with a relatively high incidence of stroke. Therefore, deci-
sion-making in these cases must be tailored to the individual,
depending upon the extent of involvement and the symptoms, Treatment and Management
and also evaluating the possibility of hybrid intervention
with the use of endovascular stent grafts [75] (Fig. 23.6). As mentioned earlier, Takayasu’s arteritis is a chronic dis-
ease, which in its initial phase has only nonspecific symp-
toms, making the differential diagnosis difficult. This is the
Coronary Lesions challenge for the clinician, because in the chronic phase, the
symptoms are actually signs of a long process of complica-
Coronary artery involvement in Takayasu’s arteritis was first tions, such as stenosis or aneurysmal formations.
described by Frovig in 1951, and the first coronary artery According to the study published by Koide [79] about the
bypass grafting was performed by Young [76] in 1973. therapeutic approach in Japan in the 1980s, the vast majority
Endo et al. [3] in 2003 published their experience in coro- of patients received drug therapy alone (75 %), and surgery
nary angiography in 130 patients with Takayasu’s arteritis. was a viable option in 12 % of patients. With the current
Thirty-one had coronary artery lesions, and only four had technical advances, especially the development of different
aneurysmal coronary ectasia (Fig. 23.7). In their experience, endovascular techniques, surgery has become a more popu-
aneurysms were not treated surgically because they were dif- lar therapy [80].
fuse and the patients had no angina. At present, a more profound understanding of the immu-
The incidence of coronary lesions complicating Takayasu’s nological mechanisms of the pathogenesis responsible for
arteritis is relatively low. Nasu [77] in 1976 reported coro- vascular injury allows a better treatment approach, trying to
nary lesions complicating Takayasu’s arteritis in 10.5 % diminish the inflammatory process [81] with more specific
(8/76 autopsy cases). More recently, Amano and Zuzuki [78] therapies.
200 C.E. Silva et al.

Fig. 23.7 Diffuse dilatation of the right and left coronaries arteries in a patient with Takayasu’s arteritis. Endo M: J Tho Card Surg 2003;125(3):
570–7

Medical Treatment thrombosis in the affected vessels with stenotic or occlusive

lesions or embolism from aneurysms.
Anti-inflammatory and immunosuppressive agents are the Future treatments, such as anti-TNF therapy, are showing
main medical therapy strategy for Takayasu’s arteritis. promising results. For example, Hoffman [85] reported a
Corticosteroids are still used in the active phase. Several sustained remission in TA. This indicates that the road ahead
reports have claimed that long-term prednisolone therapy will include immune therapies targeted to a very specific
contributes to angiographic improvement [82, 83]. Guidelines phenomenon.
of the Health Ministry of Japan (1992) recommend 30 mg/
day of corticosteroids as the initial dose for adult patients in
the active phase. The initial dose is tapered at a rate of 5 mg Surgical Treatment
every 2 weeks down to 10 mg and thereafter at a rate of
2.5 mg every 2 weeks until withdrawal or the minimum dose Takayasu’s arteritis primarily affects large arteries (the aorta
required to control inflammation [84]. and its branches). It can produce stenotic, occlusive, and
Some patients in whom withdrawal from corticosteroids aneurysmal lesions. As the disease progresses, the great
is difficult may require additional immunosuppressive drugs vessels grow thicker, developing focal and raised plaques
such as cyclophosphamide or azathioprine [84]. The use of that produce stenosis and aneurysms in the major branches
other drugs, such as methotrexate, mycophenolate mofetil, of the thoracic aorta. These plaques are usually found in the
and infliximab, has been reported [80]. These agents are usu- distal thoracic and abdominal aorta. It has been suggested
ally continued for at least 1 year after remission and are then that the growth rate and risk of rupture of aneurysms in
tapered until discontinuation in addition to a long-term low- Takayasu’s arteritis is lower than the risk of atherosclerotic
dose corticosteroid therapy. aneurysms [86]. The formation of aortic hematomas, dis-
When patients are started on corticosteroids, other pre- section, and rupture in both the ascending and descending
ventive measures are necessary, such as osteoporosis preven- arch and the abdominal aortic aneurysms has been
tion. Management of traditional cardiovascular risk factors described.
(such as dyslipidemia and hypertension includes calcium In adults, less than 20 % of patients require surgical treat-
antagonists, beta-blockers, hypotensive diuretics, cardiac ment [87, 88], which is completely different from what hap-
glycoside, coronary vasodilator agents [80]), and lifestyle pens in pediatric patients, where nearly 80 % undergo some
changes, as well as long-term aspirin therapy to prevent type of surgical treatment of stenotic lesions [89].
23 Management of Aneurysms in Takayasu’s Arteritis 201

Different studies and reports have shown low morbidity The surgical team’s experience is fundamental to obtain
and mortality rates for surgical treatment of different lesions good results in any complex disease, and Takayasu’s arteritis
of Takayasu’s arteritis, except for aortic aneurysm surgery. In is not an exception. This is especially the case when condi-
fact, although patients with Takayasu’s arteritis are younger, tions involve additional technical complications, such as the
the involvement of multiple arterial segments, such as kidney fragility of tissues and presence of microscopic disease that
or cardiac, may increase the risks, which may affect the over- has not been detected, which has been widely demonstrated
all outcome of surgery. in Takayasu’s disease aneurysms, where the operative mor-
For this reason, it may be important to maintain a conser- tality is higher, indicating that this presentation is a marker of
vative approach in the management of patients with disease severity.
Takayasu’s disease, with a complete preoperative and multi- Robbs et al. [86] from South Africa reported an operative
disciplinary evaluation being indispensable [90]. mortality of 3–4 % in their patients with Takayasu’s arteritis,
Several studies have suggested that surgery should be per- most of whom had aneurysms. The mortality was related to
formed only if there is a condition that could affect the prog- ruptured aneurysms. In 2004, Kieffer in Paris [70] reported
nosis of a patient and should be avoided during the acute an operative mortality of 9 %, paraplegia in 9 %, and satis-
illness, with steroid therapy being preferred as a first treat- factory postoperative outcomes with open surgery of
ment approach before surgery [91] to prevent progression of descending thoracic and thoracoabdominal aortic aneurysms
the disease and complications. Moreover, the AHA/ACC in 33 patients with Takayasu’s arteritis [95].
guidelines do not distinguish the surgical approach for After surgery for Takayasu’s arteritis, anastomotic false
Takayasu’s arteritis from that for other diseases of the tho- aneurysms (anastomotic detachment) can occur at any time
racic aorta. Revascularization for aortic stenosis or aneurysm in the long term, although the incidence seems to be low
occurs for the same indications as in non-inflammatory dis- even in the active phase of the disease.
orders: secondary organ vascular insufficiency or risk of rup- It is unclear what the phenomenon is that occurs in this
ture [92]. area. Some authors suggest the possibility of recurrence of
However, emergency surgery is not usually necessary arteritis in areas with disease-free margins during resec-
since the lesions are made in the chronic phase of the disease tion. Others raised the possibility of development of the
[93], permitting the development of collateral circulation. disease in an area not resected without macroscopic or
Currently, percutaneous angioplasty has become an effective angiografic involvement, but with microscopic signs of
alternative to occlusive lesions, and possibly the indications disease [90].
for this technique will increase with time. Miyata reported an incidence of anastomotic aneurysms
Surgical treatment for Takayasu’s arteritis is difficult. It is of the suture line in 8.5 % of the sutures performed in 14
very important not to forget the main pathological feature, patients (22 of 259 anastomoses). No association was
extensive destruction of the medial elastic fibers that main- found between the incidence of aneurysms and increased
tain the strength of the aortic wall. Therefore, during the pro- activity of arteritis or the use of corticosteroids, but this
cedure, fragile and inflamed tissues are manipulated, and process indeed presented more frequently in patients with
complications such as hemorrhage, pseudoaneurysm, and aneurysm disease compared with those with anastomotic
detachment of the prosthetic graft develop postoperatively disease [96].
[94]. This is why surgeons must always be aware of the anas- Therefore, constant vigilance is necessary in patients who
tomotic fragility and the risk of graft failure due to complica- have undergone replacement of a segment, since we know
tions of the suture line, which may have stenosis, aneurysm, that although the segments may appear normal on angiogra-
or pseudoaneurysm [86]. phy, the participation of microscopic disease occurs in 44 %
In the aneurysmal presentation, the surgical priority of cases [97].
should be determined based on the lesion’s diameter, mor- The reported incidence of anastomotic aneurysm among
phology, and propensity for dilatation. Different authors do patients with atherosclerosis ranges widely from 1.7 to 15 %
not distinguish between surgical indications of Takayasu’s per anastomosis. It has been speculated that the variation in
arteritis and other diseases of the thoracic aorta, and taking incidence is caused by differences in the types of arterial
into account the different results published in the literature, reconstruction, sites of anastomosis, methods of diagnosis,
the surgical approach tends to be less aggressive. and differences in the length and completeness of the fol-
Treatment consists of replacing dilated lesions, preferably low-up study. To prevent this complication, it is recom-
in single-stage surgery, especially for aortic arch or descend- mended to reinforce the sutures with Teflon felt strips and/or
ing thoracic aorta aneurysms, but multi-stage surgery some- suppression of active or persisting inflammation with corti-
times must be performed to reduce the surgical invasiveness, costeroids. In addition, if possible, sites of normal tissue
especially when the damage is very extensive or multiple without inflammatory changes should be chosen as anasto-
locations are affected. motic sites [97].
202 C.E. Silva et al.

Surgery or Endovascular Repair 13. Sueyoshi E, Sakamoto I, Hayashi K. Aortic aneurysms in patients
for Aortic Aneurysm with Takayasu’s arteritis: CT evaluation. AJR Am J Roentgenol.
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 Mesenteric Vasculitis
24
Mateus Picada-Correa and Gustavo S. Oderich

Introduction lead to aneurysm formation and vessel rupture with either

intra-abdominal or gastrointestinal hemorrhage. If the
Vasculitis is a rare disease associated with inflammatory smaller arteries are involved, ulceration, perforation, and
response of vessel walls, with or without associated necrosis stricture formation can occur. In addition to bleeding and
and granulomata. It affects 20 individuals per million a year. ischemic symptoms, patients often manifest other constitu-
Chronic inflammation can weaken or thicken the arterial tional symptoms such as weight loss, malaise, fever, night
wall, leading to aneurysm, stenoses, and occlusions. Systemic sweats, arthralgias, myalgia, peripheral weakness, and
vasculitides have varied etiologies and pathogenetic mecha- headache.
nisms, yet most have not been well defined. Vasculitides are Other less frequent manifestations include hepatitis, gas-
classified according to the vessel size and presence or absence tritis, esophagitis, pancreatitis, cholecystitis, and appendici-
of necrosis, granulomas, or both (Table 24.1). tis [1, 3–10]. Nausea and vomiting are present in one-third of
Large-vessel vasculitis affects the aorta and its branches, patients, and 27 % present with diarrhea.
medium-size vessel vasculitis has a predilection for the
visceral arteries, and small-vessel vasculitis affects arteri-
oles, venules, and capillaries. Although vasculitis of the Table 24.1 Most common causes of vasculitis
mesenteric arteries is rare, accounting for less than 5 % of Classification of vasculitis
all cases of mesenteric ischemia [2], it can lead to bowel Large-vessel vasculitis
gangrene and death if not immediately recognized and Takayasu arteritis
treated. This chapter summarizes the clinical features, Giant cell arteritis
diagnostic approaches and treatment of mesenteric vasculi- Medium-sized-vessel vasculitis
tis (MV). Poliarteritis nodosa
Kawasaki disease
Primary granulomatous central nervous system vasculitis
Clinical Presentation Small-vessel vasculitis
Antineutrophil cytoplasmic autoantibody
Wegener’s granulomatosis
MV usually presents with bleeding or ischemic symptoms.
Churg-Strauss syndrome
Upper and lower gastrointestinal bleeding is the most com-
Microscopic angiitis
mon presentation and is associated with mucosal lesions or
Immune complex small-vessel vasculitis
rupture of small branch artery aneurysms. Mesenteric isch- Henoch-Schonlein purpura
emia presents with symptoms that are indistinguishable from Cryoglobulinemic vasculitis
those of atherosclerotic or embolic origin. The classic symp- Lupus vasculitis
toms include abdominal pain, postprandial pain, “food fear,” Rheumatoid vasculitis
and weight loss. In patients with medium-size vessel vascu- Sjogren syndrome vasculitis
litis, such as polyarteritis nodosa (PAN), inflammation may Hypocomplementemic urticarial vasculitis
Behoet’s syndrome
Goodpasture’s syndrome
M. Picada-Correa, MD • G.S. Oderich, MD (*) Serum sickness vasculitis
Division of Vascular and Endovascular Surgery, Mayo Clinic,
Rochester, MN, USA Inflammatory bowel disease vasculitis
e-mail: oderich.gustavo@mayo.edu Adapted from Ha et al. [1]

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 205
DOI 10.1007/978-1-4471-4429-8_24, © Springer-Verlag London 2013
206 M. Picada-Correa and G.S. Oderich

Fig. 24.1 Imaging findings consistent with mesenteric vasculitis standard diagnostic study. Panel c shows a lateral aortography with
includes arterial wall thickening (a, white arrow) and long and smooth high-grade celiac (c, straight black arrow) and superior mesenteric
tapered lesions (b, curved white arrow). Angiography remains the gold artery stenoses (c, black arrowhead)

Diagnostic Imaging bowel wall thickening (e.g., the target sign), increased
attenuation of mesenteric fat, pneumatosis intestinalis, or
Duplex ultrasound is used to screen test and evaluate patency pneumoperitoneum is consistent with complicated acute
of the visceral arteries and presence of hemodynamically ischemia, bowel gangrene, and perforation.
significant stenoses or occlusions. The criteria to identify a
high-grade stenosis include peak systolic velocity >275 cm/s
for the superior mesenteric artery (SMA) and >200 cm/s for Specific Disorders
the celiac axis [11]. Selective mesenteric angiography
remains the gold standard for diagnosis of mesenteric vascu- A variant of specific vasculitis can manifest with symptoms of
litis. The classic finding includes long, tapered, smooth mesenteric ischemia or bleeding complications (Table 24.2).
lesions without stigmata of atherosclerosis, such as Takayasu’s Arteritis. Takayasu’s arteritis or “pulseless
calcifications or atheromatous plaque (Fig. 24.1). Multiple disease” is a large-vessel granulomatous vasculitis character-
and small aneurysms are also frequently seem. Barium ized by ocular disturbances and decreased extremity pulses.
enema may show thumbprinting due to submucosal edema Gastrointestinal manifestations include non-specific symp-
or hemorrhage. Computed tomography angiography (CTA) toms, such as anorexia, nausea, vomiting, and weight loss.
is an excellent imaging study to diagnose and plan the inter- Mesenteric ischemia can result from aortic narrowing and/or
vention. It allows greater spatial resolution and is useful to involvement of the visceral arteries. Diagnosis is confirmed
diagnose other potential causes of abdominal pain and weight by arteriography and/or CTA. Imaging findings include
loss (e.g., malignancy). Specific findings consistent with irregular thickening of the aortic wall or its main branches,
mesenteric vasculitis include vessel wall thickening, periar- with intimal wrinkling, stenosis, post-stenotic dilatation,
terial edema or stranding, and long, smooth lesions with or aneurysm formation, or occlusion with subsequent luxurious
without concomitant aneurysms or pseudoaneurysms collateral circulation [1, 3, 12].
(Fig. 24.1). This study is useful to plan open surgical recon- Giant Cell Arteritis. Giant cell arteritis (GCA) is the most
struction, allowing selection of a diseased-free site for inflow common systemic vasculitis. It occurs in the elderly and
and outflow of bypass procedures. In addition, evaluation of is characterized by inflammation involving large and
24 Mesenteric Vasculitis 207

Table 24.2 Differential diagnosis of mesenteric ischemia medium-sized arteries. The classic pathologic finding is the
Non-Occlusive presence of giant cells (Fig. 24.2). GCA most frequently
Arterial Occlusion Venous Occlusion Disease affects the aortic arch and its branches. GI symptoms include
Thromboembolism Venous thrombosis Narcotics diffuse abdominal pain, typical intestinal angina, and bowel
Left atrial origin Infiltrative conditions Cocaine occlusion. CTA and duplex scans evidenced SMA or IMA
Aortic origin Neoplasm Heroin occlusive disease and periarterial wall halo resulting from
Myxoma Inflammatory Shock Bowel arterial wall inflammation. MRA is particularly helpful in
conditions determining wall thickness [9].
Endocarditis Abdominal infectious Familial dysautomia Polyarteritis Nodosa. PAN is a fibrinoid necrotizing vas-
diseases culitis that mainly involves small and medium-sized arteries.
Cholesterol Hypercoagulable Pheochromocytoma The disease causes multiple aneurysms (50–60 %) with a
conditions predilection for the renal (80–90 %), mesenteric (50–70 %),
Atherosclerosis Polycitemia vera High-endurance hepatic (50–60 %), splenic (45 %), and pancreatic branches
athletes (25–35 %). In addition to ischemic complications, hemor-
SMA thrombosis Sickle cell disease Chronic renal failure rhage occurs in 6 % of cases and bowel perforation in 5 %
[1–4, 6]. Characteristic imaging findings include <1-cm
Arterial dissection Thrombocytosis Trauma aneurysms within the renal, mesenteric, and hepatic
Aortic surgery Thrombophilia Corrosive injury vasculature.
Stent placement Carcinoma Wegener’s Granulomatosis. Wegener granulomatosis
Therapeutic Pregnancy drugs (WG) is a medium- and small-size vessel granulomatous
embolization vasculitis of the upper and lower respiratory tract, added to
Antiphospholipid Systemic vasculitis Iatrogenic glomerulonephritis. Ten percent of patients manifest gastro-
antibody syndrome intestinal symptoms such as abdominal pain, diarrhea, and
Systemic vasculitis Wegener’s Radiation bleeding.
granulomatosis
Microscopic Polyangiitis. Microscopic polyangiitis (MP),
Takayasu’s arteritis Systemic lupus Prostraglandins
also know as hypersensivity vasculitis or leukocytoclastic
erytematous antagonist
Immunotherapy angiitis, is a necrotizing small-vessel vasculitis, identical to
Giant cell arteritis Behçet’s syndrome Chemotherapy
PAN, except for presenting in smaller vessels. Unlike PAN,
angiographic findings are usually normal and do not reveal
Polyarteritis nodosa Complicated bowel Vasoconstriction
obstruction microaneurysms.
Systemic lupus Strangulated hernia Digitalis Henoch-Schönlein Syndrome. Henoch-Schönlein syn-
erytematous drome (HSS) is a hypersensitivity-related acute small-vessel
Henoch-Shonlein Strangulated closed Ergotamine vasculitis occurring mainly in children up to 10 years. The
purpura loop obstruction most common cause is group A Streptococcus Beta-hemolytic
Wegener’s Volvulus Vasopressin accounting for 75 % of cases. Gastrointestinal bleeding is
granulomatosis related to intramural hemorrhage and may precede skin
Churg-Strauss Intussusception Epinephrine lesions. The disease is confined to the mucosa and submu-
syndrome cosa, and full-thickness necrosis and bowel perforation are
Thromboangiitis Intestinal Hypotension rare.
obliterans overdistention Systemic Lupus Erythematous. Systemic lupus ery-
Rheumatoid Enterocolic Diuretics thematous (SLE) is an autoimmune disorder that affects
vasculitis lymphocitic phlebitis
the musculoskeletal system, kidneys, GI tract, or skin.
Behçet’s syndrome Antidepressants Small blood vessel inflammation of the gut produces a
Thrombotic variety of complications, including intestinal ischemia,
thrombocytopenic
purpura
hemorrhage, ileus, ulceration, infarction, and perforation.
Visceral artery involvement has a predilection for the SMA
Hemolytic-uremic
syndrome territory.
Fybromuscular
Behçet’s Syndrome. Behçet’s syndrome (BS) is a necro-
dysplasia tizing vasculitis that involves multiple organ systems. The
Diabetes mellitus gastrointestinal tract is involved in 10–40 % of patients,
Oxalosis
predominantly the terminal ileum. BS appears with large,
deeply penetrating ulcerations of the submucosa, muscle
Amyloidosis
layer, or entire intestinal wall. As a result, a large prevalence
208 M. Picada-Correa and G.S. Oderich

Fig. 24.2 Microscopic

examination demonstrating a
giant multinucleated cell (black
arrow) in a patient with giant cell
arteritis causing bilateral renal
and superior mesenteric artery
stenoses (H and E staining)

of complications such as hemorrhage, perforation, fistula, corticosteroid therapy and aspirin. Prednisone is maintained
and peritonitis has been reported. The vasculitic process at this dosage for approximately 4–6 weeks, after which it is
affects primarily small veins rather than arteries; hence, tapered by 10 % every 2–4 weeks, depending on the absence
thrombophlebitis of superficial and deep veins and arterial of symptoms and level of inflammatory markers. The addition
thrombosis are common. Arterial involvement with aneurys- of an anti-metabolic or steroid-sparing agent may allow
mal disease involves pulmonary (50 %), aortic, and other reduction of the prednisone dose, although these medications
large vessels. The presence of severe perienteric or pericolic are reserved for patients without initial response to predni-
infiltration raises the possibility of complications such as sone. The medical treatment resolved mesenteric symptoms
microperforation or localized peritonitis. [3, 4, 13] in >87 % of our patients [2].
Thromboangiitis Obliterans. Thromboangiitis obliterans
(TAO), or Buerger’s disease, is a distinct disease character-
ized by segmental, thrombosing, acute or chronic
Open Surgical Reconstruction
inflammation of small and intermediate-sized arteries and
Open surgery is indicated in patients who fail medical therapy
veins. Although it is not a classic vasculitis, the disease is
because of persistent symptoms or intolerance of medica-
considered one because of the intense inflammatory response.
tions and in those who present with life-threatening acute
GI tract manifestations are rare.
mesenteric ischemia or bleeding. Levine et al. (2002) reported
a lower (23 %) overall mortality for surgical patients present-
Management ing with less severe GI involvement. However, severe GI
involvement has been associated with high mortality [16].
Medical Treatment According to uni- and multivariate survival analysis of 62
patients presenting with GI vasculitidis, peritonitis, bowel
Because vasculitides are primarily inflammatory processes, perforation, GI ischemia, or infarction and intestinal occlu-
corticosteroids alone or combined with other immunosup- sion were the only high-mortality predictors [4].
pressants are the basis of medical therapy [2]. Even in the Mesenteric revascularization is indicated in patients with
presence of severe GI vasculitis, medical therapy should be acute or chronic mesenteric ischemia (Fig. 24.3). Ritz and
initiated [4]. The medical regimen in the Mayo Clinic is associates reported the Mayo Clinic experience with inter-
based on previous work published in our institution [14, 15], ventions for mesenteric vasculitis. Among 7,514 patients
which includes a daily dose of 40–60 mg of prednisone, evaluated for vasculitis for 24 years, 120 had symptoms of
which is preferred over a lower dose or alternate day mesenteric ischemia. Of these, 15 patients (4 %) required
24 Mesenteric Vasculitis 209

Fig. 24.3 Illustration of a

supraceliac aorta to superior
mesenteric artery and bilateral
renal artery bypass (a) in a
patient with Giant cell arteritis
who presented with symptoms of
chronic mesenteric ischemia and
had difficult to control
renovascular hypertension.
Follow up computed tomography
angiography (b) reveals widely
patent grafts (b)

open or endovascular treatment for occlusive vasculitis. in noninflamed arteries. Similar to patients with atheroscle-
During the same period, 323 other patients required open rotic mesenteric disease, we favor an antegrade bypass from
surgery for atherosclerotic visceral disease. Procedures supraceliac aorta whenever possible. If the patient is older or
performed for mesenteric vasculitis included open has cardiac disease or a calcified aorta, a retrograde iliac-
revascularization in 14 patients and percutaneous translumi- based mesenteric bypass with straight or C-shaped
nal angioplasty (PTA) in one. Twenty-two mesenteric arter- configuration is an excellent alternative and avoids aortic
ies were treated. There were no early deaths and only three cross clamping. Both the celiac and SMA arteries are recon-
complications, which included GI bleeding and ileus and structed, which may reduce rates of late failure if one of the
superior mesenteric vein thrombosis. There were no late graft limbs narrows or occludes. Finally, although renal or
deaths after a mean follow-up of 41 months; 14 patients aortic concomitant reconstructions are avoided in patients
(93 %) remained asymptomatic. with atherosclerotic disease, these patients may require more
The most common etiologies were large- and medium-ves- extensive reconstructions if the disease affects other visceral
sel vasculitides: Takayasu’s arteritis due to aortic involvement branches (Fig. 24.3). In our report on mesenteric vasculitis, 7
proximal to or at the ostia of the mesenteric arteries in seven of 15 patients (47 %) had refractory renovascular hyperten-
patients, polyarteritis nodosa in four patients, and giant cell sion and required concomitant renal bypasses [2, 12, 17].
arteritis in one. Three patients had indeterminate vasculitis.
The Mayo Clinic experience on surgical reconstructions
performed for Takayasu’s arteritis [12] included 42 (17 %) Endovascular Treatment
patients treated over 27 years. Fields and associates reviewed
outcomes of 60 operations on 116 arteries. The survival rate Endovascular treatment of stenotic lesions should be reserved
was 100 % at 1 year and 97 % at both 5–10 years, similar to for focal and isolated lesions, or it can be used as a bridge to
age- and gender-matched controls. The only death was unre- open surgery. The durability of endovascular therapy has not
lated to the initial procedure. Eleven patients underwent graft been demonstrated but likely does not match the results
revision because of stenosis. Ten patients were reoperated obtained with open surgery. Issues include the young age,
during the first year of follow-up, related to disease activity. the normal life expectancy, and the fact that vasculitis lesions
Freedom from graft revision in 5–10 years was 100 %. are not favorable for angioplasty and stenting. These lesions
There are no guidelines for how to approach open mesen- are long, prone to recoil, and often involve branches; the
teric reconstruction in mesenteric vasculitis. The general technical result therefore is often suboptimal. In addition,
principal is to select the inflow and outflow anastomotic sites angioplasty and stent placement contradict the basic principle
210 M. Picada-Correa and G.S. Oderich

a b

c d

Fig. 24.4 Illustration depicts multiple hepatic artery branch aneurysms visceral aneurysms affecting the proper hepatic artery (PHA) and
(a) in a patient who presented with ruptured intra-hepatic aneurysm replaced right hepatic artery (c, d). The patient was successfully treated
associated with polyarteritis nodosa (PAN). Selective celiac axis (CA, by coil embolization. AO aorta, SP splenic artery, CHA common
b) and superior mesenteric artery (SMA, c and d) demonstrates several hepatic artery, GDA gastroduodenal artery

of avoiding the inflammatory bed, especially in patients with Conclusion

active disease, acute inflammation, or those with chronic dis- Mesenteric vasculitis is a rare manifestation of sys-
ease still on corticosteroids [16–19]. temic vasculitis. Most patients have involvement of
Percutaneous transcatheter embolization (PTE) of vis- other vascular territories. Clinical manifestations can
ceral aneurysms (Fig. 24.4) is an ideal technique to deal with range from mild discomfort to life-threatening bleed-
small complicated visceral aneurysms and has lower compli- ing or ischemia. Patients with vasculitis who present
cation rates. In a 10-year period, 176 patients with 185 with abdominal pain and weight loss should be investi-
visceral aneurysms were treated at the Mayo Clinic for a gated for mesenteric ischemia. Medical therapy is the
variety of causes. The overall 30-day mortality was 6.2 %, fi rst line of treatment. Open surgical and/or endo-
and immediate technical success was 98 %. After a mean vascular reconstruction is indicated in patients who
follow-up of 24 months, there were ten late deaths, which fail medical therapy or have life-threatening bowel
were not related to the aneurysm. ischemia.
24 Mesenteric Vasculitis 211

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 Part VIII
Peripheral Aneurysms
 Inflammatory Peripheral Arterial
Aneurysms 25
Gianluca Faggioli, Rodolfo Pini, Mauro Gargiulo,
Antonio Freyrie, Raffaella Mauro, and Andrea Stella

Introduction aneurysms (AAAs), and those of the femoral artery are rarer
still, affecting 2.8–6.7 % of patients with AAAs [3, 4]. Similar
The inflammatory changes occurring in the wall of arterial to aortic aneurysms, the pathological process leading to periph-
aneurysms have been extensively studied in the abdominal eral aneurysm formation is not completely clear. Atherosclerosis
aorta since the first description by While in 1972. However, is part of this process in the majority of cases; however, many
similar aspects of atherosclerotic aneurysms located in other authors have proposed the definition of “nonspecific degenera-
sites of the arterial system, such as the popliteal and femoral tive aneurysms.” However, the terminology of atherosclerotic
arteries, have been reported only exceptionally. To our aneurysms has remained commonly used [5].
knowledge, after an extensive search of PubMed using the The clinical features of these aneurysms, together with
terms inflammatory aneurysms, peripheral inflammatory the recommendations for their treatment, are well discussed
aneurysms, peripheral aneuysms, and popliteal aneurysms, in the literature. However, no extensive analysis of the wall
only two papers were found in the English language litera- characteristics is available, and studies on the inflammatory
ture, and one of them is a case report [1, 2]. parietal changes are lacking, with little or no histological
The fact that an inflammatory infiltrate has been described data on the inflammatory involvement of the tunica media
in a series of anatomical locations, such as the coronary arteries and adventitia.
and the thoracic aorta, leads to the assumption that similar In the work of our group published many years ago [1], 18
pathological processes occur more frequently than reported consecutive cases of peripheral artery atherosclerotic aneu-
for “atherosclerotic” aneurysms of any anatomical district. rysms were histologically examined and compared with a
group of atherosclerotic femoral artery specimens obtained
from the cadavers of a similar population in order to evaluate
Peripheral Aneurysms and Inflammation the prevalence of medial and adventitial inflammation, its
type, and the amount. These findings could be useful for
Atherosclerotic aneurysms of the lower limb arteries are rare evaluating pathogenetic hypotheses.
compared to aortic aneurysms. Specifically, aneurysms of the
popliteal artery, which are the most frequent among peripheral
aneurysms (70 %), are tenfold rarer than abdominal aortic Data from the Study

Eighteen consecutive patients [16 male (88.8 %), 47–79 years

G. Faggioli, MD (*) old; mean age 66.5] undergoing revascularization for aneu-
Chirurgia Vascolare, Policlinico S. Orsola,
Via Massarenti 9, 40138 Bologna, Italy rysms of the peripheral arteries were included. Symptoms
included claudication of <300 meters in six cases (33.4 %)
Department of Vascular Surgery,
University of Bologna, Bologna, Italy and rest pain in two cases (11.1 %). Ten patients (55.5 %)
e-mail: gianluca.faggioli@unibo.it were asymptomatic. Pain was not present at the aneurysm site
R. Pini, MD • M. Gargiulo, MD • A. Freyrie, MD in any of the cases. Arteries involved were the popliteal artery,
R. Mauro, MD • A. Stella, MD common femoral artery, and deep femoral artery, as reported
Department of Vascular Surgery, in Table 25.1. A diagnosis of popliteal entrapment, cystic
University of Bologna, Bologna, Italy medionecrosis, or other non-atherosclerotic causes of aneu-
e-mail: rudypini@gmail.com; mauro.gargiulo2@unibo.it;
antonio.freyrie@unibo.it; raffaella.mauro1@gmail.com; rysm was excluded in each case, and an elevated ESR, leuko-
andrea.stella2@unibo.it cytosis, or autoimmune disease was not present in any of the

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 215
DOI 10.1007/978-1-4471-4429-8_25, © Springer-Verlag London 2013
216 G. Faggioli et al.

Table 25.1 Clinical and morphological characteristics according the

histological findings
Group I Group II Group III
Patients 9 5 4
Clinic
Age 63.4 62.2 70.7
Males (%) 88.8 60 100
Smoking (%) 77.7 80 75
Diabetes (%) 22.2 40 25
Hypertension (%) 33.3 20 25
Leukocytosis – – –
Increased ESR – – –
Pain at aneurysm site – – –
Morphology
Aneurysm location
Common femoral – 2 –
Profunda femoris – – 1
Popliteal 9 3 3
Wall thickness 0.21 ± 0.03 0.36 ± 0.02 0.55 ± 0.05*
Number of inflammatory 2.2 ± 0.3 9.2 ± 0.5 13.2 ± 0.3
cells/2,116 um2
*Group I and group II: p < 0.01, group II and group III: p < 0.02

Table 25.2 Patient characteristics in the PAAA and control groups

Parameters PAAA Control
Age 64.5 68.3
Males (%) 83.3 86.6
Smoking (%) 77.7 73.3
Diabetes (%) 27.7 13.3
Hypertension (%) 27.7 20.0
Wall thickness 0.33 ± 0.047 0.23 ± 0.02* Fig. 25.1 Histological appearance of group I aneurysmatic wall show-
Atherosclerosis + + ing absence of lymphomonoplasmocytic infiltrate (<4 cells/2,116 mm2)
Macroscopic signs of inflammation − −
Numbers of inflammatory cell 6.6 ± 1.14 1.48 ± 0.24** abdominal aortic aneurysm (AAA) [6]: group I, scarce
*p = ns; **p = <0.001 inflammatory infiltrate; group II, moderate inflammation;
group III, severe degree of inflammatory infiltrate.
patients. The intraoperative macroscopic examinations did Quantitatively, the number of inflammatory cells present
not reveal the morphological aspects typical of inflammatory within a 2,116 mm2 square in 100 random fields was calcu-
abdominal aneurysms or the inflammatory variants of AAA lated. Group I was composed of specimens with <4
(perianeurysmatic fibroses with adherence to the neighbor- cells/2,116 mm2, group II of specimens with 4–11
ing structures, pearly white color) in any of the cases. In all cells/2,116 mm2, and group III of specimens with more than
the cases, gross evidence of atherosclerosis was present. 11 cells. The mean wall thickness was calculated as a mean
A segment of the aneurysm wall was harvested and then of three different random measurements in the same speci-
fixed in 10 % formalin and stained with hematoxylin & eosin, men and expressed in centimeters. The distribution of the
van Geison + elastic fibers, PTAH, and Alcian Pas. Ten speci- specimens into the three groups was treated with the
mens were also obtained from the atherosclerotic non- Kolmogorov-Smirnov test. Correlation between peripheral
aneurysmatic femoral arteries of ten autopsies of patients atherosclerotic artery aneurysms and control specimens and
with similar demographic characteristics (Table 25.2) and among the three different groups were evaluated by
submitted to the same procedure for histological examina- Mann-Whitney U test. Histological findings of cholesterol
tion. Clinical history and laboratory examinations of all clusters, fibrohyaline degeneration, and internal elastic lam-
patients were reviewed with particular attention to infections, ina disruption were always evident. In the media and
autoimmune diseases, arteritis, and the presence of non- adventitia, histological evidence of a slight lymphomono-
specific leukocitosis. plasmocytic infiltrate (<4 cells/2,116 mm2) was found in nine
Histological features of inflammation were classified aneurysmatic walls (group I) (Fig. 25.1). In five cases
according to the criteria proposed by Rose and Dent for (27.7 %), a moderate quantity (from 4 to 11 cells/2,116 mm2)
25 Inflammatory Peripheral Arterial Aneurysms 217

Fig. 25.3 The inflammatory infiltrate of patients in GIII shows a sub-

stantial number (>11 cells/2,116 mm2) of lymphomonoplasmocytic ele-
Fig. 25.2 Histological appearance of group II aneurysmatic wall. In ments, which sometimes are arranged in pseudo-follicles
this case, a moderate lymphomonoplasmocytic infiltrate can be seen in
the tunica media and adventitia (from 4 to 11 cells/2,116 mm24
cells/2,116 mm2) aneurysm specimens were considered together, the number
of inflammatory cells was significantly higher than that of
of lymphomonoplasmocytic infiltrate was found in the tunica atherosclerotic controls (p < 0.001, Mann-Whitney U test).
media and adventitia (group II) (Fig. 25.2). In the four There was no statistical difference in wall thickness between
remaining cases (22.2 %), the inflammatory infiltrate showed these two groups; however, the difference in the wall thick-
a high number (>11 cells/2,116 mm2) of lymphomonoplas- ness of the three groups of PAAA was significant (group I
mocytic elements (group III) (Fig. 25.3). In this group of and II: p < 0.01; group II and group III: p < 0.02, Mann-
cases, it was possible to observe a different arrangement of Whitney U test).
the infiltrate: in pseudo-follicles in three cases and wide-
spread in one case. In one case the lumen of the aneurysm
was almost completely occupied by recent thrombus. In the Inflammatory Peripheral Aneurysms
ten control specimens, histology did not reveal moderate or
severe inflammation in any of the cases. Mild changes were The pathogenesis of peripheral arterial aneurysms is thought
found in all of the cases. The mean number of inflammatory to be atherosclerotic in the majority of cases (99.1 %), even
cells was 1.47 ± 0.24, and they were distributed mainly in the if the exact etiology is not known, especially at the femoral
adventitia (Table 25.2). level [5, 6]. While the most appropriate definition for these
In two of ten cases (20 %) of peripheral aneurysms with forms should be “non-specific aneurysms,” the terminology
inflammatory histopathological features, an associated aortic of “atherosclerotic aneurysms” is commonly used. Various
aneurysm was present; however, the AAA did not show any etiopathogenetic hypotheses have been examined in the lit-
macro- or microscopic features of the inflammatory forms. erature: in particular the vibration of the arterial wall due to
While the distribution of the specimens in the three groups the turbulence in the collateral breaching areas and the
was not significantly different from the theoretical uniform trauma caused by the inguinal ligament during flexing of the
distribution (Kolmogorov-Smirnov’s test), when all the thigh [7]. Revascularization, either surgical or endovascular,
218 G. Faggioli et al.

is indicated because of the high percentage of complications T8 process. This process is supposed to be active and
(70 %) caused by thrombosis, peripheral emboli, and rup- proliferating, as demonstrated by the presence of IL2 recep-
ture. Different techniques are available nowadays, from the tors, HLA-DR antigens, IgG, and IgM and by the activation
replacement of the aneurysmal segment with the insertion of of complement [1, 17–21]. Unfortunately, we could not per-
a vein or prosthetic graft to endoluminal devices [8, 9]. form any immunochemistry in this group of specimens, and
The only report of a clinically evident popliteal we cannot be sure that the nature of the inflammation was
inflammatory aneurysm has been published recently [2]. identical to that seen in the aorta. Further prospective studies
In that case, local and systemic symptoms of inflammation are therefore needed. The antigens that are able to trigger this
were present, such as swelling, redness with pain, and fever. process are unknown; the role of atheromatous components
Laboratory tests also showed signs of active inflammation, and of the fragmented elastin and collagen fibers needs to be
such as elevated leukocytes and CRP levels. Similarly to the evaluated.
findings of aortic inflammatory aneurysms, CT scans showed Different hypotheses have been proposed to explain this
the typical arterial wall thickening and a surrounding hyper- phenomenon; most of them have been discounted by succes-
dense region [10]. The findings of inflammation are usually sive papers.
grossly evident in the abdominal aorta because of the fibrotic The development of the entire process and the significance
and inflammatory involvement of the surrounding structures, for the interpretation of atherosclerotic disease are still
such as the ureters, left renal vein, vena cava, and duode- obscure and require further investigation. These forms are
num. Very rarely, severe wall inflammation occurs without not correlated with the presence of parietal fibrosis, and the
macroscopic evidence of wall thickening or periadvetitial surrounding tissues in the limb would not be as dangerously
adherence [11, 12]. Histological findings or inflammatory involved as the structures around the aorta (i.e., ureters);
infiltrates have also been described in the coronary arter- therefore, the significance of these findings is only for their
ies, thoracic aorta, and non-aneurysmal abdominal aorta pathogenetic implications. It would be interesting to under-
[13, 14]. However, clinical and morphological elements stand the exact pathogenesis of fibrosis, which is almost
of inflammation are found in a percentage of AAAs, vary- always absent in these forms but is common in inflammatory
ing from 2.4 to 18.1 % of cases. The terms inflammatory AAAs, also determining differences in their postoperative
aneurysm and inflammatory variant were coined for these evolution.
forms [15, 16]. Our analysis of 18 consecutive cases of ath- The recognition that the inflammatory process can
erosclerotic peripheral aneurysms did not reveal any clinical involve arteries other than the abdominal aorta and that it is
or morphological features able to distinguish inflammatory usually associated with aneurysmal forms may lead to a
from noninflammatory cases, similarly to the aorta and the better understanding of its evolution.
fact that only recently a single case has been reported con-
sistent with our findings. The arterial wall was never affected
by periadventitial fibrotic phenomena causing adherences
to neighboring structures. However, in a significant per-
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centage of our cases (50 %), histology revealed a greater 1. Faggioli GL, Gargiulo M, Bertoni F, Bacchini P, Gessaroli M,
inflammatory infiltrate than is normally found in atheroscle- Stella A. Parietal inflammatory infiltrate in peripheral aneurysms of
rotic arteries at this level or at the aortic level. Due to the atherosclerotic origin. J Cardiovasc Surg. 1992;33:331–6.
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aneurysm. Ann Vasc Surg. 2011;25:698.e13–6.
a distinction among three groups of aneurysms according to 3. Szilagyi DE, Schwartz RL, Reddy DJ. Popliteal arterial aneurysms.
the number of inflammatory cells seen. According to these Their natural history and management. Arch Surg. 1981;116(5):724–8.
criteria, a total of nine atherosclerotic aneurysms (50 %) were 4. Mahmood A, Salaman R, Sintler M, Smith SR, Simms MH, Vohra
divided between group II and group III. This result is rather RK. Surgery of popliteal artery aneurysms: a 12-year experience.
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which correspond indeed to the absence of fibrosis. Hoc Committee on Reporting Standards, Society for Vascular
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Dent TL, Lindenauer SM, et al. Clinical significance of arterioscle-
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for asymptomatic popliteal artery aneurysm: results of a prospec- 16. Mikami Y. Inflammatory abdominal aortic aneurysm. Ryoikibetsu
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 Endovascular Femoropopliteal
Interventions: Evolving Devices 26
Cassidy Duran and Jean Bismuth

Introduction infrainguinal disease, the angioplasty first strategy was asso-

ciated with similar amputation-free survival and decreased
Peripheral arterial disease (PAD) is caused by systemic costs [4]. This, however, did not take into account the early
atherosclerosis and is strongly associated with cardiovascular endovascular failure rate of 20 % that required re-intervention.
and cerebrovascular disease. Important risk factors for PAD It is estimated that the reason endovascular interventions
include age > 70, history of smoking, diabetes, hypertension, looked so good was that patients often go on to have a surgical
and hyperlipidemia, all known markers for cardiovascular bypass later, and so probably overall surgical results are better
disease [1]. While medical management in conjunction with in spite of short-term drawbacks. In practice, interventions
an exercise regimen is the recommended initial approach, have moved far beyond the scope of the consensus guidelines
according to the American Heart Association/American (which in 2000 addressed only percutaneous transluminal
College of Cardiology guidelines for the management of angioplasty (PTA), bare metal stents, and open surgical
PAD, patients with lifestyle-compromising pain, nonhealing bypass). Since first being introduced, widespread develop-
ulcers, or critical limb ischemia require invasive endovascu- ment of new technologies for peripheral endovascular inter-
lar or surgical intervention [2]. There is some disagreement ventions has occurred. This is true not only for the therapeutic
about the appropriate management of femoral-popliteal device, but also for the platform that provides access to and
lesions among various groups of interventionalists, but the the ability to treat the pathology. Flexible robotics offers the
Inter-Society Consensus for the Management of PAD (TASC) ability to reliably provide a stable platform through which
provides a general approach. Because of the rapidly chang- one can deliver a variety of therapeutic devices. This has been
ing technology, for many interventionalists the endovascular demonstrated in a recent first-in-man study in which the tech-
option is the first line of therapy, despite very poor evidence nical success rate was 100 % for the navigation of 20 iliofe-
for many of the products currently on the market. moral lesions and 95 % for successful delivery of therapeutic
According to the 2007 TASC II updated guidelines, TASC interventions (the only failure occurring when a surgeon with
A and B lesions requiring intervention should be managed no previous endovascular experience was unable to cross the
with endovascular intervention. TASC C lesions in patients lesion). Safety of the device was demonstrated with no
who can tolerate open surgery should receive open bypass, peri-procedural complications (Duran et al., article in press).
but many patients will have comorbid conditions that limit In this chapter, we describe the pathophysiology of femoral
surgical options, and in that case endoluminal intervention is atherosclerosis and restenosis, followed by an overview of
appropriate [3]. These recommendations are supported with current endovascular therapies for femoral-popliteal athero-
only level C evidence, meaning no randomized or well- sclerotic disease and the role of inflammation in the durability
conducted clinical trials have been performed and the evi- of endovascular interventions.
dence is based on solely expert opinion. According to the
BASIL trial, the only multi-center randomized controlled
trial (RCT) of angioplasty versus open surgical bypass for Pathophysiology of PAD

PAD results from atherosclerosis of the aortoiliac and lower

C. Duran, MD • J. Bismuth, MD (*) extremity vasculature. It occurs concurrently with athero-
The Methodist DeBakey Heart and Vascular Center,
sclerotic processes throughout the body, including the extrac-
The Methodist Hospital, 6550 Fannin St. Smith Tower 1400,
Houston 77030, TX, USA erebral and coronary vasculature, and is associated with the
e-mail: jbismuth@tmhs.org same risk factors. Atherosclerosis develops slowly over time

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 221
DOI 10.1007/978-1-4471-4429-8_26, © Springer-Verlag London 2013
222 C. Duran and J. Bismuth

and in the majority of individuals will not become symptom- review, mortality and amputation rates did not differ
atic. The initial step in the development of atherosclerotic significantly between bypass surgery and PTA. Primary pat-
plaques involves diffuse initimal thickening and formation of ency was significantly higher in the bypass group after
a fatty streak of lipid-filled macrophages and smooth muscle 12 months (OR 1.6) but not after 4 years (P = 0.14) [12]. The
cells (SMCs). These lesions are not pathologic, but retain the outcomes for PTA, however, depend on lesion characteris-
potential to develop into fibrous plaques that contain lipids tics, and the best results are seen in the group with short,
and fibrous connective tissues. These fibrous plaques become focal lesions [3]. A 2008 meta-analysis of PTA found a
calcified and can rupture, erode into the endothelium, or pooled estimate of success was 89.0 ± 2.2 % for immediate
hemorrhage within the plaque, all processes that are associ- technical results. Results at 1–36 months were 77.4 ± 4.1 % and
ated with clinical sequelae. Ultimately, the plaques develop a 48.6 ± 8.0 % for primary patency, 83.3 ± 1.4 %
necrotic core that is surrounded by inflammatory cells and and 62.9 ± 11.0 % for secondary patency, 93.4 ± 2.3 % and
SMCs, which are prone to rupture, intraplaque hemorrhage, 82.4 ± 3.4 % for limb salvage, and 98.3 ± 0.7 %
and occlusion [5]. Not all plaques are created equal, how- and 68.4 ± 5.5 % for patient survival, respectively [13].
ever, and atheromatous lesions are known to differ by vascu- Outcomes following PTA depend on a number of known
lar bed [6]. Examination of plaque morphology demonstrates factors, including lesion length, presence of total occlusion,
that fibrous cap atheromas predominate in the carotid arter- size of vessel, vessel overdilation, residual stenosis, and dis-
ies, while fibrocalcific plaques form in the femoral arteries section, all parameters that influence the degree of vessel
[7]. The implication is that lesions with higher levels of disruption and resultant inflammation following angioplasty.
inflammatory cells, while unstable, are less prone to recur- Following PTA, the resultant injury to the vascular intima
rent stenosis, while more stable plaques are highly calcified and media leads to proliferation of vascular smooth muscle
and prone to restenosis. However, because the time between cells and induces local and systemic inflammatory responses
the initial insult of lower extremity ischemia and intervention [14–16]. Though the process has been more extensively
is prolonged compared to cerebral ischemia resulting from studied in coronary interventions, the phenomenon has been
carotid disease, it is unclear if these differing plaque charac- shown to occur in peripheral vasculature as well [17]. Sheer
teristics represent differing linear progressions of disease. stress during PTA induces a vascular inflammatory process
in which polymorphonuclear neutrophils (PMNs) and mono-
cytes are localized to the injured endothelium. These
Restenosis Following Infrainguinal inflammatory mediators induce the migration of smooth
Intervention muscle cells (SMC) from the medial layer of the vessel to the
subendothelium. In turn, SMCs induce proliferation of extra-
Rates of recurrent stenosis following endovascular interven- cellular matrix proteins and myofibroblasts that are respon-
tions are significantly different in the femoral system as com- sible for neointimal hyperplasia, negative vascular
pared to the carotid and coronary arteries. Histopathologic remodeling, and ultimately restenosis [18].
evaluation of atherosclerotic plaques suggests that following
intervention; stable plaques are actually more susceptible to
restenosis [8]. In the carotid arteries, unstable, inflammatory Alternative Modalities for Angioplasty
plaques with high levels of macrophages and lipid cores were (Table 26.1)
associated with lower restenosis rates, presumably related to
extensive remodeling of the tissue induced by the inflammatory Cryoplasty
cells [9]. As opposed to the extensive remodeling induced by
inflammatory mediators, which appears to result in positive Because of the high restenosis rates following PTA alone,
remodeling in the carotid system, the fibrotic characteristics alternative endovascular modalities have been developed to
of femoral plaques lead to constrictive remodeling and pro- improve patency rates. One approach designed to limit the
gressive vessel occlusion [10], and constrictive remodeling inflammatory response following angioplasty is endovascu-
may be the primary driver for luminal compromise in patients lar cryoplasty in which cold thermal energy is delivered
with recurrent disease [11]. Understanding this process may simultaneously inside an angioplasty balloon. Experimentally,
ultimately guide the choice of intervention or device. cryotherapy induces SMC apoptosis, which would theoreti-
cally halt the inflammatory response to vessel injury during
balloon angioplasty. However, a single-center experience
Percutaneous Transluminal Angioplasty with 86 patients failed to demonstrate improved outcomes
over expected patency rates from PTA (48–37 % at
The primary endovascular intervention for treatment of flow- 12–24 months, respectively) [19]. Schmidt published a series
limiting femoropopliteal atherosclerosis is balloon angio- in which 109 infrapopliteal lesions (the most challenging of
plasty or PTA. According to a 2008 Cochrane Database the lower extremity lesions) were treated and reported
26 Endovascular Femoropopliteal Interventions: Evolving Devices 223

Table 26.1 Outcomes following traditional PTA and alternative angioplasty approaches for femoropopliteal lesions
Technical Amputation Primary Secondary Time to
Intervention Study type success (%) free (%) Survival (%) patency (%) patency (%) f/u (months)
PTA Meta-analysis 95.8 93.4 98.3 77.4 83.3 1
82.4 68.4 48.6 62.9 36
RCT (BASIL) 80 NR 78 50 NR 12
Cryoplasty Prospective 88 NR NR 47 NR 12
38 24
RCT (COLD) 35 NR NR 79 NR 9
CBA Prospective 91 100 NR 88 NR 3
RCT NR 93 100 38 NR 6
Subintimal angioplasty Prospective 87 75 99 45 76 12
25 50 36
Drug-coated balloon RCT NR 95.6 83.6 96 NR 12
91.5 24
Prospective NR 96 84.6 91.7 NR 12
NR = not reported

improvement in 94 %, healing in 74 %, and a limb salvage endovascular tools for subintimal navigation and vessel
rate of 95 % [20]. The single RCT of comparing cryotherapy re-entry, as well as high rates of morbidity and mortality fol-
to balloon angioplasty (COLD trial) demonstrated a mean lowing open surgery in a subset of high-risk patients,
patency of 79 % in the cryoplasty arm versus 67 % in the increasing numbers of threatened limbs are being treated
PTA arm (P = 14) at 9 months and a 30 % rate of stent place- percutaneously [32]. Scott and colleagues published their
ment for residual stenosis or dissection following cryoplasty single-center experience with 506 infrainguinal occlusions.
versus 39 % in the PTA group [21]. Long-term results are Primary patency at 12–36 months was 45 % (SE 3.0 %) and
pending, but at this time cryoplasty does not appear to offer 25 % (SE 3.6 %), respectively, and secondary patency was
significant advantages over PTA. 76 % (SE 2.6 %) and 50 % (SE 4.8 %) at 12–36 months.
Patients with femorotibial occlusions and critical limb isch-
emia had worse outcomes. Limb salvage in patients with CLI
Cutting Balloon Angioplasty (CBA) was 75 %, and open surgical bypass was avoided in 77 % at
36 months [33]. These results indicate that in experienced
Cutting balloons are designed with atherotome blades that hands, subintimal angioplasty is a reasonable first-line ther-
score atherosclerotic plaques. This technique treats lesions apy for patients with infrainguinal occlusions. The afore-
while limiting overdilation of the vessel and therefore elastic mentioned results are unlikely to be a true representation of
recoil as well as distal dissection. Reports on their use in the the outcomes to be expected in the average interventional
coronary, pulmonary and peripheral vasculature indicated community practice, as the procedure is anecdotally plagued
that there is in fact a reduction in vessel trauma and elastic by being extremely operator dependent.
recoil during CBA, with a positive impact in remodeling
[22–28]. Initial results of this technology in femoropopliteal
lesions demonstrated high rates of technical success (93 %), Stents (Table 26.2)
limb salvage (100 %), and primary patency (88 %) [29].
However, in a RCT of CBA versus PTA in short (<10 cm) Disappointing long-term patency rates following PTA in the
SFA stenosis, CBA yielded increased restenosis rates at femoropopliteal segment prompted the use of stents follow-
6 months (62 %) compared to PTA (38 %) [30]. ing angioplasty. Balloon angioplasty leads to thrombus for-
mation, recoil, intimal hyperplasia, and ultimately negative
remodeling, while stents are impacted only by thrombus for-
Subintimal Angioplasty mation and inflammatory-mediated intimal hyperplasia [34,
35]. Additionally, stents in the muscular infrainguinal arter-
The theories on the precise role of endovascular interven- ies are subject to stresses that result in stent fracture, which
tions in femoropopliteal chronic total occlusions are in flux. also induces intimal hyperplasia and in-stent stenosis.
Open surgical bypass remains the de facto gold standard, In the early years of infrainguinal endovascular interven-
but dedicated re-entry catheters designed for subintimal tions, stainless-steel stents were deployed with disappoint-
angioplasty have been shown to be safe and the procedure ing results. Studies failed to demonstrate improved outcomes
technically feasible [31]. In light of the improvements in over angioplasty alone, and the indication for stents was
224 C. Duran and J. Bismuth

Table 26.2 Outcomes following standard and alternative stent deployment and atherectomy for femoropopliteal lesions
Technical Amputation Primary Secondary Time to f/u
Intervention Study type success (%) free (%) Survival (%) patency (%) patency (%) (months)
Nitinol stent RCT (RESILIENT) 95.8 100 92.8 (30 day) 87.3 100 12
RCT NR NR 95.8 66.6 NR 12
Stent-graft RCT 100 98 92 72 83 12
63 74 24
DES RCT 100 NR NR 100 NR 6
Atherectomy Prospective 100 100 98 80 100 6
NR = not reported

limited to bail-out for residual stenosis or arterial dissection Drug-Eluting Stents

following PTA [36]. The role of primary stent placement
has been revisited using nitinol stents. Second generation Drug-eluting stents (DES) have been used with great success
nitinol stents have spirally oriented interconnections, which in the coronary vasculature, and their use is now well defined
have reduced rates of stent fracture and the resultant steno- [44]. The utility of DES use in the infrainguinal arteries has
sis [37]. Recently, the RESILIENT trial demonstrated that begun to be explored. In a non-randomized, single-arm trial,
primary deployment of self-expanding nitinol stents in mod- everolimus-eluting stents use was found to be feasible with
erate length femoral and popliteal lesions yielded better success rates comparable to established endovascular
results than angioplasty alone [38]. Overall, studies examin- approaches [45]. The SIROCCO II trial randomized 57
ing the role of nitinol stents have yielded variable results, patients to sirolimus-eluting stents versus nitinol bare metal
with moderate improvement in outcomes over PTA alone, stents for treatment of SFA disease. Despite a trend toward
and results varying significantly based on lesion specifics improved outcomes in the DES group, there were no statisti-
(TASC classification, lesions length, outflow vessel status) cally significant differences in outcomes between the two
[39, 40]. groups [46]. Given the significant cost of DES stents, currently
treatment with DES cannot be recommended, although more
data are on the way, which may very well influence that.
Stent-Grafts

Efforts to overcome the challenges of percutaneous Drug-Coated Balloons

interventions in the femoropopliteal segment have led inter-
ventionalists to consider a role for covered stents. The idea is Local administration of the antiproliferative drug paclitaxel
that covered stents will slow tissue in-growth and delay in- has also been found to effectively reduce rates of re-stenosis
stent re-stenosis. In 2000, Lammer and colleagues estab- following PTA, but unlike DES, drug-coated balloons are
lished feasibility in a multicenter, international trial [41]. effective in both the coronary and peripheral vessels. In a
In 2005, ePTFE-covered stent-grafts (Viabahn, WL Gore multicenter randomized trial of 154 patients with femoral or
and Associates, Flagstaff, AZ) were approved for deploy- popliteal artery stenosis/occlusions, at 12 months 20 of 54
ment in the superficial femoral artery, and in 2007, approval (37 %) lesions in the control group required revasculariza-
was extended to a heparin-bonded Viabahn for SFA lesions. tion compared with 2 of 48 (4 %) in the group treated with
A 2007 single-center randomized study of Viabahn versus paclitaxel-coated balloons (P < 0.001 vs. control); at
surgical bypass in 100 limbs showed that primary and sec- 24 months, the re-intervention rates increased to 28 of 54
ondary patency rates were comparable at 12 months [42], (52 %) in the control group and 7 of 48 (15 %) in the pacli-
and in 4-year follow-up of patients randomized to surgical taxel group [47]. These early results are promising, but
bypass versus stent-graft for SFA lesions, differences in pri- require further investigation before definitive recommenda-
mary and secondary patency rates were not statistically tions can be made. Currently, two large European studies are
significant. Additionally, stent-grafts were much less likely recruiting patients to further elucidate the role of drug-coated
to fracture, making them less vulnerable to failure from in- balloons in the treatment of peripheral vascular lesions.
stent stenosis at the fracture site, and unlike bare-metal stents,
successful outcomes were not dependent on lesion length
[43]. Therefore, it is likely preferable to treat long lesions Atherectomy
with stent-grafts, and these results indicate that stent-grafts
should be considered a viable alternative to bypass in these In contrast to the aforementioned devices, atherectomy
patients. devices aim to treat peripheral lesions through excision of an
26 Endovascular Femoropopliteal Interventions: Evolving Devices 225

atherosclerotic plaque using percutaneous means. The led to a paradigm shift in disease management. While
SilverHawk directional atherectomy device (EV3, there is no silver bullet for treating these complex lesions,
Minneapolis, MN) has a highspeed carbide cutting disc that increasingly endovascular interventions are being utilized
cuts ribbons of atheroma and stores the excised plaque in the as a first line therapy in even the most diseased segments.
nose cone of the device. In 2004, Zeller reported his initial Interventionalists should closely scrutinize their approach
experience in 52 patients using the SilverHawk device. to devices as clearly not all devices and techniques are
Although <50 % stenosis was found in 96 % and <30 % in created equal. Expectations often need to be tempered as
78 % of patients following atherectomy, additional percuta- the few and relatively poor studies are generally per-
neous procedures were performed in 58 % of the patients. formed in centers with vast experience. Furthermore, the
The device was safe, and rates of recurrent disease were not key to any success in the interventional space is the under-
higher in the atherectomy-only group compared to the group standing that we are managing the complications of an
in which additional procedures were performed [48]. inflammatory disease and long-term success is in great
Recently, the group with the largest experience (579 infrain- part based on the continued management of the medical
guinal lesions) reported on their outcomes. The primary pat- aspects of this disease.
ency at 12–18 months was 59.1–49.4 % with a limb-salvage
rate of 87.9 % at 18 months for patients with critical limb
ischemia and 100 % limb salvage in patients with claudica-
tion [49]. At this time, no RCTs have compared atherectomy
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 Part IX
Cardiopulmonary Bypass
 Modulation of Inflammatory
Response in Cardiopulmonary Bypass 27
Shahzad G. Raja

Introduction Avoiding Cardiopulmonary Bypass

Cardiac surgery with cardiopulmonary bypass provokes Off-Pump Coronary Artery Bypass Surgery
a systemic inflammatory response syndrome (SIRS). Contact
of the blood components with the artificial surface of the A radical and effective way of counteracting the effects of
bypass circuit, ischemia-reperfusion injury, endotoxemia, SIRS may be the omission of CPB itself. This idea provided
and operative trauma are all possible causes of SIRS [1, 2]. the impetus for reintroduction of off-pump coronary artery
This inflammatory reaction may contribute to the develop-
ment of postoperative complications, including myocardial Table 27.1 Factors influencing systemic inflammatory response
dysfunction, respiratory failure, renal and neurologic dys-
Biomaterial-dependent factorsa
function, bleeding disorders, altered liver function, and, ulti- Type of extracorporeal circuit
mately, multiple organ failure [1, 2]. Type of oxygenator and pump
The incidence, severity, and clinical outcome of SIRS Biomaterial-independent factors
are influenced by a large number of factors that can be Extracorporeal perfusion factors
broadly classified as biomaterial-dependent and biomate- Composition of the priming solution
rial-independent (Table 27.1). The precise role of each of Cardioplegia
these factors and the reasons why certain patients develop Pulsatile or non-pulsatile perfusion
life-threatening perioperative complications are currently Temperature during CPB
the focus of considerable research. Diverse therapeutic Preoperative factors
strategies to modulate the systemic inflammatory response Morbid conditionsb
after cardiac surgery are being examined in experimen- Perioperative hemodynamic factors
tal and clinical studies [2]. Currently available strategies Low cardiac output
can be broadly classified as (1) avoiding CPB altogether Splanchnic hypoperfusion
Anesthetic techniques
(off-pump surgery), (2) technical strategies (including
Thoracic epidural anesthesia
modifying perfusion techniques and circuitry), (3) phar-
Anesthetic agents and drugs
maceutical strategies, and (4) endotoxemia-reducing
Lung management during CPB
strategies (Table 27.2). This chapter provides an overview Surgical factors
of these strategies and focuses on their evidence-based Incision and approach
potential and actual impact in reducing the systemic Duration
inflammatory response. Cardiotomy blood management
Shear stress
Transfusion
Postoperative factors
Continuous renal replacement therapies
Mechanical ventilation
S.G. Raja, BSc, MBBS, MRCS, FRCS(C-Th)
Department of Cardiac Surgery, CPB cardiopulmonary bypass
a
Harefield Hospital, London, UK Related to the composition of the synthetic surface of the circuit
b
e-mail: drrajashahzad@hotmail.com Such as poor left ventricular function or diabetes

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 231
DOI 10.1007/978-1-4471-4429-8_27, © Springer-Verlag London 2013
232 S.G. Raja

Table 27.2 Strategies to modulate inflammatory response It would, however, be incorrect to expect that OPCAB
Cardiopulmonary bypass avoidance will abolish the systemic inflammatory response completely.
Off-pump coronary artery bypass grafting It is worth remembering that while performing OPCAB, the
Technical strategies response to surgical trauma, manipulation of the heart, peri-
Miniaturized extracorporeal circulation cardial suction, heparin, protamine, other drugs, and anes-
Heparin-bonded circuits thesia are still there, and all produce an increase in the
Hemofiltration markers of acute inflammation. Increasing acceptance to per-
Leukocyte depletion form OPCAB in elderly patients and those with comorbid
Centrifugal pumps conditions is proof that this attenuated systemic inflammatory
Cardiopulmonary bypass temperature response reduces organ dysfunction [3].
Pharmacologic strategies
Corticosteroids
Aprotinina
Antioxidants
Technical Strategies
Mannitol
Allopurinol Minimized Extracorporeal Circulation System
N-acetyl cysteine
Vitamin C Recently, a minimized extracorporeal circulation (MECC)
Vitamin E system has been developed based on the concept of a short
Complement inhibitors closed total CPB circuit [29]. The basic elements are a cen-
Monoclonal C5 antibody trifugal pump, a membrane oxygenator, and an arterial filter.
Compstatin The priming volume can be reduced to 500 ml or less, thus
C1 inhibitor limiting hemodilution. The complete circuit is coated with
Recombinant soluble inhibitor-1 heparin to maximize biocompatibility. The blood-air interface
Monoclonal C3 antibody is eliminated, and suction of shed blood is carried out only
Monoclonal C5a antibody through a cell-saving device. Thus, blood is washed before
Phosphodiesterase inhibitors retransfusion into the patient. In a randomized controlled trial,
Milrinone
Fromes and colleagues [29] showed that the MECC system
Dopexamine
initiated a milder inflammatory reaction than standard CPB:
Cyclooxygenase inhibitors
IL-6, TNF-a, and elastase release was significantly less in
Endotoxemia-reducing strategies
patients who were operated on with the MECC system.
Antimediator and antiendotoxin therapies
Selective digestive decontamination
However, currently there is a paucity of randomized controlled
Enteral nutrition & immunonutrition trials highlighting long-term survival, clinical outcomes, and
a
delayed complications in this area. Despite this, MECC
FDA restriction on routine use
remains a promising alternative to conventional extracorporeal
circulation, especially in terms of its inflammatory results.
bypass (OPCAB) surgery—a technique that predates CPB
but was rapidly off-staged by on-pump coronary artery
bypass graft (CABG) soon after the invention of the heart- Heparin-Bonded Circuits
lung machine because of the attraction of operating on a still
heart in a bloodless field [3]. Coating the artificial surfaces of the CPB circuit with heparin
Analysis of current best available evidence [4] from random- was initially suggested in the late 1960s [30], predominantly
ized controlled trials [6–28] indicates that OPCAB reduces the because of its known antithrombotic property [31]. Since
systemic inflammatory response but does not prevent it (grade then, however, it has been proven to have many other bio-
A/level Ib). Use of OPCAB decreases concentrations of cytok- compatibile properties, including inhibition of contact, acti-
ines such as tumor necrosis factor (TNF)-a, interleukin (IL)-6, vation of complement and neutrophil, reduction in the release
IL-8, IL-10, TNFsr1, and TNFsr2. It also attenuates the cellular of proinflammatory cytokines, and improvement of platelet
inflammatory response, decreasing neutrophil and monocyte function [32]. Furthermore, it adsorbs lipoproteins to create
counts, neutrophil elastase, intracellular heat shock protein 70, a surface that may simulate cell membranes [32].
and E-selectin concentrations. Indices of complement activa- The method by which the circuit is coated and the type of
tion, such as C3a and C5a, are decreased. In addition, OPCAB heparin used may have implications for its effects on the
attenuates other indices including platelet ß-thromboglobulin coagulation and complement systems. The Duraflo II HCC
and procalcitonin. Finally, OPCAB decreases injury induced by (Baxter Healthcare Corp., Irvine, CA), which uses ionically
reactive oxygen species (Table 27.3). bonded unfractionated heparin, reduces kallikrein and com-
27 Modulation of Inflammatory Response in Cardiopulmonary Bypass 233

Table 27.3 Randomized controlled trials comparing impact of OPCAB and conventional CABG on systemic inflammatory response
Intervention
Study Level of evidence (n per group) Main result
Lin et al., 2010 [5] Level Ib CABG with CPB (25)a Elevated serum IL-8, IL-10, and IL-12 were found in all three
vs. OPCAB (20) groups. HSP70 expression within leukocytes was enhanced in
CABG patients
Onorati et al., 2010 [6] Level Ib CABG with CPB (40)b OPCAB was associated with slight endothelial activation and
vs. OPCAB (20) cytokine response. Pulsatile cardiopulmonary bypass CABG
significantly attenuates endothelial/cytokine leakage
Serrano et al., 2010 [7] Level Ib CABG with CPB (41) OPCAB better preserves the myocardium and attenuates
vs. OPCAB (40) inflammation compared to on-pump CABG
Rasmussen et al., 2007 [8] Level Ib CABG with CPB (17) Oxygenation was more affected by OPCAB. Only part of the
vs. OPCAB (18) systemic inflammatory response (IL-8 and IL-10) was attenuated
by OPCAB
Parolari et al., 2007 [9] Level Ib CABG with CPB (16) The postoperative protracted activation of inflammation is not
vs. OPCAB (14) affected by surgical strategy (on-pump or off-pump)
Tatoulis et al., 2006 [10] Level Ib CABG with CPB (50) The incidence of low SVR and patterns of SVR changes were
vs. OPCAB (50) similar in both groups and were clinically unimportant as few
patients required vasopressor support. Cardiac outputs and clinical
outcomes were excellent in both groups
Cavalca et al., 2006 [11] Level Ib CABG with CPB (25) OPCAB revealed less perioperative oxidative stress, as reflected
vs. OPCAB (25) by lack of excretion of iPF2alpha-III in urine, by lack of increase
of plasma free malondialdehyde, and by lower decreases in plasma
total antioxidant status
Wehlin et al., 2005 [12] Level Ib CABG with CPB (9) Monocyte expression and in vitro mobilization of complement
vs. OPCAB (11) receptors, CD11b and CD35, were similar in both study groups
during and after surgery, as was the expression of CD62L
Wan et al., 2004 [13] Level Ib CABG with CPB (19) IL-10, 1 L-6, 1 L-8, TNFa, and VCAM-1significantly higher in
vs. OPCAB (18) CABG + CPB group
Wehlin et al., 2004 [14] Level Ib CABG with CPB (16) Less complement activation in low- risk OPCAB patients
vs. OPCAB (21)
Dorman et al., 2004 [15] Level Ib CABG with CPB (25) Postoperative ET levels were higher in patients who underwent
vs. OPCAB (25) CPB for CABG
Al-Ruzzeh et al., 2004 [16] Level Ib CABG with CPB (10) Less activation of circulating neutrophils in OPCAB patients
vs. OPCAB (10)
Moller et al., 2003 [17] Level Ib CABG with CPB (15) Platelets after OPCAB are more easily activated in the early
vs. OPCAB (15) postoperative period. After CABG with CPB there is a temporary
platelet dysfunction that improves within the first postoperative
day
Jemielity et al., 2003 [18] Level Ib CABG with CPB (25) Peak IL-6 level significantly lower after OPCAB; CRP higher after
vs. OPCAB (25) CABG; AGP rise comparable
Okubo et al., 2003 [19] Level 1b CABG with CPB (10) Postoperative expression of m-RNA for IL-1, -8, and -10,
vs. OPCAB (10) TNF-alpha, HO-1, PECAM, and Mac-1 increased significantly in
the on-pump group but not in the off-pump group (p < 0.05)
Wildhirt et al., 2001 [20] Level Ib CABG with CPB (13) Significant reduction in systemic and cardiac adhesion molecular
vs. OPCAB (13) expression after OPCAB
Schulze et al., 2000 [21] Level Ib CABG with CPB (13) Significant increase in the TNF system and sIL-2r in CABG; no
vs. OPCAB (13) difference in IL-6 levels; CRP and total nitrate/nitrite levels
significantly lower in OPCAB
Wildhirt et al., 2000 [22] Level Ib CABG with CPB (13) OPCAB reduces myocardial cell damage and lipid peroxidation
vs. OPCAB (13) and is also associated with a reduced activation of endothelin
Gulielmos et al., 2000 [23] Level 1b CABG with CPB (20)c The use of CPB was associated with higher levels of troponin-T
vs. OPCAB (20) and CK- MB as signs of myocardial damage. Surgical access was
identified as a trigger of inflammatory response, as minithoraco-
tomy was related to higher levels of IL-6
Czerny et al., 2000 [24] Level Ib CABG with CPB (16) Significantly lower IL-10, P-selectin, ICAM-1, myoglobin,
vs. OPCAB (14) CK-MB, and troponin I release after OPCAB
Ascione et al., 2000 [25] Level Ib CABG with CPB (30) Neutrophil elastase (p < 0.0001), IL-8 levels (p = 0.01), WBC
vs. OPCAB (30) counts (p < 0.01) and incidence of postoperative infection
(p < 0.0001) higher in CABG
(continued)
234 S.G. Raja

Table 27.3 (continued)

Intervention
Study Level of evidence (n per group) Main result
Diegeler et al., 2000d [26] Level Ib Full sternotomy CABG A significant increased release of C3d, C5a, IL-8 IL-10, TNF-a
with CPB (10), full receptors p55 and p75 after CABG
sternotomy OPCAB
(10), limited LAT
OPCAB (10)
Matata et al., 2000 [27] Level Ib CABG with CPB (10) Significant increase in lipid H2O2 (190 % at 4 h), protein carbonyls
vs. OPCAB (10) (250 % at 0.5 h), and nitrotyrosine (510 % at 0.5 h), IL-8, elastase,
C3a and sE-selectin in CABG
Gu et al., 1998 [28] Level Ib CABG with CPB (31) Leukocyte elastase, platelet beta- thromboglobulin, and C3a levels
vs. MIDCAB (31) significantly increased in CABG
CABG coronary artery bypass grafting, CPB cardiopulmonary bypass, OPCAB off-pump coronary artery bypass surgery, HSP70 heat shock protein
70, IL interleukin, VCAM-1 vascular cell adhesion molecule-1, ICAM-1 intercellular adhesion molecule-1, TNF tumor necrosis factor, CRP C reac-
tive protein, AGP acid glycoprotein, CK-MB creatine kinase-MB, LAT left anterior thoracotomy, MIDCAB minimally invasive direct coronary artery
bypass, SVR systemic vascular resistance, HO-1 heme oxygenase-1, PECAM platelet endothelial cellular adhesion molecule, ET endothelin
a
CABG on-pump with cardioplegic arrest = 12, CABG on-pump beating heart = 13
b
CABG with pulsatile cardiopulmonary bypass = 20, CABG with linear cardiopulmonary bypass
c
Four surgical techniques were compared: group 1, median sternotomy with CPB in ten patients (eight male, two female; aged 59.6 ± 11.0 years
(mean ± SD); group 2, median sternotomy and off-pump in ten patients (seven male, three female; aged 65.1 ± 10.0 years); group 3, minithoraco-
tomy with CPB in ten patients (seven male, three female, aged 61.2 ± 10.4 years); group 4, minithoracotomy and off-pump in ten patients (nine
male, one female, aged 62.9 ± 9.8 years). All patients received a left internal mammary artery graft to the left anterior descending artery (LAD)
d
The type of operative approach did not influence this immune response

plement activation but is less effective in attenuating coagu- [39]. Furthermore, the use of HBCs in clinical practice
lation or fibrinolysis [33, 34]. The Carmeda Bioactive Surface appears to vary among different centers and countries [40]
system (Medtronic, Inc., Minneapolis, MN) uses end- with little up-to-date data available at present.
attached, covalently bonded heparin that has been fragmented
by treatment with nitric acid. The Carmeda circuit seems
superior to the Duraflo II in reducing complement and neu- Hemofiltration
trophil activation and endothelin-1 concentrations [35, 36].
A significant amount of work has been performed to eval- Hemofiltration is a process that uses ultrafiltration (convec-
uate any potential benefit in using heparin-bonded circuits tion or osmosis under a hydrostatic pressure gradient) to
(HBCs), but controversy remains. HBCs have been shown remove fluid and low-molecular-weight substances from
to reduce transfusion requirements, lung injury, neurocogni- plasma. Initially introduced to treat patients with renal fail-
tive dysfunction, and markers of occult myocardial damage ure and to correct accumulation of extravascular water fol-
in patients undergoing CPB [32]. A large multicenter ran- lowing CPB, hemofiltration appears to exert beneficial
domized trial investigating HBCs for high-risk patients antiinflammatory effects, particularly in pediatric patients
undergoing CPB showed reduced hospital length of stay (Table 27.4) [41–48].
(LOS) and intensive care unit (ICU) LOS and reduced renal The hemodilution associated with CPB is most marked
and pulmonary postoperative dysfunction [33]. However, in the pediatric population, and, as a result, modified ultra-
other studies have reported no difference between HBCs and filtration (MUF) has been studied more extensively and with
standard circuits when investigating a range of differing out- more definitive outcomes within this population. Several
comes [37, 38]. pediatric studies have suggested that MUF may effectively
A meta-analysis of 41 randomized trials including 3,434 remove some of the inflammatory mediators released during
patients found significant reductions in the duration of venti- CPB, including complement, TNF-a, IL-6, IL-1, IL-8, and
lation, the incidence of postoperative transfusion, resterno- myeloperoxidase [41–48]. However, these findings have not
tomy rates, ICU LOS, and hospital LOS [39]. This always been replicated [49]. Clinical benefits also have been
meta-analysis failed to show effect of HBCs on other adverse reported, including increased hematocrit, improved cardio-
events evaluated. However, many of these positive effects vascular performance, and reduced postoperative chest tube
were marginal and of moderate clinical significance. drainage [41].
Currently, the majority of trials performed in this area MUF is used less frequently in adult CPB patients, and
have been relatively underpowered to adequately explore key any potential benefits remain controversial. There are a num-
clinically relevant outcomes, have involved heterogeneous ber of randomized controlled trials and case control studies
patient groups, and have studied a number of different HBCs that have reported positive clinical outcomes for adult
27 Modulation of Inflammatory Response in Cardiopulmonary Bypass 235

Table 27.4 Impact of modified ultrafiltration on systemic inflammatory response

No. of patients
Author Study type (level of evidence) MUF Control Key result
Hiramatsu et al. [42] RCT (level 1b) 11a 11b Significant increase in ET-1 levels in the control
group
Chew et al. [43] RCTc (level 1b) 10 8 No intergroup differences detectable for TNF-a,
IL-1b, IL-1ra, C3d, and C4d
Pearl et al. [44] Non-RCT (level 3) 22 12 MUF does not appear to have a significant effect on
post-CPB levels of TXB2, ET-1, and LTB4
Portela et al. [45] Single group (level 3) 22d – Significant decrease in levels of IL-6, ICAM-1, and
VCAM-1 after MUF
Wang et al. [46] RCT (level 1b) 20 20 Significant decrease in IL-8 and ET levels and no
change in TNF-a levels after MUF
Journois et al. [47] RCT (level 1b) 10 10 Significant decrease in TNF-a, IL-8, IL-1, IL-6,
myeloper-oxidase, and C3a after MUF
Journois et al. [48] RCT (level 1b) 16 16 Significant decrease in TNF-a, C3a, C5a, and IL-6
after MUF
RCT randomized controlled trial, MUF modified ultrafiltration, ET-1 endothelin-1, IL-8 interleukin-8, TNF-a tumor necrosis factor-alpha, CPB
cardiopulmonary bypass, TXB2 thromboxane B2, LTB4 leukotriene B4, IL-6 interleukin-6, ICAM-1 intercellular adhesion molecule-1, VCAM-1
vascular cell adhesion molecule-1, IL-1ra interleukin-1ra, C3d & C4d complement split products
a
Combined dilutional and modified ultrafiltration group
b
Control group had conventional ultrafiltration
c
Methylprednisolone added to pump prime
d
Combined conventional and modified ultrafiltration done

patients [32]. It is noteworthy that there is a significant varia- Leukocyte Depletion

tion in the techniques used to perform UF and that the tech-
nique has been studied in a variety of patient subgroups, Leukocytes play a central role in the inflammatory response
including CABG surgery patients, high-risk patients, and to cardiac surgery. Leukocyte depletion during cardiac sur-
patients on chronic renal dialysis [32]. UF does appear to gery, by means of leukocyte-specific filters, decreases circu-
improve post-CPB hematocrit and in some instances postop- lating leukocyte and platelet concentrations and attenuates
erative transfusion requirements [32]. Luciani et al. [50] have indices of inflammation and oxidative stress [54–58]. There
performed the largest randomized controlled trial in adults is increasing evidence that leukocyte depletion may limit
and showed a significant reduction in hospital morbidity and pulmonary and myocardial injury following CPB. Benefits
a statistically nonsignificant fall in mortality. The reduction appear to be the most consistent in patients with risk factors
of proinflammatory cytokines and adhesion molecules by such as left ventricular dysfunction, urgent surgery, or long
UF during or after CPB has been shown in adults, but has not CPB time. Leukocyte depletion has been shown to improve
always been associated with clinical advantage in terms of postoperative respiratory function in CPB patients, particu-
postoperative complications or LOS [51]. Finally, a recent larly in those with a low preoperative oxygenation capacity
meta-analysis of randomized trials investigated the effect of or long CPB time [56, 57]. In addition, leukocyte depletion
UF on perioperative coagulopathy in adult cardiac surgery of the residual heart-lung machine blood, which contains
and found that UF does appear to reduce postoperative hem- large quantities of activated leukocytes, prior to re-transfu-
orrhage and transfusion requirements, although the extent of sion improved lung function in patients undergoing elective
these reductions was of arguable clinical benefit according to CABG [54]. Leukocyte depletion during CPB, combined
the authors [52]. with leukocyte depletion of transfused blood, decreased indi-
In both patient groups, uncertainty does remain concern- ces of myocardial cell injury in patients undergoing urgent
ing both the type and combination of UF strategies [32]. CABG for unstable angina [58]. Conversely, in low-risk
Work is ongoing to clarify this and the overall risk/benefit to patients, depletion of activated neutrophils during CPB did
the patient because not only do some benefits appear not confer a clinical benefit [59]. Limiting leukocyte deple-
transitory, but also UF is not without risk; increased plasma tion to the reperfusion phase of CPB (following aortic dec-
heparin concentrations, entrainment of air through the aortic lamping) did not appear to provide any clinical benefit to
cannula, an increase in the duration of exposure of the CABG patients [60]. Leukocyte depletion of blood car-
patient’s blood to nonendothelialized surfaces, hemody- dioplegia alone attenuated myocardial cell injury and
namic instability, and human or equipment error all can improved early myocardial function in patients with left ven-
occur [32, 53]. tricular dysfunction undergoing CABG with CPB [61, 62].
236 S.G. Raja

Leukocyte depletion of terminal blood cardioplegia (blood benefits are best described as modest [69]. It can be said that
cardioplegia administered for 10 min immediately prior to although there is a significant level of evidence to suggest
aortic declamping as an adjunct to crystalloid cardioplegia) that hyperthermia must be avoided in patients on CPB [70],
decreased myocardial injury and improved cardiac function there is currently not enough evidence to clearly identify the
in patients with left ventricular hypertrophy undergoing optimal temperature at which CPB should be conducted.
valve surgery [63].
Despite the aforementioned benefits, currently, there is
not enough high-quality or consistent evidence to advocate Pharmacologic Strategies
the routine use of leukofiltration as an anti-inflammatory
strategy within routine CPB. Corticosteroids

Corticosteroid pretreatment may blunt the inflammatory

Centrifugal Pumps response in humans by several distinct mechanisms.
Administration of glucocorticoids prior to CPB may attenu-
Under physiologic conditions, blood flow occurs in a pulsa- ate endotoxin release and complement activation [71, 72].
tile manner, but during CPB this situation changes, a varia- Methylprednisolone lowers post-CPB concentrations of the
tion that may worsen the inflammatory response [1, 32]. proinflammatory cytokines TNF-a, IL-6, and IL-8 and
A large number of studies have thus been conducted to inves- increases concentrations of the antiinflammatory cytokines
tigate any possible benefits in using centrifugal pumps, origi- IL-10 and IL-1ra, but not IL-4 [73]. Corticosteroids also
nally developed for prolonged postoperative cardiac assist attenuate post-CPB leukocyte activation, neutrophil adhe-
and for extracorporeal membrane oxygenation [32]. sion molecule upregulation, and pulmonary neutrophil
Centrifugal pumps have been reported to reduce platelet sequestration [2, 74]. Pre-bypass administration of methyl-
aggregation (and thus lower susceptibility to postoperative prednisolone in aprotinin-treated patients improves early
thrombotic phenomena) [64], decrease the incidence of neu- postoperative indices of pulmonary, cardiovascular, hemo-
rologic and renal complications [65], decrease chest tube static, and renal function [75]. Glucocorticoid pretreatment
drainage, and reduce transfusion requirements [66]. However, may improve cardiac performance and reduce evidence of
other randomized controlled trials comparing the two pump bronchial inflammation following CPB [76]. Low-dose
types have failed to show improvements in blood transfusion methylprednisolone in the pump prime solution appears to
rates, postoperative cardiac performance, duration of postop- attenuate myocardial cell damage [77]. However, the ability
erative mechanical ventilation, ICU LOS, hospital LOS, and of corticosteroid pretreatment to attenuate post-CPB pulmo-
mortality [64]. More importantly, the impact of centrifugal nary inflammation, endotoxemia, and complement activation
pumps on inflammation is an underexplored area, and there is disputed [2, 78]. The clinical implications of corticoster-
is a paucity of evidence to validate their universal usage as a oid use are not yet fully elucidated, and clear benefit is not
strategy to reduce SIRS. yet demonstrated. The dosage, formulation, and timing of
administration of corticosteroids may be critical, and differ-
ences in dosage regimens may explain conflicting results.
Cardiopulmonary Bypass Temperature Preoperative combined with pre-bypass administration may
be superior to pre-bypass administration alone [79]. It is pre-
The optimal temperature at which to conduct CPB remains a mature to advocate the use of corticosteroids in the absence
controversial area. The controversy is further compounded of proven outcome benefit, determination of optimal dosage
by the varying definitions of “normothermia” used by differ- regimens, and characterization of the harmful effects that
ent investigators. Some groups refer to a temperature of may result from their use [2].
33–34 °C as normothermia, while others regard 36–37 °C as The Cochrane review regarding the use of prophylactic
physiologic normothermia [32]. Significant reductions in the steroids in pediatric patients undergoing CPB reported that
levels of inflammatory mediators (e.g., p-selectin, IL-1, IL-8, the existing evidence did not support this practice in this
and elastase) have been shown when comparing hypother- patient group [80]. Similarly, the Cochrane review for this
mic patients (28–30 °C) with patients at 34 °C [67]. However, practice in adults showed no beneficial effect of corticoster-
although hypothermia appears to delay this reaction, it does oid use on mortality or cardiac and pulmonary complications
not prevent it entirely, and other groups looking at similar in cardiac surgery patients [81].
molecular markers have found no difference among three Finally, recent expert guidelines on CABG surgery from
differing temperatures [68]. The clinical outcome data are no the American Heart Association and the American College
more convincing. Some studies suggest that moderate hypo- of Cardiology state “corticosteroid administration is inex-
thermia (32 °C) may reduce neuropsychologic injury, but pensive and appears to reduce the risk of the systemic
27 Modulation of Inflammatory Response in Cardiopulmonary Bypass 237

inflammatory response associated with CPB with little down- of massive postoperative bleeding and need for postsurgical
side risk. Current understanding supports liberal prophylac- administration of blood products [92]. Despite this, patients
tic use in patients undergoing extracorporeal circulation” who received aprotinin had an increased risk of 30-day mor-
[82]. Hence, at present, evidence for the efficacy and safety tality of more than 50 % (relative risk, 1.53; 95 % confidence
of corticosteroids is controversial. interval, 1.06–2.22), an outcome that led trial investigators to
conclude that aprotinin should no longer be used in patients
undergoing high-risk cardiac surgery [92]. Whether aprotinin
Serine Protease Inhibitors (Aprotinin) now has a role in cardiac surgery appears doubtful; the con-
ventional wisdom had always been that it was for patients at
Many effector proteins of the cytokine, complement, and a high risk of bleeding who had the most to gain from aproti-
hemostatic cascades are serine proteases; when activated, they nin, but it was precisely this cohort whom BART was set up
catalyze the next step in the cascade by hydrolyzing and acti- to investigate, and the study subsequently provided convinc-
vating further proteins, a process termed “cascade amplification”. ing evidence of the superiority of lysine analogs in this role.
Control processes that limit inflammation to the sites of injury What is clear is that many lessons can be learned from the
and reduce systemic inflammation include serine protease “aprotinin story” regarding the assessment of new pharma-
inhibitors. Aprotinin is the best known and most studied of ceuticals as they enter clinical practice [32, 93].
these inhibitors [2]. Aprotinin, a nonspecific serine protease
inhibitor isolated from bovine lung tissue, was first used clini-
cally in the 1960s to treat acute pancreatitis [83]. Knowing that Antioxidants
it inhibited kallikrein, one of the key components of the contact
system, led in the 1980s to it being tested as a potential A key part of the cellular damage witnessed during the isch-
antiinflammatory agent in CPB. However, the key findings of emia-reperfusion (I/R) injury that occurs during CPB is attrib-
initial studies were that it significantly decreased the periopera- utable to the reactive oxygen species (ROS, also known as
tive hemorrhage associated with cardiac surgery [84]. These oxygen-free radicals) released by activated neutrophils. This is
findings led to the widespread adoption of aprotinin to reduce compounded by CPB depleting the endogenous ROS scaven-
postoperative bleeding in cardiac surgery. gers, such as vitamins E and C. Experimental animal studies
Subsequent studies confirmed that aprotinin possesses have investigated the efficacy of exogenous antioxidants, such
important antiinflammatory properties. It inhibits trypsin, as mannitol, allopurinol, and N-acetyl cysteine, in preventing
chymotrypsin, plasmin, kallikrein, elastase, and thrombin or attenuating ROS-mediated damage [2, 32]. Encouraging
[85]. By inhibiting kallikrein and plasmin, it reduces the lev- results were seen using superoxide dismutase and catalase,
els of contact activation and limits fibrinolysis. It prevents both oxygen free radical scavengers, to reperfuse heart trans-
proteolysis of the major thrombin receptor on platelets (pro- plants in a rat model [94]. Reperfusion of human myocardium
tease activated receptor 1) [86], inhibiting platelet activation with blood cardioplegic solution instead of with crystalloid
and suggesting simultaneous pro- and antithrombotic effects. may reduce I/R injury because of the endogenous ROS scav-
Aprotinin reduces complement activation; the levels of cir- engers present in erythrocytes [95]. Improved myocardial
culating proinflammatory cytokines such as Il-6, IL-8, and function and reduced perioperative morbidity have been found
TNF-a; and expression of leukocyte adhesion molecules in patients undergoing CABG surgery who were administered
(MAC-1) [87]. Aprotinin has been shown to reduce markers preoperative oral vitamin E, a lipid-soluble chain-breaking
of myocardial injury (troponin T, CK-MB, and lactate dehy- antioxidant, both in isolation [96] and in combination with
drogenase) in patients undergoing CABG surgery [88], and a vitamin C and allopurinol [97]. Despite some of these promis-
meta-analysis suggested a decrease in all-cause mortality of ing results, most human studies have not shown any significant
almost twofold [89]. benefits, and, thus, antioxidant therapy cannot be recom-
Despite the aforementioned benefits, aprotinin is no longer mended as a regular therapeutic option.
available for routine use. This restriction came into force fol-
lowing publication of the results of the studies by Mangano
et al. [90], Karkouti et al. [91], and more importantly Complement Inhibitors
the Canadian BART (Blood Conservation using
Antifibrinolytics) trial, which compared aprotinin to two Therapies that utilize endogenous soluble complement inhib-
lysine analogs (tranexamic acid and aminocaproic acid) in itors may be a suitable approach to reducing contact activa-
high-risk patients undergoing cardiac surgery [92]. The high- tion and thereby controlling the inflammatory response.
quality BART trial reported in late May 2008 and provided A two-stage randomized clinical trial of a monoclonal anti-
modest evidence that aprotinin was the more effective hemo- body specific for human C5 demonstrated its efficacy and
static agent because patients who received it had a reduced risk safety in patients undergoing CPB [98]. The generation of
238 S.G. Raja

activated complement mediators and leukocyte adhesion clinical trials. Traditional NSAIDs, such as indomethacin,
molecule formation was inhibited in a dose-dependent man- inhibit both the constitutive cyclooxygenase 1 (COX-1) as
ner. Furthermore, C5 inhibition resulted in a dose-dependent well as COX-2, the inducible isoform activated by
reduction in myocardial injury, postoperative cognitive inflammatory stimuli [32]. Nonspecific COX inhibition
deficits, and coagulation dysfunction. These data suggest attenuates the increase in pulmonary vascular resistance and
that C5 inhibition may represent a promising therapeutic acute lung injury and reverses pulmonary microvascular
modality for preventing complement-mediated inflammation dysfunction in CPB models [106]. The only published clini-
and tissue injury in patients undergoing CPB [98]. Compstatin, cal study of indomethacin demonstrated that it decreased
a recently discovered peptide inhibitor of complement, may the duration of postoperative fever, chest pain, malaise, and
have the potential to prevent complement activation during myalgias following CPB [107]. However, inhibition of
and after cardiac surgery. In preliminary primate studies, COX-1 appears to increase free-radical-generated isopros-
compstatin completely inhibited in vivo heparin-protamine- tane formation, which aggravates postischemic myocardial
induced complement activation, without adverse effects [99]. dysfunction [108].
Other promising strategies include the C1 inhibitor, recombi- Specific COX-2 inhibitors exhibit considerable potential
nant soluble inhibitor-1, monoclonal antibodies to C3 and to attenuate the inflammatory response following cardiac
C5a, and strategies that attenuate complement receptor surgery. COX-2 has been implicated in the pathogenesis of
3-mediated adhesion of inflammatory cells to the vascular adverse events after cardiac surgery [109]. COX-2 is upregu-
endothelium. Utilization of membrane-bound complement lated in multiple tissues following CPB, including the brain,
regulators may also be feasible by means of transfection while COX-2 products, particularly thromboxanes and vaso-
techniques [100]. Although not enough data currently exist constrictor prostaglandins, are increased [107, 110]. COX-2
to recommend routine incorporation into clinical practice, it upregulation following experimental CPB may contribute to
would seem complement inhibitors have significant potential postoperative coronary vasospasm and increased pulmonary
to play a future role [2]. vascular resistance [111]. In addition, myocardial COX-2 is
upregulated during cardiac allograft rejection and myocar-
dial infarction and contributes to endotoxin-induced myocar-
Phosphodiesterase Inhibitors dial depression [112]. Inhibition of COX-2 attenuates the
myocardial inflammatory response during cardiac allograft
Phosphodiesterase inhibitors increase intracellular cyclic rejection, reduces endothelial dysfunction following myo-
adenosine monophosphate levels, thereby increasing myo- cardial ischemia and reperfusion, and improves cardiac func-
cardial inotropy and lowering systemic vascular resistance tion in experimental myocardial infarction [112, 113]. In
by causing peripheral vasodilatation. They also have been addition, COX-2 inhibition decreases endotoxin-induced
shown to exert an antiinflammatory effect, possibly through myocardial depression and lung ischemia and reperfusion
the same mechanism [2]. Immune cells contain type IV and injury [114]. However, the clinical efficacy of specific COX-2
type III phosphodiesterase, and phosphodiesterase inhibitors inhibitors in attenuating the inflammatory response to car-
appear to directly limit inflammatory activation and organ diac surgery remains to be determined.
dysfunction in sepsis models [101]. Milrinone attenuates the
reduction in gastric intramucosal pH, reduces both venous
and hepatic endotoxin concentrations, and may decrease Strategies to Reduce Endotoxemia
postoperative IL-6 concentrations in healthy patients under-
going cardiac surgery, although this has been disputed [102, Antimediator and Antiendotoxin Therapies
103]. Dopexamine attenuates the postoperative increase in
IL-6 concentrations and reduces gastrointestinal permeabil- Direct antimediator therapies that focus on the endotoxin
ity, but does not improve splanchnic perfusion (as measured molecule itself and the proinflammatory cytokine cascade
by intramucosal pH) or decrease plasma endotoxin concen- following CPB offer new approaches. A recently published
trations following CPB [104, 105]. small randomized controlled trial of IgM-enriched intrave-
nous immunoglobulin preparation showed it to be effective
when used prophylactically in patients undergoing proce-
Cyclooxygenase Inhibitors dures with CPB [115]. However, the complex pathway
observed in patients with SIRS does not appear to respond
Aspirin, the prototype nonsteroidal antiinflammatory drug readily to antimediator therapy. Multicenter clinical trials
(NSAID), is widely used in cardiac surgical patients for the blocking endotoxin and proinflammatory mediators such as
purposes of pain relief and antiplatelet activity. However, IL-1 or TNF-a conducted in SIRS patients have shown no
the potential for NSAIDs to attenuate the inflammatory benefit in reducing mortality secondary to sepsis [116].
response to cardiac surgery has not been widely evaluated in Reasons for the relative failure of immunomodulatory
27 Modulation of Inflammatory Response in Cardiopulmonary Bypass 239

therapies to date may include the timing of intervention, the [124]. The use of glutamine supplementation may improve
heterogeneous nature of the inflammatory response, and the the survival of patients with organ failure who require par-
reciprocating and redundant nature of the proinflammatory enteral nutrition [125]. There is no information available
cascades. High circulating concentrations of antiinflammatory concerning the effect of nutritional support in patients
mediators, such as the cytokine antagonists IL-1ra, TNFsr1, undergoing cardiac surgery who have a complicated postop-
and TNFsr2, may also limit the efficacy of therapies that aim erative course.
to augment natural defenses against endotoxin or the
proinflammatory cytokines [117].
Conclusion
The therapeutic potential of strategies to control the sys-
Selective Digestive Decontamination temic inflammatory response after cardiac surgery is clear.
However, the optimal therapeutic strategy (or strategies),
Selective digestive decontamination (SDD) is a technique to as well as the optimal target subgroup of cardiac surgical
reduce the gut content of enterobacteria. This is achieved by patients, remains to be fully elucidated. Our goal must be
preoperative administration of oral nonabsorbable antibiotics to attenuate the deleterious effects of the systemic
such as polymyxin E, tobramycin, and amphotericin B and inflammatory response while preserving the ability of the
has been demonstrated to reduce plasma concentrations of patient to mount an appropriate defense to the physiologic
endotoxin, TNF-a, and IL-6 in patients undergoing CPB trespasses of the perioperative period. Modulation of the
[118]. A recent meta-analysis of SDD suggests that it reduces stress response, rather than simple inhibition, is likely to
rates of postoperative infection, but not mortality, in patients confer substantial benefit. Furthermore, therapeutic strat-
undergoing cardiac surgery [119]. Since mortality reduction egies should be focused on the subset of cardiac surgical
with SDD in critically ill patients appears to be related to patients most likely to suffer deleterious consequences
baseline mortality risk, trials of SDD in cardiac surgery thus and hence most likely to experience benefit. This sub-
far contain too many low-risk patients, resulting in inadequate group of high-risk patients is increasingly well character-
study power. In high-risk cardiac surgical patients, SDD may ized. Large-scale clinical trials of the more promising
prove worthwhile, but since its use raises both practical issues therapeutic strategies, restricted to the patient group at
(notably the logistics of performing it) and theoretical con- significant risk of perioperative morbidity, are urgently
cerns (changes in bacterial flora, emergence of resistance), its needed. Finally, many of these interventions have been
adoption is unlikely pending further studies [119]. studied in isolation, and it may be that, to be truly effec-
tive, methods of combining both pharmacologic and
mechanical strategies are required to inhibit the differing
Enteral Nutrition and Immunonutrition pathways by which the inflammatory response is trig-
gered and propagated.
Hypoalbuminemia and low body mass index independently
predict increased morbidity and mortality after cardiac
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 The Systemic Inflammatory Response
Syndrome Following Cardiopulmonary 28
Bypass in Children

Harald L. Lindberg and Tom N. Hoel

To a large extent, reducing the effects of the surgical trauma activation and diffuse endothelial dysfunction. Inflammatory
itself is not possible. However, delicate tissue handling and a mediators, including tumor necrosis factor alpha (TNF)-α
short operative time may reduce this factor and should be and interleukin one (IL)-1, bind to specific receptors on the
striven for, but not at the cost of the patient’s safety or the endothelium, initiating diverse signal transduction pathways,
quality of operative repair. which in turn activate a specific set of genes within the
The effects of the cardiopulmonary bypass and blood nucleus of the endothelial cell, termed activation genes.
exposure to a foreign surface can be modified by trying to Sheppard et al. [1] showed that transcription factor nuclear
make the artificial surfaces as biocompatible as possible. factor B plays a pivotal role in the signal transduction pro-
This can be done in different ways by coating the surfaces. cess. This process results in the translation of proteins,
Also, modification of the secondary effects of the activation including adhesion molecules (e.g., E-selectin, intercellular
of signal substances, such as complement factors and cytok- adhesion molecule-1) and cytokines (e.g., IL-8) required for
ines, has been attempted with pharmacological agents. Other endothelial cell activation, a process that takes approximately
measures, such as leukocyte filtration and ultrafiltration, 4 h and peaks at 8–24 h, depending on the gene.
have been in use to attenuate the SIRS. Generally, the most The activated endothelial cell plays a major role in linking
effective method for brain protection is the use of hypo- the inflammatory and coagulation systems by expressing
thermia during cardiopulmonary bypass. This chapter dis- proteins central to the activation of coagulation and
cusses these factors in detail. inflammation [2, 3]. Endothelial cell adhesion molecule
expression mediates the interaction between the neutrophil
and the endothelial cell, resulting in neutrophil adhesion,
The Endothelium activation, and degranulation. This further damages the
endothelium, causing diffuse capillary leak and edema for-
The endothelium fulfills the definition of an organ because mation [2, 4]. Endothelial injury results in the expression of
of its physical size (5,000 m2 surface area) and its ability to tissue factor, augmented by IL-1 and TNF-α, which activates
synthesize and release a large number of physiologically the extrinsic pathway of coagulation as shown by Cicala and
active products. It is a dynamic participant in cellular and Cirino [3] and may result in disseminated intravascular coag-
organ function rather than a static barrier. It is intimately ulation [5]. In addition, protein C, a key inhibitory regulator
involved in a variety of physiologic and pathologic pro- of hemostasis, is antagonized in inflammatory states, most
cesses and has emerged as the central focus of many of the probably by TNF-α, further shifting the balance toward a
biologic events that affect the perioperative course of the procoagulant state [3].
patient. Vascular endothelium plays a central role in the pathogen-
The inflammatory response to cardiopulmonary bypass esis of microcirculatory derangement following CPB.
(CPB) is characterized by a state of widespread endothelial Endothelial regulation of local vascular tone is mediated via
a variety of endothelium-derived relaxing and contracting
factors such as nitric oxide (NO), prostacyclin, endothelium-
derived hyperpolarizing factor, endothelin, and thromboxane
H.L. Lindberg, MD, PhD (*) • T.N. Hoel, MD, PhD A2 [6]. The increase in pulmonary vascular resistance fol-
Department of Thoracic and Cardiovascular Surgery,
lowing CPB is attributed to reduced NO release from dys-
University of Oslo, Rikshospitalet University Hospital,
Oslo, Norway functional pulmonary endothelium and is reversed by NO
e-mail: hlindber@ous-hf.no supplementation [6].

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 245
DOI 10.1007/978-1-4471-4429-8_28, © Springer-Verlag London 2013
246 H.L. Lindberg and T.N. Hoel

Biocompatible Surfaces The Complement System and Inflammation

In order to attenuate the inflammatory response to CPB, tre- The complement system has the capability of initiating an
mendous efforts have been made to synthesize CPB surfaces inflammatory response whenever it comes into contact with
that the body would recognize as non-self as little possible. foreign surfaces. It is one of the body’s cascade systems that
Already in 1963, Gott et al. [7] described an attempt to inter- initiate an accurately tuned reaction, tightly controlled by
vene in the artificial surface-induced blood activation by coat- several membrane-bound and fluid-phase inhibitors. Almost
ing surfaces with heparin. Later studies showed that such a all mammalian cells express regulators of the complement
surface modification of the CPB circuit reduced the activation system to protect against an autologous attack on the self
of some of the cascade systems, both in vitro [8–10] and in vivo [18]. There is considerable cross talk between the cascade
[11, 12]. The role of heparin in reducing the inflammatory systems in the body sharing some common regulatory pro-
response is still controversial despite reports on a favorable teins [19]. Complement components C3a, C4a, and C5a
clinical outcome [13] and a reduced need for systemic antico- (anaphylotoxins) mediate many inflammatory effects, such
agulation [14]. In a meta-analysis of heparin-coated circuits, as chemotaxis for human neutrophils and mast cells, smooth
the authors concluded that heparin coating reduces postopera- muscle cell contraction, increased permeability of the ves-
tive bleeding as well as the need for reoperations [15]. sels, platelet aggregation and activation, and histamine
Different coatings are available for clinical use, both hep- release from mast cells. The complement system, a key fac-
arin-based coatings and non-heparin coatings: tor in acute and chronic inflammatory response, is capable of
The Carmeda bioactive surface (CBAS) is composed of a promoting a powerful inflammatory response when the
layer of polyethyleneimine onto which the end point is organism is exposed to “non-self” or “danger,” subsequently
attached and partially degraded heparin is covalently adjusting the response in proportion to the intensity of the
bound. stimuli and finally terminating the response when the normal
Duraflo II is based on an ionically bound heparin-benzalko- condition is restored.
nium-chloride complex, which enables a relatively firm
connection with the foreign substance. This coating is
somewhat unstable since approximately 10 % of the Cytokines
bound heparin leaks into the circulation [16].
The Trillium Bio-passive Surface is a water-soluble synthetic Cytokines are mainly produced by monocytes, macrophages,
polymer. The polymer is covalently bound to a primer and lymphocytes, and endothelial cells and can be either protec-
is composed of sulfate and sulfonate groups, polyethylene tive or damaging depending on the concentration of each
oxide chains (PEO), and heparin. The hydrophilic PEO cytokine, the receptor, the cell types they are acting on, and
chains are thought to decrease protein adsorption and cell the presence of other cytokines. Many of the cytokines are
adhesion. Sulfonation is intended to mimic the functional produced through stimulation of the transcription factor
groups responsible for heparin’s anticoagulant effect. The NF-kB [10]. The cytokines are produced locally, but in case
Trillium coating also incorporates small amounts of cova- of extensive stimulation there is a spillover to peripheral
lently bound heparin. blood, and they have potential harmful effects on organ func-
BioLine coating brings high molecular weight heparin onto tion [8] (partly through different cascades such as comple-
a base layer of immobilized polypeptides. This polypep- ment activation and the coagulation cascade) (Fig. 28.1).
tide adsorption can occur on hydrophilic as well as hydro- The cytokines interact in a complex network and exhibit pro-
phobic surfaces. or antiinflammatory properties or both. The most important
Phosphorylcholine inert surface (PHISIO) is a non-heparin cytokines in relation to cardiac surgery are the
coating. The idea is to produce a surface that largely mim- proinflammatory cytokines TNF-a, IL-6, and IL-8 and the
ics the main lipid head group component of the outer cell anti-inflammatory cytokines IL-10 and IL-1ra. They are
membrane. These neutral phospholipids do not activate mostly measured in blood samples or in bronchoalveolar
the clotting system and are therefore thought to be non- lavage (BAL) fluid.
thrombogenic [17].
Surface-modifying additive (SMA) is a non-heparin coating
based on a mixture of two copolymers added to the resin Proinflammatory Cytokines
polymer structure. During processing, these two amphip-
athic copolymers migrate and concentrate at the lumen TNF-a plays an important role for leukocyte-endothelium
surface, thus determining a mosaic structure with interaction and the release of oxygen radicals from adherent
alternating hydrophilic and hydrophobic groups. This polymorphonuclear neutrophils (PMNs) [20]. Reports on the
reduces fibrinogen adsorption and consequently platelet TNF-a response after CPB are conflicting. A significant
activation. increase in TNF-a was demonstrated after release of the aor-
28 The Systemic Inflammatory Response Syndrome Following Cardiopulmonary Bypass in Children 247

Fig. 28.1 Schematic illustration The complement cascade

of the complement system and
some of its inhibitors and Classical Alternative
pathway C4BP I pathway
activators. C complement, MBL
mannose-binding lactin, H and I Lectin H
C4b MASP1 pathway
factors H and I, inhibitors of C3 P
C1qrs C3b
formation in the fluid phase, DAF MASP2 MBL
C2a
decay accelerating factor (CD C1-INH Bb D
55), MCP membrane cofactor
protein, MASPI and MASP2 DAF MCP CR1
MBL-associated serine proteases,
CR1 complement receptor 1, C4a
C3b
C4RP C4 binding protein, C3a
C1-INH C1 inhibitor, CPN
CPN C5a
carboxypeptidase N, CD59 C5b
protectin, P properdin, TCC
terminal complement complex
(By courtesy of Tom Eirik
Mollnes) C6 C7 C8 C9
Vitronectin
CD59
C5b-9(m)
SC5b-9 TCC
Membrane
Clusterin Fluid phase

tic cross clamp and termination of CPB in some studies [21], inflammatory state measured as increased plasma levels of
while others reported no detectable TNF-a [22]. In a few elastase and the complement split products C3d/ C3 [28].
studies, TNF-a was detectable preoperatively but without
further changes in the TNF-a plasma concentration during or
after CPB. A similar inconsistency in TNF-a response was Anti-inflammatory Cytokines
found in pigs subjected to CPB [23]. Animal studies have
further revealed that administration of small amounts of IL-10 and IL-1 receptor antagonists (IL-1ra) seem to be the
TNF-a decrease myocardial performance, suggesting that most consistent antiinflammatory cytokines released during
even small TNF-a levels may also contribute to myocardial and after cardiac surgery with CPB, both in adults and chil-
dysfunction in humans. dren [28]. The antiinflammatory response is not caused by
IL-6 is a good predictor of clinical outcome [24] and is blood contact with the circuit because none of these cytok-
thought to be related to the extent of tissue injury. Normally, ines were detectable when blood was drawn through an iso-
IL-6 is undetectable in peripheral blood in healthy individuals, lated pediatric CPB circuit [29]. However, when the CPB is
but has been found preoperatively in some children with con- connected to an animal, the stress from the CPB procedure
genital heart disease [25]. In general, IL-6 plasma levels increase itself elicits an IL-10 response when compared to sham-
during and after surgery and CPB and are related to the duration operated animals [23].
of aortic clamp time [26]. It is still not clear whether it is the C-reactive protein (CRP) is an acute-phase protein with
CPB procedure, the surgery, or the combination that elicits the antiinflammatory properties as it downregulates PMN
IL-6 response as no differences were found between pediatric chemotaxis. Clinically, CRP is often used as an unspecific
patients subjected to surgery with or without CPB [27]. marker for infections, and its plasma concentration correlates
In children subjected to cardiac surgery during CPB, an to the extent of the surgical trauma. High CRP levels are
early IL-8 response has been detected with increasing unequivocally found in children after heart surgery during
concentration in the following hours. The plasma levels were CPB with a peak on the first to third postoperative day, and
related to the duration of ischemia/reperfusion and total the response is delayed compared with the IL-6 release [30].
bypass time [21]. It has been suggested that the stress of sternotomy is sufficient
The proinflammatory cytokine response in children under- to elicit a CRP response as piglets subjected to anesthesia
going cardiac surgery with CPB shows a large variation in and sternotomy show the same CRP response as piglets
the release pattern and plasma concentrations. This is in con- exposed to the CPB procedure [23].
trast to the proinflammatory response in adults, which is well In conclusion, the antiinflammatory response in pediatric
defined and temporary. It is still unknown whether the preop- cardiac patients shows a more clear release pattern compared
erative high cytokine levels in children are of clinical impor- to the proinflammatory counterpart. Evidence has emerged
tance, but neonates with clinical signs of capillary leak that the balance between the pro- and antiinflammatory
syndrome after heart surgery showed signs of a preoperative mediators is most important for the outcome of patients
248 H.L. Lindberg and T.N. Hoel

experiencing a systemic inflammatory response [19]. It is without supportive treatment, and a shorter stay in the
therefore irrelevant to follow changes in a single cytokine intensive care unit for dexamethasone-treated patients
concentration in the patient at present. In general, the cytokine (receiving 1 mg/kg) compared to nontreated patients. Another
response is characterized by great variability and interindi- study showed that two doses of 30 mg/kg MP before CPB
vidual differences. In uncomplicated cases, the systemic and before declamping of the aorta suppressed the produc-
response is temporary, balanced, and of a few days’ duration tion of IL-8 and 6 [38]. The authors also found a higher post-
in both pediatric and adult patients [31]. surgical cardiac index in the MP-treated group. In the Varan
study, the increase in IL-6 and 8 levels after surgery was not
significantly different in low- and high-dose MP groups. The
Steroid Pretreatment cumulative inotropic support required, the duration of
mechanical ventilation, the stay in intensive care unit, urine
Although steroids have been used for years to attenuate post- volume, blood loss, and peak core temperature were not
bypass inflammation, data to support this derive almost significantly different between the two groups. Several stud-
entirely from trials in adults with coronary artery disease. ies have demonstrated suppression of levels of interleukins.
Even in adults, steroid use for cardiac surgery is controver- Jorens et al. [39] showed that MP pretreatment of 30 mg/kg
sial, and data in children are inconclusive. failed to prevent IL-8-mediated pulmonary neutrophil
The actions of steroids are protean with both immediate infiltration after CPB, although an increase in serum IL-8
and delayed effects. The limitation of inflammatory capillary levels was less pronounced in MP-treated than in nonsteroid-
permeability by either by diminishing recruitment of acti- treated patients. Butler et al. [40] investigated the levels of
vated white blood cells to vascular beds or inhibiting prosta- cytokines during cardiopulmonary bypass and the effects of
cyclin production and induction of nitric oxide synthase has intraoperative MP at a dose of 10 mg/kg versus no steroids in
been shown [32, 33]. Also, steroids appear to increase the pediatric age group. Clinical and hemodynamic conse-
antiinflammatory and decrease proinflammatory cytokine quences were not mentioned. The IL-6 level was elevated
levels [34]. Corticosteroids upregulate the production of above baseline, peaking earlier in the nonsteroid group. Both
b-adrenergic receptors and decrease reuptake, thus increas- IL-6 and CRP levels at 24 h postoperatively were higher in
ing the availability of these receptors to respond to endoge- the nonsteroid group.
nous or exogenous catecholamines. The availability of Cardiopulmonary bypass has also been shown to play a
cytosolic calcium in myocardial and vascular smooth muscle role in the development of pulmonary dysfunction after
cells, augmenting contractility, may be increased by physio- open-heart surgery. Increased protein leakage as early as
logic doses of corticosteroids. 10 min after the onset of CPB in patients with clinical signs
Methylprednisolone is able to reliably (and beneficially) of capillary leak syndrome has also been demonstrated by
alter the balance of proinflammatory and antiinflammatory Seghaye et al. [41]. Corticosteroids in several doses have
mediators in the blood of patients subjected to CPB, indicat- been used with the hope of preventing pulmonary dysfunc-
ing that the drug decreases the SIRS associated with CPB. tion after CPB surgery. Varan et al. [35] did not observe any
Specific hemodynamic benefits (increased CI, decreased difference in oxygenation parameters for any patients in the
SVR) seem to be associated with use of the drug in this set- two groups, indicated by similar ratios of PaO2/FiO2 in the
ting, yet these alterations may increase the need for postop- early postoperative period.
erative IV hemodynamic agents (vasoconstrictors, etc.). They concluded that CPB surgery initiates an SIR and
Pulmonary compliance seems not to be influenced by ste- high-dose MP is not superior to low-dose MP in suppressing
roids. Increased P(A-a)O2 (perhaps by increasing pulmonary this reaction. In this study, a low-dose treatment with MP
shunt) and early postoperative tracheal extubation may be (2 mg/kg) is preferable to a high-dose treatment considering
hindered for undetermined reasons. Several studies have the possible side effects, although none were observed.
used different doses of MP and dexamethasone. There is no Children who received steroids prior to CPB had fewer febrile
general agreement on the type of preparation and dose of the episodes, improved respiratory gas exchange, and better renal
steroid. Most of the studies are concerned with adult patients. function, and they required less supplemental fluid postop-
Varan et al. [35] demonstrated that the increase in cytokine eratively than did controls. As a result, the group given dex-
levels and CRP was not significantly different between high amethasone required fewer days of mechanical ventilatory
and low doses. Niazi et al. [36] demonstrated an increase in support and was discharged from the ICU sooner.
the cardiac index during and after CPB in patients undergo- Gessler et al. [42] evaluated the effects of steroids on
ing coronary artery bypass surgery that received 30 mg/kg of SIRS by measuring, among other parameters, IL-8 and the
MP. In this study, after an initial increase in the cardiac index, total neutrophil count (TNC), as well as some clinical param-
it gradually decreased in the post-bypass period. Jansen et al. eters. In this study, administration of steroids did not show a
[37] reported normothermia, higher blood pressure levels significant impact on the clinical outcome and the degree of
28 The Systemic Inflammatory Response Syndrome Following Cardiopulmonary Bypass in Children 249

the inflammatory response following cardiac surgery. They ing CPB form conjugates both between themselves and with
concluded that the lack of suppression of the inflammatory leukocytes. P-selectin is expressed by activated platelets,
reaction may have been due to the dose and timing of steroid which contribute to leukocyte conjugate formation by bind-
administration, the lower inflammatory reaction in patients ing P-selectin glycoprotein. Activated platelets use this adhe-
with shorter time on CPB and less severe operative trauma, sion pathway to stimulate conjoined monocytes, thus leading
or an age older than 3 months at the time of surgery. to secretion of the proinflammatory cytokines IL-1b, IL-8,
Although not measuring the amount of SIRS, some publi- and MCP-1. P-selectin also induces tissue factor expression
cations have shown beneficial effects of steroid administra- and fibrin deposition by monocytes, thus contributing to the
tion by measuring other parameters. Checchia et al. [43] evolution of thrombus. Endothelial cells express the adhe-
showed in 2003 that steroids reduced the postoperative tro- sion molecule CD40 and activated platelets express the com-
ponin levels in a pediatric population, indicating better myo- plementary CD40 ligand on their surface. CD40 ligand is
cardial preservation. The Group from Toronto has shown structurally related to TNF-a and induces endothelium to
clinically improved outcomes after the use of steroids in a secrete chemokines and express further adhesion molecules.
study of high-risk pediatric cardiac surgery [44]. Substantial secretion of IL-8 and MCP-1 was noted on plate-
Additional well-designed (prospective, randomized, dou- lets binding to endothelium [51].
ble-blind, placebo-controlled) clinical investigations (with Assessment of platelet activation can be done my means
large numbers of patients and tightly controlled periopera- of flow cytometry and the analysis of granule proteins (such
tive management) involving corticosteroids and patients as b-TG) after degranulation. Thrombospondin, an extracel-
undergoing cardiac surgery with CPB need to be done. lular matrix protein, has also been investigated, but b-TG
Whether or not suppression of the SIRS associated with CPB seems superior to thrombospondin as a marker for platelet
with corticosteroids (or any other drug/technique) is clini- activation in vivo [52].
cally desirable and beneficial remains to be determined.

Temperature
Platelet Activation
Along with CPB came hypothermia, representing another
Platelets are known to be activated during CPB because of milestone in the history of open-heart surgery. Hypothermia
contact with the foreign surfaces of the extra-corporeal cir- was used as a tool for lowering the metabolic needs of
cuit and also because of numerous other factors, such as selected regional beds and/or the whole body. Although
hypothermia, shear forces, use of exogenous drugs, and hypothermia was introduced in the 1950s by Dr. Wilfred
release of endogenous chemicals [45]. Platelets are also acti- Gordon Bigelow, allowing open-heart operations to be per-
vated by surgical trauma where the surgical incision, via acti- formed in a bloodless field after interruption of blood flow, it
vation of tissue factor and subsequently factor VII and factor was not until the 1960s that hypothermia begun to be used in
X, may at least partly explain this process [46]. Activated conjunction with CPB, ushering in the era of modern-day
platelets express reorganized surface molecules, such as gly- open-heart surgery.
coprotein IIb/IIIa, which forms a fibrinogen-binding com- There are a number of proposed clinical applications of
plex. Simultaneously, there is a movement of cytoplasmic hypothermia, including traumatic brain injury. During car-
granules toward the cell surface. These granules fuse with diac surgery with cardiopulmonary bypass (CPB), deep
the cell membrane and extrude their contents. This is the hypothermia is used to protect immature organs from isch-
secretion method of platelet factor-4, b-TG, and von emia when surgery requires complete arrest of the systemic
Willebrand factor. At the same time, those molecules that circulation. CPB itself, because of the contact of blood with
previously were an integral part of the granule membrane, the large non-endothelial surfaces and air/blood interface,
such as P-selectin, now will be expressed on the surface of triggers the whole body inflammatory response. This often
the activated platelets [45]. Extracorporeal circuits are manu- leads to capillary leakage, edema, organ dysfunction, and
factured from synthetic materials, and there is a material- SIRS. This might explain why in this condition prolonged
derived platelet activation dependent on glycoprotein IIb/IIIa inflammation together with an acute systemic inflammatory
receptors [47]. P-selectin is upregulated by several mecha- response is one of the major correlates with the adverse clini-
nisms. One is through thrombin, which is redundant because cal outcomes associated with CPB and a major cause of post-
of formation during CPB [48]; another is through newly gen- operative morbidity [31, 53, 54]. Hypothermia has been
erated cytokines that stimulate platelets [49]. Both the pro- suggested to play a protective role in reducing the acute
thrombotic and the proinflammatory mechanisms occurring inflammation, but there are scant data demonstrating a
during CPB might be attributed to the release of soluble CD beneficial effect of hypothermic CPB [55]. Data focusing on
40 ligand (sCD40L) by platelets [50]. Platelets activated dur- cellular and molecular effects of hypothermia are limited.
250 H.L. Lindberg and T.N. Hoel

The inflammatory response that accompanies open-heart IL-10, which in turn upregulates SOCS-3 and finally attenu-
surgery is multifactorial, in both adults and children [56]. The ates TNF-a production. This antiinflammatory shift in the
mismatches between the foreign surfaces in the heart-lung cytokine balance is associated with liver protection.
machine and blood vessel surfaces are extreme in children. Hypothermia has become the subject of scientific and
Therefore, specially designed heart-lung machines with small clinical interest as growing evidence points to therapeutic
priming volumes and surfaces have been developed [57]. The effects not only during but also after an ischemic event.
surgical trauma, anesthesia, and deviation from normal organ A widely publicized study has shown improved survival and
perfusion are other important factors causing inflammatory neurologic recovery when hypothermia is instituted in
activation [58]. It has also been suggested that the degree of patients who remain comatose after resuscitation from car-
hypothermia may influence the inflammatory response dur- diac arrest [65]. Hypothermia also has been shown to be
ing CPB. Deep hypothermia and circulatory arrest have been effective in selected subsets of patients presenting with stroke
shown to trigger less-pronounced inflammatory response [66], head trauma [67], and myocardial infarction [68]. Thus,
than low-flow CPB in newborns, as assessed by measure- there is considerable interest in understanding the mecha-
ments of IL-6, IL-8, and C3a [59]. This phenomenon may be nisms by which hypothermia works and especially to deter-
the result of a shorter CPB time, but a protective effect of mine whether benefits may involve mechanisms other than
hypothermia per se may also be part of the explanation [60, reduction in metabolic activity. Recent studies have in fact
61]. However, in a randomized study [62], designed to further shown that hypothermia can activate cell- protecting path-
elucidate this issue, researchers did not find any significantly ways. For example, hypothermia can induce expression of
attenuated inflammatory response in the moderate hypo- heat shock protein 70 [69] and cause a shift in the inflammatory
thermia group. In fact, this group showed an enhanced IL-8 cascade during CPB, reducing proinflammatory mediators
response and an attenuated IL-10 response during CPB, and increasing the antiinflammatory cytokine IL-10 [70].
potentially suggesting an inflammatory net effect. A recent study by Stocker et al. [71] has addressed an
Diestel et al. [61] used endothelial cells as they play a piv- important and previously unresolved clinical question regard-
otal role during activation of the inflammatory cascade by ing the most appropriate temperature during pediatric CPB.
expression of cytokines. A special cell culture model was This study has shown that moderate hypothermia at 24 °C
used to exclusively study the effects of hypothermia and drug does not offer any advantages over mild hypothermia at
treatment on the inflammatory response of endothelial cells. 34 °C during pediatric CPB for repair of congenital heart
Using time-temperature settings analogous to clinical appli- disease in terms of the postoperative clinical course and
cation during CPB in children, they measured the concentra- severity of SIRS or markers of organ injury. Moreover, there
tions of IL-6, IL-8, and MCP-1. They concluded that was a tendency toward a shorter duration of mechanical ven-
hypothermia upregulated IL-6 and TNF-a and that tilation with mild hypothermia. The depth of hypothermia
MP-pretreatment attenuated this response. during CPB did not influence the risk of postoperative bleed-
Qing and colleagues [63] investigated the cell mecha- ing, blood product transfusion requirements, or infection. As
nisms by which hypothermia could ameliorate inflammation expected, there was a trend toward a shorter duration of CPB
using a pig model of CPB and sham cardiac operation. In in the mildly hypothermic group, although this was related to
half of the animals (n = 6), the core temperature was main- the shorter duration of the rewarming period.
tained at 28 °C during CPB and in the other half at 37 °C. When considering the biochemical and cellular manifes-
Measurements made in liver samples obtained before CPB tations of inflammation, CPB resulted in a marked acute
and 6 h after corroborated previous findings indicating that phase reaction in all children, but this was not influenced by
hypothermia increases intrahepatic concentrations of IL-10 temperature. In keeping with previous observations, CPB
while decreasing TNF-a. This effect was associated with less also resulted in activation of the receptor pathways and in
hepatic cell necrosis but without effects on apoptosis. They deactivation of circulating monocytes. No influence by the
further documented increased activation of the signal trans- temperature during CPB was noted. Of particular interest is
ducer and activator of the transcription (STAT)-3 pathway the fact that TNF-a was not influenced by CPB in either
and increased expression of the suppressor of cytokine sig- group. In this study, no difference in any clinical or biochem-
naling (SOCS)-3. These two signaling events are important ical markers of end-organ injury between the two study
because they have been associated with antiinflammatory groups was found. As would be expected, there was postop-
effects in settings other than hypothermia [64]. Activation of erative deterioration in lung and renal function, but again, the
STAT-3 is known to increase IL-10, and both IL-10 and acti- CPB temperature did not influence this. A transient microal-
vated STAT-3 can increase expression of SOCS-3 with sub- buminuria early after bypass indicated a significant capillary
sequent decreases in TNF-a. These data demonstrate that leak, although independent of bypass temperature.
moderate hypothermia during CPB is associated with activa- Chemokines such as IL-8 and MCP-1 are, respectively,
tion of the Jak/STAT pathway, leading to the expression of potent activators of neutrophils and monocytes [72]. Activation
28 The Systemic Inflammatory Response Syndrome Following Cardiopulmonary Bypass in Children 251

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 Vacuum-Assisted Venous Drainage
in Cardiac Surgery 29
Wakako Fukuda, Takeshi Goto, and Ikuo Fukuda

In 1937, the first heart-lung machine was built by John the venous line to generate negative pressure and consequently
Heysham Gibbon, who also performed the first human open- increase venous return. This technique has been shown to
heart operation [2]. Around 1954, the SigmaMotor pump, a guarantee adequate global tissue perfusion for use in mini-
multiple finger pump, was produced, and it became extremely mally invasive CPB procedures [6]. VAVD involves a constant
popular. The multiple finger pump or the roller pump was vacuum pressure onto an airtight venous reservoir, allowing
used for years in the cardiopulmonary bypass circuit for more blood to be drained from the patient via the venous line
venous drainage by surgeons and perfusionists. However, [6]. Murai et al. [7] suggested the indications for use of VAVD
because they were difficult to control, these were discarded were insufficient venous return by siphon drainage alone, per-
in favor of the more simple and effective gravity siphon sistent elevation of the central venous pressure and insufficient
method [3]. Gravity siphon drainage, which has been venous drainage in the operative field.
employed as the standard for venous return during CPB for
many years, is accomplished with a pressure gradient of
approximately 40 mmHg, attributable to the height differ- Advantages of Vacuum-Assisted Venous
ence between the patient and the venous reservoir [4]. Drainage
With the advent of minimally invasive cardiac surgery
and the progression of congenital heart surgery, there is a The Use of Smaller Cannulae and Shorter Tubing
desire to reduce the diameter of the venous cannula to
improve surgical access, decrease pump priming volumes, In several situations, such as minimally invasive surgery,
and enable cannulation of vessels remote from the heart [5]. repeat-cardiovascular operation, pediatric cardiac surgery,
Unfortunately, decreasing cannula diameter increases resis- and emergency cardiac resuscitation, peripheral venous can-
tance; thus, blood drainage is limited. Gravity siphon or pas- nulae are needed. Smaller venous cannulae facilitate venous
sive venous drainage may provide insufficient blood return cannulation.
for adequate tissue perfusion [6]. This drawback has led to Vacuum-assisted venous drainage (VAVD) does not rely
the development of assisted venous drainage (AVD), which on the height differential between the patient’s heart and the
can increase venous return to more acceptable levels of venous reservoir, unlike conventional gravity siphon venous
perfusion. drainage. It is possible to raise the height of the venous res-
AVD is generally divided into kinetic-assisted venous ervoir, shorten the venous and arterial lines, and decrease the
drainage (KAVD) and vacuum-assisted venous drainage tubing diameter. This allows remodeling of the pump con-
(VAVD) (Fig. 29.1). KAVD uses a centrifugal pump placed in sole and circuit. With smaller cannulae and shorter tubing,
VAVD could dramatically reduce priming volumes, maxi-
mally decrease tubing dead space, and lower patient hemodi-
W. Fukuda, MD • I. Fukuda, MD, PhD (*) lution [8]. VAVD is becoming especially advantageous in the
Department of Thoracic and Cardiovascular Surgery, neonate and pediatric populations for reducing circuit size
Hirosaki University Graduate School of Medicine, and thereby decreasing priming volume [3].
5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
Banbury et al. [9] reported that a VAVD resulted in a
e-mail: ikuofuku@cc.hirosaki-u.ac.jp
smaller CPB volume (1.4 ± 0.4 l with VAVD vs. 2.0 ± 0.4 l
T. Goto, ME
with gravity siphon, p < 0.0001) in valve operations.
Department of Clinical Engineering,
Hirosaki University School of Medicine and Hospital, In neonates and infants, with use of 3/16-in. venous and arte-
Aomori, Japan rial tubing, no arterial line filter, no prime in the venous line,

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 255
DOI 10.1007/978-1-4471-4429-8_29, © Springer-Verlag London 2013
256 W. Fukuda et al.

Fig. 29.1 Vacuum-assisted

venous drainage

Vacuum VAVD Pressure

sauce regulator monitor

Purge line

Moisture trap
Atmosphere
line

Positive pressure
relive valve

and the use of VAVD, the prime volume for a neonatal circuit Shin et al. [12] reported a case in which the huge right
reportedly is as low as 200 ml [10]. atrial malignant lymphoma was successfully resected using
Improved venous drainage reduces the fluid overload of VAVD without snaring the inferior vena cava. Fukuda et al.
patients. Less interstitial edema should result in better organ [13] described a case of re-tricuspid valve replacement with
function and faster recovery. Reduced flow through the right VAVD. CPB with VAVD established before median sterno-
atrium and less blood in the heart should reduce rewarming tomy facilitated surgery by decompressing the heart and
of the heart and contribute to improved myocardial protec- allowed safe reentry to the mediastinum [13]. Aklog et al.
tion [11]. It may ameliorate the inflammatory reaction caused [14] performed bicaval orthotopic heart transplantation in
by contact activation of neutrophils on the CPB circuit. ten patients using an open IVC anastomosis with VAVD, and
they have reported good results. They stated the visualization
during performance of IVC anastomosis was improved [14].
Provide an Unobstructed Surgical Field

VAVD can provide total cardiopulmonary support with Increases Venous Drainage and Eliminates
adequate cardiac decompression and reduce blood exposure the Risk of Air Blocks in the Venous Line
to the damaging effects of pump suction and basket suction
salvage. At the same time, VAVD can maintain higher arte- In VAVD, additional negative pressure in the venous line will
rial perfusion flow and higher blood levels in the venous augment venous blood return. An in vitro study conducted by
reservoir, resulting in a drier, “bloodless” surgical field while Fiorucci et al. [15] found that the VAVD can increase venous
also minimizing blood cell trauma [9]. drainage by as much as 50 %. Munster et al. [11] showed
29 Vacuum-Assisted Venous Drainage in Cardiac Surgery 257

positive relationships between vacuum pressure and venous perfusionist stops the vacuum when the arterial pump is no
drainage and between blood temperature and venous longer in use. Wilcox [19] suggests the development of novel
drainage. de-airing devices that can be incorporated safely into the per-
According to LaPietra et al. [16], negative pressure easily fusion circuit.
handled the macrobubbles and eliminated the risk of air
blocks in the venous line in the event that gross air entered
the venous line. VAVD permits the use of smaller caliber Overpressurization of the Sealed Venous
venous cannulae and allows the right heart chambers to be Reservoir Induces Blood Trauma
opened without the threat of venous air block.
During CPB, red blood cells are damaged mainly by shear
stresses, and this damage results in either immediate hemol-
Disadvantages and Pitfalls of VAVD ysis, with release of free hemoglobin, or a shortened red cell
life span with delayed hemolysis. This damage may poten-
Possibility of Transmission of Gaseous tially be increased by VAVD because of the negative pressure
Microemboli from the Venous Line to within the circuit and because of the turbulence generated at
the Arterial Side of the Circuit the tip of the smaller venous cannulae, especially when they
lie in the vena cava [21].
Cardiac surgery and the use of CPB are associated with dam- In in vitro and in vivo studies, investigators have reported
age to end organs [5]. Roach et al. [17], in the largest pro- that VAVD does not increase trauma to blood cells and hemo-
spective study on cerebral outcome after coronary artery lysis caused by VAVD is not a clinical problem [11, 12, 21].
bypass surgery, found that 6.1 % of the 2,108 patients devel- However, the safe range of VAVD is unknown [7].
oped serious neurological complications ranging from stroke
to seizures and to deterioration of intellectual function after
surgery. There is substantive evidence particularly with VAVD Makes the CPB Circuit More Complicated
regard to brain injury implicating emboli as a cause of organ
damage during CPB. Emboli may be gaseous, liquid, or par- VAVD equipment attaches to the venous reservoir and
ticulate, and they may originate in the circulation or be intro- changes an open system to a closed system. Using a closed
duced into the circulation [5]. system is different from using routine gravity venous drain-
VAVD is based on the application of a vacuum to a hard- age and requires additional training of perfusionists to
shell venous reservoir, and it facilitates the pull of air into the ensure functional understanding of the principles underly-
venous line from around the venous cannula. Gaseous micro- ing VAVD [8].
emboli (GME) that pass through the oxygenator and arterial
filter could enter the patient’s body and be responsible for
neurocognitive impairment after CPB [18]. Wilcox [19] have VAVD Reduces Pump Flow Rate
shown that VAVD can increase entrainment of venous air
with vacuum-assisted drainage and have raised safety issues When using higher negative pressure, VAVD reduces the
concerning the system. In their study, arterial line emboli pump flow rate. Fiorucci et al. [15] investigated the efficiency
increased eight- to tenfold after the introduction of air into of the VAVD and the VAVD + gravitational drainage in
the venous line of a salvaged clinical adult circuit. Wang increasing the venous return and quantified the relationship
et al. [18] demonstrated that, when a fixed volume air was between the negative pressure applied to the reservoir and
introduced into the venous line of a simulated neonatal CPB the resultant flow delivered by the pump. Their study showed
circuit, VAVD with higher negative pressures, increased flow that VAVD with a negative pressure >50 mmHg could reduce
rates, and pulsatile flow delivered more gaseous microem- the flow delivered by the roller pump. Increased negative
boli at the post-pump site. pressure at the inlet of the raceway tubing reduces its re-ex-
Carrier et al. [20] compared the incidence of neurological pansion, resulting in a net reduction in the stroke volume.
complications in patient who underwent valvular surgery
with and without VAVD added to standard CPB system, and
they concluded that the use of VAVD during CPB in patients VAVD May Lead to Serious Accidents
undergoing valve replacements does not increase the risk of
significant neurological injuries. Jegger et al. [6] analyzed There are reports on accidents. Davila et al. [22] reported
the vacuum pressure required to produce bubble transgres- a complication of VAVD by inadvertent positive pressuriza-
sion using an in vitro circuit successively including a closed tion of a venous circuit resulting in a paradoxic air embolus
reservoir, a pump (centrifugal or roller), and an oxygenator, across a patent arterial septal defect. Jahangiri et al. [23]
and they stated that VAVD is a safe technique as long as the reported a cerebrovascular accident after VAVD in a Fontan
258 W. Fukuda et al.

patient. Cautious use of VAVD and real-time monitoring of 10. Lake CL, Booker PD. Pediatric cardiac anesthesia. 4th ed.
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Applying VAVD allows for reduced circuit size and prime giant right atrial lymphoma using vacuum-assisted cardiopulmo-
volume. It also improves venous drainage and flow rates nary bypass without snaring the inferior vena cava. Ann Thorac
Cardiovasc Surg. 2004;10(4):249–51.
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assisted drainage. J Artif Organs. 2005;8:91–4. M, Von Segesser LK. Vacuum assisted venous drainage does not
8. Wang S, Üudar A. Vacuum-assisted venous drainage and gaseous increase trauma to blood cells. ASAIO J. 2001;47:651–4.
microemboli in cardiopulmonary bypass. J Extra Corpor Technol. 22. Davila RM, Rawles T, Mack MJ. Venoarterial air embolus: a com-
2008;40:249–56. plication of vacuum-assisted venous drainage. Ann Thorac Surg.
9. Banbury MK, White JA, Blackstone EH, Cosgrove DM. Vacuum- 2001;71:1369–71.
assisted venous return reduces blood usage. J Thorac Cardiovasc 23. Jahangiri M, Rayner A, Keogh B, Lincoln C. Cerebrovascular
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a cautionary tale. Ann Thorac Surg. 2001;72:1727–8.
 Miniaturize CPB Versus Off-Pump
Surgery 30
Francesco Formica

Introduction it is not yet clear whether the combination of these advan-

tages is superior in MECC compared to OPCABG in terms of
Off-pump coronary artery bypass grafting (OPCABG) surgery mortality and morbidity because multicenter randomized
has been accepted since the early 1990s when it was recog- studies currently are lacking.
nized that conventional extracorporeal circulation (cECC) is
associated with a systemic inflammatory response syndrome
(SIRS). SIRS is implicated in myocardial, renal, pulmonary, Anatomy of the Miniaturized Extracorporeal
and neurologic dysfunction. For these reasons, the OPCABG Circulation System
technique is widely applied as the first choice in patients
affected by acute or chronic renal dysfunction, obstructive Different types of MECC circuits are available on the market,
pulmonary disease, cerebrovascular disease, and peripheral and although they can have some differences in terms of
obstructive arteriopathy [1]. However, although the effects of characteristics of the blood pump, oxygenator membrane,
cECC are often subclinical, in some situations they can be length of tubing, and arterial and venous filters, the main
responsible for worse outcomes in the early postoperative concept is substantially the same for each system: a closed
period. OPCABG has produced very encouraging results, and circuit without a venous cardiotomy reservoir that strongly
this technique has seen wide popularity during the last decade, reduces the blood-air interfaces. Several other key compo-
with many cardiac centers performing OPCABG in more nents forming the structure of MECC are the following:
than 80 % of coronary patients [2]. However, the OPCABG (a) Circuit coating. All components of the MECC circuit
technique presents some drawbacks, such as the significant are coated with heparin, phosphorylcholine, or polymer
learning curve for the surgeon, the high rate of incomplete according to the different techniques available on the
revascularization in dilated and hypokinetic hearts due to the market. The heparin pre-treatment of the circuit mini-
very difficult exposure of obtuse coronary marginal branches, mizes the systemic heparinization dose requirements
and the lesser quality of the coronary anastomosis with an (usually a half dose of the conventional ECC: 150 IU/kg
increased graft restenosis identified [3, 4]. Over the past 10 instead of 300 IU/kg) [7–10] and provides biocompati-
years, miniaturized extracorporeal circulation (MECC) has bility for blood cells [5, 6, 11, 12].
been developed with the aim of reducing the side effects of (b) Tubing length. The MECC circuit is usually shorter
cECC, strengthening the advantages of cECC, and eliminat- than that of the conventional ECC. Tubing length of
ing the drawbacks of OPCABG [5, 6]. Utilizing a shorter cir- about 100 cm is frequently reported as well as a
cuit without the interposition of a venous reservoir may offer smaller tubing section than in conventional ECC tub-
several benefits, such as a reduction in hemodilution, coagul- ing (3/8″ size instead of 1/2″ size) [8, 13]. These char-
opathy, and SIRS. In other words, MECC should combine the acteristics are reflected in a lower prime volume
best of cECC with the best of “off-pump” surgery. However, ranging between 200 and 650 ml for the MECC com-
pared to 1,200–1,600 ml for the standard ECC [8, 12,
14]. The combination of short length tubing, heparin
F. Formica, MD pre-treatment, small size tubing, and absence of a
Cardiac Surgery Clinic, Department of Surgical Science,
University of Milano-Bicocca, San Gerardo Hospital,
venous reservoir leads to a significant reduction of
Via Pergolesi 33, 20900 Monza, Italy hemodilution, clotting factor consumption, and trig-
email: francesco_formica@fastwebnet.it gering of SIRS [5, 15, 16].

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 259
DOI 10.1007/978-1-4471-4429-8_30, © Springer-Verlag London 2013
260 F. Formica

(c) Centrifugal pump. The blood pump included in the multifactorial syndrome that is known to be associated with
circuit is a centrifugal pump, which is very versatile, ECC. The SIRS to ECC is initiated by many aggressive factors,
reducing the cell trauma in the erythrocytes and platelets including surgical trauma, blood contact with nonendothelial
with possible lower effects on hemolysis. surfaces, cardioplegia, and ischemia-reperfusion injury [22–24].
(d) Oxygenator. The oxygenator of the MECC is one of the Several blood elements, such as neutrophils, monocytes,
most important components of the circuit itself. endothelial cells, platelets, and complement proteins, are
Oxygenators have an oxygenation membrane of either involved in the SIRS. When activated, these blood components
microporous polypropylene [16, 17] or polymethylpen- release cytotoxic and vasoactive substances, produce
tene [8, 12, 18, 19]. In the latter case, the membrane is inflammatory and inhibitory cytokines, and express cell recep-
considered a diffusion membrane. Usually the oxygen- tors interacting with specific cellular substance [24]. Therefore,
ator has an integrated heat exchanger and one of the larg- when the SIRS has been initiated, several inflammatory media-
est gas exchange surface areas, reaching about 2.4 m2. In tors, including anti- and proinflammatory cytokines, could be
this way, the oxygenator can give full oxygenation also associated with a worse postoperative course.
with a high-blood-flow pump up to 7 l/min. Cytokines are small proinflammatory peptides strongly
(e) Arterial and venous filters. Many MECC circuits include involved in the myocardial stunning process and in multior-
an arterial filter between the oxygenator and the aortic gan failure syndrome [23]. Important cytokines involved in
cannula and a venous bubble trap between the venous the SIRS are interleukin 1b (IL-1b), interleukin 6 (IL-6),
cannula and the centrifugal pump. The arterial filter has tumor necrosis factor a (TNF-a), and soluble CD 40 ligand
a prime volume ranging between 150–200 ml and (sCD40L).
strongly reduces the risk of cerebral and systemic embo- IL-1b is produced mainly by monocytes. This cytokine
lization. The venous bubble trap reduces large air entrain- derives from IL-1 by the action of the IL-1b-converting
ment in the circuit, which could be one of the causes of enzyme. An increase of IL-1b was found after ECC with a
accidental blockage of the MECC circuit. Aortic and peak concentration after 24 h [5].
atrial cannulation is equal to that in conventional ECC. IL-6 is produced and released by the monocytes and
Usually an aortic vent catheter is positioned in the endothelial cells following a stimulus by IL-1 and TNF-a.
ascending aorta, and a further vent is inserted in the pul- IL-6 has its peak concentration a few hours after the end of
monary main trunk during aortic valve surgery. ECC and gradually decreases within the following 24 h [5,
(f) Cell-saver device. This can be associated with the MECC 10, 16]. The IL-6 concentration also increases after major
with the aim of removing all the pericardial bloodshed. noncardiac operations, and the peak concentration occurs
This can then be washed and transfused during the sur- 6–24 h after the end of the operation.
gery by means a soft reservoir bag or in the immediate TNF-a is a cytokine produced by neutrophils and mono-
postoperative period via an intravenous cannula. cytes. A significant increase of TNF-a was shown after
The major difference between the MECC and cECC is the removal of the cross clamp, and a peak concentration is
absence of a venous reservoir; also, the capillary vascular bed of reached 24 h after the end of ECC. TNF-a has a negative
the patient works as a biological human venous reservoir. The inotropic effect, and the myocardium is a major source after
direct collaboration among the cardiac surgeon, the anesthesi- ischemic reperfusion injury.
ologist, and the perfusionist is extremely important to guarantee sCD40L is produced by activated platelets and upregu-
the best outcome. Use of vasodilator and vasoconstrictor drugs, lates the expression of inflammatory adhesion receptors
Trendelenburg or anti-Trendelenburg position of the patient, including E-selectin, VCAM-1, tissue factor, and matrix
and reducing or increasing the centrifugal pump flow are all metalloproteinases [25]. Furthermore, sCD40L has been
fundamental keys to handling an MECC system with the aim of described as a major mediator of vascular inflammation [26].
avoiding malperfusion syndrome, systemic embolization, fail- Plasma levels of CD40L increased within 1 h on ECC and
ure of MECC, and rapid conversion to cECC. increased by fourfold after 2 h [25]. A high preoperative
Table 30.1 shows the different types of MECC systems level of CD40L was associated with a high risk of postopera-
currently available. tive atrial fibrillation in patients who underwent off-pump
myocardial revascularization [27].

Systemic Inflammatory Response

Syndrome (SIRS) Miniaturized Extracorporeal Circulation
Compared to Off-Pump Surgery
Recent publications have described the association of the
MECC with minimal activation of inflammation and coagul- At this time, there are not many publications comparing
opathy, less hemodilution with low blood transfusion, and a low MECC to off-pump surgery, and obviously many further
incidence of cerebral stroke [8, 20, 21]. The SIRS is a complex randomized studies are needed to verify the superiority of
30 Miniaturize CPB Versus Off-Pump Surgery 261

Table 30.1 Different types of MECC systemc currently available

Resting Heart CORx
(Medtronic) MECC (Maquet) ECC.O (Sorin) ROCSafe (Terumo) (CardioVention)
Circuit coating Carmeda bioactive Bioline (with heparin) Prosphorylcoline Xcoating, biopassive Not coated
surface (with heparin) polymer coating
Centrifugal pump Affinity (prime Rotaflow (prime volume Revolution Impeller Sarns (prime volume Impeller, integrated
volume 40 ml) 32 ml) type integrated with 48 ml) with oxygenator
oxygenator
Oxigenator Affinity (hollow fibers) QuadroxD (polymethilpen- Hollow fiber Capiox (microporous Hollow fiber
tene diffusion membrane) polypropylene) polypropylene
Filters Arterial and venous: Arterial (40 mm pore size) Arterial filter (40 mm Arterial filter (37 mm Integrated
Affinity (38 mm pore and venous bubble trap pore size). pore size). (defoamer)
size) (175 mm pore size) Venous bubble trap Venous bubble trap
(170 mm pore size)
Total prime 1,000 800–900 400 665 820
volume (ml)

one technique over the other. The few studies available did MECC with cardioplegic arrest should be considered equiva-
not identify significant differences between the two tech- lent tools.
niques in terms of hospital mortality, neurocognitive distur- Recently, Formica et al. [8] in a prospective randomized
bance, triggering of SIRS, blood loss and transfusion study evaluated the release of tumor necrosis factor-a and
requirements, and rate of postoperative atrial fibrillation. interleukin 6 in a group of patients operated on with MECC
In-hospital mortality did not differ among the different compared to off-pump surgery. They observed a higher
studies. Puehler et al. [9] did not find significant in-hospi- release of interleukin 6 in off-pump surgery than in MECC
tal mortality in patients undergoing CABG with MECC or surgery 24 h after the operation, whereas levels of tumor
cECC or off-pump surgery. Each group had 558 patients, necrosis factor-a were not different in the two groups.
and overall in-hospital mortality in the MECC group was Moreover, the authors observed no difference in the cardiac
3.22 % compared to the off-pump group, which was release of these cytokines in the two groups. The authors
3.76 %. However, in a subgroup of an emergent popula- suggested that, according to their findings, MECC can be
tion, the in-hospital mortality of the MECC group was used extensively in all patients with multivessel disease in
significantly lower than that of the off-pump group (5.6 and whom off-pump surgery could have more operative risks.
10.7 %, respectively). However the in-hospital mortality Neurocognitive disturbance and cerebrovascular events
ranged between 0 and 5.4 % in the different studies [8, 16, such as stroke/transient ischemic attack can seriously com-
19, 28]. plicated the postoperative course of patients undergoing
SIRS, hemolysis, and coagulopathy are among the most coronary surgery. It has been recognized that off-pump sur-
studied events in the studies comparing MECC to off-pump gery is associated with a lower incidence of cerebral stroke
surgery. Wippermann et al. [16] reported no significant when compared to CABG with ECC, above all in patients
changes in prothrombin fragment 1.2 levels, interleukin 6 who have undergone off-pump surgery with the no-touch
releases, and plasmin-antiplasmin complex levels between aorta technique. At this time, no reports exist showing evi-
the MECC and off-pump groups over the immediate postop- dence of an increased rate of neurological sequelae in MECC
erative course. Instead, they found a significant difference patients. However, neurological complications are always
when these two groups were compared to cECC patients. caused by multifactorial events such as micro- and macro-
Van Boven et al. [29] reported no differences in serum con- embolizations, cerebral hypoperfusion, cerebrovasculopathy,
centrations of malondialdehyde, allantoin/urate ratios, and and carotid disease, and for this reason, it is not possible to
lung epithelium-specific proteins (CC16) in MECC com- find a direct correlation between MECC and postoperative
pared to off-pump patients. The release of these biomarkers neurological outcome.
was higher in cECC patients, and they speculated that the At the present time, few studies study have primarily inves-
oxidative stress parameters showed a tendency toward tigated the incidence of postoperative atrial fibrillation (AF)
improved global organ protection in MECC and off-pump in MECC compared to off-pump surgery. In their study,
patients compared to cECC patients. Panday et al. [30] reported a lower incidence of postoperative
Mazzei et al. [13] compared interleukin 6 and serum AF in the MECC and off-pump groups (25 and 21.7 %,
S-100 protein levels between MECC and off-pump surgery respectively) compared to the cECC group (35.6 %). Other
in a prospective randomized trial. No differences were authors reported a very low incidence of postoperative
reported in terms of release of these biomarkers over a 24 h atrial fibrillation without differences in the MECC, off-pump,
period, and this evidence suggests that off-pump surgery and and cEE groups (3.6, 3.9, and 5.4 %, respectively) [9].
262 F. Formica

Formica et al. [8] reported no significant difference in the inci- comparative studies currently available and by the lack of
dence of AF, but the rate of AF in the MECC group was higher large randomized controlled trials. However, current data
than in the off-pump group (40 and 23.3 %, respectively; suggest that MECC is comparable to OPCAB, with no
p = 0.9). Postoperative AF is considered a multifactorial com- significant difference in mortality, morbidity, length of stay,
plication in which hypoglycemia due to hemodilution, release neurological outcomes, blood transfusions, or blood loss.
of proinflammatory cytokines, need for blood, and advanced Further to this, both techniques have shown several advan-
age can be associated with the development of this event. tages when compared to conventional techniques of cardio-
Completeness of revascularization, reoperation for graft pulmonary bypass in terms of less SIRS, less morbidity,
failure, and composite outcome at midterm are considered reduced blood loss, and fewer blood transfusions. Further
some of the main weaknesses of off-pump surgery. Some randomized trials are needed focusing not only on the short-
recent large trials compared off-pump surgery to cECC and term endpoints, but also the long-term outcomes and differ-
reported survival of less than 10 years for off-pump surgery ences between these techniques, including angina recurrence,
[31], more early reinterventions after the off-pump proce- the need for repeat revascularization, and mortality and
dure [32], fewer grafts performed, poorer long-term graft morbidity.
patency, and increased incidence of composite outcome
(death and major cardiac events) in off-pump surgery [3].
These results have led to less acceptance of off-pump sur-
gery worldwide. Formica et al. [8] reported fewer grafts per-
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 Thyroid Hormones and Cardiovascular
Surgery 31
Edmo Atique Gabriel and Sthefano Atique Gabriel

At some point, it seems to be incompatible to correlate In addition to some thyroid hormones, inflammatory and
thyroid hormones with cardiovascular surgery. Furthermore, biochemical parameters were addressed over the same time
it is unusual to think about thyroid function when surgeons point. These authors found out that on-pump coronary artery
are performing any kind of cardiovascular surgery [1, 2]. bypass can induce a significant reduction in some cellular,
However, from now on, we postulate that cardiopulmo- protein, and thyroid hormone concentrations at the end of
nary bypass and its complex inflammatory universe can bypass surgery. Moreover, they postulated that recovery of
interfere with thyroid hormone levels in such a way that these parameters tends to occur by 24 h postoperatively
postoperative heart function may become considerably (Tables 31.1, 31.2, 31.3, and 31.4; Figs. 31.1, 31.2, 31.3,
depressed. This is possible because thyroid hormones play a 31.4, 31.5, 31.6, 31.7, 31.8 and 31.9) [7].
cardiotonic and inotropic role. Some authors have correlated Many authors have assumed that decreased thyroid hor-
modifications of thyroid hormone levels with higher inci- mones levels occurring during cardiopulmonary bypass
dence of atrial fibrillation postoperatively. Some controver- should be preoperatively balanced by T4 or T3 supplemen-
sial hypotheses try to elucidate the real causes for depressed tation. The rationale for this undertaking is prevention
heart function in great detail. One of them considers irregular of negative effects from depressed cardiac output, perfu-
thyroid perfusion during cardiopulmonary bypass as a not sion pressure, stroke volume, and contractility intra- and
entirely physiological state [3, 4]. postoperatively [8, 9].
Euthyroid sick syndrome encompasses a group of Nonetheless, as pointed out previously, this matter is so
modifications in thyroid hormones levels that can be detected intriguing that some authors, such as Velissaris et al. [10],
following heart surgery that requires cardiopulmonary have advocated that a reduction in thyroid hormone levels
bypass. The main features of this syndrome are depressed might consist of an organic adaptive process of reduced
total and free triiodothyronine (T3) levels, whereas thyroid- catabolism rather than a true hypothyroid state. The basis for
stimulating hormone (TSH) and total and free thyroxine (T4) this theory was the association between low free T3 levels
hormone concentrations tend to remain stable [5, 6]. and high global oxygen consumption (Fig. 31.10) [10].
Gabriel et al. [7] designed clinical research focusing on Anyway, turning our attention to the role of thyroid hor-
the profile of thyroid hormone variation over the early post- mones during cardiovascular surgery is somehow wise, par-
operative period following on-pump coronary artery bypass. ticularly in case of heart surgery requiring cardiopulmonary
bypass. Furthermore, in the context of on-pump heart sur-
gery, it is important to add some comments on the impact of
ultrafiltration on thyroid hormone levels to such an interest-
E.A. Gabriel, MD, PhD (*) ing discussion [11].
Department of Cardiovascular Surgery, University Nove de Julho, The thyroid hormone concentration in the ultrafiltrate
São Paulo, Brazil can be positively correlated with prolonged recovery in
e-mail: edag@uol.com.br
patients who have undergone heart surgery. Velissaris et al.
S.A. Gabriel, MD [10] and Bartkowski et al. [12] demonstrated this trend in a
Department of Vascular Surgery, Pontifical Catholic University of
clinical study encompassing infants who had undergone
Campinas,
São Paulo, Brazil heart surgery with cardiopulmonary bypass and ultrafiltration.
These authors noticed remarkable relationships between
Department of Vascular Surgery, Celso Pierro Hospital and Maternity,
Campinas, São Paulo, Brazil decreased thyroidhormone levels and eventful recovery
e-mail: sthefanogabriel@yahoo.com.br postoperatively (Table 31.5; Fig. 31.11) [10, 12].

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 265
DOI 10.1007/978-1-4471-4429-8_31, © Springer-Verlag London 2013
 266

Table 31.1 Comparison among the time points of simultaneous observation for total leukocytes, neutrophils, and platelets
Calculated
Block of variables n Average SD Minimum Maximum 25th Quartile Median 75th Quartile significance (P)
Total leukocytes pre 18 7,369.44 2,629.74 2,090.00 12,450.00 5,980.00 7,180.00 9,190.00
Total leukocyte intra 18 11,507.22 5,950.92 2,930.00 21,100.00 6,940.00 9,255.00 18,002.50
Total leukocytes 24 h 18 13,738.33 3,763.50 7,990.00 23,980.00 10,655.00 13,680.00 15,275.00 <0.001
Total leukocytes 48 h 18 12,966.67 3,933.52 8,060.00 23,320.00 10,290.00 12,410.00 13,825.00
Total neutrophils pre 18 7,927.22 13,646.36 690,00 62,000.00 3,920.00 4,670.00 6,520.00
Total neutrophils intra 18 9,342.78 5,258.52 1,140.00 19,620.00 5,240.00 8,225.00 13,897.50
Total neutrophils 24 h 18 11,646.67 3,926.20 6,310.00 23,260.00 8,920.00 11,480.00 12,807.50 <0.001
Total neutrophils 48 h 18 10,607.11 4,655.99 858.00 20,990.00 8,145.00 9,515.00 12,522.50
Total platelet pre 18 244,444.44 76,814.69 130,000.00 385,000.00 177,750.00 247,000.00 307,750.00
Total platelet intra 18 166,277.78 62,520.40 85,000.00 311,000.00 117,000.00 160,000.00 201,500.00 <0.001
Total Platelet 24 18 160,994.44 59,754.86 73,000.00 305,000.00 122,250.00 142,500.00 209,750.00
Total platelet 48 h 18 160,994.44 63,178.99 83,000.00 306,000.00 129,250.00 147,500.00 223,500.00
E.A. Gabriel and S.A. Gabriel
31 Thyroid Hormones and Cardiovascular Surgery 267

Table 31.2 Comparison between the time points of simultaneous observation for total protein and albumin
Block of variables n Average SD Minimum Maximum 25th Quartile Median 75th Quartile Calculated significance (P)
Total protein pre 18 6.78 0.88 5.00 7.90 6.03 7.00 7.50
Total protein intra 18 4.70 0.90 2.80 6.20 4.30 4.85 5.33
Total protein 24 18 4.85 0.58 3.20 5.70 4.58 5.00 5.13 <0.001
Total protein 48 h 18 5.11 0.68 3.20 6.40 4.88 5.10 5.40
Total albumins pre 18 4.05 0.56 2.80 4.90 3.73 4.10 4.40
Total albumins intra 18 2.72 0.53 1.70 3.60 2.33 2.75 3.20
Total albumins 24 h 18 2.86 0.39 2.00 3.50 2.68 2.90 3.03 <0.001
Total albumins 48 h 18 2.94 0.37 1.80 3.50 2.80 3.00 3.13

Table 31.3 Comparison between the time points of simultaneous observation for total T3 and free T3
Block of Variables n Average SD Minimum Maximum 25th Quartile Median 75th Quartile Calculated significance (P)
T3 pre 18 134.46 32.31 61.70 190.30 113.33 130.85 161.18
T3 intra 18 103.81 37.18 51.90 187.30 79.68 101.10 122.10
T3 24 18 84.77 19.57 56.70 124.30 73.05 79.95 91.78 <0.001
T3 48 h 18 138.60 191.35 53.80 899.00 78.00 89.60 127.25
Free T3 pre 18 2.54 0.67 1.40 4.30 2.30 2.60 2.90
Free T3 intra 18 2.14 0.82 0.50 4.10 1.60 2.35 2.60
Free T3 24 18 1.72 0.65 0.60 2.80 1.30 1.75 2.15 <0.001
Free T3 48 h 18 1.73 0.76 0.50 3.10 1.10 1.90 2.15

Table 31.4 Comparison among the time points of simultaneous observation for total T4, free T4, and TSH
Block of variables n Average SD Minimum Maximum 25th Quartile Median 75th Quartile Calculated significance (P)
T4 pre 18 9.96 3.23 6.00 20.25 8.08 9.45 10.90
T4 intra 18 8.27 2.20 4.70 13.00 6.58 8.30 10.00
T4 24 18 7.80 2.11 4.90 12.10 6.00 7.55 9.40 < 0.001
T4 48 h 18 8.35 2.11 5.00 13.90 7.08 8.25 9.70
Free T4 pre 18 1.36 0.29 0.90 1.80 1.10 1.30 1.70
Free T4 intra 18 1.44 0.37 1.00 2.30 1.18 1.40 1.53
Free T4 24 h 18 1.14 0.23 0.80 1.70 0.98 1.10 1.25 <0.002
Free T4 48 h 18 1.24 0.23 1.00 1.70 1.08 1.20 1.40
TSH pre 18 3.04 2.00 0.20 7.90 1.40 2.75 4.55
TSH intra 18 2.85 2.06 0.30 6.90 1.25 2.50 3.83
TSH 24 18 1.69 1.90 0.30 8.60 0.68 1.25 1.95 <0.157
HRT 48 h 18 2.30 1.87 0.10 8.90 1.45 2.00 2.75
 268

of neutrophils
total leukocytes

time points regarding number

time points regarding number of

Fig. 31.2 Comparison between

Fig. 31.1 Comparison between

Number of Neutrophils Number of Leukocytes

0
2000
4000
6000
8000
10000
12000
14000
16000

0
2000
4000
6000
8000
10000
12000
14000
NEUTROPHILS Preop LEUKOCYTES Preop

P=0.015

P=0.02
NEUTROPHILS Intra LEUKOCYTES Intra

NEUTROPHILS Preop LEUKOCYTES Preop

P=0.003
P<0.001
NEUTROPHILS 24h LEUKOCYTES 24h

NEUTROPHILS Preop LEUKOCYTES Pré

P=0.008
NEUTROPHILS 48h LEUKOCYTES 48h
P<0.001

NEUTROPHILS Intra LEUKOCYTES Intra

P=0.184
NEUTROPHILS 24h LEUKOCYTES 24h
P=0.231

NEUTROPHILS Intra LEUKOCYTES Intra

P=0.616
P=0.679

NEUTROPHILS 48h LEUKOCYTES 48h

NEUTROPHILS 24h LEUKOCYTES 24h

P=0.157
NEUTROPHILS 48h LEUKOCYTES 48h
P=0.133
E.A. Gabriel and S.A. Gabriel
 of platelets

total proteins
time points regarding number

time points regarding levels of

Fig. 31.4 Comparison between
Fig. 31.3 Comparison between

g/dL Number of Platelets

0
1
2
3
4
5
6
7
8
0
50000
100000
150000
200000
250000
300000

PROTEINS Preop
31 Thyroid Hormones and Cardiovascular Surgery

PLATELETS Preop

P<0.001
PROTEINS Intra

P=0.001
PLATELETS Intra
PROTEINS Pré
PLATELETS Preop

P<0.001
PROTEINS 24h

P<0.001
PLATELETS 24h
PROTEINS Pré
PLATELETS Preop

P<0.001
PROTEINS 48h
P=0.001

PLATELETS 48h

PROTEINS Intra
PLATELETS Intra

P=0.522
PROTEINS 24h
P=0.705

PLATELETS 24h

PROTEINS Intra
PLATELETS Intra

P=0.019
PROTEINS 48h
P=0.614

PLATELETS 48h

PROTEINS 24h PLATELETS 24h

P=0.010
PROTEINS 48h
P=0.247

PLATELETS 48h
269
270 E.A. Gabriel and S.A. Gabriel

Fig. 31.5 Comparison between 4.5

time points regarding levels of
albumin 4

3.5

2.5

g/dL
2

1.5

0.5

0
ALBUMIN Pré

ALBUMIN Intra

ALBUMIN Pré

ALBUMIN 24h

ALBUMIN Pré

ALBUMIN 48h

ALBUMIN Intra

ALBUMIN 24h

ALBUMIN Intra

ALBUMIN 48h

ALBUMIN 24h

ALBUMIN 48h
P<0.001 P<0.001 P<0.001 P=0.138 P=0.644 P=0.503

160

140

120

100
ng/dL

80

60

40

20

0
T3 Preop

T3 Intra

T3 Preop

T3 24h

T3 Preop

T3 48h

T3 Intra

T3 24h

T3 Intra

T3 48h

T3 24h

T3 48h

Fig. 31.6 Comparison between

P=0.003 P<0.001 P=0.006 P=0.048 P=0.647 P=0.157
time points regarding levels of
total T3
31 Thyroid Hormones and Cardiovascular Surgery 271

Fig. 31.7 Comparison between 12

time points regarding levels of
total T4
10

mcg/dL
6

0
T4 Preop

T4 Intra

T4 Preop

T4 24h

T4 Preop

T4 48h

T4 Intra

T4 24h

T4 Intra

T4 48h

T4 24h

T4 48h
P=0.003 P<0.001 P=0.001 P=0.240 P=0.948 P=0.201

2.5

2
pg/mL

1.5

0.5

0
Free T3 Preop

Free T3 Intra

Free T3 24h

Free T3 24h

Free T3 Preop

Free T3 48h

Free T3 Intra

Free T3 24h

Free T3 Intra

Free T3 48h

Free T3 24h

Free T3 48h

Fig. 31.8 Comparison between

P=0.001 P<0.001 P<0.001 P=0.006 P=0.024 P=0.831
time points regarding levels of
free T3
272 E.A. Gabriel and S.A. Gabriel

Fig. 31.9 Comparison between 1.6

time points regarding levels of
free T4 1.4

1.2

ng/dL
0.8

0.6

0.4

0.2

0
Free T4 Preop

Free T4 Intra

Free T4 Preop

Free T4 24h

Free T4 Preop

Free T4 48h

Free T4 Intra

Free T4 24h

Free T4 Intra

Free T4 48h

Free T4 24h

Free T4 48h
P=0.348 P=0.015 P=0.189 P=0.004 P=0.037 P=0.034

180
160
140
VO2 (ml/ml/n/m2)

120
100
80
60 OPCAB
40 ONCAB
Fig. 31.10 Perioperative VO2 levels in the two groups. The error bars
20
represent 95 % confidence intervals around the mean (for clarity only
the positive error bars are displayed for the OPCAB group and the nega- 0
tive for the ONCAB group) Baseline Operation end 1h 6h
31 Thyroid Hormones and Cardiovascular Surgery 273

Table 31.5 Perioperative thyroid hormone levels in the two groups

Variable Preop Operation end 1h 6h 24 h
TSH (mU/l)
ONCAB 2.16 ± 2.45 2.11 ± 2.31 1.60 ± 1.37 1.01 ± 0.77 1.89 ± 1.36
OPCAB 2.74 ± 1.57 1.94 ± 1.17 1.49 ± 0.98 1.01 ± 0.59 2.07 ± 1.70
fT4 (pmol/l)
ONCAB 16.40 ± 2.45 16.8 ± 2.57 15.64 ± 2.43 13.84 ± 1.99 14.42 ± 2.55
OPCAB 15.88 ± 2.28 18.50 ± 3.55 16.04 ± 2.78 12.94 ± 2.01 13.83 ± 1.86
fT3 (pmol/l)
ONCAB 5.12 ± 0.41 4.62 ± 0.43 4.56 ± 0.47 3.68 ± 0.63 3.31 ± 0.69a
OPCAB 5.04 ± 046 4.88 ± 0.71 4.67 ± 0.57 3.57 ± 0.59 3.34 ± 0.52a
Data are presented as mean ± standard deviation. Reference ranges, fT4: 8.0–22.0 pmol/l, fT3: 3.5–7.0 pmol/l, TSH: 0.5–5.5 mU/l
TSH thyroid-stimulating hormone, fT4 free thyroxine, fT3 free triiodothyronine
a
p < 0.001 compared to preoperative value

Fig. 31.11 The average amount The average amount of triiodothyronine in ultrafiltrate
of triiodothyronine in the [pg] (In patients with or without intensive care treatment)
ultrafiltrate (in patients with or 0.09
without intensive care treatment)

0.07

0.05
pg

0.03

0.01

–0.01
±Std. DEV.
±Std. Err.
Mean
–0.03
Group of patients without Group of patients with
prolonged recovery prolonged recovery

5. Portman MA, Fearneyhough C, Ning XH, Duncan BW, Rosenthal GL,

References Lupinetti FM. Triiodothyronine repletion in infants during cardiopulmo-
nary bypass for congenital heart disease. J Thorac Cardiovasc Surg.
1. Murzi B, Iervasi G, Masini S, Moschetti R, Vanini V, Zucchelli G, 2000;120:604–8.
et al. Thyroid hormones homeostasis in pediatric patients during and 6. Wieselthaler GM, Riedl M, Schima H, Wagner O, Waldhäusl W,
after cardiopulmonary bypass. Ann Thorac Surg. 1995;59:481–5. Wolner E, et al. Endocrine function is not impaired in patients with
2. Jones TH, Hunter SM, Price A, Angelini GD. Should thyroid func- a continuous MicroMed–DeBakey axial flow pump. J Thorac Cardiovasc
tion be assessed before cardiopulmonary bypass operations? Ann Surg. 2007;133:2–6.
Thorac Surg. 1994;58:434–6. 7. Gabriel EA, Locali RF, Matsuoka PK, Cherbo T, Buffolo E. On-pump
3. Park YJ, Yoon JW, Kim KI, Lee YJ, Kim KW, Choi SH, et al. coronary artery bypass graft surgery:biochemical, hormonal and cel-
Subclinical hypothyroidism might increase the risk of transient lular features. Rev Bras Cir Cardiovasc. 2011;26(4):525–31.
atrial fibrillation after coronary artery bypass grafting. Ann Thorac 8. Pearce EN, Yang Q, Benjamin EJ, Aragam J, Vasan RS. Thyroid
Surg. 2009;87:1846–52. function and left ventricular structure and function in the
4. Cerillo AG, Storti S, Clerico A, Iervasi G. Thyroid function and Framingham Heart Study. Thyroid. 2010;20(4):369–73.
cardiac surgery: what should we measure, and when? Ann Thorac 9. Virtanen VK, Saha HH, Groundstroem KW, Salmi J, Pasternack
Surg. 2010;89:1010–1. AI. Thyroid hormone substitution therapy rapidly enhances
274 E.A. Gabriel and S.A. Gabriel

left-ventricular diastolic function in hypothyroid patients. 12. Bartkowski R, Wojtalik M, Korman E, Sharma G, Henschke J,
Cardiology. 2001;96(2):59–64. Mrówczyński W. Thyroid hormones levels in infants during and
10. Velissaris T, Tang AT, Wood PJ, Hett DA, Ohri SK. Thyroid func- after cardiopulmonary bypass with ultrafiltration. Eur J Cardiothorac
tion during coronary surgery with and without cardiopulmonary Surg. 2002;22(6):879–84.
bypass. Eur J Cardiothorac Surg. 2009;36(1):148–54.
11. Reinhardt W, Mocker V, Jockenhövel F, Olbricht T, Reinwein D,
Mann K, et al. Influence of coronary artery bypass surgery on thy-
roid hormone parameters. Horm Res. 1997;47(1):1–8.
 Inflammatory Response
in Cardiovascular Surgery 32
Kaan Kaya

CPB, first performed by John H. Gibbon in 1953, is still a nisms integrated with each other (Fig. 32.1). The major
standard method to operate on most patients undergoing car- mechanism is exposure of blood to cardiopulmonary bypass
diac surgery. There are many studies in the literature of its use (CPB) circuits. The second is ischemia-reperfusion injury of
and complications, and systemic inflammatory response has vital organs during CPB. The third mechanism is systemic
been largely documented. Currently, the systemic inflammatory endotoxemia from the gut following splanchnic hypoperfu-
response to CPB is well diagnosed, but it is not clearly under- sion. Inflammatory mediators can be classified as humoral
stood. Both the cellular and humoral complexes are activated and cellular factors. These factors are shown in Table 32.1.
during CPB, but their effects and interactions remain poorly
defined. Recently, many surgeons tried to perform off-pump
cardiac surgery to prevent systemic inflammation caused by Humoral Response
CPB, but they did not succeed in preventing inflammation
caused by the surgery itself. This chapter describes the etio- The initial response is probably the humoral response, and it
pathogenesis and mechanisms of the development of the is initiated by the blood coming in contact with the foreign
inflammatory response as well as its prevention in cardiac surfaces (the extracorporeal circuit). The greatest stimulus is
surgery. the oxygenator as gas exchange requires a large surface area.
Although the patient is heparinized, many cascades includ-
ing coagulation, complement, kallikrein and fibrinolysis
Etiology and Pathogenesis responds immediately. It has been shown that many split
products resulting from all the cascades can be found in the
The inflammatory response can be caused by burns, chemi- circulation during and after CPB. Hageman factor (factor
cal irritations, trauma, and infections. Inflammation can be XII) activation has an important initial role in activation of
classified into two categories: acute and chronic inflammation. these cascades. Activated products have strong physiologic
Chronic inflammation can be observed during rheumatoid effects. For example, by activation of the complement
arthritis, systemic lupus erythematosus, atherosclerosis, and cascade powerful anaphylatoxins are produced (C3a and
inflammatory bowel disease. In these diseases, inflammation C5a), and they increase vascular permeability and leukocyte
may last several weeks or months. But during cardiac sur- chemotaxis.
gery, the extracorporeal circulation plays the major role, and
the inflammatory response is acute.
Nonspecific activators of the stress response include sur- Complement System
gical trauma, blood loss and transfusion, hypothermia, or
hyperthermia. The extracorporeal circulation may activate The complement system includes a large number of plasma
the inflammatory response via at least three distinct mecha- proteins, and it is activated by the classic and the alternative
pathways during CPB. The exposure of blood to extracorpo-
real circuits activates the alternative pathway, which leads to
K. Kaya, MD
the formation of C3a and C5a, and reversal of heparin with
Division of Cardiovascular Surgery,
Kavaklidere Umut Hospital, Ankara, Turkey protamine activates the classical pathway that produces C4
e-mail: drkaankaya@yahoo.com and C2. Thus, C4 and C2 activation does not occur in patients

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 275
DOI 10.1007/978-1-4471-4429-8_32, © Springer-Verlag London 2013
276 K. Kaya

Fig. 32.1 Complexity of the Contact of plasma with foreign

inflammatory response in cardiac surface (CPB)
surgery Surgical trauma

Oxygen derived
Protamine
free radicals
sulphate
Coagulation Cytokin release
cascade

Complement Celllullar Neutrophil

system activation activation

Kallikrein-bradykinin C3a-C5a Endothelial cells

system

Fibrinolytic Prostoglandins
system Thromboxanes
Pulmonary
Split products Leukotriens
leukocyte infiltration
Lipoxins
Platelets

Ischemia-reperfusion α-antitripsin
injury β-thomboglobulin
Platelet factor 4
Lysosomes
Splancnic hypoperfusion ATP
ADP

• Increased vascular permeability

• Capillary leak
• Electrolyte imbalance
• Arteriolar dilatation
• Smooth muscle contraction
• Neutrophil aggregation
• Destroying effect to extracellular
structures

Table 32.1 Humoral and cellular factors of the inflammatory and basophils release histamine, and white blood cells release
response free oxygen radicals and lysosomal enzymes. The comple-
Humoral factors Cellular factors ment system can be activated by contact of blood with
Contact activation products Neutrophils extravascular surfaces, probably by way of the Hageman fac-
Factor XIIa Endothelial cells tor. Complement activation has also been shown during hemo-
Thrombin dialysis during exposure of blood to the dialysis membrane.
Kallikrein The extent of complement activation during CPB corre-
Fibrinogen degradation products lates with the severity of the operation and the development
Complement system of complications. However, most clinical problems do not
Cytokines occur until the first or second postoperative days. CRP, one
Tumor necrosis factor of the acute-phase proteins, has strong potency to activate
Interleukin
complement. But it is not clear whether CRP contributes to
Leukotriene
complement activation during or after CPB. The duration of
the CPB does not affect the final C3a level, but protamine
undergoing off-pump surgery without protamine administra- administration has a strong effect. Pretreatment of the patient
tion. By activation of the complement system, a number of with steroids may decrease complement activation but does
active products increase the vascular permeability, mast cells not prevent it completely.
32 Inflammatory Response in Cardiovascular Surgery 277

Pulmonary sequestration of the polymorphonuclear leu- Platelet-activating factor (PAF): This is a phospholipid
kocytes and neutropenia during CPB has been shown to released from endothelial cells. It has strong vasoactive
be related to complement system activation. Thus, activa- effects And causes the release of cytokines.
tion of the complement system is involved in production of Leukotriene: This causes endothelial cell contraction and
pulmonary edema. Once the complement system has been increases capillary leakage.
activated, pulmonary neutrophil migration occurs, neutro- Thromboxane A2: This is derived from macrophages
phil-mediated pulmonary endothelial injury begins, pulmo- and platelets. It has forcing effects on platelet aggregation
nary vascular permeability increases, and reactive oxygen and causes vasoconstriction and thrombosis.
radicals may contribute to the adverse effects of CPB on pul-
monary function.
Free Oxygen Radicals

Cytokines These products increase permeability via its effect on mem-

brane lipids, and they cause organ dysfunction. Hyperoxic
Cytokines are a kind of protein produced by immune system CPB is widely used during cardiac operations, but it induces
cells. Myocardium, lungs and kidneys play a role in seques- oxygen-derived free radicals. These products represent a
trating proinflammatory cytokines. These cytokines may potential risk for the myocardium and lungs [9, 10].
damage them in the presence of hypoperfusion [1]. They
include interleukins (IL), tumor necrosis factor-a (TNFa),
and transforming growth factor-b. They need to bind specific Endotoxins
receptors to activate cells, and they can affect autocrine
(effective in its own cell), paracrine (effective in the neigh- Endotoxins have very strong effects on the inflammatory
boring cells), and endocrine (effective in the remote cells). cascade during cardiac surgery. It has been shown that there
Proinflammatory cytokines are increased in pulmonary is a significant increase of endotoxin levels during CPB.
venous blood [2]. Extracorporeal circulation, pulmonary arterial catheters,
Interleukin-1: Its main role is a mediator in the intravenous fluid administration, and blood transfusions are
inflammatory response. It has a chemotactic effect for mac- believed to be responsible for endotoxemia. The presence of
rophages and neutrophils. It also causes fever via central ner- circulating endotoxins is a major stimulus for producing
vous system effects. TNF-a. In addition, endotoxins activate the complement sys-
Interleukin-2: Mainly, this is produced from T-helper tem and cause the release of some cytokines. During CPB,
cells. Its most important role is proliferation of T-cells. splanchnic hypoperfusion can result in increased permeabil-
Interleukin-6: This is produced by macrophages, mono- ity of the gut mucosal barrier and consequently endotoxemia.
cytes, fibroblasts, and endothelial cells. IL-6 is a Endotoxemia causes the release of inflammatory and
proinflammatory cytokine. It has effects on proliferation of antiinflammatory mediators [11].
B-cells. Its most important effect is the coordination of the
generalized systemic inflammatory response, and it is one of
the acute phase reactants [3]. IL-6 has been accepted as the Kallikrein-Bradykinin System
best proinflammatory cytokine predictor of LV systolic dys-
function and myocardial ischemia [4]. IL-6 levels rise in car- Many investigations have shown that the amount of bradykinin
diac surgery with extracorporeal circulation [5]. increases during CPB. Because the lungs play a primary role
Interleukin-8: This is produced by macrophages, mono- in the elimination of bradykinin, reduced pulmonary circulation
cytes, fibroblasts, and endothelial cells. It is an activator of causes reduced bradykinin elimination during CPB. Bradykinin
neutrophils, and it has a chemotactic effect on neutrophils. is a powerful vasodilator, and this effect has great importance
IL-8 levels rise in cardiac operations with using CPB [5]. in the body’s inflammatory response to CPB.
Tumor necrosis-alpha (TNF-a): This is mainly produced
by activated macrophages. It is produced by activated mono-
cytes and plays a very significant role in inflammation [6]. Coagulation System
During CPB, its plasma levels have been shown to rise [7]. It
is a powerful activator of neutrophils and phagocytes. It Exposure of blood to the extracorporeal circuit activates the
causes fever, hypoglycemia, and vasodilatation, and it stimu- contact system because the CPB circuit lacks endothelial
lates the coagulation cascade. TNF-a can directly cause cells. Although coagulation is largely inhibited by adminis-
hypotension, coagulopathy, and renal dysfunction [8]. tering heparin during CPB, its activation cannot be
278 K. Kaya

completely prevented. Due to incomplete inhibition of the localized ischemia, and increased concentrations of abnor-
coagulation cascade by heparin, small amounts of fibrin are mal mediators and split products.
present during routine CPB. Because of this process, some
of the coagulation factor levels are reduced by the end of
CPB. Neutrophil Activation
The coagulation system has two pathways: intrinsic (con-
tact activation) and extrinsic. The intrinsic pathway is acti- During CPB, an initial leukopenia occurs, but it returns to
vated by the Hageman factor, and at the end of this pathway, baseline levels soon. At the end of CPB, leukocytosis is pres-
thrombin is produced. The intrinsic pathway is mostly acti- ent. Pulmonary sequestration of neutrophils develops during
vated by tissue damage. The extrinsic pathway is activated CPB. Activation of complement system produces C3a and
by infection and systemic inflammation. Activation of the C5a complement fragments, and these products activate neu-
coagulation system is not only important for cloth formation, trophils to liberate oxygen-derived free radicals. This is asso-
it is also important for the proinflammatory response. ciated with the damaging effects of CPB.
In healthy persons, neutrophils are resting cells. However,
when stimulated, they aggregate and cluster with each other
Fibrinolytic Cascade and the other cell types. This process is rapid, and it is a criti-
cal step in the development of inflammatory and immune
The fibrinolytic cascade may be initiated by activation of the responses.
Hageman factor during CPB. Kallikrein is produced by acti-
vation of the Hageman factor, and it facilitates the conver-
sion of plasminogen to plasmin. Platelet Response

During extracorporeal circulation, the platelet count decreases

Arachidonic Acid Cascade significantly. Membrane oxygenators tend to reduce more than
bubble oxygenators. The number of platelets in circulating
During CPB, the lungs are the major site of synthesis, release, blood after CPB is decreased to about 60 % of the pre-bypass
and degradation of the eicosanoids (products of the arachi- value, but it doesn’t correlate with the duration of CPB.
donic acid cascade). Prostacyclin and prostaglandin E2 pro-
duction appears to be increased during CPB, and they can
cause pulmonary vasodilation, while leukotriene-C4 and Erythrocytes
thromboxane tend to cause vasoconstriction. It is believed
that thromboxane-A2 is mostly produced by platelets, but its Shear stress results in injury of the erythrocyte membrane
release occurs in the lungs. Platelet-activating factor (PAF) is during CPB. This causes the release of free hemoglobin into
another factor in the arachidonic acid cascade, and it is an the circulating blood. Viscosity and oncotic pressure are
important mediator of the inflammatory response. increased, and tissue perfusion is decreased. After autooxi-
Leukotriene-B4 is another product of this cascade and pro- dation of hemoglobin, cytotoxic free oxygen radicals are
motes plasma leakage and leukocyte adhesion; it is also released.
increased after CPB.

Metabolic Response
Cellular Response
During CPB, because of the acute elevation of catecholamine
Whole blood cells (platelets, neutrophils, etc.), endothelial levels, a strong metabolic response to stress may develop. Its
cells, and lymphocytes participate in the cellular inflammatory magnitude is directly correlated with catecholamine levels in
response. Polymorphonuclear leukocytes play a major role the circulating blood.
in the response to CPB. Neutrophils are activated by comple-
ment and other mediators. Once they are activated, they
become more adhesive, and they secrete cytotoxic sub- Anti-inflammatory Strategies
stances, such as oxygen-derived free radicals. Platelets are
strongly affected during CPB. They can be activated by direct Many investigations have been performed to prevent the sys-
surface contact, abnormal shear stress, and mechanical temic antiinflammatory response, and some drugs (corticos-
injury. Endothelial cells are also activated by shear stress, teroids, sodium nitroprusside, etc.) or some manipulations
32 Inflammatory Response in Cardiovascular Surgery 279

(off-pump cardiac surgery, minimal invasive surgery, normo- antithrombin complex were significantly reduced with the
thermic approaches, etc.) have been used. However, it should use of heparin-coated circuits [14, 15].
not be forgotten that the antiinflammatory response is a kind
of defense mechanism, and we do not know if it is stopped
completely. Leukocyte Filters

Inflammation has been reported to be reduced by implanting

Corticosteroids a leukocyte filter in the arterial line, but there have been many
contrasting investigations. Some clinics use leukocyte filters
Commonly used corticosteroids in the prevention of the sys- routinely, but others do not believe that they have beneficial
temic inflammatory response during cardiac surgery are effects. Using leukocyte filtering during CPB may limit the
methyl-prednisolone and dexamethasone. They inhibit phos- postoperative inflammatory response as measured by reduced
pholipase activity and protect myocardial cells. These effects IL-8 production [16]. Some of the investigators have reported
reduce damage in the myocardium and lungs. Steroids can- leukocyte filtering did not improve pulmonary hemodynamics
not prevent endotoxemia during CPB but prevent activation [16], but others have reported better lung functions [17, 18].
of complement and reduce the release of proinflammatory
cytokines. Bronicki et al. [12] demonstrated that preopera-
tive administration of 1 mg/kg dexamethasone decreases the Off-Pump Beating Heart Technique
inflammatory response.
Perhaps the most effective prevention method against
the inflammatory response is using the off-pump cardiac
Aprotinin surgery technique. This technique involves some techni-
cal difficulties and cannot be used for all types of cardiac
This is a protease inhibitor derived from bovine lungs. It has surgery (valve surgery, etc.). The perioperative release of
antagonist effects on proteolytic enzymes such as kallikrein inflammatory response markers IL-6 and TNF-a was found
and plasmin. It inhibits complement activation and produc- to be significantly lower after off-pump cardiac surgery. It
tion of TNF-a and IL-6. Aprotinin also reduces neutrophil has also been shown that the number of circulating mono-
migration to the lungs and IL-8 production. cytes and polymorphonuclear cells was significantly lower
following off-pump cardiac surgery [19]. Gu et al. reported
that C3a, b-thromboglobulin, and leukocyte elastase levels
Adenosine are lower than in patients who undergo on-pump cardiac sur-
gery [20]. This result shows that CPB is the major factor
Adenosine can block oxygen-derived free radical production in activating the complement system. It is also reported that
from neutrophils. higher TNF-a levels are observed in patients undergoing on-
pump surgery [21]. However, there is no difference in IL-6
levels between the patients who were operated on off-pump
Sodium Nitroprusside and on-pump with median sternotomy [22] (Table 32.2).

Nitric oxide decreases ischemia-reperfusion injury. Nitric

oxide also has cardiac protective effects. Sodium nitroprus-
side is a nitric oxide donor. It inhibits complement activation. Table 32.2 Inflammatory mediators during cardiac surgery
Off-pump On-pump
Complement activation [11] ↓ ↑
Heparin-Coated Circulation TNF-a level [11] ↓ ↑
IL-6 level [2, 12] ↔ ↔
During cardiopulmonary bypass, blood exposure to the IL-8 level [8] ↓ ↑
extracorporeal circulation circuit is the most important factor IL-10 level [2] ↓ ↑
causing systemic inflammatory reactions. It has been thought Neutrophil elastase level [11, 15] ↓ ↑
that heparin-coated extracorporeal circuit lines can prevent Leukocyte activation [12] ↔ ↔
thrombosis. Many studies have shown that heparin-coated C-reactive protein ↔ ↔
circuits decrease leukocyte activation and repair platelet C3a and C5a levels [11] ↓ ↑
functions [13]. Levels of TNF-a, IL-6, IL-8, and thrombin- ↔ no difference, ↓ significantly lower, ↑ significantly higher
280 K. Kaya

References 11. Kirklin JK, Westaby S, Blackstone EH, et al. Complement and the
damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc
1. Ng CSH, Wan S, Yim APC, Arifi AA. Pulmonary dysfunction after Surg. 1983;86:845–57.
cardiac surgery. Chest. 2002;121:1269–77. 12. Bronicki RA, Backer CL, Baden HP, Mavroudis C, Crawford SE,
2. Massoudy P, Zahler S, Becker BF, Braun SL, Barankay A, Gren TP. Dexamethasone reduces the inflammatory response to car-
Meisner H. Evidence for inflammatory response of the lungs during diopulmonary bypass in children. Ann Thorac Surg. 2000;69:1490–5.
coronary artery bypass grafting with cardiopulmonary bypass. 13. Matheve C. Clinical evidence of improved biocompatibility using
Chest. 2001;119:31–6. heparin-coated surfaces. Perfusion. 1996;11:264–9.
3. Cassey WF, Hauser GJ, Hannalah RS, Midgley FM, Khan W. 14. Moen O, Hogasen K, Fosse E, et al. Attenuation of changes in leuko-
Circulating endotoxin and tumour necrosis factor during paediatric cyte surface markers and complement activation with heparin-coated
cardiac surgery. Crit Care Med. 1992;20:1090–6. cardiopulmonary bypass. Ann Thorac Surg. 1997;63:105–11.
4. Fortenberry JD, Bhardwaj V, Niemer P, et al. Neutrophil and 15. Hamulu A, Discigil B, OZbaran M, et al. Complement consump-
cytokine activation with neonatal extracorporeal membrane tion during cardiopulmonary bypass: comparison of Duraflo II
oxygenation. J Pediatr. 1996;128:670–8. heparin-coated and uncoated circuits in fully heparinized patients.
5. Gessler P, Pfenninger J, Pfammatter JP, Carrel T, Baenziger O, Perfusion. 1996;11:333–7.
Dahinden C. Plasma levels of interleukin-8 and expression of inter- 16. Gu YJ, de Vries AJ, Vos P, et al. Leukocyte depletion during cardiac
leukin-8 receptors on circulating neutrophils and monocytes after operation. A new approach through the venous bypass circuit. Ann
cardiopulmonary bypass in children. J Thorac Cardiovasc Surg. Thorac Surg. 1999;67:604–9.
2003;126:718–25. 17. Olivencia-Yurvatti AH, Ferrara CA, Tierney N, Wallace N, MAllet
6. Jansen NJ, van Oeveren W, van der Brock L, et al. Inhibition by RT. Strategic leukocyte depletion reduces pulmonary microvascular
dexamethasone of the reperfusion phenomenon in cardiopulmonary pressure and improves pulmonary status post-cardiopulmonary
bypass. J Thorac Cardiovasc Surg. 1991;102:515–25. bypass. Perfusion. 2003;18 suppl 1:23–31.
7. Sun D, Xu C, Li J, Jiao X, Chen Y. Changes of inflammatory factors 18. Morioka K, Muraoka R, Chiba Y, et al. Leukocyte and platelet
in patients with coronary artery disease during perioperation. depletion with the blood cell separator: effects on lung injury after
Zhonghua Wai Ke Za Zhi. 2002;40:571–3. cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc
8. Khabar KS, elBarbary MA, Khouqeer F, et al. Circulating endotox- Surg. 1996;111:45–54.
ins and cytokines after cardiopulmonary bypass: differential corre- 19. Ascione R, Lloyd CT, Underwood MJ, et al. Inflammatory response
lation with duration of bypass and systemic inflammatory response/ after coronary revascularization with or without cardiopulmonary
multiple organ dysfunction syndromes. Clin Immunol bypass. Ann Thorac Surg. 2000;69:1198–204.
Immunopathol. 1997;85:97–103. 20. Gu YJ, MAriani MA, van Oeveren W, et al. Reduction of the
9. Clermont G, Vergely C, de Girard C, Rochette L. Cellular injury inflammatory response in patients undergoing minimally invasive
associated with extracorporeal circulation. Ann Cardiol Angeiol. coronary artery bypass grafting. Ann Thorac Surg. 1998;65:420–4.
2002;51:38–43. 21. Brasil LA, Gomes WJ, Salomao R, et al. Inflammatory response
10. Ulus AT, Aksoyek A, Ozkan M, Katircioglu SF, Basu S. after myocardial revascularization with or without cardiopulmo-
Cardiopulmonary bypass as a cause of free radical-induced oxida- nary bypass. Ann Thorac Surg. 1998;66:56–9.
tive stress and enhanced blood-borne isoprostanes in humans. Free 22. Wan S, LeClere JL, Vincent JL. Inflammatory response to cardio-
Radic Biol Med. 2003;34:911–7. pulmonary bypass. Chest. 1997;112:676–92.
 Lung Protection in Cardiovascular
Surgery 33
Edmo Atique Gabriel and Sthefano Atique Gabriel

Lung protection is a cutting-edge topic for cardiovascular sur- bear in mind that coronary perfusion is as relevant as lung per-
geons; for several decades the main concern has been just to fusion. Perhaps we still need to devote major effort to convinc-
protect the heart by preventing ischemia-reperfusion injury [1]. ing heart teams to add lung protection to their operative checklist
Nonetheless, in recent years, some heart teams have turned [7, 8]. Implementation of lung protection can be carried out by
their attention to the importance of the lungs throughout and employing some of the strategies depicted in Table 33.1 [9].
following cardiovascular surgery. The lungs have lagged The role of two substances in lung protection – protein C
behind everything considering that the heart-lung machine has and adenosine – has been extensively addressed in recent
an unmatchable ability to carry out pulmonary function with- papers worldwide. Thus, understanding their mechanism of
out metabolic, biochemical, or structural modifications [2, 3]. action and the effective impact on pulmonary function will
The concept of lung protection has evolved so far that allow heart surgeons to attenuate the inflammatory response
many cardiovascular surgeons worldwide have published and ischemia-reperfusion injury during heart surgery [10].
numerous papers consistently advocating this idea and carry- Protein C has an activated form – activated protein C;
ing it out during heart operations. Furthermore, one of the this is a natural anticoagulant generated by the thrombin-
greatest breakthroughs on this topic was proving that bron- thrombomodulin complex on endothelial cells. In addition
chial arterial circulation alone is not enough to provide blood to the anticoagulant role, this activated protein has antiinflam-
flow to the lungs, and thus one could conclude that bronchial matory properties as it downregulates proinflammatory
circulation will not protect the lungs from ischemia-reperfu- cytokines and regulates cardiopulmonary bypass-induced
sion injury. Even when the heart is placed on a bypass neutrophil activation [10, 11].
machine and kept beating during surgery, lung protection is Yamakazi et al. [12] designed intriguing experimental
inadequate because the flow provided by conventional car- research depicting the inflammatory and functional benefits
diopulmonary bypass is low and not pulsatile [4–6]. of using activated protein C in heart surgery requiring
Many steps should be taken to obtain optimal results after
cardiovascular surgery in terms of adequate lung protection. Table 33.1 Strategies for lung protection in heart surgery
First, heart teams must be aware of the importance of lung cir- Utilization of heparin-coated circuits
culation for the postoperative quality of the procedure. In addi- Utilization of synthetic co-polymer(methacrylate)-coated circuits
tion, they must be concerned about managing inflammatory Utilization of phosphorylcholine-coated circuits
factors, which can considerably impair surgical outcomes, and Use of ultrafiltration techniques
Use of leukocytes filters
Use of the Drew-Anderson techniquea
E.A. Gabriel, MD, PhD (*) Lung perfusion with controlled perfusion pressure
Department of Cardiovascular Surgery, Lung perfusion with antibiotics and antiinflammatory solutions
University Nove de Julho, São Paulo, Brazil
Lung perfusion with pulsatile flow
e-mail: edag@uol.com.br
Lung perfusion with low-volume ventilation
S.A. Gabriel, MD Inhalation of NO
Department of Vascular Surgery,
Pontifical Catholic University of Campinas, Inhalation of CO
São Paulo, Brazil Miniaturized cardiopulmonary circuit
Management of hemodilution
Department of Vascular Surgery,
Celso Pierro Hospital and Maternity, Monoclonal anticytokine antibodies
a
Campinas, São Paulo, Brazil Technique designed to keep lungs ventilating in such a way that lungs
e-mail: sthefanogabriel@yahoo.com.br are natural oxygenators.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 281
DOI 10.1007/978-1-4471-4429-8_33, © Springer-Verlag London 2013
282 E.A. Gabriel and S.A. Gabriel

a b

Fig. 33.1 Microphotograph of the left lung. The left lung section in severe neutrophil accumulation. Inflammatory change in the APC group
each group was stained with hematoxylin & eosin. Lungs in the control lung is minimized. Original magnification: x200. Black bar = 50 mm.
and DIP groups show interstitial edema, alveolar hemorrhage, and Control (a), DIP (b), and APC (c) groups

cardiopulmonary bypass. These authors defined three Taking into consideration that adenosine has many relevant
groups as follows: control, DIP (intravenous inactive benefits for lung protection, a feasible strategy would be to
derivative of activated protein C), and APC (intravenous use adenosine agonists in an attempt to improve lung function.
activated protein C). Histological analysis, arterial oxygen Based on this concept, Emaminia et al. [14] just published
pressure, proinflammatory marker concentration, and an experimental study in which two groups were assigned
CD11b expression are shown in Figs. 33.1, 33.2, 33.3, and according to the strategy of ex vivo lung perfusion. The con-
33.4. These figures allow us to suggest that, in terms of trol group (EVLP) underwent 14 h of ischemia, and subse-
pulmonary function, activated protein C can play a protec- quently the lungs were perfused with a protective solution for
tive role, minimizing inflammatory injury and providing 5 h. The treatment group (EVLP+ adenosine agonist) under-
functional balance [12]. went the same procedure, but the lungs were perfused with the
Adenosine is a useful substance for lung protection that same protective solution plus a selective adenosine agonist.
can be employed either during heart-lung procedures or dur- Some results obtained by Emaminia et al. [14] corrobo-
ing ex vivo lung perfusion. Thus, it is evident that adenosine rate the protective effects of adenosine as well as adenosine
plays a remarkable role in conventional heart-lung opera- agonists in lung function (Figs. 33.5 and 33.6). Its benefits
tions and some particular operations, such as heart-lung are seen in terms of less mean airway pressure and less
transplantation/lung transplantation [13]. expression of inflammatory markers.
33 Lung Protection in Cardiovascular Surgery 283

a 18 b 600

Arterial oxygen pressure (mmHg)

Peak airway pressure (cmH2O)

#
400

12

200

Control Control
DIP-APC DIP-APC
APC APC

6 0
Before CPB End of the experiment
Before CPB End of the experiment

c 10

8
W/D ratio

#
6

4
Control DIP-APC APC

Fig. 33.2 (a) Peak airway pressure before CPB and at the end of the experiment. Results are expressed as mean ± SEM. #P < 0.01 versus the
experiment. The APC group shows a relatively lower value than the control or DIP group. (c) W/D weight ratio of the left lung. The APC
other groups at the end of the experiment, although there are no group shows a significantly lower value than the other groups. Results
significant differences among the groups. Results are expressed as mean are expressed as mean ± SEM. #P < 0.01 versus the control or DIP
± standard error of the mean (SEM). (b) Arterial oxygen pressure before group. APC activated protein C, CPB cardiopulmonary bypass, DIP
CPB and at the end of the experiment. The APC group shows a diisopropyl fluorophosphate, W/D wet to dry
significantly higher value than the other groups at the end of the
284 E.A. Gabriel and S.A. Gabriel

a 3 b 15

TNF-α (pg/μg protein)

MIP-2 (pg/μg protein)

2 10

1 5
#

0 0
Control DIP-APC APC Control DIP-APC APC

c 15
IL-1β (pg/μg protein)

10

0
Control DIP-APC APC

Fig. 33.3 (a) Tissue MIP-2 concentration in the left lung. The APC (c) Tissue IL-1b concentration in the left lung. The APC group shows a
group shows a relatively lower value than the control group and a relatively lower value than the other groups, although there are no
significantly lower value than the DIP group. Results are expressed as significant differences among the groups. Results are expressed as mean
mean ± SEM. #P < 0.01 versus the DIP group. (b) Tissue TNF-a ± SEM. DIP diisopropyl fluorophosphate, APC activated protein C,
concentration in the left lung. The APC group shows a relatively lower TNF tumor necrosis factor, MIP macrophage inflammatory protein, IL
value than the other groups, although there are no significant differ- interleukin
ences among the groups. Results are expressed as mean ± SEM.
33 Lung Protection in Cardiovascular Surgery 285

a 300 b 150

#
CD11b expression (%)

CD62L expression (%)

200 100 *

*
**
100 50

Control Control
DIP-APC DIP-APC
APC APC

0 0
Before After End of Before After End of
CPB CPB the experiment CPB CPB the experiment

Fig. 33.4 (a) CD11b expression in circulating neutrophils. Percentage before CPB was calculated. CD62L expression remains level in the
change in geometric mean from the value before CPB was calculated. APC throughout the experiment, whereas expression in the control and
The APC group maintains level CD11b expression at all of the time DIP groups gradually decreases to approximately 50 % at 120 min after
points, whereas expression in the control and DIP groups approximately the initiation of CPB. Results are expressed as mean ± SEM. #P < 0.01
doubles at 60 and 120 min after the initiation of CPB. Results are versus the control or DIP group. *P < 0.05 versus the DIP group. CPB
expressed as mean ± SEM. *P < 0.05 versus the DIP group. **P < 0.05 cardiopulmonary bypass, DIP diisopropyl fluorophosphate, APC acti-
versus the control or DIP group. (b) CD62L expression on circulating vated protein C
neutrophils. Percentage change in geometric mean from the value

* 120
14 *
100
Mean airway pressure (Cm H2O)

12

10 80
IFN-γ (pg/mL)

8
60
6
40
4

2 20

0
EVLP EVLP + A2AR agonist 0
EVLP EVLP + A2AR agonist
Fig. 33.5 Comparison of the wet-dry (W/D) weight ratio between the
treatment and control groups. Low edema formation rates were observed Fig. 33.6 Tissue level of interferon gamma (IFNg) was significantly
in lungs exposed to the A2A agonist; *P = 0.03. EVLP ex vivo lung lower in treatment lungs after 5 h of ex vivo lung perfusion (EVLP) and
perfusion, A2AR A2A receptor exposure to adenosine A2A agonist; *P = 0.05. A2AR A2A receptor
286 E.A. Gabriel and S.A. Gabriel

References macrophage in lung ischemia-reperfusion injury. J Thorac

Cardiovasc Surg. 2004;127:1502–8.
1. Sievers HH, Freund-Kaas C, Eleftheriadis S, Fischer T, Kuppe T, 8. Anvari F, Sharma AK, Fernandez LG, Hranjec T, Ravid K, Kron IL,
Kraatz EG, et al. Lung protection during total cardiopulmonary et al. Tissue-derived proinflammatory effect of adenosine A2B
bypass by isolated lung perfusion: preliminary results of a novel receptor inlung ischemia – reperfusion injury. J Thorac Cardiovasc
perfusion strategy. Ann Thorac Surg. 2002;74:1167–72. Surg. 2010;140:871–7.
2. Farivar AS, Delgado MF, McCourtie AS, Barnes AD, Verrier ED, 9. Carvalho EMF, Gabriel EA, Salerno TA. Pulmonary protection dur-
Mulligan MS. Crosstalk between thrombosis and inflammation in ing cardiac surgery: systematic literature review. Asian Cardiovasc
lung reperfusion injury. Ann Thorac Surg. 2006;81:1061–7. Thorac Ann. 2008;16:503–7.
3. Zhang L, Kumar S, Kaminski A, Kasch C, Sponholz C, Stamm C, 10. Murakami K, Okajima K, Uchiba M, Johno M, Nakagaki T, Okabe
et al. Importance of endothelial nitric oxide synthase for the H, et al. Activated protein C prevents LPS-induced pulmonary vas-
hypothermic protection of lungs against ischemia-reperfusion cular injury by inhibiting cytokine production. Am J Physiol.
injury. J Thorac Cardiovasc Surg. 2006;131:969–74. 1997;272:L197–202.
4. Iglesias M, Jungebluth P, Petit C, Matute MP, Rovira I, Martínez E, 11. Lisle TC, Gazoni LM, Fernandez LG, Sharma AK, Bellizzi AM,
et al. Extracorporeal lung membrane provides better lung protec- Schifflett GD, et al. Inflammatory lung injury after cardiopulmo-
tion than conventional treatment for severe postpneumonectomy nary bypass is attenuated by adenosine A2A receptor activation.
noncardiogenic acute respiratory distress syndrome. J Thorac J Thorac Cardiovasc Surg. 2008;136:1280–8.
Cardiovasc Surg. 2008;135:1362–71. 12. Yamazaki S, Inamori S, Nakatani T, Suga M. Activated protein C
5. Gazoni LM, Walters DM, Unger EB, Linden J, Kron IL, Laubach attenuates cardiopulmonary bypass-induced acutelung injury
VE. Activation of A1, A2A, or A3 adenosine receptors attenuates through the regulation of neutrophil activation. J Thorac Cardiovasc
lungischemia-reperfusion injury. J Thorac Cardiovasc Surg. Surg. 2011;141:1246–52.
2010;140:440–6. 13. Link AA, Kino T, Worth JA, McGuire JL, Crane ML, Chrousos GP,
6. Krishnadasan B, Naidu BV, Byrne K, Fraga C, Verrier ED, Mulligan et al. Ligand-activation of the adenosine A2a receptors inhibits IL-12
MS. The role of proinflammatory cytokines in lung ischemia- production by human monocytes. J Immunol. 2000;164:436–42.
reperfusion injury. J Thorac Cardiovasc Surg. 2003;125:261–72. 14. Emaminia A, LaPar DJ, Zhao Y, Steidle JF, Harris DA, Laubach
7. Naidu BV, Woolley SM, Farivar AS, Thomas R, Fraga CH, Goss VE, et al. Adenosine A2A agonist improves lung function during ex
CH, et al. Early tumor necrosis factor-a release from the pulmonary vivo lung perfusion. Ann Thorac Surg. 2011;92:1840–6.
 Part X
Coronary Artery Disease
 Fifteen Years of ‘No-Touch’ Saphenous
Vein Harvesting in Patients Undergoing 34
Coronary Artery Bypass Surgery:
What Have We Learned?

Michael R. Dashwood and Domingos S.R. Souza

Introduction Saphenous Vein: Structure

Coronary artery disease (CAD) is the major cause of mortality As with most blood vessels, the SV is characterized by three
in the Western world. Methods for restoring blood supply to main layers (Fig. 34.1):
the heart have changed over the years and include percutane- 1. The innermost layer, the intima, consisting of little more
ous transluminal coronary angioplasty (PTCA), bare metal than a thin basement membrane and its endothelial lining.
or drug-eluting stents, with more recent attempts using tech- 2. The middle layer, the media, consisting mainly of vascu-
niques such as gene targeting and stem cell therapy. Once lar smooth muscle cells (VSMCs) separated by collagen
these techniques have failed, the remaining method for revas- in which the vasa vasorum is located.
cularization of the myocardium is coronary artery bypass 3. The outermost layer, the adventitia, is the thickest layer and
surgery (CABG) using autologous blood vessel grafts as is composed of collagen fibers and fibroblasts that merge
‘conduits,’ restoring blood supply to diseased heart muscle. with the surrounding connective tissue and fat. Also, within
The main vessels used include the internal thoracic artery the adventitia are embedded the vascular (autonomic)
(ITA), radial artery (RA), and saphenous vein (SV). The suc- nerves and vasa vasorum. Surrounding the adventitia is a
cess of CABG relies on the long-term patency of the conduit pronounced cushion of perivascular fat (PVF).
used for revascularization. Originally, SV grafts were used, The inner border of the media and intima is divided by the
but the ITA has subsequently become the first conduit of internal elastic lamina. In medium-sized veins, such as the SV,
choice since it has superior patency compared with SV grafts the intima is thrown into folds, and there may be signs of thick-
[1, 2]. The poor long-term results with SV grafts and the ening due to the presence of smooth muscle cells and collagen
encouraging results with ITA have led to a search for other within regions of neointimal hyperplasia. These features are
arterial conduits for CABG. Among arterial grafts, the radial only seen in ‘normal,’ non-distended/immersion-fixed sections
artery (RA) has gained the widest popularity as in many and often not represented by published examples that have
studies it has shown an excellent long-term patency [3] com- been perfusion fixed at ~100 mmHg compared with the vein’s
pared to SV grafts. However, recent studies have shown no normal ~10 mmHg basal pressure. The media and adventitia
difference between RA and SV grafts regarding their clinical are divided by the external elastic lamina, which is less distinct
outcome [4] or patency [5]. There is no doubt that the SV in veins than arteries. The vascular nerves are located in the
remains an important and the most widely used complemen- adventitia, and also within this layer is a microvessel network,
tary conduit for patients undergoing CABG, and improve- the vasa vasorum, which penetrates the media and may extend
ment of its long-term patency has been a major goal. into the vessel lumen. During conventional vein harvesting, all
vessel layers are damaged to varying degrees.
M.R. Dashwood, PhD (*)
Department of Clinical Biochemistry,
Royal Free and University College Medical School,
London NW3 2QG, UK Intima and Endothelium
e-mail: m.dashwood@ucl.ac.uk
D.S.R. Souza, MD, PhD The single layer of cells lining the vein lumen, the endothe-
Department of Cardiovascular Surgery
lium, is affected during harvesting. There may be some
and Anesthesiology, Örebro University Hospital,
Örebro, Sweden ‘mechanical’ detachment of endothelial cells caused during
e-mail: domingos.souza.orebro@gmail.com removal and handling during surgery. The most striking

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 289
DOI 10.1007/978-1-4471-4429-8_34, © Springer-Verlag London 2013
290 M.R. Dashwood and D.S.R. Souza

Fig. 34.1 Structure of human saphenous vein. (Left) Whole transverse magnification of the wall of the SV showing the three distinct layers
section of non-distended human saphenous vein (SV) where the (I intima, M media, A adventitia). The arrows indicate the vasa
intima, surrounding the lumen (L) is thrown into folds. (Right) High vasorum

effect is the dramatic endothelial denudation caused by dis- the media, with striking shape changes to VSMCs as well as
tension at pressures of up to or over 700 mmHg [6]. While intracellular effects, including increased signs of nuclear divi-
these effects are apparent by light microscopy [7], further sion [8]. In addition to the effects on medial VSMCs, there
shape changes and cell detachment are revealed using elec- are signs of damage to the vasa vasorum, where many of these
tron microscopy [8, 9] (Fig. 34.2). Apart from the striking microvessels appear collapsed and their endothelial cells mis-
effects observed on the endothelium, distension-induced shapen and/or occluded by erythrocytes [8].
‘smoothing’ of the intima has been described where the folds
that are evident in non-distended vein segments are absent in
veins that have been subjected to high-pressure intraluminal Adventitia
distension [10] (Fig. 34.3). There may also be evidence of
damage to cells within the intima as well as rupture of the It is the adventitia, the outermost layer of the SV, that is gener-
internal elastic lamina. ally removed or severely damaged during conventional harvest-
ing but spared when using Souza’s ‘no-touch’ technique [11]
(Figs. 34.3 and 34.4). First, along with its adjacent connective
Media tissue and cushion of surrounding fat, the adventitia consti-
tutes a robust perivascular structure that protects the vein
While the VSMCs that predominate within the media control against the effects of altered hemodynamics once implanted
venous tone, they may also alter their phenotype from con- into the coronary arterial system. In addition to this mechani-
tractile to synthetic. In this state these cells migrate and pro- cal role, the adventitia contains the major proportion of auto-
liferate and are associated with the medial and intimal nomic nerves innervating the vessel, as well the vasa vasorum,
thickening observed in occluded vein grafts. Although there microvessels responsible for the exchange of gases and nutri-
may be some damage to the media caused by manipulation by ent supply to the vessel wall. Although the excised vein is
surgical instruments, the most pronounced effect is due to essentially denervated, removal of the adventitia will further
high-pressure distension during harvesting. This additional reduce the perivascular nerves, although these have been
insult causes considerable thinning of the vessel wall [10] shown to proliferate in experimental porcine grafts [12, 13].
(Fig. 34.3), presumably because of overstretching of smooth Perhaps the most serious consequence of removing the
muscle cells exposed to high/raised circumferential pressures. adventitia is the damage caused to the vasa vasorum
Again, dramatic cellular changes have been reported within (Fig. 34.5). There is convincing evidence from experimental
34 Fifteen Years of ‘No-Touch’ Saphenous Vein Harvesting in Patients Undergoing Coronary Artery Bypass Surgery 291

Undamaged Damaged

Fig. 34.2 Endothelium of undamaged and damaged human saphenous human SV where there is a smooth, intact endothelium lining of undam-
vein. The panels on the left are representative examples from undam- aged veins but denudation and shape change of endothelial cells of the
aged (no-touch) veins and on the right are damaged (conventional) damaged vein. The lower panels show examples of transmission elec-
veins. The top panels show immunohistochemical localization of lumi- tron micrographs of luminal endothelial cells. There is a marked altera-
nal endothelium (identified using CD31: red stain), which is continuous tion in endothelial cells (En, arrows) in damaged versus undamaged
in the undamaged vein. In the damaged (conventional) vein, there are veins. sm smooth muscle, col collagen, N nucleus, Fo luminal fold,
large areas of endothelial denudation (arrow). The middle panels show ju junction, el elastin (Modified from Refs. [8, 9])
examples of scanning electron micrographs of en face preparations of

animal models that occlusion of the vasa vasorum by a close- compounds, suggesting that they play a role in the regulation
fitting external collar [14] or adventitial removal [15] leads of the tone of the vasa vasorum, implicating this microvessel
to neointimal hyperplasia and atherosclerosis, both features network in conduit vessel physiology [16].
associated with vein graft failure. It has been suggested that
these effects are mainly due to ischemia of the vessel’s media,
and this is supported by studies showing that reduced trans- Perivascular Fat
mural oxygen levels are detected in occluded femoral arter-
ies in an experimental model of atherosclerosis [14]. Using the no-touch harvesting technique, the SV is removed
Interestingly, it has been shown that the vasa vasorum is with minimal surgical damage and complete with its pro-
affected by application of both dilator and constrictor nounced cushion of perivascular fat (PVF) (Fig. 34.4). In this
292 M.R. Dashwood and D.S.R. Souza

Fig. 34.3 Media and vascular Undamaged Damaged

smooth muscle of undamaged
and damaged human saphenous
vein. (Top panels) Representative
transverse sections of undam-
aged vein (left) and damaged
(right) human SV. (Lower
panels) Transmission electron
micrographs where the
undamaged vascular smooth
muscle cells are uniform in
shape in the undamaged vein but
exhibit dramatic shape changes
in the damaged cells. sm smooth
muscle, N nucleus, small white
arrow nuclear division (Modified
from Ref. [8])
34 Fifteen Years of ‘No-Touch’ Saphenous Vein Harvesting in Patients Undergoing Coronary Artery Bypass Surgery 293

Fig. 34.4 No-touch and No-touch Conventional

conventional saphenous vein
used as bypass grafts in CABG.
(Left) The no-touch vein is
removed complete with its
cushion of surrounding PVF
perivascular fat (PVF). Handling
the vein via this cushion
prevents the vein from going
into spasm (lower arrow).
(Right) Conventionally
harvested vein is stripped of
surrounding tissue causing
spasm (arrow) that is overcome
using high-pressure saline
distension (shown at upper
segment of the vein). To the left
is a tied off side branch

No-touch Conventional

Fig. 34.5 Vasa vasorum of no-touch and conventionally harvested the adventitia removed (top panel) with the lower panel showing
saphenous vein. Left panels show representative examples of a no-touch a scanning electron micrograph of the damage to the adventitial vasa
vein with adventitia intact. The lower panel shows retrograde blood vasorum. The endothelial cells lining both the lumen and vasa vasorum
flow through the adventitial vasa vasorum on release of vascular clamps in the top panels are identified using CD31 (dark immunostaining). The
at completion of graft insertion – evidence of luminal termination. Right dotted line shows the external elastic lamina that separates the media
panels show examples of conventionally harvested veins with much of (M) and adventitia (A)
294 M.R. Dashwood and D.S.R. Souza

Angiograms of “no-touch” grafts without kinking

Fig. 34.6 Angiographic examples of no-touch saphenous vein grafts. Two examples of angiograms of no-touch saphenous vein grafts in CABG
patients where the surrounding cushion of tissue prevents kinking (arrows), maintaining blood flow in excessively long grafts

way, the vein retains its normal architecture, providing supe- anti-inflammatory, and antiproliferative properties [20, 21].
rior graft patency when compared with veins prepared by We have also identified leptin in extracts of PVF from human
conventional methods. When performing conventional har- SV [22]. Positive immunostaining for leptin is associated
vesting, the vein is stripped of much of its surrounding tis- with adipocytes of the PVF surrounding the SV, and, as an
sue, a procedure that inflicts considerable vascular damage. adipokine with both vasorelaxant and angiogenic properties,
In addition, a high proportion of veins to go into spasm, we hypothesize that this, and other adipocyte-derived factors
which is overcome using high-pressure intraluminal disten- such as adiponectin [23], may play an important role in the
sion. We have evidence that the intact PVF of SVs harvested improved performance of no-touch SV grafts.
by the no-touch technique plays an essential role in its suc-
cess. Since the vein is handled during surgery by the PVF,
direct contact by surgical instruments and consequent spasm Conventional Saphenous Vein
are avoided, distension is unnecessary, and the luminal Harvesting Technique
endothelium remains intact. In addition, the vasa vasorum is
preserved and the supply of oxygen and nutrients to the graft The SV has been the vessel of choice for autologous vein
wall maintained. The PVF also provides mechanical support grafts since its introduction for CABG by Favarolo in 1969
to the vein once implanted into the coronary arterial circula- [24]. The use of autologous grafts eliminates problems of
tion where it acts as a buffer, protecting the graft against arte- tissue rejection and the need for tissue typing and matching.
rial hemodynamics as well as preventing kinking of The SV also has a number of practical advantages: it is
excessively long grafts (Fig. 34.6). Finally, the surrounding expendable, since lower limb drainage can rely solely on the
cushion of fat is a source of adipocyte-derived relaxing fac- deep venous system; its long length allows its use for multi-
tors (ADRFs) [17–19], many of which are vasculoprotective. ple grafts, and its superficial position renders it easily acces-
For example, PVF surrounding no-touch-harvested SVs sible, facilitating its exposure at harvest [25]. Since its
obtained from patients undergoing CABG is a potential introduction as a graft, the SV has become the most com-
source of NO, a vasorelaxant factor with antithrombotic, monly used conduit in patients undergoing CABG. However,
34 Fifteen Years of ‘No-Touch’ Saphenous Vein Harvesting in Patients Undergoing Coronary Artery Bypass Surgery 295

the patency rate of this vessel is poor, with 15–25 % grafts bed using scissors and electrocautery. The vein should be left
occluding within 1 year and over 50 % patients requiring in situ and covered with a moistened compress at least until a
redo surgery within 10 years [26]. few minutes after heparinization. This allows continuous hep-
Although there may be minor modifications made by car- arinized blood perfusion to be carried out and obviates the
diac surgeons, during conventional harvesting, the SV is need for rinsing or flushing the vein with saline solution.
either harvested endoscopically or exposed by a longitudinal After removal, the vein is stored in heparinized blood obtained
leg incision, where the surrounding connective tissue, includ- from the aortic cannula. While performing the anastomosis,
ing the adventitia, is stripped off and its side branches ligated. the vein is handled via the surrounding cushion, thereby
Generally, veins are then distended with saline to check for avoiding direct contact between the vein and instruments.
leakage, often at high pressure to overcome the spasm that This prevents spasm from occurring. After each completed
occurs because of surgical trauma [25]. Rather than preserv- distal anastomosis, the vein graft is briefly connected to the
ing their normal architecture, SV grafts are frequently pre- arterial cannula of the cardiopulmonary bypass system using
pared in such a way that they merely serve as channels (hence a three-way stopcock to check for any leakage from the anas-
the general term “conduit”) for redirecting blood flow past tomosis or side branches. Manual distension using a syringe
occluded regions of the coronary vasculature in order to should be avoided, as this procedure damages the endothelial
maintain or restore myocardial perfusion. For example, the lining of the lumen [3, 7, 10]. After removal of the aortic
original paper describing the use of the SV as a bypass graft cross-clamp, and before suturing the proximal anastomoses,
for CABG states that, “Care must be taken to dissect only the the grafts are once again connected to the arterial line. This
vein, avoiding as much as possible the adventitia that sur- procedure assists in determining the graft length and main-
rounds it” [24]. These instructions have been taken by many tains the vein in a dilated condition. Accordingly, this is a true
cardiac surgeons to indicate that the vein should be stripped “no-touch” technique as the SV is not handled with instru-
of surrounding tissue at harvesting. Consequently, a high ments nor is it distended or flushed during the whole proce-
proportion of SVs go into spasm, with the high pressure dure. SVs prepared by this no-touch technique exhibit an
saline distension employed causing further damage to the improved early graft performance [30, 31] with patency at
vein [22, 25]. The potential effect of vascular damage on 18 months for no-touch SV grafts of 95 % versus 89 % for
graft patency has been recognized for some time, and various conventional grafts and similar to the ITA. A long-term (mean
atraumatic dissecting techniques have been introduced in an 8.5 years) follow-up study described a no-touch SV graft pat-
attempt to improve vein graft performance [11, 27, 28]. ency that was comparable to the ITA (both 90 %) and superior
to conventional SV grafts (76 %) [32].

No-Touch Saphenous Vein Harvesting

Vein Harvesting and Vascular Damage
The particular ‘no-touch’ technique that is the focus of this
chapter was described by Souza in1996 [11]. Various minor Clearly, damage to the proximal and distal segments of the
modifications have been made subsequently, with details of SV to be grafted is inevitable since the vessel is ‘discon-
the technique, including video footage, available online nected’ from the remainder of the native vein during
(http://mmcts.ctsnetjournals.org/cgi/content/full/2009/0731/ harvesting. There seems no basis for the additional damage
mmcts.2008.003624) [29]. Briefly, the day before the opera- caused when ‘clearing’ the vein of surrounding tissue apart
tion, a Duplex examination of the SV should be performed in from identifying leaks and ligating side branches. Otherwise,
order to mark the course of the vein on the skin. This allows stripping the vein of adherent tissue appears to be only for
an incision to be made precisely over the vein to avoid creat- ‘aesthetic’ purposes. In isolating the vein from its outer cush-
ing a flap of subcutaneous tissue, thus reducing the risk of ion, we believe that subsequent graft occlusion is associated
complications such as hematomas, seromas, or infection. with a number of factors ranging from endothelial disruption
Also, on the day of CABG, the SV is located and harvested to medial ischemia and altered vascular smooth muscle com-
with minimal delay. It is imperative to follow the surgical pliance and deformation resulting from the removal of the
technique in all details from harvesting to implantation. mechanical influences of the vein’s outer layer and surround-
A longitudinal incision is made over the skin and the required ing cushion of tissue. When using conventional harvesting
length of vein exposed, keeping its perivascular tissue in place procedures the luminal endothelium is denuded mainly
(Fig. 34.4). After exposure, a margin of about 0.5 cm is cre- because of the high pressure distension used to overcome
ated around the vein to include the fat pedicle using electro- spasm [7–9, 33] (Fig. 34.2), ultrastructural changes occur to
cautery, and all visible side braches are ligated and divided at the VSMCs in the media [8] (Fig. 34.3), and the damage to
the same level (0.5 cm from the vein). The SV, together with the adventitia when removing the SV causes severing of the
its cushion of surrounding tissue, is then separated from its vasa vasorum [10, 34] (Fig. 34.5) and sectioning of the
296 M.R. Dashwood and D.S.R. Souza

perivascular nerves [35, 36]. A clinical study demonstrated There can be no doubt that EVH inevitably causes a
that, by avoiding this vascular damage, more patients receiv- degree of vascular damage, in particular to the outer layers of
ing no-touch-harvested SV grafts were free from angina with the vein. While a number of studies suggest that SV prepared
fewer patients with cardiac death or myocardial infarction by EVH, using the Mayo extraluminal dissector, preserves
than with conventionally harvested grafts [37]. A study endothelial function [45] as well as endothelial integrity and
employing angiography and intravascular ultrasound showed eNOS content [46], our data suggest that any damage to, or
that, at a mean time of 8.3 years, no-touch SV grafts had a removal of, the adventitia (as occurs using EVH) is likely to
lower intimal thickness, fewer multiple/advanced plaques have a detrimental effect on the SV when used as a graft in
and less plaque thickness, as well as a lower progression of CABG [7, 25], in particular through adverse effects on vas-
atherosclerosis than conventional SV grafts [38]. cular tissue sources of nitric oxide [7, 20]. A recent study
comparing the patency of ‘open harvested’ grafts versus
those prepared by EVH showed that endoscopic harvesting
Vascular Damage and Vein Graft Performance resulted in increased vein graft failure and adverse clinical
outcomes [47], supporting our suggestion that no-touch har-
When using the SV as a graft, this vessel, which is normally vesting would result in superior SV grafts to those prepared
subjected to low pressures (~5–8 mmHg), non-pulsatile flow, endoscopically [48].
and a shear stress of ~0.2 dyn/cm2, is grafted into the coro-
nary arterial system where it is subjected to high pressures
(~60–140 mmHg), pulsatile flow, and a shear stress of ~3–6 Concluding Remarks
dyn/cm2 [39]. These conditions lead to the ‘remodeling’ or
‘arterialization’ that contributes to graft failure when the SV The no-touch technique outlined in this chapter was intro-
is used in revascularization procedures. The combined effects duced in 1996, a major aim being to reduce surgical trauma at
of altered hemodynamics, shear stress, and increased pulsa- harvesting and to preserve the vessel’s normal architecture.
tile flow stimulates the release of a number of endothelium- Subsequent early and long-term follow-up studies showed that
derived factors [40] and causes a proportion of the VSMCs to no-touch-harvested SVs have a dramatically improved pat-
undergo a phenotypic change from the contractile to syn- ency rate, comparable to the ITA. Laboratory-based research
thetic, factors associated with vein graft occlusion [41]. techniques into mechanisms underlying the improved perfor-
Furthermore, although the role of the vasa vasorum in supply- mance of no-touch SV grafts have revealed various potential
ing the vessel wall with oxygen and nutrients has been recog- processes, many of which were unexpected. With such prom-
nized for some time [42], the importance of this microvessel ising follow-up results and supporting laboratory-based
network in maintaining ‘healthy vessels’ is frequently ignored, research data, it is disappointing that so many cardiac surgeons
and it is severely damaged when using most conventional har- are not prepared to adopt this technique, particularly consider-
vesting techniques. This interruption of transmural flow ren- ing the profound benefits to patients undergoing CABG.
ders the vessel wall ischemic, a condition triggering many of
the processes involved in vein graft failure [14, 15].
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 Platelets and Coronary Artery Disease
35
Meinrad Gawaz, Harald Langer, and Tobias Geisler

Introduction manner, they might regulate the adhesion and infiltration of

leukocytes, in particular of monocytes, into the vascular wall, a
Platelets play a critical role in thrombosis and hemostasis [1, 2]. process, that is thought to play a key role in acute and chronic
Beyond that, platelets have been recognized to act as an inflammation. Normal “resting” endothelium represents a non-
interface between thrombosis and inflammation [3]. Previous adhesive and non-thrombogenic surface that prevents extrava-
research has shown that inflammation plays a key role in the sation of circulating blood cells. In contrast, activated
development of coronary artery disease (CAD) and other endothelial cells are pro-adhesive and promote the adhesion of
manifestations of atherosclerosis [4]. Recently, platelets have circulating blood platelets. Adhesion of platelets to the intact
been recognized to trigger atherosclerotic lesion formation, but activated endothelium in the absence of previous endothe-
to favor plaque instability, and to form thrombosis at areas of lial denudation involves a surface receptor-dependent process
vulnerable plaques, resulting in myocardial infarction and that allows “capturing” of circulating platelets toward the ves-
tissue ischemia. During atherogenesis platelets interact with sel wall even under high shear stress. Similar to the recruitment
a variety of vascular and blood-borne cells (e.g., endothelial of leukocytes [5], the adhesion of platelets to the vascular
cells and leukocytes) and regulate chemotaxis, migration, endothelial surface is a multistep process in which platelets are
and cytokine/chemokine release, which further propagate tethered to the vascular wall followed by platelet rolling and
inflammation within vascular lesions [3, 5]. Understanding subsequent firm adhesion. Whereas the adhesion receptors
the role of platelets in atherogenesis will allow developing involved in platelet attachment to the subendothelial matrix,
new strategies in the treatment of coronary artery disease. e.g., following rupture of an atherosclerotic plaque, have been
well defined during the past decade, few studies have focused
on the molecular determinants that promote the interaction
Platelets Interact with Endothelium between platelets and the intact vascular endothelium.
and Propagate Inflammation During the adhesion process, platelets are activated and
release an arsenal of potent proinflammatory and promito-
In the past, numerous studies have shown that platelets can genic substances into the local microenvironment, thereby
adhere to the intact endothelial monolayer and substantially altering chemotactic, adhesive, and proteolytic properties of
modulate endothelial cell function [6–8]. Thus, under certain endothelial cells (Fig. 35.1). These platelet-induced altera-
pathophysiological circumstances, endothelial denudation and tions of the endothelial phenotype support chemotaxis,
exposure of the subendothelial matrix are not required for adhesion, and transmigration of monocytes to the site of
platelet adhesion to the vascular wall. Adherent platelets release inflammation. Among the various platelet-derived proinflam-
a variety of proinflammatory mediators and growth hormones matory proteins, IL-1b has been identified as a major
and have the potential to modify signaling cascades in vascular mediator of platelet-induced activation of endothelial cells.
cells, inducing the expression of endothelial adhesion receptors The IL-1b activity expressed by platelets appears to be asso-
and the release of endothelial chemoattractants [3]. In this ciated with the platelet surface [9], and co-incubation of
endothelial cells with thrombin-activated platelets induces
IL-1b-dependent secretion of IL-6 and IL-8 from endothelial
cells. Furthermore, incubation of cultured endothelial cells
M. Gawaz, MD (*) • H. Langer, MD • T. Geisler, MD
with thrombin-stimulated platelets significantly enhances
Department of Cardiology, University of Tübingen,
Tübingen, Germany the secretion of endothelial monocyte chemoattractant pro-
e-mail: meinrad.gawaz@med.uni-tuebingen.de tein-1 (MCP-1) in an IL-1b-dependent manner [10, 11].

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 299
DOI 10.1007/978-1-4471-4429-8_35, © Springer-Verlag London 2013
300 M. Gawaz et al.

Fig. 35.1 Platelets induce Platelets Adhesion

chemotactic, adhesive, Chemotaxis
and proteolytic properties
of endothelial cells VCAM-1 Proteolysis
ICAM-1
MCP-1 MMP
uPAR Migration

αvβ3
NF-kB ↑
p38 ↑ αvβ3
Nucleus

Endothelial cell

Fig. 35.2 Platelets activate Inflammation

the endothelial monolayer of Adhesion Secretion leukocyte recruitment Plaque formation
arteries and induce monocyte
chemotaxis and migration, thus
Fibrinogen IL-1β
propagating atherosclerotic CD40L Leukocytes MCP-1
Plaque
Platelets RANTES
lesion formation PF4
MMPs
PF4 LDL

Receptors GPLba/P-selectin P-selectin ICAM-1

PSGL-1/P-selectin
αvβ3

However, platelet IL-1b not only modifies endothelial the recruitment of both neutrophils and monocytes to the
release of chemotactic proteins, but it also has the potential endothelial cell surface, thus inducing inflammation.
to increase endothelial expression of adhesion molecules. Another platelet-derived chemokine is RANTES, which
Surface expression of ICAM-1 and avb3 on endothelial cells has been identified to trigger monocyte arrest on inflamed
is significantly enhanced by activated platelets via IL-1b and atherosclerotic endothelium [13]. Deposition of plate-
[10, 12]. Both enhanced chemokine release and upregulation let RANTES induces monocyte recruitment mediated by
of endothelial adhesion molecules through platelet-derived P-selectin. Furthermore, release of platelet-derived CD40
IL-1b act in concert and promote neutrophil and monocyte ligand induces inflammatory responses in endothelium.
adhesion to the endothelium. IL-1b-dependent expression of CD154 (CD40L), a 30–33 kDa protein, belongs to the TNF
early inflammatory genes, such as MCP-1 or ICAM-1, family of cytokines, which includes TNF-a and Fas ligand.
involves the activation of the transcription factor nuclear fac- CD40L was originally thought to be restricted to CD4+
tor kappa B (NF-kB). Transient adhesion of platelets to the T-lymphocytes, mast cells, and basophils. Henn et al. [14]
endothelium initiates degradation of IkB and supports acti- showed that platelets store CD40L in high amounts and
vation of NF-kB in endothelial cells, thereby inducing release CD40L within seconds following activation in vitro
NF-kB-dependent chemokine gene transcription [11]. and in vivo. Ligation of CD40 on endothelial cells by CD40L
Parallel to this finding, transfection of “decoy” kB oligonu- expressed on the surface of activated platelets increased the
cleotides or a dominant negative IKK mutant attenuates release of IL-8 and MCP-1, the principal chemoattractants
platelet-induced nuclear translocation of NF-kB and MCP-1 for neutrophils and monocytes. In addition, platelet CD40L
secretion in endothelial cells [10]. Likewise, platelet-induced enhanced the expression of endothelial adhesion receptors
NF-kB-activation was largely reduced by IL-1b antagonists, including E-selectin, VCAM-1, and ICAM-1, all molecules
supporting the notion that platelet IL-1b is the molecular that mediate the attachment of neutrophils, monocytes, and
determinant of platelet-dependent activation of the transcrip- lymphocytes to the inflamed vessel wall (Fig. 35.2). Hence,
tion factor. Taken together, platelet-derived IL-1b initiates like IL-1b, CD40L expressed on platelets induces endothelial
NF-kB-dependent expression of chemotactic and adhesive cells to release chemokines and to express adhesion molecules,
proteins in endothelial cells. In this manner, platelets promote thereby generating signals for the recruitment of leukocytes
35 Platelets and Coronary Artery Disease 301

in the process of inflammation. CD40 ligation on endothe- This suggests that platelets attached to the vessel wall may
lial cells, smooth muscle cells, and macrophages initiates recruit leukocytes. In addition, P-selectin/PSGL-1-dependent
the expression and release of matrix degrading enzymes, the platelet-leukocyte interaction brings platelets into close
matrix metalloproteinases (MMPs). These enzymes, which vicinity with neutrophils and may facilitate leukocyte activa-
degrade extracellular matrix proteins, significantly contribute tion by platelet proinflammatory mediators. Earlier studies
to destruction and remodeling of inflamed tissue. Adhesion indicated that GPIba and JAM-3 on platelets are potential
of activated platelets to endothelial cells results in generation counterreceptors for MAC-1 [20] and that they mediate
and secretion of MMP-9 and of the protease receptor uPAR on mechanism of platelet-leukocyte adhesion. Furthermore,
cultured endothelium [15]. The endothelial release of MMP-9 ICAM-2 and aIIbb3-associated fibrinogen have also been pro-
was dependent on both the fibrinogen receptor GPIIb–IIIa posed to mediate MAC-1-dependent platelet-leukocyte adhe-
and CD40L because inhibition of either mechanism resulted sion. Thus, platelets either immobilized on a surface or
in reduction of platelet-induced matrix degradation activity activated in suspension express a complete machinery to
of endothelial cells. Moreover, GPIIb–IIIa ligation resulted recruit leukocytes: (1) platelet P-selectin is a mediator of the
in substantial release of CD40L in the absence of any fur- first contact (tethering), (2) interaction of platelet P-selectin
ther platelet agonist. These results propose that the release of with its counterreceptor PSGL-1 on leukocytes induces sig-
platelet-derived proinflammatory mediators such as CD40L naling events relevant for MAC-1 activation, and (3) the acti-
is dependent on GPIIb–IIIa-mediated adhesion. This mech- vated b2-integrin (MAC-1) on leukocytes allows and
anism may be pathophysiologically important to localize reinforces firm platelet-leukocyte adhesion through binding
platelet-induced inflammation of the endothelium at a site of to counterreceptors (ICAM-2, fibrinogen bound to GPIIb–
platelet-endothelium adhesion. IIIa, GPIba, JAM-3) present on the platelet surface.

Platelets Interact with Circulating

Platelets Interact with Leukocytes Progenitor Cells

Platelet adhesion to the endothelium or the subendothelial There is increasing evidence showing that circulating pro-
matrix induces platelet activation and the release of sub- genitor cells contribute to vascular repair mechanisms and
stances that are able to cause chemotaxis and migration of limit atheroprogression. Impairment of progenitor-dependent
circulating leukocytes toward the site of platelet accumula- vascular repair due to either low numbers of circulating pro-
tion. Similar to platelet adhesion to the vessel wall, leukocyte genitor cells or dysfunctional progenitor cells leads to inade-
recruitment to vascular endothelium requires multistep adhe- quate vascular healing and atheroprogression. Recently, the
sive and signaling events, including selectin-mediated roll- role of platelets for recruitment and subsequent differentia-
ing, leukocyte activation, and integrin-mediated firm tion of progenitor cells has been recognized [21–23]. Adherent
adhesion and diapedesis [5]. On leukocytes, members of the platelets recruit circulating progenitor cells and induce dif-
b2-integrin family, LFA-1, MAC-1, and p150.95, as well as ferentiation of the latter into endothelial cells or macrophages
b1-integrins interact with endothelial counterligands such as and foam cells [21–23]. Further, the combination of platelets
ICAM-1, surface-associated fibrinogen [16], or vascular cell and fibrin promoted CD34+ cell migration even to a greater
adhesion molecule-1 (VCAM-1) to mediate the described extent than vascular endothelial growth factor in vitro [24].
heterotypic cell interaction. At sites of platelet adhesion to Moreover, the chemokine stromal cell-derived factor-1
the endothelium or subendothelium, leukocyte infiltration (SDF-1) was found to be secreted by activated platelets,
can occur through interactions with platelets and fibrin [5]. which supports chemotaxis and primary recruitment of
Similar to the leukocyte-endothelium adhesion, a sequential progenitor cells on the surface of arterial thrombi in vivo
adhesion process of leukocytes to adherent platelets has been [22, 23]. Moreover, cytokine-mediated deployment of SDF-1
proposed. Leukocyte adhesion to platelets involves surface coming from activated platelets induces revascularization
expression of P-selectin on activated platelets and binding to through mobilization of CXCR4 hemangiocytes [25].
PSGL-1, the counterreceptor present on neutrophils and Adhesion of human CD34+ cells to immobilized platelets
monocytes [17]. Diacovo et al. [18, 19] have previously is significantly attenuated in the presence of blocking mAbs
demonstrated that leukocytes tether, roll, and subsequently anti-CD162 or anti-CD62P, indicating that the platelet
rest on activated platelet monolayers via sequential action of P-selectin interacts with the endothelial progenitor cells
platelet P-selectin and ICAM-2 binding to their leukocyte (EPCs) through interaction with P-selectin glycoprotein
counterreceptors PSGL-1 and CD11b/CD18, respectively. ligand-1 [24, 26, 27]. Thus, platelets act as an intermediate
302 M. Gawaz et al.

mediator to tether progenitor cells, indicating that platelets Inhibition of platelet adhesion by blocking monoclonal anti-
are a prerequisite for the initial step of the homing process of GPIb antibodies substantially attenuated atheroprogression
CD34+ cells to vascular injury. in ApoE−/− mice [28]. Next, we studied the role of GPVI-
Platelets play a critical part not only in the capture, but mediated platelet adhesion for atheroprogression. Prolonged
also in the subsequent differentiation of murine EPCs, induc- administration of the soluble form of GPVI [28] substantially
ing the differentiation of the latter into spindle-shaped cells reduced atheroprogression in ApoE-deficient mice. Further,
that are positive for vWF [21]. Furthermore, human CD34 gene transfer of GPVI-Fc to the carotid vascular wall
progenitor cells can form colonies on immobilized platelets significantly attenuated atheroprogression and endothelial
similar to immobilized fibronectin and further differentiate dysfunction in atherosclerotic rabbits in vivo [29]. In addi-
into mature endothelial cells [23]. Under distinct circum- tion, administration of soluble GPVI-Fc preferentially bound
stances, however, in vitro co-culture experiments between to sites of vascular injury and was able to inhibit neointimal
platelets and human CD34+ cells induce distinct morphologi- formation after wire-induced vascular injury in ApoE−/− mice
cal changes of the latter and differentiation into macrophages [30] (Fig. 35.3). Thus, inhibition of platelet adhesion via
at an early phase and later on into foam cells [26]. GPIb- or GPVI-blockers might be a promising strategy to
attenuate lesion progression [31].

Conclusion
Inhibition of Platelet Adhesion Platelets are central players in thrombosis and inflammation
Attenuates Atheroprogression and contribute significantly to development of coronary
artery disease. Understanding the molecular mechanisms
Enhanced chronic interaction of platelets with the arterial of platelet-mediated inflammatory reactions within the
wall results in endothelial inflammation and atheroprogres- vessel wall discloses important aspects of the pathophysi-
sion [3]. The platelet von Willebrand receptor GPIba and the ology of coronary artery disease. Platelet-mediated vascular
collagen receptor GPVI have been demonstrated to largely inflammation is an attractive therapeutic strategy to limit
contribute to endothelial platelet adhesion in vivo in ApoE−/− atheroprogression.
mice [28], making them good candidates for inhibition.
Acknowledgement The authors were supported in part by the Deutsche
Inhibition of GP1b prevented adhesion of circulating plate- Forschungsgemeinschaft and the Klinische Forschergruppe KFO-274
lets to endothelial cells at the carotid artery of ApoE−/− mice. “Platelets-Molecular Mechanisms and Translational Implications”.

a b
Human GPVI
Fig. 35.3 Glycoprotein VI extracellular region
binds to vascular lesions and GPVI-Fc
reduces atherosclerotic lesion
formation. Glycoprotein VI
binds to vascular lesions and Linker region
reduces atherosclerotic lesion
formation. (a) Schematic of the
recombinant GPVI-Fc. (b)
Reduced neointimal formation
in GPVI-Fc-treated ApoE−/−
Fc
mice after wire-induced injury
of the
carotid artery (H&E staining,
Human IgG Fc
bar 100 mm) [30]. (c) Binding
of radiolabeled GPVI-Fc to
injured carotid artery shown by
PET/CT (left) and autoradiogra-
phy (right) [30]
35 Platelets and Coronary Artery Disease 303

Fig. 35.3 (continued) c PET/CT Morphology [124]GPVI-Fc

Injury

Intact

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 Part XI
Heart Valve Diseases
 Role of Bone Morphogenetic
Proteins in Valvulogenesis 36
Russell A. Gould and Jonathan T. Butcher

Valvular Morphogenesis atrioventricular (AV) canal, and two (proximal and distal)
develop in the outflow tract (OFT). The processes by which
Initiation of Valvular Morphogenesis the AV and outflow cushions remodel into thin fibrous
leaflets are discussed below.
Valvulogenesis is a complex process involving the forma-
tion and morphogenesis of both the atrioventricular and
semilunar valves. The early embryonic heart is a single Atrioventricular Valve Remodeling
myocardial tube lined with endocardial cells. During the
looping process, simultaneous valve formation initiates by By HH26 (E12.5 in mouse), the AV cushions fuse together at
deposition of hyaluronan-rich gelatinous matrix, called car- the midline along a superior/inferior axis, dividing the canal
diac jelly, forming swellings that project into the lumen. At into the right and left conduits. Even before fusing, the
the onset of Hamburger and Hamilton (HH14−, E9.0 in expansion of the cushions creates a “dog-bone” shape of
mouse), a process called EMT (epithelial-mesenchymal the ventricular inlet that begins to divert blood flow around
transition) takes place in which the lining of endocardial the cushions, potentially contributing to their eventual fusion
cell swellings differentiated from an EMT phenotype. This [4]. From the left and right lateral aspects of this fused cen-
process is associated with downregulation of cell-cell con- tral cushion mass evolves the septal leaflets of the left and
tacts, such as E-cadherin and PECAM1, the acquisition of right AV valves. At about the same time as central cushion
cell-matrix adhesions, and cytoskeleton rearrangement [1]. fusion, new cushions begin to form from the left and right
Loss of tight junctions in EMT is concomitant with the lateral walls, which will eventually form the mural AV
acquisition of a spindle-shaped morphology and migratory/ leaflets. The process by which the AV leaflets form is thought
invasive phenotype. The invasiveness of the mesenchymal to involve a process of proliferation, extension, condensa-
phenotype is critical, as these cells dive into the hyaluronan- tion, and delamination [5]. Briefly, a subendocardial portion
rich cardiac jelly, degrade the underlying matrix, and deposit of the AV cushion expands and extends along the myocardial
newly synthesized collagen I, II, III, versican, and other pro- substrate, which is mediated in part by a fibroblast growth
teoglycans [2]. These newly populated mesenchymal swell- factor 4 (FGF4) section by the endocardium [6]. These cells
ings are called “cushions” because of their soft visual form a progressive-like zone and begin to differentiate fur-
appearance while stitched to the myocardial wall. Cushions ther toward a fibroblastic phenotype. This zone of differenti-
are formed in pairs that oppose each other during the cardiac ated cells condenses the cushion matrix into a thinner and
cycle to act as primitive valves by maintaining unidirec- more fibrous tissue consisting of a subendocardial surface,
tional blood flow [3]. One pair of cushions develops in the which is largely positive for laminin, while the ventricular
side is predominately collagen III. Furthermore, fenestra-
tions between the myocardial wall and valve tissue begin to
R.A. Gould, BS form, possibly because of expansion of the ventricular cavi-
Department of Biomedical Engineering, ties or changes in hemodynamic loading [7]. Upon further
Cornell University, Ithaca, NY 14850, USA
delamination, residual contacts between the valve tissue and
J.T. Butcher, PhD (*) myocardium form the site of newly developing papillary
Department of Biomedical Engineering,
muscles. This creates mesenchymal tissue strands that
Cornell University, 304 Weill Hall,
Ithaca, NY 14853, USA develop into the tendinous chords of the AV valves. By
e-mail: jtb47@cornell.edu HH36, full delamination from the myocardial wall occurs

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 307
DOI 10.1007/978-1-4471-4429-8_36, © Springer-Verlag London 2013
308 R.A. Gould and J.T. Butcher

and the distinct tri-layer structure (atrialis/spongiosa, fibrosa, the receptors. Phosphorylated Smads 1/5 (pSmad1/5) form
and ventricularis) with a largely organized lamellar network heterodimers with partner Smad4 and translocate to the
of elastin and newly formed collagen (I, II, III, V, VI) [8]. nucleus. During translocation to the nucleus, pSmad com-
plexes can join with other co-activators to form a unique tran-
scription factor complex capable of regulating specific genes.
Semilunar Valve Morphogenesis Intracellular BMP signal transduction can be negatively
influenced by modulating Smad phosphorylation and trans-
Similar to AV valves in terms of mesenchymal transformation port into the nucleus, e.g., SMURF or Smad6 [13]. Also
and formation of the tri-layered valve structure, semilunar cross-talk with other signaling pathways has been observed to
valves become excavated from the aortic side inward. Between affect the phosphorylation status of the Smads and nuclear
HH17 and HH26 (E10–E12), the conal and truncal cushion accumulation such as ERK modulation. Although Smad-
pairs of the outflow tract become invaded and populated by mediated signaling is the most extensively studied, BMP sig-
activated endocardially derived cells. The aorticopulmonary naling can also be mediated by MAP3K7/MAP3K7IP1 (Tak1/
(AP) septum spirals through the outflow tract lumen with a Tab1) leading to the activation of MAPK14 (p38 MAPK), as
counterclockwise rotation so that the right portion of the semi- well as of PI3K (PI3 kinase), RAS, MAPK1 (ERK), and
lunar ring is derived from the original left side of the primitive MAPK8 (JNK) (Fig. 36.1) [14, 15].
outflow tract [9, 10]. The splitting of the parietal and septal
distal truncal cushions by the AP septum, combined with the
intercalated cushions of the distal outflow tract creates the six Spatial and Temporal Localization
cushions required for the formation of the semilunar valves, of BMP Signaling in Valve Development
which is completed by HH34 (E14.5). The tissue on the arterial
side becomes a more condensed fibrous matrix, as the small BMPs are uniquely expressed during cushion formation and
depression continues to deepen, sculpting the leaflet cusps. By valve maturation in both the OFT and AV canal (AVC). BMP2
HH39–40, the leaflets begin to appear trilaminar in nature, with and BMP4 have been widely studied because of their localiza-
an elastin–collagen lamellar structure forming at the ventricu- tion within the myocardium along the cushion-forming regions.
lar surface. By HH45, fibrous tissue is seen radiating from the BMP2 and BMP4 are expressed within the myocardium of the
attachment of the valve cusps into the aortic wall from the base AVC and OFT and thought to be a strong inducers of EMT and
to the level of the commissures, creating an anchoring ring of cushion formation. In mice, BMP2 expression dissipates in the
fibro-cartilaginous tissue around the sinuses [11]. OFT by E10.5 while continuing to persist throughout the AVC
myocardium. On the other hand, BMP4 expression dissipates
in the AVC by E10.5 while continuing to persist throughout the
BMP Signaling OFT myocardium. BMP5 is expressed in the myocardium
before and during cardiac cushion EMT (at E8.5) [16].
Canonical Smad Signaling However, it is later downregulated, and its role in cushion for-
mation or maturation is thought to be minimal. BMP6 is found
Bone morphogenetic proteins (BMP) are a subset within the within the endocardium of the OFT at E8.5 and E9.5 [17], OFT
cytokine superfamily transforming growth factor beta (TGFb). myocardium at E10.5, and in the mesenchyme of the cushions
They are multipotential proteins that regulate a wide variety of the AVC at E10.5 [18]. At later stages, however, it has been
of cellular functions during development. All BMP signaling described in the cushion mesenchyme of the OFT. BMP7 is
occurs through a family of homodimeric proteins that interact widely expressed throughout the myocardium with modest
with BMP type I and type II receptors. Thus far, three out of expression in AV valve mesenchyme [19, 20].
seven type I and three out of five type II receptors have been Traditional mouse knockout models used to define the
identified to transduce the BMP signal into the cell. Unlike role of BMP in valve morphogenesis has been challenging.
the other TGFb family members, BMP has a higher affinity Both BMP2 and BMP4 null mutant mice have early pre-
for the type I than the type II receptors. The type I receptors cardiac embryonic lethality [21, 22]. Interestingly, BMP5,
are ACVR1 (Alk2), BMPRIA (Alk3), and BMPR1B (Alk6), BMP6, and BMP7 alone do not produce cardiac defects.
and the type II are BMPR2 (BMPRII), ACVR2A (ActRIIA), However, combinations of BMP knockout mice models have
and ACVR2B (ActRIIIB). BMP ligands (BMP2, 4, 5, 6, 7) proven to affect valve formation. Within the BMP5/BMP7
directly bind to the type II receptors, which form heterodim- double–knockout mouse, cardiac cushions do not form, but
ers with type I receptors. This activates the receptors serine/ the precise role is difficult to determine because of the global
threonine kinase activity to phosphorylate and activate the disruption in development [16]. BMP6/BMP7 double-knockout
receptor Smads 1/5/8 [12]. Other ligands, e.g., NOG (Noggin), mice show a marked delay in the formation of outflow tract
can directly bind BMP, inhibiting their interaction with cushions because of reduced cell proliferation. Compared
36 Role of Bone Morphogenetic Proteins in Valvulogenesis 309

BMP
• NOG
BMP Type II Type I
• CHRD
ACVR2A AVCR1
BMP • GREM1
ACVR2B BMPR1A
BAMBI • FST
BMPR2 BMPR1B

• RAS
BIRC4 • MAPK1
MAP3K7IP1
P • PIK3

P MAP3K7
• MAPK8
No signal
• SMAD6 SMAD
1,5,8
• SURF
P MAPK14

SMAD4

P
Transcription
co-factor

Fig. 36.1 Canonical BMP signaling pathways. BMP form a heteromeric can also be transduced via MAP3K7(Tak1)/MAP3K7IP1 (Tab1), RAS,
complex with type I and type II BMP receptors. Subsequent to this com- MAPK1 (ERK), or PI3 kinase. Extracellularly, BMPs can be inhibited by
plex formation, the type II receptor phosphorylates the type I receptor, secreted inhibitors, such as NOG, CHRD (chordin), GREM1 (Gremlin),
through which the Smad1, Smad5, or Smad8 is phosphorylated. and FST (follistatin), or by the decoy receptor BAMBI, which lacks the
Phosphorylated Smad forms a complex with the common Smad4 and is intracellular domain for signal propagation. BMP signal transduction is
transported into the nucleus. Besides signaling via Smads, the BMP signal intracellularly inhibited by Smad6 or SMURF (van Wijk et al. [15])

with the outflow tract cushions, AV canal cushions are gener- in the heart has not been described in detail. The main type II
ally less compromised by the loss of BMP6 and BMP7 [17]. BMP receptor, BMPRII (which mainly binds with Alk3), is
This suggests that the combinations of these growth factors ubiquitously expressed in the heart, and all tissues during
are critical for valve morphogenesis. development [20] (Fig. 36.2).
Analysis of BMP receptor expression patterns and condi- Mice lacking type II or type IA BMP receptors die at gas-
tional mutations have provided additional insight into the role trulation and cannot be used to assess potential later roles in
of BMP in valve formation and remodeling because of their valvular morphogenesis. However, Cre/Lox-targeted dele-
reduced lethality. However, extracting mechanistic under- tion of Alk3 in cardiac myocytes revealed an unexpected role
standing is challenging because of their promiscuity. Of the for this receptor in the formation of the AVC cushions. EMT
type I receptors, Alk6 (BMPRIB) is not expressed, and Alk3 in both AVC and OFT regions is normal, suggesting these
(BMPRIA) is ubiquitously expressed, while Alk2 (ACVR1) BMP receptors were either not required or more likely redun-
can transduce both BMP and TGFb signals, is expressed in the dant. However, during the remodeling process, cushions
heart rather widely [23, 24]. Two type II receptors have been were found smaller in size and cushion fusion does not occur.
described as being able to transduce a BMP signal. ActRII, Elimination of Alk3 was also found to diminish TGFb2
originally described as a type II receptor for activins, can also expression in the AVC, which further supports the notion
transduce a BMP signal [25], although its pattern of expression that BMP is an important contributor to the TGFb paracrine
310 R.A. Gould and J.T. Butcher

dimensional collagen gel explants. In this system, AV canals

(chick or mouse embryos) are isolated and then explanted
onto the collagen gel surface. The endocardium of the AV
canal adheres to the surface, from which a subset of these
Bmp2 Bmp7
cells undergoes the mesenchymal transformation and invades
the underlying matrix. Interestingly, EMT does not take
place if the myocardium is removed directly after the endo-
cardium has been attached to the collagen gel surface. This
suggests that the AV myocardium has a unique capacity to
E9.5 E10.5 secrete specific signals for EMT [28]. After these landmark
observational studies, the focus shifted to understand the
Bmp4
makeup of the myocardial inductive signal for EMT in AV
canal endocardial cells. Through segmental patterning, it
was found that myocardial cells express BMP2 in a manner
consistent with the segmental pattern of cushion formation.
E10.5 E12.5
Using these AV explants in mice, Sugi et al. showed that
E9.5
BMP2 was sufficient to induce EMT in mouse AV canal
Bmp6 cultures in the absence of AV myocardium [29]. Furthermore,
treatment of AV cultures with Noggin, a BMP inhibitor, pre-
vented mesenchymal cell formation in untreated cultures and
also prevented BMP2 induced EMT in AV cultures with
intact AV myocardium.
Bmp3, Bmprll, Interestingly, BMP2 treatments of AV explants resulted
Bmp8, Alk6 Alk2, Alk3 in increased TGFb2 protein levels [29]. This is particularly
important because antagonists to TGFb2 and TGFb3 show
Fig. 36.2 Expression patterns of BMP family genes in the developing
mouse heart. BMP2 is expressed only briefly and faintly in the OFT
that they play distinct but complementary roles in regulating
myocardium, but strongly and persistently in the myocardium of the the initial transformation events in chick. Endocardial
AVC (and atria). BMP4 expression switches from the myocardium of TGFb2 expression is required for cell separation and hyper-
the AVC to the myocardium of the OFT between E9.5 and E10.5. The trophy, while TGFb3 signaling is required for mesenchymal
very dynamic expression of BMP6 is seen first in the endocardium at
E9.5, then in the mesenchyme of the AVC cushions and in the myocar-
transformation and migration [30]. TGFb3 induces expres-
dium of the left OFT at E10.5, and finally becomes restricted to the sion of MMP-2 and MT-MMP, which digest the collagen IV
mesenchyme of the OFT at E12.5. BMP7 is expressed strongly in all endocardial matrix permitting invasion [31]. At the onset of
the myocardium at all stages described. BMP3, BMP8, and receptor EMT in chick cardiogenesis, TGFb3 is expressed in trans-
Alk6 are not expressed in the developing heart, while Alk2, Alk3, and
BMPRII are ubiquitous (Delot [20])
forming endothelial and invading mesenchymal cells, while
BMP2 is expressed in the subjacent myocardium. To restrict
this entire process to the cushion forming region in the
response [26]. Likewise, mice with a hypomorphic BMP lumen, endocardial Notch1 signals repress myocardial
receptor II allele (BMPR2) die before birth as a result of BMP2 through the Hey1 transcription factor [20].
cardiovascular abnormalities. Similar to the Alk3 mutant Furthermore, chick AV explants experiments have investi-
mice, EMT is initiated in both the AV and OFT endocardial gated the combinatory role of both TGFb3 and BMP2. In
cushions. However, OFT cushions failed to develop past the summary, it was found that (1) myocardially derived induc-
initial EMT events, suggesting that BMPR2 is required for tive signals upregulate the expression of AV endothelial
subsequent growth and maintenance of the conotruncal TGFb3 at the onset of EMT, (2) TGFb3 needs to be expressed
cushions [27]. by these endothelial cells to trigger the initial phenotypic
changes of EMT, and (3) myocardial BMP2 acts synergisti-
cally with TGFb3 in the initiation of EMT [32].
Growth Factor Regulation of Valve
Formation by BMP
Cushion Maturation
Initiation of EMT
During cushion formation, type I BMP receptors, BMPR1A
Efforts to investigate the mechanisms of EMT and cushion (Alk3), BMPR1B (Alk6), and Alk2, have all been localized
formation have been greatly facilitated by the use of a three- in AV cushion mesenchyme in stage-24 chick embryos. AV
36 Role of Bone Morphogenetic Proteins in Valvulogenesis 311

AV cushion mesenchymal cell-aggregates

from HH stage 24 chick hearts 72 h

Control
(medium 199)

BMP-2
or
caBMPR-1B Periostin ↑
Twist↑ Id1↑
Cell migration ↑
Psmad 1/5/8 ↑
BMP-2+Noggin Proliferation (no Δ)
or
dnBMPR-1B

Periostin ↓
Twist↓ Id1↓
Cell migration ↓
Psmad 1/5/8 ↓
Proliferation (no Δ)

Fig. 36.3 Summary diagram illustrating the results from bioassays to treatment inhibited BMP2 promoted cell migration and expression of
assess the role of BMP2 and BMP signaling using AV cushion mesen- periostin, Twist, and Id1. Phospho-Smad 1/5/8 expression was induced
chymal cell aggregates cultured on 3D-collagen gels. Exogenous BMP2 by BMP2 or caBMPR1B treatments but reduced by Noggin or
or caBMPR1B treatments induced mesenchymal cell migration and dnBMPR1B treatments (Inai et al. [33])
expression of periostin, Twist and Id1. In contrast, Noggin or dnBMPR1B

explant experiments applying exogenous BMP2 or caBM- tin overexpression, mesenchyme invasion was enhanced in a
PR1B (Alk6) treatments significantly promoted expression dose-dependent manner through 3D collagen gels and
of an extracellular matrix (ECM) protein periostin, a known increased matrix compaction. It was also found that this
valvulogenic matrix maturation mediator whereas periostin invasion was dependent on avb3 more than b1 integrin sig-
expression was repressed by adding Noggin or dnBMPR1B naling and was mediated differentially by Rho kinase and
(Alk6)-virus to the culture [33]. Moreover, transcripts of PI3 kinase [35].
Twist and Id1, were induced by BMP2 but repressed by BMP4 signaling is thought to be involved in both car-
Noggin in cushion mesenchymal cell cultures. This data pro- diac cushion EMT and later stage valve remodeling. By
vides evidence that BMP2 signaling induces biological pro- combining the use of a hypomorphic BMP4 allele with
cesses involved in early AV valvulogenesis, i.e., mesenchymal conditional gene inactivation, BMP4 was found to signal
cell migration and expression of periostin, indicating critical from the myocardium and directly mediate atrioventricular
roles for BMP signaling in post-EMT AV cushion tissue septation. Likewise, more pronounced reductions in myo-
maturation and differentiation (Fig. 36.3). cardial BMP4 expression results in a complete atrioven-
BMP2-induced periostin expression plays an important tricular septal defect (AVSD). The AVSDs in these mouse
role in the developing cushion and maturation of valves. models appear to result from decreased cell proliferation
As a secreted fasciclin domain-ECM protein that associates within the AV cardiac cushions [36]. Furthermore, the
with areas of fibrosis, periostin can directly interact with anterior heart field (AHF)–derived myocardium, another
other ECM proteins, such as fibronectin, tenascin-C, colla- essential source of BMP4, is required for normal endo-
gen I, collagen V, and heparin sulfate proteoglycans. Periostin cardial cushion expansion and remodeling. Loss of BMP4
serves as a ligand for select integrins, such as avb3, avb5, from the AHF in mice results in an insufficient number of
and a4b6, where it can affect the ability of cells (fibroblasts cells in the developing OFT endocardial cushions, defec-
or cancer cells) to migrate and/or undergo mesenchymal tive cushion remodeling, ventricular septal defects, per-
transformation in select tissues [34]. Using the aforemen- sistent truncus arteriosus, and abnormal semilunar valve
tioned in vitro assays, Butcher et al. found that upon perios- formation [37].
312 R.A. Gould and J.T. Butcher

Downstream signaling through Smad phosphorylation lethality occurs between E11.5 and E12.5 with hypoplastic
is dependent upon the formation of the Smad1-Smad4 and/ endocardial cushions. It is thought that loss of Sox9 inhibits
or Smad5-Smad4 transcription factor complexes. Smad6 is EMT after delamination and initial migration, but before
an important Smad protein capable of attenuating BMP definitive mesenchymal transformation [44]. During targeted
signaling through competition of Smad4 binding [38]. loss of Sox9 with Col2a1Cre in the remodeling valve,
Smad6 is expressed in the AV and OFT regions of the heart decreased expression of cartilage-associated proteins Col2a1
during development. Smad6 homozygous knockout mice occurs. In adult mice, heterozygous loss of Sox9 in Col2a1Cre
displayed hypercellular AV and OFT cardiac cushions. results in thickened valve leaflets and calcification character-
The hypercellular cushion phenotype in Smad6 null mice istic of valve disease [42]. This suggests that that a relation-
is consistent with BMP mediating either EMT or subse- ship between BMP and Sox9 has a critical role in endocardial
quent mesenchymal cell proliferation within cardiac cush- cushion formation and valve remodeling.
ions. In addition, the role of Smad6 in the homeostasis of
the adult valves is indicated by the development of bone-
related ossification upon Smad6 knockout [39]. It would Msx1/Msx2
seem that BMP-induced mesenchyme formation or prolif-
eration is controlled by a negative feedback mechanism Expression of the Msx1 and Msx2 homeobox genes has been
involving Smad6 and controlling expression of bone- shown to be co-coordinately regulated with the BMP2 and
related genes in adult homeostasis [2]. BMP4 ligands in a variety of developing tissues. It known
that that both Msx1 and Msx2 are crucial downstream effectors
of BMP signaling in endocardial cushion. Upon mouse
Transcriptional Regulation knockout, Msx1 and Msx2 single homozygous mutant mice
of Valve Formation by BMP exhibited normal valve formation, while hypoplastic AV
cushions and malformed AV valves were evident in the dou-
The role of BMP directing the differentiation of mesenchy- ble Msx1 and Msx2 homozygous mutant mouse. These
mal valve progenitor cells is becoming more understood at results support redundant functions for Msx1 and Msx2 dur-
the transcriptional level. Recent work by Chakraborty et al. ing AV valve morphogenesis. In the Msx1/2 mutant embryos,
conducted gene expression profiling analysis of murine endocardial expression of Notch1, BMP2/4, and NFATc1 is
E12.5 AV endocardial cushions compared with E17.5. They reduced, and patterning of the AVC myocardium is also
hypothesized the existence of shared regulatory pathways abnormal, leading to compromised EMT [45]. In addition,
active in developing AV valves and bone progenitor cells. loss of both Msx1 and Msx2 were also found to affect sec-
Overall, MC3T3 cells (pre-osteoblasts) were significantly ondary heart field and neural crest anomalies related to
more similar to E17.5 valves than to E12.5 cushions, sup- defects in cell proliferation and migration [46]. Taken
porting the hypothesis that valve maturation involves the together, combined Msx1 and Msx2 mutations lead to
expression of many genes also expressed in osteoblasts. a spectrum of cardiac malformations including double outlet
Several transcription factors characteristic of mesenchymal right ventricle (DORV), a pulmonary stenosis, atrial and
and osteoblast precursor cells, including Twist1, Sox9, ventricular septal defects, and hypoplastic ventricle [47].
Tbx20, and Msx1/Msx2, are predominant in E12.5 cushion
[40]. We will now discuss these transcription factors with
regards to valve formation below. Twist1

Endocardial cushion expression of Twist1 is induced by BMP2

Sox9 in both chicken and mouse embryos. During valve morpho-
genesis, Twist1 is expressed throughout the endocardial cush-
Sox9 is thought to be a master regulator required for endocar- ions of the AVC and OFT, and expression is downregulated in
dial cushion cell lineage expansion, as well as differentiation the remodeling valves [48]. Shelton et al. performed gain and
associated with cartilage progenitor cells [41, 42]. In both loss of function studies in avian endocardial cushion cell cul-
chick and mouse, Sox9 is expressed within the endocardial tures to demonstrate that Twist1 promotes cell proliferation
cushions and remodeling leaflets. BMP2 activates expression and migration, while increasing the expression of periostin
of Sox9 and the cartilage differentiation marker Col2a1, and MMP-2 [49]. Twist1 activity was examined in transgenic
which has been observed in cultured avian endocardial cush- mice with persistent expression in the developing valves.
ion cells [43]. Upon gene knockout of Sox9 in mice, embryonic Persistent expression leads to increased valve cell
36 Role of Bone Morphogenetic Proteins in Valvulogenesis 313

proliferation, increased expression of Tbx20, and increased Changes in RUNX2 and osteopontin expression levels are
ECM gene expression, characteristic of early valve progeni- thought to be preceded by phosphorylation of Smad1 and
tors. Among the ECM genes predominant in the endocardial extracellular signal-regulated kinase 1/2 but not p38 MAPK
cushions, Col2a1 was identified as a direct transcriptional [59]. It is also important to note that elevated stretch may
target of Twist1. Increased expression also leads to dysregu- cause valve calcification via a BMP-dependent mechanism.
lation of fibrillar collagen and periostin expression, as well For example, cyclic stretch of porcine aortic valve leaflets,
as enlarged hypercellular valve leaflets prior to birth [50]. pathological magnitudes elicited a stronger calcification
response compared with physiological magnitudes in a fully
osteogenic medium. BMP2, BMP4, and RUNX2 expression
Tbx20 was also found upregulated on the fibrosa surface of the valve
cusp in a stretch dependent manner after 3 days. Tissue cal-
Tbx20 is thought to maintain BMP2 expression localized to cium content and alkaline phosphatase activity were similarly
the AVC region. Tbx20 is strongly expressed in the myocar- stretch dependent and significantly reduced by Noggin in a
dium of the AVC in both mouse and chick [51, 52]. Mice dose-dependent manner. These results underline the potential
lacking Tbx20 in the AVC myocardium fail to form the AVC role of BMP in valve calcification because of altered stretch
constriction, and EMT is severely perturbed. Furthermore, [60]. Taken together, these findings suggest that excessive
downstream genes, such as Twist1, Sox9, and Msx1 involved BMP signaling within the human aortic valves contribute to
in the EMT initiation were found nearly absent. During the calcification process in a side-specific manner.
re-expression of BMP2 in the AVC myocardium, BMP2 sub-
stantially rescues the EMT defects resulting from the lack of Conclusion
Tbx20, suggesting BMP2 is one of the key downstream tar- Valvulogenesis is an extremely complex process by which
gets of Tbx20 in AVC development [53]. Furthermore, Tbx20 a fragile gelatinous matrix is populated and remodeled
gain and loss of function studies performed in chicken AVC during embryonic development into thin fibrous leaflets
explants were found to increase cell proliferation and migra- capable of maintaining unidirectional flow over a lifetime.
tion while repressing ECM maturation. Tbx20 promotes Studies from transgenic knockout mice and in-vitro explant
expression of the ECM remodeling enzymes, MMP9 and studies have shown that BMP are critical contributors to
MMP13, while repressing expression of the chondroitin sul- this process, regulating both the initiation of cushion for-
fate proteoglycans, aggrecan, and versican [54]. Overall, mation and later stages of leaflet maturation. Understanding
Tbx20 has essential roles in regulating AVC development the role of BMP in this complex process is not only impor-
that coordinate early cushion formation. tant for determining the origins of congenital defects, but
may also provide insight into potential regenerative and/or
therapeutic strategies to combat valvular dysfunction.
Recently, Sox9 expression was found to have a protective
BMP and Post-natal Valve Dysfunction role on calcific valve phenotypes in vivo, completely
reversing the effects of mineralization, and activation of
Degenerative valve calcification in cardiac valves has been inflammatory and matrix remodeling processes [61]. This
associated with the expression of BMP [55]. However, their is a remarkable finding since BMP-induced Sox9 has been
precise role in this process remains largely unknown. In suggested as a master regulator of valve progenitor differ-
human aortic leaflets, both BMP2 and BMP4 expression has entiation for proper valve maturation. Taken together, the
been upregulated in calcific stenotic valves [56]. Interestingly, orchestration of BMP signaling during valvulogenesis is
downstream signaling of BMP has been shown preferentially critical. By exploiting these controlled embryonic derived
activated in a side-specific manner. Smad-1/5/8 was preferen- paradigms, re-expression of BMP-associated factors may
tially activated in the calcified fibrosa endothelium of human potentially be used to combat pathological stimuli within
aortic valves and correlates with low expression of BMP the clinic.
antagonists and inhibitory Smad6. These results suggest a
dominant role of BMP antagonists in the side-dependent
calcification of human aortic valves [57]. Further in-vitro References
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 Dysfunctional Mechanisms
of Anti-inflammation in Aortic Stenosis 37
David A. Fullerton and Xianzhong Meng

Aortic valve disease is the third most common cardiovascular in calcified aortic valve leaflets removed at the time of aortic
disease in the United States, exceeded only by hypertension valve replacement. Early aortic valvular lesions demonstrate
and coronary artery disease. Approximately 2–7 % of the lipid accumulation as well as an infiltrate of chronic
population older than 65 years has aortic stenosis [1], and inflammatory cells such as macrophages, mast cells, and T
calcific aortic stenosis is the most common indication for lymphocytes [12, 13]. Histological data such as these pro-
valve replacement. Despite its prevalence, the pathogenesis vide circumstantial evidence that mechanisms of inflam-
of calcific aortic stenosis is not well understood. In particu- mation may play an important role in the pathogenesis of
lar, the cellular mechanisms by which the aortic valve leaflets aortic stenosis.
become calcified are unclear. In another line of investigation, histological evidence of
Calcific aortic stenosis has traditionally been considered active bone formation has been found in aortic valves
a “degenerative” process with passive accumulation of cal- removed at the time of aortic valve replacement. The calcified
cium on the aortic valve leaflets. Recently, however, separate aortic leaflets have features that resemble the osteogenic
lines of investigation have begun to coalesce, suggesting that bone formation found in skeletal bone [14]. Skeletal bone
the pathogenesis of calcific aortic stenosis may be an active formation is dependent upon osteoblasts, which create a
biologic process. mineralized extracellular matrix [15]. Osteoblast cells are
One such line of investigation includes epidemiologic stud- phenotypically characterized by several proteins associated
ies that have identified several clinical risk factors for the with bone formation, including osteopontin, osteocalcin, and
development of aortic stenosis, including hypertension, hyper- bone sialoprotein. Using RT-PCR, increased mRNA levels
lipidemia, and diabetes mellitus [1–3]. Importantly, these same for all of these have been found in calcified aortic valves
clinical risk factors are also associated with atherosclerosis. It [14]. Such data indicate that bone-forming cells (osteoblasts
is now appreciated that inflammatory mechanisms initiate and or osteoblast-like cells) are present in calcified aortic valve
perpetuate atherosclerosis on a cellular level [4]. Hence, it is leaflets and in fact are responsible for the calcification. The
logical to postulate that given the similarity of clinical risk fac- origin of the bone-forming cells is not known. It is notewor-
tors for the development of aortic stenosis and atherosclerosis, thy, however, that bone formation has been reported in cul-
the cellular mechanisms of the two disease states may have tured myofibroblasts from aortic valves [16], suggesting the
common features as well (i.e., mechanisms of inflammation). possibility that aortic valve myofibroblasts may differentiate
It is therefore noteworthy that patients with aortic stenosis into bone-forming cells.
have circulating evidence of systemic inflammation such as Taken together, these background studies strongly sug-
elevated C-reactive protein and elevated levels of circulating gest that calcific aortic stenosis is (1) an inflammatory dis-
soluble adhesion molecules [5–11]. ease and (2) the process of calcification results from active
Such clinical investigations are supported by studies in bone-like formation.
which histological evidence of inflammation has been found The fact that calcified aortic valve leaflets have a histo-
logical appearance consistent with bone formation suggests
that calcific aortic stenosis is a process of active bone forma-
D.A. Fullerton, MD (*) • X. Meng, MD, PhD tion rather that a passive degenerative process. This implies
Division of Cardiothoracic Surgery, that bone-forming cells (osteoblasts or osteoblast-like cells)
The University of Colorado School of Medicine,
may be responsible for the calcification and that some cells
12631 E. 17th Avenue, Room 6602, MS-C310,
Aurora, CO 80045, USA within the valve may have the potential to become osteo-
e-mail: david.fullerton@ucdenver.edu blast-like. However, the origin of such cells is unknown.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 317
DOI 10.1007/978-1-4471-4429-8_37, © Springer-Verlag London 2013
318 D.A. Fullerton and X. Meng

The normal human aortic valve leaflet is a gossamer struc- of genes for powerful proinflammatory cytokines such as
ture. It is primarily comprised of a single layer of endothelial interleukin (IL)-8, IL-6, and IL-1b. In addition, their stimu-
cells on both the aortic surface and the ventricular surface lation leads to significantly increased expression of
overlying a very thin matrix of collagen and elastin fibrils. proinflammatory adhesion molecules, such as intercellular
Interspersed among the collagen and elastin fibrils are cells. adhesion molecule 1 (ICAM1) and vascular cell adhesion
Some of these cells are fibroblasts, but the predominant cell molecule 1 (VCAM1). Further, such increased genetic
type has a phenotype with features of both myoblasts and expression is translated into significantly increased produc-
fibroblasts, hence it is called a myofibroblast. These tion of the respective proinflammatory cytokines and adhe-
myofibroblasts are referred to as aortic valve interstitial cells sion molecules [18]. Of great interest is the observation that
(AVICs). once the human AVIC is stimulated by proinflammatory
The AVIC is a biologically active cell and has been impli- stimuli, it responds with an augmented inflammatory
cated in the pathogenesis of aortic stenosis [14]. These cells response and an osteogenic response [19, 20].
have been shown to express Toll-like receptors (TLRs) 2 and Hence, not only does evidence suggest that calcific aortic
4 [17]. Toll-like receptors are phylogenetically preserved stenosis may be an inflammatory disease, but that the human
components of the innate immune system and mediate many AVIC may play a very important role in the pathogenesis of
mechanisms of inflammation; the central role of TLRs, calcific stenosis. In response to inflammatory stimuli, the
specifically TLR2 and TLR4, in the mediation of inflammatory human AVIC produces proinflammatory cytokines, chemok-
stimuli is well recognized. Toll-like receptor signaling ines, and adhesion molecules. In turn, these proinflammatory
induces gene transcription, and its downstream effects, which factors act in a paracrine and autocrine fashion to act upon
include cytokine, chemokine, and adhesion molecule pro- the AVIC and to perpetuate the proinflammatory response
duction, are mediated through NF-kB. While the role of and to stimulate the cells to assume an osteogenic pheno-
TLRs in atherosclerotic mineralization has been investigated, type. In other words, the inflammatory stimulation of the
insight into the inflammatory TLR signaling in heart valves AVIC produces an inflammo-ostiogenic response.
has only recently emerged. The net inflammatory state of any tissue is determined by
It is important to note that NF-kB also has a central role in the relative balance of proinflammatory and anti-inflammatory
controlling the expression of genes associated with bone mechanisms. In response to proinflammatory stimulation, a
mineralization. An important effector protein for mineraliza- deficiency of anti-inflammatory mechanisms will lead to
tion is Runx-2, which is held in check by the transcription unopposed actions of proinflammatory mechanisms. Such an
factors Hes and Hey. The net effect of NF-kB activation is to imbalance of pro- and anti-inflammatory mechanisms has
inhibit Hes and Hey gene expression, thereby increasing been implicated in the pathogenesis of many inflammatory
Runx-2 expression. In turn, this has been shown to lead to diseases. Specifically, increased tissue levels of interleukin-
mineralization. one beta (IL-1b) relative to its anti-inflammatory antagonist,
In response to proinflammatory stimulation via TLRs 2 interleukin-one receptor antagnosist (IL-1RA), have been
and 4, the phenotype of human AVICs changes from that of implicated in the pathogenesis of rheumatoid arthritis, inflam-
a myofibroblast to that of a bone-forming-like cell [17]. matory bowel disease, atherosclerosis, and other inflammatory
Characteristics of this osteogenic phenotype include an diseases [21].
increased expression of the potent bone forming protein, Interleukin-one beta (IL-1b) has been implicated in the
bone morphogenetic protein 2 (BMP-2), the osteogenic tran- pathogenesis of aortic stenosis as well [22]. Produced by cir-
scription factor, Runx2, and expression and activity of alka- culating mononuclear cells, the proinflammatory actions of
line phosphatase. IL-1b are mediated by the membrane-bound IL-1 receptor
Such pro-osteogenic factors have important roles in bone (IL-1R). Once stimulated, the IL-1R induces the AVIC to
formation. Bone morphogenetic proteins are osteogenic assume an osteogenic phenotype marked by the production of
growth factors and are the principal inducers of osteoblast BMP-2 and alkaline phosphatase. The specific antagonist of
differentiation and bone formation. BMP-2 is the most exten- IL-1b is the anti-inflammatory cytokine, IL-1RA, which
sively characterized osteogenic growth factor and the most blocks the actions of its receptor. The balance between IL-1b
widely studied to stimulate osteoblastic differentiation [15]. and IL-1RA in a given tissue may determine the development
Runx2 is a transcription factor expressed in mineralized tis- of inflammatory disease. In fact, a deficiency of IL-1RA rela-
sues or their precursors [16]. It directly stimulates transcrip- tive to IL-1b leads to inflammation and tissue destruction.
tion of osteoblast-related genes and is necessary for osteoblast This important defense mechanism of anti-inflammation
differentiation and bone formation. is dysfunctional in aortic stenosis. Normal aortic valve
Stimulation of TLR-2 and 4 on AVICs also produces a leaflets have been shown to have an abundance of IL-1RA.
profound proinflammatory response. Stimulation of both of However, it is virtually absent in stenotic aortic valves.
these receptors causes a significant increase in the expression Further, AVICs have been shown to be an important source
37 Dysfunctional Mechanisms of Anti-inflammation in Aortic Stenosis 319

of IL-1RA in normal valve leaflets. In normal valve leaflets, interleukin-2 receptors in nonrheumatic stenotic aortic valves.
AVICs respond to proinflammatory stimulation by sig- J Am Coll Cardiol. 1994;23:1162–70.
8. Rajamannan NM, Gersh B, Bonow RO. Calcific aortic stenosis:
nificantly increased production of IL-1RA, an important from bench to the bedside-emerging clinical and cellular concepts.
defense mechanism. Conversely, human AVICs from stenotic Heart. 2003;89:801–5.
valve leaflets contain anti-inflammatory IL-1RA in nearly 9. Galante A. C-reactive protein is increased in patients with degenera-
undetectable levels. And in response to proinflammatory tive aortic valvular stenosis. J Am Coll Cardiol. 2001;38:1078–82.
10. Sanchez PL, Mazzone AM. C-reactive protein in aortic valve dis-
stimulation, AVICs from stenotic valves produce significantly ease. Cardiovasc Ultrasound. 2006;4:37–40.
less IL-1RA than do normal AVICs. Therefore, impaired 11. Shahi CN. Elevated levels of circulating soluble adhesion molecules
mechanisms of anti-inflammation, specifically a deficiency in patients with nonrheumatic aortic stenosis. Am J Cardiol. 1997;
of IL-1RA, are associated with the pathogenesis of calcific 79:980–2.
12. Karsenty G, Ducy P, Starbuck M, et al. Cbfa1 as a regulator of
aortic stenosis [21]. It is unknown, however, whether this osteoblast differentiation and function. Bone. 1999;25:107–8.
dysfunctional mechanism of anti-inflammation is a primary 13. Aubin JE, Liu F, Malaval L, et al. Osteoblast and chondroblast dif-
deficiency or is somehow lost somewhere as the disease of ferentiation. Bone. 1995;17:77S–83.
aortic stenosis progresses. 14. Rajamannan NM, Subramanian M, Rickard D, et al. Human aortic
valve calcification is associated with an osteoblast phenotype.
In summary, the pathogenesis of aortic stenosis is one in Circulation. 2003;107:2181–4.
which mechanisms of inflammation play an important role. 15. Mohler ER, Chawla MK, Chang AW, et al. Identification and char-
However, dysfunction of mechanisms may likewise be equally acterization of calcifying valve cells from human and canine aortic
important and offer insight into the mechanisms of the disease. valves. J Heart Valve Dis. 1999;8:254–60.
16. Lane JM. Bone morphogenic protein science and studies. J Orthop
Trauma. 2005;19:S17–22.
17. Meng X, Banerjee A, Cleveland JC, Weyant MJ, Dinarello CA, Babu
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2. O’Brien KD, Knusisto J, Reichenbach DD, et al. Osteopontin is stimulation of human aortic valve interstitial cells activates
expressed in human aortic valvular lesions. Circulation. 1995;92: inflammation and osteogenesis. Ann Thorac Surg. 2008;86:71–6.
2163–8. 19. Yang X, Fullerton DA, Su X, Al L, Meng X. Pro-osteogenic pheno-
3. Srivatsa SS, Harrity PJ, Maercklein PB, et al. Increased cellular type of human aortic valve interstitial cells is associated with higher
expression of matrix proteins that regulate mineralization is associ- levels of Toll-like receptors 2 and 4 and enhanced expression of
ated with calcification of native human and porcine xenograft bio- bone morphogenic proteins. J Am Coll Cardiol. 2009;53:491–500.
prosthetic heart valves. J Clin Invest. 1997;99:996–1009. 20. Yang X, Meng X, Su X, Mauchley DC, Ao L, Cleveland JC, et al.
4. Shao J-S, Cai J, Towler DA. Molecular mechanisms of vascular Bone morphogenic protein 2 induces Runx2 and osteopontin
calcification. Lessons learned from the aorta. Arterioscler Thromb expression in human aortic valve interstitial cells: role of Smad1
Vasc Biol. 2006;26:1423–30. and extracellular signal related kinase 1/2. J Thorac Cardiovasc
5. Kaden JJ, Bickelhaupt S, Grobholz R, et al. Expression of bone Surg. 2009;138:1008–15.
sialoprotein and bone morphogenetic protein-2 in calcific aortic 21. Lee J, Meng X, Weyant MJ, Reece JB, Cleveland Jr JC, Fullerton
stenosis. J Heart Valve Dis. 2004;13:560–6. DA. Stenotic aortic valves have dysfunctional mechanisms of anti-
6. Osman L, Yacoub MH, Latif N, Amrani M, Chester AH. Role of inflammation: implications for aortic stenosis. J Thorac Cardiovasc
human valve interstitial cells in valve calcification and their Surg. 2011;141:481–6.
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7. Olsson M, Dalsgaard CJ, Haegerstrand A, Rosenqvist M, Ryden L, motes matrix metalloproteinase expression and cell proliferation in
Nilsson J. Accumulation of T lymphocytes and expression of calcific aortic valve stenosis. Atherosclerosis. 2003;170:205–11.
 Heart Valve Surgery and
the Antiphospholipid Syndrome 38
Carlos A. Mestres, Cecilia Marcacci, Gerard Espinosa,
Jose L Pomar, Andrea Colli, and Ricard Cervera

Antiphospholipid syndrome – Lupus eritematosus – Cardiac to an increase in the complexity and condition of the patients
surgery – Valve replacement device submitted for surgical correction of cardiac defects [4].
Antiphospholipid syndome (APS), an autoimmune disor-
der characterized by venous and arterial thrombosis, fetal
Introduction loss, and thrombocytopenia, in the presence of antiphospho-
lipid antibodies (aPL), namely lupus anticoagulant (LA),
For more than 5 decades, cardiac surgery has developed at a anticardiolipin antibodies (aCL), or anti-b2 glycoprotein-I
fast and steady pace. Since the early days of complex and (b2GPI) antibodies [5], is an uncommon disease bringing
cumbersome procedures initially developed at targeting the difficulties in establishing an appropriate diagnosis and
correction in congenital intracardiac defects [1, 2], all types effective treatment.
of intra- and extracardiac procedures have been performed APS belongs to a formally unclassified group of uncom-
worldwide on a routine basis at all institutions that meet the mon or infrequent diseases such as infective endocarditis
minimum requirements for intrathoracic surgery according (IE). As such, a number of cases might go underdiagnosed,
to international standards [3]. The lack of appropriate diag- and, because of the specific pathophysiology, it might also
nostic tools and advanced equipment for intracardiac surgery pose a number of problems at the time of the management.
is a stimulus for progression. The initial era of cardiac sur- Considering the specific impact of APS on thrombosis and
gery was defined by the development of basic technology for hemostasis, APS is an example of a challenging disease
diagnosis and treatment and marked by the enormous pro- when cardiovascular complications develop and surgical
gression in clinical experience. treatment is indicated.
Currently, cardiac surgery is a fully standardized specialty APS has been called to clinicians’ attention in recent years
covering all aspects of congenital and acquired cardiovascu- as patients are increasingly being diagnosed at specifically
lar diseases. Up-to-date technological development com- dedicated units [6] focusing on autoimmune disorders.
bined with massive accumulation of clinical work and
knowledge on intra- and postoperative management has led
The Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) is defined by the occur-

C.A. Mestres, MD, PhD, FETCS (*) • C. Marcacci, MD rence of venous and arterial thrombosis, often multiple, and
J.L. Pomar, MD, PhD, FETCS
recurrent fetal loss, frequently accompanied by a moderate
Department of Cardiovascular Surgery,
Hospital Clinico, University of Barcelona, thrombocytopenia, in the presence of antiphospholipid anti-
Villarroel 170, Barcelona 08036, Spain bodies (aPL), namely lupus anticoagulant (LA), anticardio-
e-mail: cmestres@clinic.ub.es lipin antibodies (aCL), or anti-b2 glycoprotein I (b2GPI)
G. Espinosa, MD, PhD • R. Cervera, MD, PhD, FRCP antibodies. Chronic biological false-positive serological tests
Department of Autoimmune Diseases, for syphilis (BFP-STS) may be present in some of these
Hospital Clinico, University of Barcelona,
patients, because these tests also detect the presence of aPL.
Barcelona, Spain
Other autoantibodies have also been found in many patients
A. Colli, MD, PhD
with an APS, such as antimitochondrial (M5 type), antien-
Department of Cardiovascular Surgery,
Cardiac Surgery Unit, University of Padova, dothelial cell, antiplatelet, antierythrocyte, and antinuclear
Padova, Italy antibodies.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 321
DOI 10.1007/978-1-4471-4429-8_38, © Springer-Verlag London 2013
322 C.A. Mestres et al.

The clinical picture of the APS is characterized by venous

Box 38.1 Revised Classification Criteria for APS and arterial thrombosis, fetal loss, and thrombocytopenia.
(Sydney Criteria) According to the largest survey of APS patients – the
Clinical criteria Europhospholipid project [6] – deep vein thrombosis, some-
1. Vascular thrombosis: times accompanied by pulmonary embolism, is the most fre-
One or more clinical episodes of arterial, venous, or quently reported manifestation in this syndrome (38.9 %).
small vessel thrombosis, in any tissue or organ. Conversely, cerebrovascular accidents – either stroke
Thrombosis must be confirmed by objective validated (19.8 %) or transient ischemic attacks (11.1 %) – are the
criteria (i.e., unequivocal findings of appropriate imag- most common arterial thrombotic manifestations. Early fetal
ing studies or histopathology). For histopathological loss (35.4 %), late fetal loss (16.9 %), premature births
confirmation, thrombosis should be present without (10.6 %), and pre-eclampsia (9.5 %) are the most frequent
significant evidence of inflammation in the vessel wall. fetal and obstetric manifestations. Additionally, several other
2. Pregnancy morbidity: clinical features are relatively common in these patients, i.e.,
(a) One or more unexplained deaths of a morpho- thrombocytopenia (29.6 %), livedo reticularis (24.1 %), heart
logically normal fetus at or beyond the tenth valve lesions (11.6 %), hemolytic anemia (9.7 %), epilepsy
week of gestation, with normal fetal morphol- (7 %), myocardial infarction (5.5 %), leg ulcers (5.5 %), and
ogy documented by ultrasound or by direct amaurosis fugax (5.4 %). However, a large variety of other
examination of the fetus, or clinical manifestations have been less frequently described
(b) One or more premature births of a morpho- in patients with the APS, with prevalences lower than 5 %.
logically normal baby before the 34th weeks Some patients have a catastrophic variant of the APS, and
of gestation because of: (i) eclampsia or severe they have in common: (1) clinical evidence of multiple organ
preeclampsia defined according to standard involvement developing over a very short period of time; (2)
definitions or (ii) recognized features of histopathological evidence of multiple small vessel occlu-
placental failure, or sions, and (3) laboratory confirmation of the presence of
(c) Three or more unexplained consecutive sponta- aPL, usually at high titers. Furthermore, more than half of
neous abortions before the 10th week of gesta- the catastrophic episodes are preceded by a precipitating
tion, with maternal anatomic or hormonal event, mainly infections [7, 8]. Although patients with cata-
abnormalities and paternal and maternal strophic APS represent less than 1 % of all patients with APS
chromosomal causes excluded. [6], they are usually in a life-threatening situation with a
Laboratory criteria nearly 50 % mortality rate [8]. In order to correlate all the
1. LA present in plasma on two or more occasions at published case reports as well as newly diagnosed cases from
least 12 weeks apart, detected according to the all over the world, an international registry of patients with
guidelines of the International Society on catastrophic APS (CAPS Registry) was created in 2000 by
Thrombosis and Hemostasis the European Forum on aPL. Currently, it documents the
2. aCL antibody of IgG and/or IgM isotype in serum entire clinical, laboratory, and therapeutic data of more than
or plasma, present in medium or high titers (i.e. >40 400 patients whose data have been fully registered (www.
GPL or MPL, or > the 99th percentile), on two or med.ub.es/MIMMUN/FORUM/CAPS.HTM). The analysis
more occasions, at least 12 weeks apart, measured of this registry has allowed the characterization of the clini-
by a standardized ELISA cal and laboratory features of catastrophic APS as well as the
3. Anti-β2 glycoprotein-I antibody of IgG and/or IgM establishment of preliminary criteria for its classification and
isotype in serum or plasma (in titers > the 99th per- guidelines for its management [9, 10].
centile), present on two or more occasions, at least In order to facilitate studies of treatment and causation,
12 weeks apart, measured by a standardized ELISA, preliminary classification criteria for APS were formulated
according to recommended procedures in 1998 in Sapporo [11] and revised in 2006 in Sydney [12]
APS is present if at least one of the clinical criteria and (Box 38.1). Classification criteria for catastrophic APS were
one of the laboratory criteria are met. published in 2003 and are depicted in Box 38.2 [9].

APS can be found in patients having neither clinical nor Heart Valve Lesions in the Antiphospholipid
laboratory evidence of another definable condition (primary Syndrome
APS) or it may be associated with other diseases. APS is the
disorder with which systemic lupus erythematosus (SLE) is The heart is one of the major target organs in APS, and car-
most commonly associated. Less frequently, aPL and, rarely, diac valve disease is the most common cardiac manifestation
APS may also be encountered in other groups of patients, [13]. In the largest series, with 1,000 APS patients, the Euro-
including those with malignancies [5]. phospholipid cohort, valvular thickening and/or dysfunction
38 Heart Valve Surgery and the Antiphospholipid Syndrome 323

the edge of the mitral valve or on the vascular face of the

Box 38.2 Preliminary Criteria for the Classification of aortic valve. However, the differential diagnosis from infec-
Catastrophic APS tive endocarditis and rheumatic fever valve lesions remains
1. Evidence of involvement of three or more organs, difficult and will require clinical and microbiological assess-
systems, and/or tissuesa ment in addition to the echocardiographic findings.
2. Development of manifestations simultaneously or There are discrepancies in the prevalence of valvular
in less than a week disease in SLE patients with or without aPL as well as in
3. Confirmation by histopathology of small vessel primary APS patients [15]. One of the reasons for this vari-
occlusion in at least one organ or tissueb ability may be the different techniques [transthoracic (TTE)
4. Laboratory confirmation of the presence of antiphos- or transesophageal (TEE) echocardiography] used to detect
pholipid antibodies (lupus anticoagulant and/or valve lesions. In particular, TTE is less sensitive, and TEE
anticardiolipin antibodies)c may detect minor non-specific valvular thickening compared
a
Usually, clinical evidence of vessel occlusions, with TTE. In this regard, TEE has a higher sensitivity to detect
confirmed by imaging techniques when appropri- valvular defects in patients with SLE (e.g., 44 % with TTE
ate. Renal involvement is defined by a 50 % rise in versus 60 % with TEE in SLE patients with aPL; 25 % with
serum creatinine, severe systemic hypertension TTE versus 63 % with TEE in SLE patients without aPL)
(>180/100 mmHg), and/or proteinuria (>500 mg/24 h) [15]. Other important points that may explain the variability
b
For histopathological confirmation, significant evi- of the prevalence of valvular disease are the different method-
dence of thrombosis must be present, although vas- ologies used to test aPL and what is considered a positive aPL
culitis may coexist occasionally test in different studies. Due to these limitations, it is difficult
c to compare studies and establish solid conclusions about the
If the patient had not been previously diagnosed as
role of aPL in the development of valvular abnormalities
having an APS, the laboratory confirmation requires
By means of Doppler echocardiography, SLE patients
that the presence of antiphospholipid antibodies
with aPL show a significantly higher prevalence of valvular
must be detected on two or more occasions at least
defects compared to those without aPL [13]. Moreover,
12 weeks apart (not necessarily at the time of the
almost 90 % of patients with SLE and valvular disease have
event), according to the revised criteria for the
been found to have aPL compared to 44 % of patients with-
classification of definite APS
out valvular involvement. However, studies analyzing the
Definite catastrophic APS: association between aPL and valvular disease in SLE patients
– All 4 criteria are contradictory. The majority of studies demonstrated a
Probable catastrophic APS: higher prevalence of valvular abnormalities in patients with
– All 4 criteria, except for only two organs, sys- SLE and aPL, ranging from 14 to 86 %. In a meta-analysis of
tems, and/or tissues involvement 13 studies [16], nearly half of aPL-positive patients with SLE
– All 4 criteria, except for the absence of laboratory had valve lesions compared with 21 % of aPL-negative SLE
confirmation at least 12 weeks apart because of patients. Conversely, Roldan et al. [17] and Gabrielli et al.
the early death of a patient never previously tested [18] found a similar prevalence of valvular involvement in
for aPL prior to the catastrophic APS event both aPL-positive and aPL-negative patients with SLE.
Regarding patients with primary APS, echocardiographic
– 1, 2, and 4
studies found heart valve abnormalities in one third of them
– 1, 3, and 4 and the development of a third event [13]. As in SLE patients, patients with primary APS had a
in more than a week but less than a month, despite higher prevalence of valvular defects with TTE compared
anticoagulation with healthy individuals (40 % versus 2 %; p < 0.0001) [13].
However, TEE has a higher sensitivity to detect valvular
defects in primary APS patients (73 % with TEE versus 39 %
appeared as a cumulative manifestation in 11.6 % of the with TTE, p < 0.0005) (15/11). Unfortunately, the studies
patients, followed by vegetations in 2.7 % [6]. In the 5-year with TEE did not include healthy individuals.
follow-up of this cohort, 1.7 % of patients developed new A few prospective studies have analyzed the pattern of
valvular thickening and/or dysfunction and 1.4 % valvular heart valve lesions over time [13]. Based on these studies, the
vegetations [14]. initial valvular lesions may worsen, improve, disappear, or
An international consensus statement published in 2006 remain stable over time. Furthermore, new valvular lesions
provided relevant definitions of heart valve lesions in APS may develop. Espinola-Zavaleta et al. [19] found valve
[12]. According to this consensus, valve lesions, as assessed lesions in 71 % of primary APS patients in the initial TEE.
by echocardiography, include valve thickness of more han After a follow-up of 84 months, valve lesions were unchanged
3 mm, localized thickening involving the leaflet’s proximal in three cases and new valve lesions were detected in three
or middle portion, and irregular nodules on the atrial face of patients, whereas in six patients the valve lesions had
324 C.A. Mestres et al.

progressed. Turiel et al. [20] evaluated 56 patients with pri- be appropriate for asymptomatic patients (recommended by
mary APS at baseline, and 47 of them had repeated TEE 13/17 experts in an independent review); and (3) committee
examinations. Initial valvular involvement was found in 32 members disagreed about whether corticosteroid therapy is
(57 %) patients. Over the 5-year follow-up, progression or helpful, but agreed that distinguishing among presumptive
new cardiac involvement was observed in 17 (36 %) patients. valvulitis (valve thickening on echocardiogram), valve
Specifically, 13 (28 %) patients developed valvular lesions [8 deformity, and vegetations is important as the treatment
(61 %) subjects developed new valvular lesions and 5 (38 %) implications may differ.
had worsening lesions]. Interestingly, using multivariate More recently, the “Task Force on Catastrophic APS and Non-
logistic regression analysis, the authors found that high IgG criteria APS Manifestations,” developed in 2010 on the occasion
aCL titers (>40 GPL) represented the only independent risk of the 13th International Congress on aPL held in Galveston,
factor for new and progressive cardiac abnormalities in Texas, USA, made the following recommendations [15]: (1)
patients with primary APS. In patients with APS and previous thrombosis, mainly with
Perez-Villa et al. [21] performed a prospective study in 61 arterial involvement, a TTE is recommended; (2) with normal
SLE patients with and without APS using TTE. Overall, val- valves and in the absence of atherosclerotic factors, follow-up
vular disease was found in 39 % of patients. After a mean controls might not be necessary; (3) if heart valve lesions exist,
time of 8 years, there was a significant increase in valvular serial echocardiographic follow-up controls are warranted;
abnormalities at the final echocardiography. The results of a and (4) larger studies examining the accuracy of heart
prospective study including 53 patients with APS and previ- valve lesions detected by TEE for the diagnosis of APS are
ous thrombosis analyzed with TTE with a longer follow-up warranted.
(more than 10 years) were recently published [22]. The main
conclusion was that patients without valvulopathy would
have a 93 % likelihood of continued valvulopathy and only a Cardiac Surgery in Antiphospholipid Syndrome
7 % chance of disappearance of valvular disease during the
disease follow-up. Moreover, patients without valvulopathy Despite all of the above, the actual occurrence of patients
at initial echocardiography would have a 92 % likelihood of requiring an operation to correct a valve defect is uncom-
remaining free of valvulopathy. In light of these results, the mon. A literature review confirms that current experience in
authors recommended an initial echocardiography in all APS valve surgery in patients with APS is still scanty and that the
patients at the time of diagnosis, mainly in the presence of majority of the accumulated experience comes in the form of
arterial thrombosis. With normal valves, serial echocardio- case reports or limited case series. We outlined this in a pre-
graphic studies might not be necessary. Conversely, if valvu- vious publication [24]. However, the published reports and
lar abnormalities are present, serial echocardiographic series do give an overview of organ involvement in patients
studies are warranted in order to detect functional changes who were referred for surgical treatment of advanced heart
that may require surgery. valve disease. Table 38.1 summarizes the organ involvement
Unfortunately, no therapeutic trials or prospective clinical found by authors in different reports. This confirms that pro-
studies have specifically addressed the question of whether tean manifestations are to be expected in patients with APS
treatment has any role in the pattern of heart valve lesions requiring valve surgery. Mortality is not to be neglected.
over time, and the number of patients who received the dif- The surgical series and reports published so far are
ferent treatments included in the echocardiographic studies defining a surgical population that is to be considered as on
is relatively low to allow strong recommendations. Although the high-risk side. Single, double, and triple valve surgery
almost all patients included in the prospective studies were has been reported in the past 2 decades in about 20 reports
under anticoagulant or antiplatelet treatment, these treat- [24–44]. Valve replacement has been commonly performed
ments were unable to reverse established valve lesions or as many of these patients have advanced disease with severe
prevent their appearance. In the same sense, immunosup- leaflet and annular involvement precluding at best repair as
pression had no effect on the evolution of valvular lesions. the first option. Although the replacement option has usually
However, from the few case reports, there is scarce evidence been reported, heart valve operations are not the only one
about the possible beneficial effects of corticosteroids and attempted. Although the vast majority of patients with APS
immunosuppression on the treatment of valvular heart suffer from valve disease, coronary bypass graft surgery has
disease [13]. also been reported, and additional miscellaneous procedures,
A consensus committee developed in 2002 on the occa- too. When valve replacement was not indicated, exploratory
sion of the tenth International Congress on aPL held in operations have also been performed for non-infectious
Taormina, Sicily, Italy, made the following statements [23]: conditions [45].
(1) anticoagulation is recommended for symptomatic patients Aortic and mitral valve replacements are the most fre-
with valvulopathy; (2) prophylactic antiplatelet therapy may quently performed procedures. They are standardized
38 Heart Valve Surgery and the Antiphospholipid Syndrome 325

Table 38.1 Organ involvements performed

Author Year Ref. Brain Vasc Eye Spleen Heart Intestinal Kidney P. valve No TE Death FU
Alvarez-Blanco A 1994 [25] 1
Schumacher M 1995 [26]
Sakaguchi G 1998 [27]
Myers GJ 1999 [28]
Matsuyama K 1999 [29] 1
Amital H 1999 [46] 1 1 1 1 17 months
Hogan WJ 2000 [47]
Hasegawa R 2001 [30]
Kurushima A 2002 [31] 1 1
Berkun Y 2004 [32] 2 1 8 years
Herrmann M 2004 [33] 1 1 1 1 13 months
Massoudy P 2005 [34] 1 3 1 years
Sasahashi N 2007 [35] 1 26 days
Einav G 2007 [36]
Hegde VA 2007 [37] 1 1 1
Wieteska M 2007 [38]
Colli A 2009 [24] 1 1 2 1 years
Cianciulli TF 2009 [39] 1 10 months
De Agustin JA 2009 [40] 1
Alaminos P 2010 [41] 1
Kondo H 2010 [42] 1
Kim HK 2010 [43] 1
Ratwat RS 2011 [44] 1
Ref reference, P. valve prosthetic valve, no TE no history of thromboembolism, FU follow-up

operations, as we currently know, and surgical results accord- routine setup and equipment in cardiac surgery. The most
ing to valve position are quite similar in terms of 30-day important example to consider is extracorporeal tubing.
mortality regardless of the region, as it can be derived from Also, intraoperative management of anticoagulation is likely
the available registries. In APS patients, there are worse to be the most important issue in patients with APS. Attention
results as postoperative complications frequently appear in was drawn to this previously by Hogan et al. concerning a
terms of thromboembolic events [24]. One of the reasons young female patient [47]. Of critical importance is throm-
may be related to the actual pathophysiological mechanisms bocytopenia as well as the prolonged clotting times.
because of the deposition of APS antibodies on valve tissue Intraoperative monitoring is a substantial part of the surgical
[46]. Whether this can be accepted as an explanation in the strategy.
presence of valve replacement devices of different designs is The conducting of the operation at our department as part
still to be clearly defined. of the strategy across the entire process has included standard
cardiopulmonary bypass with full heparinization [activated
clotting time (ACT) >450 s] and cardioplegic arrest with
The Main Issues in Cardiac Surgery intermittent cold blood cardioplegia administered through
the aortic root and coronary ostia and/or the retrograde
There are a few critical issues when considering valve sur- route. Postoperative oral anticoagulation with vitamin K
gery. First, APS is by definition a hypercoagulable state. It antagonist (VKA) and anticoagulants were started after 48 h
has to be remembered that factor XII activation will occur as postoperatively, and low-molecular-weight heparin was
thrombogenic surfaces are going to be used as part of the continued until the international normalized ratio (INR)
326 C.A. Mestres et al.

Table 38.2 Type of operation

Author Year Ref. AVR MVR TVR DVR TVr CABG CABG + O O Mortality
Alvarez-Blanco A 1994 [25] 1 –
Schumacher M 1995 [26] 1 No
Sakaguchi G 1998 [27] 1 No
Myers GJ 1999 [28] 1 No
Matsuyama K 1999 [29] 1 No
Amital H 1999 [46] 1 No
Hogan WJ 2000 [47] 1 No
Hasegawa R 2001 [30] 1 –
Kurushima A 2002 [31] 1 No
Berkun Y 2004 [32] 2 7 2 2 Yes (2)
Herrmann M 2004 [33] 1 No
Massoudy P 2005 [34] 1 2 2 Yes (3)
Sasahashi N 2007 [35] 1 No
Einav G 2007 [36] 1 No
Hegde VA 2007 [37] 5 4 No
Wieteska M 2007 [38] 1 No
Colli A 2009 [24] 3 4 1 1 Yes (2)
Cianciulli TF 2009 [39] 1 No
De Agustin JA 2009 [40] 1 No
Alaminos P 2010 [41] 1 No
Kondo H 2010 [42] 1 No
Kim HK 2010 [43] 1 No
Ratwat RS 2011 [44] 1 No
Ref reference, AVR aortic valve replacement, MVR mitral valve replacement, TVR tricuspid valve replacement, DVR double valve replacement, TVr
tricuspid valve repair, CABG coronary artery bypass graft, O other

reached a range between 2.5 and 3.5. A key component in management of patients with APS undergoing cardiac
surgery is a more aggressive management of anticoagula- surgery. As stated, protean manifestations and an extreme
tion with ACT lasting twice as long as in regular operations. tendency to thrombotic events in patients are always asso-
However, this is a relatively empirical process as the clinical ciated with long-standing steroid therapy. The excellent
experience is scanty. review of Gorki et al. identified 57 patients who had under-
gone valve surgery, other than the patients in our own cases,
and yielded interesting observations after a meta-analysis
Clinical Experience of the accumulated experience up to 2007. The first is that
the average age of cardiac surgical APS patients is younger
Our experience has been reported earlier [24]. It now than that of the average patient in westernized cardiac sur-
extends to ten clinical cases, with all patients being oper- gical units. The second is that there is a trend toward
ated on for valve disease. Two of these patients died, for an increasing aggressiveness in the intraoperative manage-
in-hospital mortality of 20 %. One of them presented with ment of the anticoagulation with more liberal use of hepa-
stroke on the 5th postoperative day, and the second had rin and less aggressive reversal by using less protamine
intracranial bleeding in the form of subdural hematoma that sulfate. Finally, the possibility of the eventual appearance
was later followed by carotid artery thrombosis. These two of catastrophic APS with multiple vascular occlusions must
cases are good illustrations of the difficulties in the overall always be kept in mind [8, 9, 48].
38 Heart Valve Surgery and the Antiphospholipid Syndrome 327

Controversy still exists about how to choose a valve

replacement device. Table 38.2 shows the procedures
performed by different authors. Our policy has usually been
to choose a mechanical valve, and actually six out of ten
patients had a mechanical valve implanted. Two had a tis-
sue valve and, and they had uneventful postoperative stays.
This is similar to the experience reported in different series.
Mechanical valves are usually the first choice considering
that these patients will be in oral anticoagulation regimens
with or without antiplatelet therapy, an issue that is also
currently under discussion. Isolated cases, including one
case from our experience [46] (Figs. 38.1, 38.2, and 38.3),
may be treated with preservation of the valve, but this is
uncommon. A very recent experience by Erdozain et al.
[49] that reviewed a multicenter experience with 33 patients
treated over a period of 27 years also stressed on similar Fig. 38.3 Normal aspect of the aortic valve after excision of the throm-
issues, namely high perioperative morbidity and mortality botic mass (Reproduced with permission from “Cirugía Cardiovascular”,
and the need of the prevention of hemorrhagic and throm- Ref. [46])
botic complications.
Comments

A brief review of this complex topic from different perspec-

tives, medical and surgical, brings the public’s attention to
the following considerations that, based on the current body
of knowledge, need to be kept in mind concerning this
condition:
APS is an uncommon disease that occurs in an small car-
diac surgical population.
Specific clinical orientation is needed. This is why specific
multidisciplinary teams are to be considered. Individual or
collaborative efforts have resulted in the accumulation of
useful information [6, 8].
Aggressive intraoperative management is mandatory.
Although the evidence is based more on empirical than evi-
dence-based data, there is a trend toward a longer ACT in
this patients, who, of course, will eventually need less rever-
Fig. 38.1 Intraoperative view of an aortic valve mass suggestive of
thrombus on a patient with APS (Reproduced with permission from
sal of anticoagulation.
“Cirugía Cardiovascular”, Ref. [46]) The patient with APS requiring cardiac surgery requires a
difficult decision-making process. This includes problems
about the prosthetic valve choice. A thorough discussion is
mandatory.

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 Part XII
Congenital Heart Diseases
 Neurohormonal Factors
in Pediatric Heart Surgery 39
Jacek Kolcz

Introduction proposed by the International Working Group on Acute

Heart Failure considering heart failure as a syndrome
Neurohormones are substances produced by neurons that involving ventricular dysfunction, elevating filing pres-
transduce information from both the environment and organ- sures, neurohormonal activation, and worsening symptoms
ism into the cells, tissues, and organs to develop an integrated [4]. This model incorporates the complex interactions of
response to a particular stimulus [1]. The precursors of the the neuroendocrine, paracrine, and immune system path-
signaling particles present in the neuroendocrine system are ways. These include the sympathetic nervous system (SNS),
detected at the most primitive levels of evolution, and some renin-angiotensin-aldosterone system (RAAS), hypotha-
of the amino acid signals, e.g., glutamic acid, are considered lamic-pituitary-adrenal axis, vasopressin, thyroid-stimulat-
to have extraterrestrial origins [2]. The evolution of complex ing hormone (TSH), natriuretic peptides, cytokines, and
forms of live was originated by the ability of the cells to other proinflammatory substances, and mediators of
communicate through secretory substances. After billions of endothelial function.
years of evolution, neurohormonal factors take part in main- While cardiac dysfunction is not yet associated with overt
taining homeostasis in the human organism. All these sub- congestive heart failure (CHF), neurohormonal activation
stances are closely related to each other and can be released plays a role in the compensatory mechanism for reduced car-
by many stimuli, such us external receptor stimuli (ophthal- diac output, increased atrial pressure, and arterial under-
mic, olfactory, auditory), baroreceptors, chemoreceptors, filling. The SNS, hypothalamic-pituitary axis, endothelin
pain, changes in organ perfusion, disturbances of the osmo- system, and RAAS act synergistically to maintain peripheral
larity, stretch receptors, inflammatory or immune response, blood pressure and redistribute blood volume to vital organs.
etc. In the field of pediatric cardiac surgery, neurohormonal The effects of these mechanisms are antagonized by counter
factors are considered as a part of the neurogenic- regulatory processes mainly by cholinergic pathway activa-
inflammatory-endocrine stress response influencing both the tion and counter-regulatory substances or reflexes that exert
preoperative and postoperative periods, playing an important many corrective effects. All these mechanisms, if not down-
role in early and late pathophysiology, diagnostics, treat- regulated after some time, become detrimental not simply as
ment, and monitoring. the result of the heart failure, but also as an important contri-
There are many definitions of circulatory failure in the bution to the progression of circulatory failure. Thus, neu-
core literature. However, the International Society for Heart rohumoral activation leads to increased myocardial volume
and Lung Transplantation in its Practice Guidelines for and mass in the remodeling process, which is responsible for
Management of Heart Failure in Children recommends increased myocardial oxygen demand, myocardial ischemia,
definition reflecting cellular and molecular processes impaired contractility, and arrhythmogenesis.
accompanying this condition [3]. A similar definition was Treating heart failure in a population of patients with
congenital heart disease can be quite challenging. In gen-
eral, evidence for the treatment of decompensated heart fail-
ure is skimpy, and the level of evidence decreases with the
J. Kolcz, MD, PhD, FECTS age of the population. Although there are both medicines
Department of Pediatric Cardiac Surgery, blocking neurohormonal activation and strategies using
Polish – American Children’s Hospital,
exogenous analogs of neurohormones available, further
Jagiellonian University,
265 Wielicka St, Krakow 30-663, Poland studies in the field of pediatric heart failure, including neo-
e-mail: mikolcz@gmail.com nates, are necessary.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 333
DOI 10.1007/978-1-4471-4429-8_39, © Springer-Verlag London 2013
334 J. Kolcz

Sympathetic Nervous System When catecholamine-resistant hypotension is encountered, a

vasopressin infusion may improve systemic vascular resis-
Sympathetic stimulation exerts many effects on the cardio- tance (usually 0.01–0.05 units/kg/h).
vascular system by norepinephrine and epinephrine, although To decrease of influence of SNS stimulation, b-blocker
the level of epinephrine is not usually elevated in heart fail- use has been reported, but in children with HF, the evidence
ure. Afferent baroreceptor signaling to the brain signals low is very limited, and no large placebo-controlled trials are
cardiac output, and efferent sympathetic pathways are acti- available. The implementation of these drugs in children
vated. The main results of it are vasoconstriction (increased with large left-to-right shunts improved neurohormonal
afterload, decreased renal perfusion), increased heart rate and profiles, decreased respiratory symptoms, and improved
contractility (increased cardiac output and wall stress), and growth [10, 11]. Sparse experience on the use of carvedilol
activation of the RAAS. These effects are aimed at the resto- in the pediatric population (at an average dose of 0.08 mg/
ration of cardiac output, however, at the expense of increased kg/day) has been reported, but the results were equivocal.
myocardial oxygen demand, increased intracellular calcium Interestingly, a significant correlation between the clinical
toxicity, and myocardial hypertrophy [5]. Sympathetic over- effects of carvedilol and systemic ventricle morphology, with
stimulation can cause many undesirable effects such as the a trend toward having less beneficial effects in patients with
expression of fetal genes, apoptosis, necrosis, and remodel- a morphologically right ventricle serving as the systemic
ing, and high levels of plasma norepinephrine are an indepen- ventricle, was noted [12, 13].
dent predictor of mortality [6] (Table 39.1).
The baseline plasma concentrations of catecholamines
are higher in neonates compared to older children and adults Endothelin
[7], and age-dependent differences in the clearance rates of
sympathomimetic inotropes have also been demonstrated Endothelins (ET-1,-2,-3) are molecules produced by the
[8]. These features, together with a higher percentage of endothelium acting as vasoconstrictors and mitogenic fac-
body water, hypoperfusion of vital organs, systemic inflam- tors. In patients with heart failure, their plasma concentra-
matory response, and differences in enzyme activity, deter- tions are increased, and their concentration is proportional to
mine age-related variation in the hemodynamic response to the severity of the disease [14]. Endothelins promote vaso-
exogenous catecholamines. Although in the neonatal popu- constriction, inflammation, fibrosis, and hypertrophy in the
lation there are no appropriate studies, low doses of dop- pulmonary and systemic vasculature.
amine (3–5 ug/kg/min) or of epinephrine (0.02–0.05 ug/kg/ Plasma ET-1 levels are elevated in patients who have car-
min) are recommended in acute heart failure. The use of diomyopathy or chronic heart failure, and they correlate with
dobutamine and norepinephrine are not advised in neonates [9]. severity and prognosis. In particular, the degree of plasma
elevation of endothelin correlates with the magnitude of
alterations in cardiac hemodynamics and functional class.
Table 39.1 Sympathetic nervous system activation Endothelin receptor antagonists cause vasodilation via
Effects of sympathetic increased nitric oxide and prostacyclin production, which
stimulation Cellular effects have antiproliferative properties. Nitric oxide and prostacy-
Heart Increased cardiomyocyte calcium entry clin reduce ET-1 activity by inhibition of pre-pro-ET produc-
Increased contractility Myocardial hypertrophy tion. Increased levels of ET-1 have been demonstrated in
(inotropy) patients with pulmonary hypertension (PAH) and Eisen-
Increased heart rate Gene expression:
menger syndrome and after cardiopulmonary bypass in chil-
Increased wall stress Increased expression of fetal genes
dren with PAH.
Decreased myocardial Decreased expression of calcium
relaxation (lusitropy) metabolism genes
Increased oxygen demand Apoptosis
Peripheral vessels Necrosis Renin-Angiotensin-Aldosterone Axis
Constriction Fibrosis
Increased afterload Myocardial hypertrophy/remodeling The renin-angiotensin-aldosterone axis exerts many effects
Kidney b1-receptor downregulation on the cardiovascular system (Table 39.2). Neural connexion
Vasoconstriction of the brain and kidneys is stimulated by low sodium,
Sodium retention decreased perfusion, and increased alpha-adrenergic activity.
Water retention It can affect the juxtaglomerular apparatus, increasing renin-
RAAS activation protease transforming angiotensinogen to angiotensin I,
Sodium retention which is converted within the endothelial cells (particularly
Water retention concentrated in the lungs) to angiotensin II by angiotensin-
39 Neurohormonal Factors in Pediatric Heart Surgery 335

Table 39.2 RAAS activation adrenal function prior to hydrocortisone administration

Mechanisms Cellular effects should be tested. Hydrocortisone should be considered in
Constriction of vessels 1. Myocyte hypertrophy patients with septic shock who have responded poorly to
൹ ൹ Afterload 4. Myocyte necrosis fluid resuscitation and vasopressor agents [19]. Treatment of
Norepinephrine release Disorganization of the adrenal dysfunction reduces inotrope requirements, which
extracellular matrix may reduce low output syndrome in intensive care units and
Afterload increase Apoptosis morbidity and improve the neurodevelopmental outcome.
Aldosterone Fetal genes expression The detrimental effects of glucocorticoid therapy should
Retention of sodium and water Myocardial hypertrophy
always be considered.
Vasoconstriction of the efferent Left ventricular remodeling
arteriole
൹ GFR
Vasoconstriction of the afferent Vasopressin System
arteriole
ൻ GFR Vasopressin is released by the hypothalamus as a result of
Retention of sodium and water baroreceptor, osmotic, and neurohormonal stimuli. It nor-
Vasopressin release mally maintains body fluid balance, vascular tone, and regu-
Retention of sodium and water lates contractility. Heart failure causes a paradoxical increase
in AVP. The increased blood volume and atrial pressure in
converting enzyme (ACE). Angiotensin II is the most potent heart failure suggest inhibition of vasopressin secretion, but
vasoconstrictor increasing vascular resistance in stress situa- it does not occur. This phenomenon is related to SNS and
tions (especially in hypovolemia) and affecting the adrenal RAAS activation overriding the volume and low-pressure
cortex, increasing aldosterone production, which increases cardiovascular receptors and osmotic vasopressin regulation
reclaiming of sodium and water. Its major role is to maintain causing an increase in AVP secretion. It contributes to the
the circulating volume status [15]. increased systemic vascular resistance (V1 receptors) and to
To influence the RAAS axis, ACE inhibitors are used in renal retention of fluid (V2 receptors) [20]. Stimulation of
children with congenital heart defects. Several studies in V1 receptors can also cause vasoconstriction of the periph-
ventricular level shunts have suggested a possible benefit eral vessels, platelet aggregation, and adrenocorticotrophic
from ACE inhibitors, presumably due to their relatively hormone stimulation. Low-dose arginine infusion initiated in
selective effect of afterload reduction, increasing systemic the operating room after complex neonatal cardiac surgery
blood flow and reducing pulmonary blood flow [16]. A few was associated with decreased fluid resuscitation and cate-
small studies reported mixed results with respect to the use cholamine [21].
of ACE inhibitors in patients with single ventricle physiol-
ogy. Perioperative ACE inhibitor treatment was shown to
decrease the severity and duration of pleural effusions after Growth Hormone
bidirectional cavopulmonary anastomosis surgery [17],
although no benefit on exercise performance or cardiac auto- Growth hormone is secreted by the anterior pituitary and
nomic activity after the Fontan operation was observed [18]. mediates its effects via insulin growth factor-1 (IGF-1).
Levels of growth hormone are elevated in patients with heart
failure as well as in patients with cardiac cachexia. In par-
Hypothalamic-Pituitary-Adrenal Axis ticular, a recent study showed that treating heart failure
patients with growth hormone may result in normalization of
Insufficiency of the hypothalamic-pituitary-adrenal axis after the abnormal immunological responses and in suppression
pediatric cardiac surgery has been observed, best described of the excessive activation of biochemical apoptotic path-
as a critical illness related to corticosteroid insufficiency ways in the human cardiovascular system.
(CIRCI). Together with derangement of other axes, it is con-
sidered one of the causes of low cardiac output syndrome in
the postoperative period. Many causes of this phenomenon Thyroid Hormones
were proposed: brain hypoperfusion, central hypothalamus
and pituitary gland insufficiency, tissue resistance to adreno- Thyroid hormones are stimulated by TSH anterior pituitary
corticotropic hormone (ACTH), adrenal dysfunction, cyano- secretion. The many actions of thyroid hormones on cardio-
sis, and tissues immaturities. The CIRCI is diagnosed by a vascular system are exerted mainly by triiodothyronine (T3).
delta cortisol level of 9 g/dl (after 250 g cosyntropin) or a These effects can be divided into genomic and extragenomic
random total cortisol of 10 g/dl. To treat adrenal dysfunction, actions. T3 binds to the nuclear receptors and activates many
336 J. Kolcz

genes corresponding to key myocardial functions: myosin Table 39.3 Mechanisms of action of natriuretic peptides
heavy chain (MHC), sarcoplasmic reticulum Caĥĥ-ATPase Systemic effects Cellular effects
(SERCA2) and its inhibitor phospholamban (affecting car- Diuretic and natriuretic action Antimitogenic action on
diac contractile function and diastolic relaxation), voltage- myocytes
gated Kt channels, b1-adrenergic receptor, guanine nucleotide ൹ GFR Reduction in the number of
fibroblasts
regulatory proteins, adenylate cyclase, NAt/Kt-ATPase, and
ൻ Retention of sodium and Inhibition of left ventricular
Na/Ca exchanger [22]. The main cardiovascular effects of water remodeling
T3 are increased cardiac contractility, reduction of afterload, Inhibition of renin secretion Inhibition of myocardial fibrosis
reduction of vascular resistance, chronotropic effects Inhibition of aldosterone Inhibition of myocardial
(increased heart rate), and increased sodium reabsorption, secretion hypertrophy
and water improves the atrial filling pressure. All of this Vasodilation
increases cardiac output. Low TH levels are common in criti- Decrease in preload
cal illness of multiple causes, e.g., sepsis, myocardial infarc- Decrease in afterload
tion, and after surgery. Euthyroid sick syndrome is common Inhibition of norepinephrine
secretion
in pediatric cardiac surgery intensive care units, and the typi-
Shift of fluid the interstitium
cal physiologic disruptions are reduced, non-pulsatile TSH
Decrease in preload
secretion and T3 reduced by increased conversion of T4 rT3
vs. T3. The total T3 < 0.6 nmol/l can predic: longer mechani-
cal ventilation, longer O2 supplementation, longer ICU stay, function. What is more, it reduces the postoperative inten-
greater use of epinephrine, and greater use of furosemide sive care time [26].
[23]. Main causes of hypothyroidism in congenital heart sur-
gery population are hemodilution, iodine skin preparations,
dopamine administration, and secondary hypothyroidism Counter Regulatory Hormones
related to abnormal cerebral perfusion. Transient secondary
hypothyroidism occurs in a large number of children after There are many counter-regulatory hormones, which are
cardiopulmonary bypass operations [24]. The postoperative stimulated by stress response (characterized among others
increase in cardiac output and systolic ventricular function by gluconeogenesis, glucogenolysis, relative insulin resis-
variables was significantly greater after tri-iodothyronine tance, reduced insulin-dependent skeletal muscle uptake of
treatment. Patients given tri-iodothyronine after longer car- glucose, and hyperglycemia). The most important are corti-
diopulmonary bypass operations showed improvement in sol, glucagon, epinephrine, and growth hormone.
cardiac function. It was also observed after a modified Fontan
procedure [25]. T3 has genomic effects that maintain
endothelial integrity, such as angiotensin receptors in vascu- Cholinergic Pathway
lar smooth muscle cells (VSMC). This supports the hypoth-
esis that the vasculature is a principal target for T3 action. T3 Together with the stimulation of the adrenergic system, the
decreases resistance in peripheral arterioles. Extragenomic feedback is also started as the antiinflammatory cholinergic
actions include modulating cellular metabolic activities, such pathway [27]. It is comprised of vagus nerve signals leading
as glucose and amino acid transport, ion fluxes at the level of to acetylcholine interaction with receptors on monocytes and
the plasma membrane, and mitochondrial gene expression macrophages, resulting in reduced cytokine production [28].
and function. It can prevent tissue injury and improve survival by exter-
Low T3 is also frequently associated with a catabolic pat- nal stimulation [29, 30]. The cholinergic antiinflammatory
tern characterized by lower insulin levels, higher cortisol pathway exerts a tonic, inhibitory influence on immune
levels, lower plasma lipid levels, lower body weight, and responses to infection and tissue injury. Interrupting this
lower albumin levels. Furthermore, in asymptomatic and pathway produces exaggerated responses to bacterial prod-
mildly symptomatic patients with non-ischemic left ven- ucts and injury [31].
tricular dysfunction, T3 values and the T3/T4 ratio are
linked to both the severity of the left ventricular dysfunction
and clinical status, being progressively lower in patients
with more depressed ventricular dysfunction (and higher Natriuretic Peptides
brain natriuretic peptide values).
There is strong evidence that tri-iodothyronine treatment The natriuretic peptide system counteracts of some of the
in children after cardiac surgery improves myocardial func- effects of neurohormonal activation causing vasodilatation,
tion without delaying postoperative recovery of thyroid reduction of aldosterone production (by direct influence on
39 Neurohormonal Factors in Pediatric Heart Surgery 337

the adrenal gland), increased diuresis and natriuresis, reduc- pressure overload (Table 39.3). In normal individuals, BNP
tion of renin production, decreased vasopressin release, and levels are elevated immediately after birth, but fall to adult
decreased activation of the sympathetic nervous system. levels by 3 months of age. In the setting of heart failure, BNP
Direct influence of the natriuretic peptides on the myocar- levels correlate closely with the NYHA Classification of
dium includes prevention of hypertrophy and reduction of Heart Failure and with ventricular filling pressures. BNP lev-
fibroblast proliferation [32]. BNP is a natriuretic peptide els of more than 80 pg/ml have a good specificity and sensi-
released in response to ventricular volume expansion and tivity in diagnosing heart failure.

↑ Catecholamine ↑ Sodium retention

↑ Vasopressine ↑ Fluid retention

↑ RAAS ↑ Vasoconstriction

↑ Endothelin ↑ Fibrosis

↓ ANP
↓ BNP
↓ CNP
↓ DNP ↑ Vascular
Shear stress

↓ Fibroblast
Proliferation

↑ ANP
↑ BNP
↓ Vasodilatation
↑ Blood pressure ↑ CNP
↑ DNP
↓ Aldosterone
↓ Afferent arteriolar tone
↓ Efferent arteriolar tone
↓ Renine

↓ Renal blood flow

↓ GFR
↓ Sodium excretion
↓ Water excretion

Ryc. Natriuretic factor interactions

338 J. Kolcz

Cardiopulmonary bypass in children induces renal and 5. Ferrara R, Mastrolilli F, Pasanisi G, Censi S, Aiello ND, Fucili A,
neurohormonal changes similar to those observed in con- et al. Neurohormonal modulation in chronic heart failure. Eur Heart
J. 2002;4:D3–11.
gestive heart failure: upregulation of the RAA axis, 6. Stanek B, Frey B, Hulsmann M, et al. Prognostic evaluation of neu-
increase of renin concentration, and release of vasopressin. rohumoral plasma levels before and during beta-blocker therapy in
These changes are more pronounced in children who advanced left ventricular dysfunction. J Am Coll Cardiol. 2001;
undergo palliative procedures for single ventricle lesions 38(2):436–42.
7. Eliot RJ, Lam R, Leake RD, et al. Plasma catecholamine concentra-
(hemi-Fontan, bidirectional Glenn, and Fontan procedures) tions in infants at birth and during the first 48 hours of life. J Pediatr.
than in children who undergo biventricular repairs, and the 1980;96:311–5.
extent of neurohormonal activation after CPB is associated 8. Allen E, Pettigrew A, Frank D, et al. Alterations in dopamine clear-
with the severity of fluid retention and development of ance and catechol- O-methyltransferase activity by dopamine infu-
sions in children. Crit Care Med. 1997;25:181–9.
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resistance [33, 34]. nous dobutamine is associated with an increased risk of death in
The endogenous biological activity of the natriuretic patients with advanced heart failure: insights from the Flolan
hormone system is decreased after the bypass. This is International Randomized Survival Trial (FIRST). Am Heart
J. 1999;138:78–86.
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mones, presence of inactive neurohormones, resistance to Bursch J. Propranolol treatment of congestive heart failure in
natriuretic hormone activity, receptor downregulation, infants with congenital heart disease: the CHF-PROINFANT trial.
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J Cardiol. 2001;79:167–73.
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It has been also shown that neurohormones can decrease therapeutic beta blockade on myocardial function and cardiac
ischemia-reperfusion injury in multiple tissues, including remodelling in congenital cardiac disease. Cardiol Young. 2003;
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12. Auerbach S, Richmond M, Hsu D, et al. BNP levels predict out-
limitation of intracellular Ca++ overload, maintenance of come in pediatric heart failure patients: post hoc analysis of the
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tion showed an improvement of urinary output, increase of 1171–9.
the cardiac index, and significant reduction of pulmonary 14. Bauer M, Wilkens H, Langer F, Schneider SO, Lausberg H, Schafers
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1034–6.
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 Antifibrinolytic Therapy in Pediatric
Congenital Heart Surgery 40
Ehrenfried Schindler

Preface coagulation factors is age-dependent, and therefore reference

limits from adult practice cannot be transferred to that for
For decades, aprotinin was the standard antifibrinolytic drug children of 1 to 2 years. Infants up to 6 months can be
used in adult and pediatric major surgery [1]. Numerous assumed to have significantly lower plasma levels of certain
studies showed that the perioperative loss of blood, and thus procoagulants, such as factor II, V, VII, IX, X, XI, and XII.
the use of homologous blood, could be limited by adminis- Andrews could show that the inhibitors aeM and C1-Inh were
tering aprotinin. Other antifibrinolytic-acting substances, increased twofold compared to adults in early childhood. In
such as e-aminocapronic acid (EACA) or tranexamic acid contrast, the mean plasma concentrations of protein C and
(TXA), tended to be misfits in routine clinical practice. HCII were significantly lower than for adults until the early
In 2006, the publication of a retrospective study carried teenage years [4]. The bleeding time in children up to
out by Managno et al., in which considerable safety concerns approximately 10 years of age is significantly longer com-
were expressed with regard to aprotinin, led to a significant pared to adults. Thromboembolic complications in children
rethinking of its clinical use [2]. Two years later, the results following major surgery or prolonged immobilization are
of the BART (Blood Conservation using Antifibrinolytics in rare and usually more likely associated to secondary under-
a Randomized Trial) study confirmed that there was an lying disorders. The reason for this could be found in the
increased postoperative mortality associated with the use of significant reduction of the endogenous thrombin potential
aprotinin compared to TXA and EACA [3]. (ETP) compared to adults. Children can considered to be
In a few adult studies so far, tranexamic acid has been protected from thrombosis, but the underlying molecular
found to be comparably as effective as aprotinin. Although basis is not yet fully understood [5–8].
TXA is a long-known drug available on the market for more Another important fact is that absolute reference range
than 50 years, the studies connecting the factors of the indi- values for coagulation assays in neonates, infants, and chil-
cation, dosage regimen, and safety are limited, especially in dren vary with different analyzers and reagent systems. This
children and infants. means that each laboratory should define specific ranges for
the children tested there.

Developmental Hemostasis
Fibrinolytic System in Pediatric Patients
In the 1980s, the pioneering work of Andrew and co-workers
showed that the coagulation system of children is different The coagulation system involves a fine balance between
from that of adults. They introduced the term “developmen- coagulation and fibrinolysis to prevent uncontrolled coagula-
tal hemostasis” to describe this phenomenon. The study of tion in vivo. The principle of developmental hemostasis is
Andrew and co-worker showed that the concentration of conferrable to the fibrinolytic part of the coagulation swing.
The fibrinolytic system is age-dependent, being different
compared to that of adults.
E. Schindler Fibrinolysis is defined as the degradation of intravascular
Department for Pediatric Anesthesiology, fibrin clots by the action of plasmin, which results from plas-
German Pediatric Heart Center, Asklepios Klinik
minogen hydrolysis. This action is mediated throughout a
Sankt Augustin, Arnold-Janssenstr. 29,
Sankt Augustin 53737, Germany series of serine proteases that interact to cleave insoluble
e-mail: e.schindler@asklepios.com fibrin into soluble fibrin degradation products [9]. During clot

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 341
DOI 10.1007/978-1-4471-4429-8_40, © Springer-Verlag London 2013
342 E. Schindler

Fig. 40.1 Mechanism of action

for tranexamic acid (TXA),
e-aminocaproic acid (EACA),
and aprotinin during fibrinolysis
(t-PA tissue-type-plasminogen t-Pa, u-Pa Fibrin clot
Kallikrein
activator, u-PA urokinase PAI-1,
FXla, Xlla
type-plasminogen activator, PAI PAI-2
plasminogen activator inhibitor,
FDP fibrin degradation Aprotinin
products)

Plasminogen Plasmin

α2-AP
α2-M

TXA EACA

FDP
FDP

FDP

formation, plasminogen is incorporated into the thrombus by Table 40.1 Changes of reference values over the first month after
binding on fibrin and cell surfaces. The tissue-type plasmino- birth for the coagulation system in healthy children compared to adults.
All data are presented in more detail in [4, 6, 9]
gen activator (t-PA) binding is also attracted by fibrin and is
also incorporated into the clot formation. There it activates 3 month 6 month
Parameter Day 1 of age of age
the degradation of plasminogen to plasmin. To prevent exces-
Antithrombin (AT)   -
sive fibrinolysis, several modulating substances are present.
Protein C   -
Plasminogen activator inhibitor-1 and -2 (PAI-1 and PAI-2)
Protein S   -
regulate fibrin-bound t-PA. Several other molecules fine-tune
Plasminogen   
the fibrinolytic system, such as a2-antiplasmin(a2-AP), a2- t-PA  - -
macroglobulin (a2-M), and thrombin-activated fibrinolysis PAI-1  - -
inhibitor (TAFI), to name the most important (Fig. 40.1). PAI-2  - -
Studies showed that major components of the coagulation a2-AP - -
system could be detected in the fetus approximately from a2-M - - -
10 weeks of gestation. Immediately after birth, the coagula-
tion system is developed with its all parts, but the blood con-
centrations are different. Reference values are given by decrease in plasminogen levels, the activity of the fibrinolytic
Andrews and were documented in a more recent study by system in infants and very young children is increased com-
Monagle [4, 6]. One major difference is the concentration of pared to adults. The most important differences in the plasma
plasminogen, which is reduced by more than half the amount concentration of coagulation molecules compared to that of
compared to adults. After 6 months of age, the adult concen- adults are presented in Table 40.1.
tration is nearly equal, and it remains constant during child-
hood. t-PA in contrast is significantly increased immediately
after birth. Very short after birth the plasma concentration of Antifibrinolytic Agents for Children
t-PA is decreasing progressively. There is a rapid increase in
t-PA levels after the first period of life, and t-PA levels will Aprotinin
reach about 50 % of the adult value during childhood com-
pared to adulthood. Like t-PA, the plasminogen activator Aprotinin is a so-called “serine protease” molecule inhibitor
inhibitor levels are increased after birth compared to adult when administered in large doses. Serine molecules can
values. This may explain why, despite the remarkable be found in the coagulation pathway and are needed for
40 Antifibrinolytic Therapy in Pediatric Congenital Heart Surgery 343

initiating fibrinolysis [10]. Aprotinin augments and prolongs The optimal dosage for TXA to prevent fibrinolysis has
coagulation initiated by activation of both intrinsic and not yet been defined for pediatric patients. According to
extrinsic pathways. The main influence on the fibrinolytic in vitro studies, a concentration of 10 mg/ml can decrease
system is mediated by blocking kallikrein and the plasmin- 80 % of t-PA activity, and a concentration of 16 mg/ml can
activating molecules i-PA, u-PA, and t-PA. Additionally, inhibit platelet activation induced by plasmin [17–19]. The
aprotinin, like other antifibrinolytic drugs, will interfere with concentration of TXA necessary to prevent fibrinolysis in vivo
the lysine-binding site of plasminogen or plasmin. The effect is unknown. A recent study aiming to optimize the dosing
of t-PA is enhanced more than 400 fold in the presence of schedule in adult patients in cardiac surgery had the objective
fibrin. Several studies showed that aprotinin decreases throm- of achieving a stable plasma concentration >20 mg/ml.
bin formation during surgery with cardiopulmonary bypass.
Therefore, it is recommended to start with the aprotinin ther-
apy before fibrin formation has been initiated, which means Indication for Antifibrinolytic Agents
before the skin incision in major surgery [11]. in Cardiac Surgery
There are numerous studies on the aprotinin dosage
regimes, especially for cardiac or pediatric cardiac surgery. There are many publications on adult cardiac surgery that
In recent years, “high-dose” schemes were mostly recom- support the use of antifibrinolytic substances for high-risk
mended [12]. patients because of the reduction in the amount of blood prod-
ucts transfused. Less information is available for pediatric
open-heart surgery. Moreover, estimation of the effectiveness
e-Aminocaproic Acid (EACA) of the prophylactic use of antifibrinolytics varies a great deal.
For example, the study by Davies et al. [20] showed a reduc-
EACA is not available in all European countries. Comparable tion in neither blood loss nor in the blood products used under
to tranexamic acid, EACA reversibly inhibits the transforma- aprotinin therapy. Williams et al. [21] also found no effects of
tion of plasminogen to the active protease plasmin. Saturation aprotinin on newborns with congenital heart defects. However,
of the lysine-binding site of plasminogen with EACA dis- for Carrel et al. [22] and more recently Murugesan et al. [23],
places plasminogen from the surface of fibrin. Even if plas- aprotinin had a blood-saving effect in surgery for transposi-
minogen is transformed into the active component plasmin, tion of the great arteries. Other authors demonstrated a blood-
it cannot bind to fibrin, and its fibrinolytic action is inhibited saving effect for all antifibrinolytic agents during repair of
[13]. Over 20 years ago, there were reports that high-dose cyanotic defects [24]. In conclusion, complex neonatal car-
EACA therapy will inhibit the platelet aggregation induced diac surgery, cyanotic defects, and rethoracotomies constitute
by collagen and ADP [14]. Shortly after the introduction of the three reported indications for using antifibrinolytic drugs
EACA, serious concerns arose about thromboembolic and for pediatric open-heart surgery. An up-to-date, large multi-
renal complications. After a warning message published in center study including a total of 22,258 patients (25 centers)
the New England Journal of Medicine in 1969, the routine looking at blood saving aspects and adverse events associated
use of EACA dropped, especially for children [15, 16]. with aprotinin, TXA, and EACA found no difference in the
A recent large multicenter study including a total of 22,258 rates of renal failure requiring dialysis in any of the groups.
patients (25 centers) looking at adverse events associated The blood-saving aspects of all of the used substances were
with aprotinin, TXA, and EACA found no difference in renal comparable. Interestingly, the study favored the TXA group,
failure requiring dialysis in any of the groups. Interestingly, and comparative analyses suggested similar efficacy of EACA
the study favored the TXA group, and comparative analyses and improved outcomes associated with TXA [25].
suggested similar efficacy of EACA and improved outcomes
associated with TXA.
Dosage and Infusion Schemes
of Tranexamic Acid
Tranexamic Acid (TXA)
Up to now, no consensus has been reached about the ideal
Tranexamic acid has been available for a long time. In dosage of TXA for pediatric patients undergoing congenital
Europe, it was introduced for clinical use starting in 1970. heart surgery with cardiopulmonary bypass (CPB). When
Tranexamic acid is a synthetic derivate of the amino acid analyzing the existing studies regarding the dosage and
lysine that exerts its antifibrinolytic effect through the revers- efficacy of TXA, it should be noticed that in most of the stud-
ible blockade of lysine-binding sites on plasminogen, thus ies the age range was large, including neonates, infants, chil-
preventing fibrin degradation. Its main action in the coagula- dren, and adolescents, which makes the results analysis
tion system is promoting clot stability. Tranexamic acid also difficult, especially as the results are usually not stratified by
preserves platelet function by reducing the effect of plasmin age. Additionally, it is important whether the patients are
on glycoprotein 1b receptors. suffering from a cyanotic or non-cyanotic disease because
344 E. Schindler

cyanotic heart defects are known to involve platelet dysfunc- Timing of Antifibrinolytic Therapy
tion, and these patients tend to bleed more than non-cyanotic in Pediatric Heart Surgery
patients. Second, if analyzing efficacy studies, the main clin-
ical endpoints could be blood loss volume, transfusions Most of the study protocols using antifibrinolytic therapy are
requirement, coagulation parameters, or a combination of focused on different dosage schemes. Considering the mech-
these. Some other endpoints are also found in studies, such anism of fibrinolysis and especially antifibrinolytic therapy,
as time needed for chest closure, rethoracotomies, platelet the drugs act by binding to the lysine-binding site of plasmi-
activation analysis, and biochemical parameters. Of note, the nogen by interfering with the tissue plasminogen activator.
endpoint blood product transfusion volume may be biased in Remember that the potential of t-PA is enhanced more than
low weight children since blood products may also be used 400 fold in the presence of fibrin. This means that the activa-
for hemodynamic reasons and do not always consequently tion of the fibrinolytic system must be suppressed before a
indicate perioperative blood loss. Additionally, in low body significant amount of fibrin or fibrin clots have been gener-
weight children, blood must be administered if platelets or ated. In the setting of congenital heart surgery, it is therefore
fresh frozen plasma have to be given to prevent dilution and considered to be effective to start any antifibrinolytic therapy
therefore low hematocrit values. before skin incision. Data from the available literature do not
Chauhan and coworker could show the efficacy of TXA support the mandatory initiation of antifibrinolytic therapy
on blood loss and blood product requirements in three out of after skin incision or sternotomy, but strongly suggest start-
four groups with different dosage schemes except one single ing before the beginning of CPB. Additionally, the initiation
bolus application of 50 mg/kg [26]. In the four study groups, of a cardiopulmonary bypass as well as the reversal of hepa-
they have used: group 1, 50 mg/kg TXA at induction of rin to start coagulation with administration of protamine is
anesthesia; group 2, 10 mg/kg at induction followed by an associated with a significant activation of the coagulation
infusion of 1 mg/kg/h; group 3, 10 mg/kg at induction, cascade. If not, a2-antiplasmin will immediately begin
10 mg/kg on bypass, and 10 mg/kg after protamine (end of degrading plasmin, and a reduction of a2-antiplasmin is asso-
surgery); group 4, 20 mg/kg at induction and 20 mg/kg after ciated with the risk of excessive bleeding [31–34].
protamine (end of surgery). These results could explain the
absence of any significant reduction in the use of blood
products in two Canadian studies of Levin and Zonis because Risks and Side Effects
they also used a single bolus injection of 50 mg/kg BW
[16, 27]. Van der Staak and coworker used TXA continu- The aforementioned observational study by Mangano et al.
ously in major pediatric surgery. They found a significant published in 2006, observed an increase in the number of
reduction in postoperative blood loss and transfusion cases of renal failure, myocardial infarction, and stroke under
requirements with a dosage scheme of 4 mg/kg 10 min prior aprotinin therapy [2]. In 2007, Mangano, using the same set
to skin incision followed by an infusion of 1 mg/kg/h for of data, found an increase in the 5-year mortality rate, which
24 h after surgery [28]. Bulutcu could show a significant was not the case in the tranexamic acid or in the e-aminocaproic
decrease in blood loss and blood product requirements with acid groups [35]. The criticism was that the aprotinin group
TXA compared to placebo, especially in cyanotic patients was at a disadvantage in these observational studies because
[29]. The reported using a high dose scheme of one single the high-risk constellation of the patients was countered in
bolus of 100 mg/kg followed by 100 mg/kg in the pump 2008 by the data of the prospective, randomized study by
prime and 100 mg/kg after CPB. If comparing this high- Fergusson et al. [3]. This study had to be prematurely aban-
dose scheme with that of Chauhan, no significant difference doned as a distinct trend toward mortality was established. In
could be seen regarding the primary endpoints, allowing the his publication, Fergusson stated that for aprotinin, the “num-
conclusion that the efficacy does not increase dose depend- ber needed to harm” is 50. However, in two other more recent
ently. Because even in the presence of heparin during car- studies with a large number of pediatric cardiac surgical
diopulmonary bypass fibrin formation and therefore patients, Szekely et al., with nearly 700 children, were not
activation of coagulation could be assumed, a continuous able to show that aprotinin was responsible for renal dysfunc-
dosage regimen seems favorable over a single-bolus injec- tion [36], and Backer et al., with over 2,500 children, were not
tion. The most recent regimen used at our institution is based able to establish a connection between aprotinin and renal
on our own experience [30] and was later modified after insufficiency, neurological complications, or an increase in
pharmacokinetic calculation according to the in-vivo stud- mortality [37]. The question is to what extent the data com-
ies of Andersson and Soslau [17, 19]. We now use a single piled by Mangano and Fergusson in adult surgery can be
bolus of 10 mg/kg BW followed by a continuous infusion of transferred to the field of pediatric surgery. It is to be noted
3 mg/kg/h, adding 0.1 mg/kg TXA per ml of pump prime that in some recent studies, while aprotinin reduced the ten-
volume to the cardiopulmonary bypass circuit. dency to bleeding, it was not shown to influence the rate of
40 Antifibrinolytic Therapy in Pediatric Congenital Heart Surgery 345

mortality or to impair organ function. However, the meta- the dose administered and the size of the exposed area.
analysis of Brown et al. [38] states that the risks of using Consequently, the administration of TXA in the CSN or close
aprotinin outweigh the risks of using tranexamic acid, and the to the CSN can immediately evoke epileptic seizures.
authors of a new issue of the Cochrane collaboration over- In the “aprotinin era,” the group of cardiac surgical
view came to a similar conclusion. patients was the largest investigated group receiving
Breuer et al. found an increase (albeit not statistically antifibrinolytic drugs in the adult as well as in the pediatric
significant) in the number of seizures in patients treated with population. Whereas aprotinin was associated with renal
tranexamic acid [39]. Data are available from adult cardiac failure, TXA can cause seizures or convulsions in children as
surgery patients, as well as from the field of neurosurgery, well as in adults. In a case series after pediatric neurosurgery,
indeed showing a connection between the use of tranexamic we observed convulsions in four patients postoperativly
acid and epileptic seizures. This can be explained by the associated with TXA therapy. The first appearance of con-
antagonistic effect of tranexamic acid on GABA receptors vulsions in our case series was in the early postoperative
[40, 41]. To what extent this aspect affects endpoints such as period after neurosurgery between the first 40 min after extu-
cerebral ischemia or mortality has yet to be examined. bation and the last 5 h post extubation. In most of the pediat-
However, this demonstrates the importance, in the “post- ric cardiac centers, children below 6 months of age are kept
aprotinin era,” of arousing interest in the safety aspects of intubated, sedated, and ventilated for at least 6 h after cardiac
other antifibrinolytic alternatives. surgery. It is possible that pathological electroencephalo-
The use of antifibrinolytics always naturally interferes grams (EEG) or silent seizures were not recognized because
with the balance of pro- and anticoagulatory forces. There are of ventilation and sedation so that the real number of patho-
justifiable fears that inhibition of fibrinolysis may lead to a logical neurologic events after TXA administration in pedi-
thrombotic event. In children with cyanotic defects, activation atric cardiac surgery is higher than suspected.
of fibrinolysis may already be found in the preoperative One important message from earlier animal studies was
period. It is difficult to say how often thrombosis occurs when that the convulsive effects of the tranexamic acid are dose-
using antifibrinolytic therapy in pediatric cardiac surgery. For dependent. In our neurosurgical patients, we used a
both aprotinin and tranexamic acid, the reports are predomi- significantly higher dose than described in some other publi-
nantly episodic. Whether tranexamic acid offers an advantage cations (100 mg/kg as a bolus followed by 10 mg/kg/h).
over aprotinin (which is also said to have anticoagulatory Neurotoxic signs occurred in rats at doses starting from
characteristics) in this respect has not yet been sufficiently 0.5 mg/ml. At 5 mg/ml, two out of six rats showed signs of
examined. In a study by Jaquiss et al., no thrombotic events major toxicity and died. Lastly, at a TXA concentration of
were observed in 865 children who underwent cardiac sur- 47.5 mg/ml, all the tested rats died. Considering the calcu-
gery with aprotinin therapy [42]. When one considers that the lated ratio between concentrations leading to neurotoxic
incidence of thrombosis in the area of the central venous cath- effects estimated in rats and concentrations in the cerebrospi-
eter is said to be 20 % in pediatric cardiac surgery patients, nal fluid (CSF) after IV administration of 66 mg/kg TXA in
one would assume that thrombotic events are probably under- adults or 20 mg/kg in children older than 1 year, it can be
diagnosed. In our study, two patients from the aprotinin group concluded that convulsive effects are not expected to be com-
had to undergo rethoracotomy because of thrombosis. mon after this maximum dose [41].
However, in comparison with the tranexamic acid group, no Regarding its use in cardiac surgery, the present data are
significant difference could be determined from this. But insufficient to reach a conclusion about a potential risk of
there was no control group for comparison [30]. TXA inducing a convulsive effect when administered intra-
At this point, it is of course interesting to discuss what venously. Unless there are clinical safety data available, TXA
dose of tranexamic acid should be given to achieve the should be indicated carefully in neonates and infants aged
desired effect and still avoid undesirable side effects. less than 12 months of age.
Convulsive effects following TXA were first shown in ani- To evaluate the effects of tranexamic acid on death, vascu-
mal studies. The mechanism by which TXA can evoke epi- lar occlusive events, and blood transfusion in trauma patients,
leptic seizures includes binding to the GABA (g-aminobutyric the CRASH-2 study was initiated as a randomized, placebo-
acid) binding sites of GABA, and dose-dependent inhibition controlled multicenter investigation [44]. The results of this
of the binding of the GABA receptor agonist, muscimol, and study are based on the data of 274 hospitals including 20,211
consequently antagonistic effects on GABA receptors trauma patients. Although outcome measures on subgroup
[41, 43]. These convulsive effects are dose dependent. The analysis were considered, no special “children’s” group could
convulsive effect of TXA, after application directly in situ in be created, so data are from adult patients. In the group of
the cortex area or the lumbar spinal cord, is induced by block- patient <25 years, there were only five patients younger than
ing GABA-mediated inhibition in the central nervous system 16 years of age. As an overall result, the conclusion was that
(CSN). Two factors may increase the epileptic effect of TXA: the all-cause mortality was significantly reduced with
346 E. Schindler

tranexamic acid compared to placebo. No increased risk of neonates undergoing open-heart surgery. Paediatr Anaesth. 2008;18:
non-fatal vascular occlusive events with TXA could be noted. 812–9.
22. Carrel TP, Schwanda M, Vogt PR, Turina MI. Aprotinin in pediatric
The final conclusions were to recommend TXA for inclusion cardiac operations: a benefit in complex malformations and with
on the WHO list of Essential Medicines and to consider TXA high-dose regimen only. Ann Thorac Surg. 1998;66:153–8.
safe for use in bleeding trauma patients. 23. Murugesan C, Banakal SK, Garg R, Keshavamurthy S, Muralidhar
K. The efficacy of aprotinin in arterial switch operations in infants.
Anesth Analg. 2008;107:783–7.
24. Schouten ES, van de Pol AC, Schouten AN, Turner NM, Jansen NJ,
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 Thromboembolism in Cyanotic Heart
Disease: Mechanisms and Therapies 41
Toshio Nakanishi

Mechanisms of Thrombus Formation anticoagulant barrier between the blood and endothelium,
preventing blood from clotting on the internal surface of ves-
Thrombosis is formed in the presence of an abnormal vascu- sels. The plasma thrombomodulin level initially increases
lar wall including endothelial damage and dysfunction, with acute vascular injury, but it decreases with subsequent
altered function of platelets and coagulation factors, and/or downregulation of its production during chronic vessel injury
abnormal bloodstream. Once the endothelium has been [10]. It was reported that downregulated gene expression of
injured and the blood exposed to the thrombogenic matrix, thrombomodulin by rapid atrial pacing induced local coagu-
such as collagen, on the vascular wall, platelets adhere to the lation imbalance on the internal surface of the atrial cavity,
endothelium via platelet-glycoprotein (GP) interaction with leading to atrial intramural thrombus formation.
von Willebrand factor on the vascular wall. After platelet Downregulation of this molecule may, therefore, disturb the
adhesion, platelets are activated and bind to fibrinogen via optimal coagulation balance and promote thrombogenesis.
GP 2b/3a receptors, and they release their granules into the
bloodstream. Platelet activation and granule secretion result
in further platelet aggregation and thrombin generation. Cyanotic Congenital Heart Disease
Thrombin activates the coagulation cascade and platelets
[1–4]. In addition to normal hemostasis, platelet activation Cyanotic congenital heart disease (CCHD) is associated with
may result in the pathologic process of thrombosis and an increased risk of stroke and thromboembolism [11, 12].
inflammation. Ammash and Warnes [12] reported that the incidence of
P-selectin is an adhesion molecule found in the secretory cerebrovascular events were observed in about 14 % of adult
granules of platelets [5] and is mobilized to the plasma mem- patients with CCHD (1/100 patient-years). Conditions that
brane on activation [2]. P-selectin expressed on platelets may further predispose to thrombosis are (1) after aortopulmo-
be a direct inducer of procoagulant activity associated with nary shunt, especially using a conduit, (2) after the Glenn
vascular and thrombotic diseases [6]. procedure, (3) after the Fontan procedure, and (4) Eisen-
menger syndrome. A recent study using contrast-enhanced
computed tomography revealed a high prevalence of pulmo-
Endothelial Function nary thrombosis in patients with Eisenmenger syndrome
[13]. The precise mechanisms behind the increased incidence
Thrombomodulin is expressed mainly on the surface of vas- of thromboembolism in patients with CCHD have not yet
cular endothelial cells. Endothelial thrombomodulin is a key been determined, but endothelial dysfunction, coagulation
component of the protein C anticoagulant pathway, which abnormalities, platelet activation, and an abnormal blood-
facilitates the activation of protein C by thrombin [7–9]. stream may be underlying factors causing thromboembolism
Activated protein C is known to inhibit clotting factors V [14, 15].
and VIII. Therefore, thrombomodulin acts as an intrinsic

Platelet Activation
T. Nakanishi, MD
Department of Pediatric Cardiology,
Horigome et al. [16] measured plasma levels of P-selectin
Heart Institute, Tokyo Women’s Medical University,
8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan and showed that the plasma level of P-selectin was elevated
e-mail: pnakanis@hij.twmu.ac.jp in CCHD. We previously demonstrated that P-selectin

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 349
DOI 10.1007/978-1-4471-4429-8_41, © Springer-Verlag London 2013
350 T. Nakanishi

expression on the platelets is elevated in patients with CCHD, The role of hyperviscosity in platelet activation in CCHD
indicating that platelet activation does exist in CCHD [17]. should be studied further.
Some studies failed to demonstrate elevated platelet P-selectin
in patients with CCHD [14, 18]. The reason for that is not
clear, but different methods of platelet P-selectin measure- Thromboembolic Events
ment may be partly responsible, since P-selectin is rapidly
mobilized to the platelet surface and lost in the plasma [19]. Increased incidence of thromboembolism and organ infarc-
Although patients in our study were receiving an antiplatelet tion has been reported in patients with CCHD [11, 12]. In
drug (aspirin or ticlopidine) or a combination of an antiplate- patients with CCHD <4 years old, the risk of cerebrovascular
let and an anticoagulant drug (heparin or warfarin), the plate- thrombosis in intracranial veins is increased, and the reported
let P-selectin level was elevated in many patients [17]. incidence varies from 1.6 to 20 % [11, 12]. Candice et al.
[13] reported that a pulmonary artery thrombus was noted in
21 % of patients with Eisenmenger syndrome. We showed
Endothelial Dysfunction previously that the platelet P-selectin level was higher in
patients with than in those patients without thromboembolic
Previous studies showed decreased plasma thrombomodulin events in CCHD, suggesting that elevated P-selectin could be
levels of protein C activity in patients with CCHD [16, 17]. a risk factor for cerebral thromboembolism in CCHD [17].
This suggests the presence of impaired endothelial function In addition to elevated P-selectin on platelets, we showed
in patients with CCHD. These data are in agreement with the plasma levels of thrombin antithrombin complex III (TAT) in
study of Ferreiro et al. [20] showing that nitric oxide synthe- patients with thromboembolic events were higher than in
sis activity was blunted in patients with CCHD, suggesting those without [17]. Thus, elevated P-selectin and TAT may
that the endothelial function is impaired. indicate a high risk of thromboembolism. It should be noted
The endothelium may be damaged by the increased shear that aspirin alone cannot always inhibit platelet activation.
stress on the vessel wall caused by increased blood viscosity
and/or by chronic hypoxemia in CCHD [7]. It has been spec-
ulated that in patients with primary pulmonary hypertension, Fontan Circulation and Thromboembolism
damage to the endothelium leads to a decreased thrombo-
modulin level [10]. It is likely that in patients with CCHD, A Fontan circulation is associated with an increased risk of
the plasma thrombomodulin level may be downregulated by thromboembolism [24–26]. The precise mechanisms by
its decreased production due to chronic endothelial injury which thrombus is formed in patients after the Fontan proce-
and persistent hypoxemia. dure remain undetermined, but the process is most likely
multifactorial. Possible factors that predispose to thrombus
formation after Fontan procedures include an enlarged right
Endothelial Dysfunction and Platelet Activation atrium, slow blood flow, prosthetic material, atrial arrhyth-
mias, blind cul-de-sacs of the pulmonary artery stump, right-
It is possible that the decreased expression of protein C and to-left-shunts, and hypercoagulablility. The prevalence of
the increased expression of P-selectin on platelets due to a thromboembolic events has been reported to range from 3 to
reduced thrombomodulin level may contribute to the forma- 30 % among Fontan patients [27–29]. The probability of
tion of thrombi in patients with CCHD. Recently, Kario et al. freedom from thromboembolism decreases with the interval
[21] demonstrated that endothelial cell damage is a potential after the Fontan procedure [26, 27]. Right atrial volume
risk factor for cerebral infarction. It was also reported that increases with the interval after atriopulmonary anastomosis.
the increased expression of platelet P-selectin associated Slow blood flow in the enlarged atrium may further predis-
with a reduced NO level, a marker of endothelial dysfunc- pose to thrombus formation. However, whether there is a dif-
tion, was a risk factor for cerebral infarction in patients with ference in the prevalence of thromboembolism among three
atrial fibrillation [22]. An elevated plasma P-selectin level types of Fontan procedures (atriopulmonary anastomosis,
has been reported in patients with congestive heart failure, lateral tunnel, and total cavopulmonary connection) remains
primary pulmonary hypertension, and CCHD [18]. The to be clarified.
platelet activation under these conditions could be due to the
increased shear stress and/or endothelial dysfunction [23].
Horigome et al. [16] reported that the hematocrit value Coagulation
showed a positive correlation with soluble P-selectin, and
they speculated that increased shear stress due to hypervis- Various abnormalities in the coagulation system have been
cosity could be a major factor causing platelet activation. postulated as mechanisms of the increased incidence of
41 Thromboembolism in Cyanotic Heart Disease: Mechanisms and Therapies 351

thromboembolism in Fontan patients, including decreased status is enhanced. Iron-deficient erythrocytosis in patients
protein C, protein S, and antithrombin III levels [24, 30, 31]. with CCHD <4 years old predisposes to cerebrovascular
thrombosis in the intracranial venous sinuses and veins rather
than in the artery [11]. Dehydration enhances the chance of
Platelets thromboembolic events in children, and treatment for dehy-
dration is important in children with CCHD. Erythrocytosis
Platelets play an important role in thrombus formation, and and hyperviscosity itself do not increase the chance of cere-
collagen-induced and adenosine-induced platelet aggrega- bral thromboembolic events in adults [35], and therefore
tions are elevated in patients after the Fontan procedure [32]. phlebotomy is not recommended. Phlebotomy causes iron
We previously demonstrated that P-selectin expression on deficiency and ultimately enhances hyperviscosity. The risk
platelets is elevated in patients after the Fontan procedure, factors associated with cereborovascular events in adults
indicating that platelet activation occurs in Fontan patients were systemic hypertension, atrial fibrillation, phlebotomy,
[33]. and iron-deficiency anemia [12], and attempts should be
made to eliminate these risk factors. Iron deficiency should
be corrected, especially when the mean corpuscular volume
Endothelium is <82, by oral intake of low-dose ferrous sulfate.

We also showed previously that plasma thrombomodulin

levels and protein C activity were decreased in Fontan Eisenmenger Syndrome
patients [33], suggesting the presence of impaired endothe-
lial function. Previous studies using near-infrared spectros- As in Eisenmenger syndrome patients with CCHD, there is a
copy and flow-mediated vasodilation have suggested that dilemma between bleeding and thromboembolism. Anti-
endothelial function in Fontan patients is impaired [34]. The coagulation is recommended in patients with idiopathic
endothelium in Fontan patients may be damaged by increased pulmonary arterial hypertension. However, there are no data
shear stress on the vessel wall caused by increased blood vis- supporting routine anticoagulation therapy in patients with
cosity and/or by chronic hypoxemia before the Fontan proce- Eisenmenger syndrome. Because of the risk of bleeding,
dure [17]. The negative correlation between thrombomodulin prophylactic administration of antiplatelets and anticoagu-
levels and the interval after the Fontan procedure suggests lants is not recommended. Indications for these drugs in
the deterioration of endothelial function over time following patients with Eisenmenger syndrome are (1) frequent epi-
the Fontan procedure [33] This may partly explain the high sodes of atrial flutter or fibrillation and (2) recurrent throm-
prevalence of thromboembolic events long after the Fontan botic events.
procedure.

Shunt
Management of Thrombosis in CCHD
Systemic-to-pulmonary shunt using a conduit (modified
Prophylasis Balock-Taussig shunt) is performed as palliation for tetral-
ogy of Fallot and complex congenital heart diseases with
Prophylactic administration of antiplatelets and anticoagulants severe pulmonary stenosis or pulmonary atresia or hypoplas-
in general is not recommended in patients with CCHD. tic left heart syndrome. Beneficial effects of antiplatelets are
A bleeding tendency exists in patients with CCHD, and the shown in some studies [36, 37], but not in others [38, 39].
bleeding includes epistaxis, menorrhagia, hemoptysis, and The use of aspirin after shunt placement is recommended in
internal pulmonary bleeding, which are sometimes fatal. There the guideline of the American College of Chest Physicians
is a dilemma between a bleeding tendency and thrombotic dis- [40].
position in the management of patients with CCHD [11].

Fontan Procedures
Erythroytosis
There is no consensus regarding the efficacy of antiplatelet and
In patients with CCHD, secondary erythrocytosis due to low anticoagulant therapy in patients after Fontan procedures.
systemic oxygen saturation and an increased erythropoietin Basically, there are three policies concerning thromboembo-
level is observed. In iron-deficient microcytic erythrocytosis, lism in the management of patients after Glenn and Fontan pro-
the erythrocyte is less deformable and the hyperviscosity cedures: (1) no medication, (2) the use of antiplatelets, and (3)
352 T. Nakanishi

the use of anticoagulants. The policy depends on the institution 9. Suzuki K, Kusumoto H, Deyashiki Y, Nishioka J, Maruyama I,
and/or primary physician taking care of patients. Marrone et al. Zushi M, et al. Structure and expression of human thrombomodu-
lin, a thrombin receptor on endothelium acting as a cofactor for
[41] in their meta-analysis reported that the thromboembolic protein C activation. EMBO J. 1987;6:1991–7.
incidence long after extracardiac total cavopulmonary connec- 10. Cacoub P, Karmochkine M, Dorent R, Nataf P, Piette JC, Godeau P,
tion (TCPC) with antiplatelet therapy (4.5 %) was similar to et al. Plasma levels of thrombomodulin in pulmonary hypertension.
that with anticoagulation therapy (5 %). Kaulitz et al. [42] Am J Med. 1996;101:160–4.
11. Perloff JK. Neurologic disorders. In: Perloff JK, Child JS, editors.
reported that thrombotic events were observed in 7 % of patients Congenital heart disease in adults. 2nd ed. Philadelphia: W B
long after TCPC, and the incidence was similar among patients Saunders; 1998. p. 237–46.
without medication, with aspirin, and with warfarin. Cheung 12. Ammash N, Warnes CA. Cerebrovascular events in adult patients with
et al. [43] also reported similar data. Irrespective of the anti- cyanotic congenital heart disease. J Am Coll Cardiol. 1996;28:768–72.
13. Candice KS, John TG, Eli K, Michelle AH. Pulmonary thrombosis
thrombotic medication policy, Jacobs and Pourmoghadam [44] in adults with Eisenmenger syndrome. J Am Coll Cardiol.
emphasized the importance of careful evaluation of thrombosis 2003;42:1982–7.
in the follow-up of post-Fontan patients, including transesoph- 14. Levin E, Wu J, Devine DV, Alexander J, Reichart C, Sett S, et al.
ageal echocardiography. Hemostatic parameters and platelet activation marker expression in
cyanotic and acyanotic pediatric patients undergoing cardiac surgery
Whether the risk of thromboembolism is high in patients in the presence of tranexamic acid. Thromb Haemost. 2000;83:54–9.
after the Glenn procedure has not been determined. In the 15. Adatia I, Barrow SE, Stratton P, Ritter JM, Haworth SG.
presence of right-to-left shunt before Fontan completion, it Abnormalities in the biosynthesis of thromboxane A2 and prosta-
may be prudent to use antiplatelets and/or anticoagulants in cyclin in children with cyanotic congenital heart disease. Br Heart
J. 1993;69:179–82.
patients after the Glenn procedure [45]. 16. Horigome H, Murakami T, Isobe T, Nagasawa T, Matsui A. Soluble
P-selectin and thrombomodulin-protein C-Protein S pathway in
cyanotic congenital heart disease with secondary erythrocytosis.
Laboratory Tests Thromb Res. 2003;112:223–7.
17. Kajimoto H, Nakazawa M, Murasaki K, Mori Y, Tanoue K,
Kasanuki H, et al. Increased thrombogenicity in patients with cyan-
In order to prevent thromboembolic events in patients with otic congenital heart disease. Circ J. 2007;71:948–53.
CCHD, laboratory tests examining platelet activation, such 18. Horigome H, Hiramatsu Y, Shigeta O, Nagasawa T, Matsui A.
as the platelet aggregation test and P-selectin, and hyperco- Overproduction of platlet microparticles in cyanotic congenital heart
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agulability, such as TAT, should be performed, and if neces- 19. Michelson AD, Barnard MR, Hechtman HB, MacGregor H, Connoly
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should be added for each patient. Among antiplatelet medi- ulated platelets rapidly lose surface P-selectin but continue to circu-
cations, clopidogrel is an option [46]. The efficacy of this late and function. Proc Natl Acad Sci. 1996;93:11877–82.
20. Ferreiro CR, Chagas AC, Carvalho MH, Dantas AP, Jatene MB, Bento
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and gene expression in children with congenital heart disease: a novel
pathophysiological adaptive mechanism. Circulation. 2001;103:2272–6.
21. Kario K, Matsuo T, Kobayashi H, Asada R, Matsuo M. ‘Silent’
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 Endovascular Management
of Coarctation of the Aorta 42
Edward B. Diethrich

Introduction Patient Selection

Aortic coarctation has been recognized since the late 1700s Because de novo lesions are rare in adults, most patients who
[1], but the first and largest post-mortem series appeared in are candidates for endovascular repair have had a previous
1928 [2]. Nevertheless, the condition was not commonly intervention. Factors to be considered when deciding the
diagnosed clinically until the early 1930s. Although de novo most appropriate form of management include age, aortic
lesions in adults are rare, primary aortic coarctation has been morphology, any previous surgical or endovascular treat-
documented in patients over a wide range of ages and with ment, and the interventionist’s experience. Arch hypoplasia
varying degrees of severity—in general, the condition pres- may cause a residual gradient following coarctation repair,
ents most commonly in infancy. Aortic coarctation is consid- particularly if it is severe and this condition represents a
ered significant if an invasively determined pressure gradient significant challenge for successful repair.
is >20 mmHg at rest or >30 mmHg after exercise in adoles- Approximately 10 % of patients who underwent surgical
cents and adults. Untreated coarctation can cause left ven- repair of neonatal aortic coarctation will develop recurrence
tricular pressure overload and left ventricular hypertrophy, as an adult and present with associated aortic diseases. Open
premature coronary artery disease, and, eventually, heart repair can be challenging because of complex aortic pathol-
failure. ogy with the recoarctation, intercostal collateral circulation,
Successful surgical correction of coarctation of the aorta and pleural scar tissue from the original operative approach.
by resection with end-to-end anastomosis was first described Early repair of native coarctation is associated with a
by Crafoord and Nylin in 1945 [3]. Until fairly recently, open lower risk of late hypertension and improved survival, but
surgical repair using either a left thoracotomy with end-to- the risk of recoarctation is higher. Recoarctation with aneu-
end anastomosis or end-to-side anastomosis was considered rysm or pseudoaneurysm formation is fairly common.
“gold-standard” treatment of coarctation [4–7]. Despite good Aneurysms may develop at the site of surgical repair or
long-term success, recurrence of coarctation is consider- within the proximal aorta and often these are best treated
able—as high as 15 % [4–8]. Percutaneous balloon angio- with endovascular therapy; aneurysmal disease distal to a
plasty was introduced as a treatment in 1981 [9], and we recoarctation is fairly common. Untreated aneurysms carry
performed one of the early stenting procedures at The a considerable risk of aortic rupture. With late repair, there is
Arizona Heart Institute in 1995 [10]. In recent years, stenting a greater risk of recurrent hypertension and a lower overall
(sometimes combined with hybrid repair) has become an risk of recoarctation; nevertheless, survival and hypertension
accepted treatment for aortic coarctation, reserving surgery may still be improved by treating patients who are first diag-
for those patients not suited for the endovascular approach or nosed as adults.
in whom it has failed [11–15].

Indications

The presentation of coarctation is dependent on the severity

of obstruction and associated cardiac lesions; in general,
E.B. Diethrich, MD
those diagnosed as infants exhibit congestive heart failure,
Founder and Medical Director of The Arizona Heart Foundation,
Department of Cardiovascular and Endovascular Surgery, severe acidosis, and ischemia of the lower extremi-
Phoenix, AZ, USA ties. Adolescent and adult patients often present with

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 355
DOI 10.1007/978-1-4471-4429-8_42, © Springer-Verlag London 2013
356 E.B. Diethrich

hypertension that is difficult to control, headaches, nose- angioplasty requires a delicate balance, as underdistension of
bleeds, leg cramps, muscle weakness, claudication, ischemia the vessel may cause residual stenosis, and overdistension
of the bowel and lower extremities, and neurologic changes. can result in aortic dissection, rupture, or aneurysm forma-
tion. In addition, neointimal proliferation and restenosis may
result from vessel wall trauma following intervention.
Technique Because of these potential adverse events, stenting (rather
than angioplasty alone) has become almost routine at our
The goal of an endovascular approach to treat coarctation of institution as well as others.
the aorta is to restore anatomical relief of the obstruction
resulting in reduction of the aortic gradient pressures. This
concept is exemplified well in Fig. 42.1, which was contrib- Stenting
uted by one of my former fellows. Endovascular approaches
are preferable to open surgery in the vast majority of patients Bare stents are generally used to ensure adequate aortic
with recoarctation, and balloon angioplasty and stent implan- lumen reduction of the pressure gradient and a lower recur-
tations are widely used [11, 16]; endoluminal grafting rence rate than that seen with angioplasty. Stenting addresses
(including covered stents) may also be appropriate in selected resulting vessel wall trauma from ballooning, prevents elas-
cases [14]. Both covered and uncovered stents can be used to tic recoil, and seals small dissections. Neointimal response
achieve satisfactory results. At our institution, we use endo- and proliferation may be observed following stenting, but
vascular techniques to provide relief from obstruction at the stent treatment of coarctation in older children, adolescents,
coarctation site and improve pressures proximally and dis- and adults results in immediate hemodynamic benefit
tally as well as to exclude pericoarctation aneurysms or dis- [10– 13, 15]; in larger vessels, the recurrence rate is very low.
section to minimize the risk of rupture. The average duration Our preference for stenting has been the Palmaz XL 10 series
of hospitalization following stenting of aortic coarctation is stent (Cordis, Miami Lakes, FL) since for a time it was the
about 2 days, whereas open surgery may require a stay as only large product available. The IntraStent Max (ev3
long as 2 weeks. We strive to avoid disruption of blood flow Endovascular Inc., Plymouth, MN), approved in 2002, offers
to the left upper extremity and vertebral circulation, but when another option; however, because of its rounded edges, it
subclavian artery coverage is required, a carotid-subclavian results in less pressure in the vessel wall, and migration may
bypass prevents vascular compromise to the left upper be a problem. Other stents, such as the Cheatham-Platinum
extremity. All patients with documented coarctation-associ- stent (NuMED, Hopkinton, NY), appear to be highly effec-
ated pseudoaneurysms routinely undergo preoperative com- tive in reducing the coarctation gradient and increasing lesion
puted tomography (CT) angiography and Doppler studies to dilation in both native coarctation and recoarctation but are
delineate the anatomical and physiological status of their not yet available in the US [17].
carotid and vertebral arteries and its branches. If the opera- Some technical details regarding the procedure are war-
tive procedure entails coverage of the left subclavian artery, ranted since mishaps have occurred and caused less-than-fa-
we perform elective left carotid-subclavian bypass grafting vorable results. As the majority of patients will present with
whenever the right vertebral artery is abnormally small or recurrent coarctation and a narrow lumen surrounded by scar
diseased, or when there is evidence of an incomplete circle tissue, our first step after crossing the area with a 0.33-in.
of Willis [12]. In the rare case in which the patient has had a Glidewire (Terumo, Somerset, NJ) is an intravascular ultra-
left internal mammary artery bypass to the coronary circula- sound. The exam provides accurate measure of aortic diam-
tion, the carotid-subclavian bypass is also necessary. eters proximal and distal to the coarctation and an exact
lumen diameter (Fig. 42.2). A small-diameter balloon (usu-
ally no more than 8–10 mm, depending on the degree of
Angioplasty stenosis) is used to dilate prior to stent deployment. Serial
balloon dilatations are often indicated in heavily calcified,
Balloon angioplasty is a widely accepted treatment for subatretic, or recurrent lesions; however, the major purpose
patients with native and recurrent coarctation of the aorta in of the balloon is to permit unobstructed passage of the stent
patients older than 6 months of age. The angioplasty proce- deployment system. The large Palmaz stent is loaded by
dure stretches and tears the intima and, in some cases, the hand crimping onto the delivery balloon. A long sheath is
media of the vessel wall. While ample luminal gain can be passed across the deployment site, and the mounted stent is
achieved, the correct balloon size is key in preventing elastic centered at the deployment location (usually in the middle of
recoil and inordinate trauma to the vessel. In older patients the coarctation). This centering within the sheath is impor-
with degenerative disease and calcification, great care must tant since sometimes the stent moves on the balloon even
be taken when dilating the vessel. Indeed, safe use of after careful crimping. Once positioned, the sheath is
42 Endovascular Management of Coarctation of the Aorta 357

Fig. 42.1 (a) Angiogram

a
showing narrow (arrow)
recurrent coarctation distal to the
left subclavian artery (Courtesy
of Dr. Preventza and Dr. Coselli
[Texas Heart Institute at St. Luke
’s Episcopal Hospital, Baylor
College of Medicine]).
(b) Pressure tracings using
pigtail catheter proximal to
coarctation. (c) Tracings distal to
coarctation. (d) Tracings
proximal to coarctation after
stent and balloon angioplasty
using 12 mm balloon. (e) Tracing
distal to repair with no pressure
gradient. (f) Comparison
of pre- and postoperative
angiograms following successful
angioplasty. (g) Post-procedure
CT examination showing good
apposition of stent and
satisfactory 14.1 mm residual
aortic diameter

c
358 E.B. Diethrich

Fig. 42.1 (continued)

d

e
42 Endovascular Management of Coarctation of the Aorta 359

f g

Fig. 42.1 (continued)

retracted to the lower end of the stent, where it prevents the these cases, dilatation of a bare stent may be associated with
stent from migrating during expansion. When a significant the risk of dissection or rupture. In addition, older patients in
portion of the stent is adequately apposed to the aorta, the whom the vessel wall appears rigid and less compliant may
sheath is pulled distally, and the balloon is fully expanded. also benefit from placement of a covered stent. Due to the
The goal of the procedure is the eradication of the pressure ever-present potential for aortic dissection and rupture, cov-
gradient; it is important to understand that a perfect angio- ered stents should always be available in the endovascular
graphic picture is not necessarily indicative of that achieve- suite as illustrated in Fig. 42.5.
ment. This is nicely illustrated in Figs. 42.3 and 42.4.

Treatment of Complex Cases

Covered Stents
Complex forms of coarctation are frequently managed by
Although both covered and uncovered stents can be used to anatomic and extra-anatomic bypass techniques commonly
achieve satisfactory results, covered stents and endoluminal referred to as hybrid procedures. These procedures combine
grafts may be used for post-coarctation repair associated classical surgical techniques with endovascular approaches
with aneurysm formation at or near the site of previous sur- to treat both the recoarctation and its associated pathologies.
gery. In patients with a small thoracic aorta, endoluminal Figure 42.4a illustrates a frequently observed pattern in
grafting may be preferable to stenting because various com- which the site of the recoarctation is expanded distally and
ponents and types of endoluminal grafts are available, and proximally, even involving the origins of the left subclavian
the device may be customized as needed [14]. Covered stents artery. The operative approach (Fig. 42.4b) involved expo-
are also useful in patients with “tight” native coarctations; in sure of the left subclavian arteries and carotid arteries with a
360 E.B. Diethrich

supraclavicular approach, resection of the proximal subcla- Procedural Risks/Complications

vian aneurysm with carotid-subclavian, and endoluminal
graft exclusion of the entire aneurysm segment (Fig. 42.6). Possible complications that may arise from balloon angio-
Another problem encountered in recoarctation is the size plasty and stent placement include aortic rupture, dissection,
discrepancy between the aortic segments adjacent to the nar- and pseudoaneurysm formation. Large sheath sizes are
rowed segment. Figure 42.5 shows marked dilation beyond required to deliver stents and endoluminal grafts, and the use
the coarctation with a narrow proximal segment. The repair of hemostatic control devices is advisable to prevent or mini-
was accomplished by using separate endografts of different mize groin hematomas when appropriate. Acute aortic dis-
sizes in a customized configuration. Fortunately, endograft section and aneurysm formation following bare stent
design has now evolved enough to include tapered grafts implantation can be seen in 10–15 % of patients. Size dis-
(Fig. 42.7) that are useful in treating complex pathologies. crepancies in the device versus the vessel may be the cause
of some complications, including stent migration and
endoleak. Stent migration is a serious concern and is likely
the result of insufficient balloon pre-dilation prior to stent
deployment. Excessive force in balloon deployment of the
stent may also cause it to slip and migrate. A gentle gradual
inflation of the stent is recommended. Reintervention to treat
endoleaks that form around the device is sometimes neces-
sary; endoleaks can often be treated by inserting another
endoluminal graft. Additional procedures such as coil embo-
lization or plugging may be required in case of a large leak
arising from the subclavian artery. Small leaks, however,
may resolve spontaneously [12] (Fig. 42.8).
In some cases, when endovascular grafts are used, left
carotid–left subclavian bypass procedures must be performed
as well to prevent pseudoaneurysm formation and left upper
extremity ischemia resulting from coverage of the subcla-
vian artery with an endoluminal graft. Except as indicated
earlier, we do not routinely perform a left carotid-subclavian
bypass even if the left subclavian artery is covered.
Late hypertension is relatively common, even in the
absence of residual or recurrent coarctation. Hypertension
Fig. 42.2 Intravascular ultrasound image showing extremely tight that persists after stenting in adult life is likely due to struc-
recoarcted aortic area that is almost the same as the diameter of the tural and functional abnormalities of the arterial wall, which
probe. Such measurements are useful in determining balloon size selec- can result in diminished arterial wall compliance and
tion for progressive dilatation of the lesion

Fig. 42.3 Stent deployment can

result in distal migration when
the coarctation is inadequately
dilated and the stenotic region is
highly fibrotic. Further stent
deployment can result in
additional migrations
42 Endovascular Management of Coarctation of the Aorta 361

Fig. 42.4 The migration problem can be prevented by placing a sheath across the coarcted area. The sheath is withdrawn, allowing the proximal
portion of the stent to deploy and anchor into the stenotic area. The sheath is slowly withdrawn as the balloon is progressively expanded

Fig. 42.5 (a) Illustration of recoarctation (arrow) in an adult previ- pseudoaneurysm formation (arrow). (c) Procedure further complicated
ously treated as a child with end-to-end anastomosis. (b) Balloon angio- by Palmaz stent migration times two. Endoluminal graft deployment
plasty and stent deployment resulted in iatrogenic dissection with closed the pseudoaneurysm and restored normal blood flow distally
362 E.B. Diethrich

b c

Fig. 42.5 (continued)

increased rigidity. The causes of late hypertension are not with a history of coarctation is imperative following repair.
known, but decreased aortic compliance, abnormal barore- Our experience indicates both de novo and recurrent aortic
ceptor function, and neuroendocrine activation may be coarctations as well as secondary aneurysmal disease can be
involved. Coarctation may also result in large artery stiffness safely and effectively treated using endovascular therapy;
that reduces the aortic reserve and causes adverse left ven- however, additional follow-up in these patients is needed to
tricular remodeling and functional disturbances. If a patient determine the durability of endovascular therapy. The advent
remains hypertensive and has a substantial residual gradient, of hybrid procedures has greatly expanded the ability to treat
repeated stent dilatation may be appropriate as the recur- the complex conditions.
rence of hypertension contributes to progression of cerebro-
vascular disease, aortic rupture, and heart failure.
Toward the Future

Procedural Success As with any new technology or device, there is always the
question of long-term durability. However, in the absence of
Improvement in aortic diameter and decreases in gradients randomized trial results, there is mounting evidence favoring
across the coarctation are measures of acute success, as are stent deployment to treat coarctation with approaches that
reductions in symptoms and need for antihypertensive ther- include covered stents. Endoluminal grafts are now an impor-
apy; such results can be achieved with endovascular therapy. tant component in the armamentarium of endovascular spe-
In the intermediate term, we have seen anatomical and con- cialists. It can be anticipated that minimally invasive
tinued clinical improvements as well; however, recoarctation endovascular approaches will be considered the gold stan-
is a significant concern, and lifelong follow-up in all patients dard for treating coarctation and recoarctation in the future.
42 Endovascular Management of Coarctation of the Aorta 363

Subclavian
aneurysm

Previous
coarctation
repair

Large associated
aneurysm

b C-S graft bypass

Resection subclavian
aneurysm

Fig. 42.6 (a) Angiogram and CT illustration of recurrent coarctation formation. (d) Endoluminal graft across origin of left subclavian artery
where a hybrid approach is used for correction. (b) Left supraclavicular and distal to the coarctation isolates the aneurysmal disease. (e) A
approach is used to resect proximal subclavian aneurysm with suture Gianturco Z stent with the barbs removed assure proper apposition of
closure. Carotid-subclavian bypass restores circulation to left vertebral endoluminal graft preventing endoleak. (f) Palmaz stent is required to
and subclavian arteries. (c) Illustration depicting the hybrid technique ensure relief of pressure gradient. (g) Control angiogram showing com-
to correct complicated recurrent coarctation with diffuse aneurysm plete disease resolution and the effectiveness of the hybrid approach
364 E.B. Diethrich

c d

e f

Fig. 42.6 (continued)

42 Endovascular Management of Coarctation of the Aorta 365

Fig. 42.7 (a) This image shows a

the size discrepancy between the
aortic segments adjacent to the
coarctation with a small proximal
aorta and the marked dilation
distally. (b) Until recently, the
sizing problems required
customization using various
components of endoluminal
grafts and covered stents

b
366 E.B. Diethrich

3. Crafoord C, Nylin G. Congenital coarctation of the aorta and its

surgical treatment. J Thorac Surg. 1945;14:347–61.
4. Toro-Salazar OH, Steinberger J, Thomas WI, et al. Long-term fol-
low-up of patients after coarctation of the aorta repair. Am J Cardiol.
2002;89:541–7.
5. Pollack P, Freed MD, Castaneda AR, Norwood WI. Reoperation for
isthmic coarctation of the aorta: follow-up of 26 patients. Am J
Cardiol. 1983;51:1690–4.
6. Rao PS, Najjar HN, Mardini MK, Solymar L, Thapar MK. Balloon
angioplasty for coarctation of the aorta: immediate and long term
results. Am Heart J. 1988;15:657–64.
7. Fawzy ME, Dunn B, Galal O, et al. Balloon coarctation angioplasty
in adolescents and adults: early and intermediate results. Am Heart
J. 1992;24:167–71.
8. Maron BJ, Humphries JO, Rowe RD, Mellits ED. Prognosis of sur-
gically corrected coarctation of the aorta. A 20-year postoperative
appraisal. Circulation. 1973;47:119–26.
9. Singer MI, Rowen M, Dorsey TJ. Transluminal aortic balloon
angioplasty for coarctation of the aorta in the newborn. Am Heart J.
1982;103(1):131–2.
10. Diethrich EB, Heuser RR, Cardenas JR, Eckert J, Tarlian H.
Endovascular techniques in adult aortic coarctation: the use of
stents for native and recurrent coarctation repair. J Endovasc Surg.
1995;2(2):183–8.
11. Wheatley 3rd GH, Koullias GJ, Rodriguez-Lopez JA, Ramaiah VG,
Diethrich EB. Is endovascular repair the new gold standard for
primary adult coarctation? Eur J Cardiothorac Surg. 2010;38(3):
305–10.
12. Shennib H, Rodriguez-Lopez J, Ramaiah V, Wheatley G, Kpodonu
J, Williams J, et al. Endovascular management of adult coarctation
and its complications: intermediate results in a cohort of 22 patients.
Eur J Cardiothorac Surg. 2010;37(2):322–7.
13. Kpodonu J, Ramaiah VG, Rodriguez-Lopez JA, Diethrich EB.
Endovascular management of recurrent adult coarctation of the
aorta. Ann Thorac Surg. 2010;90(5):1716–20.
14. Kpodonu J, Wheatley 3rd GH, Williams JP, Rodriguez-Lopez JA,
Ramaiah VG, Diethrich EB. A novel approach for the endovascular
repair of the small thoracic aorta: customizing off-the-shelf endolu-
Fig. 42.8 Photograph of new endograft with tapering to accommodate minal grafts to treat a post-coarctation pseudoaneurysm. Ann
the size discrepancies encountered in complex coarctation repair Thorac Surg. 2008;85(3):1115–7.
15. Preventza O, Wheatley 3rd GH, Williams J, Hughes K, Ramaiah
VG, Rodriguez-Lopez JA, et al. Endovascular approaches for com-
plex forms of recurrent aortic coarctation. J Endovasc Ther.
References 2006;13(3):400–5.
16. Kische S, Schneider H, Akin I, Ortak J, Rehders TC, Chatterjee T,
1. Paris M. Rétrècissement considerable de l’aorte pectorale observé à et al. Technique of interventional repair in adult aortic coarctation.
l’Hotel Dieu de Paris. J Chir Desault. 1791;ii:107. J Vasc Surg. 2010;51(6):1550–9.
2. Abbott ME. Statistical study and historical retrospect of 200 17. Erdem A, Akdeniz C, Saritas T, Erol N, Demir F, Karaci A, et al.
recorded cases, with autopsy, of stenosis or obliteration of the Cheatham-platinum stent for native and recurrent aortic coarctation
descending arch in subjects above the age of two years. Am Heart J. in children and adults: immediate and early follow-up results.
1928;3:392–421, 574–618. Anadolu Kardiyol Derg. 2011;11(5):441–9.
 Part XIII
Thoracoabdominal Aortic Aneurysm
 Inflammatory Response in Open
and Endovascular Treatment 43
Edmo Atique Gabriel and Sthefano Atique Gabriel

Patients presenting with aortic aneurysm basically tend to be endovascular era, devices and technological resources have
candidates for two therapeutic approaches using either an allowed surgeons to manipulate aortic aneurysm in a risk-
open (conventional) or endovascular strategy. Over the last free manner [8–10].
years, another surgical option has been developed, called the Walker et al. designed a very elegant study demonstrating
hybrid procedure because it encompasses open and endovas- operative complications of open and endovascular proce-
cular features [1–4]. dures that showed better patient outcomes using the endovas-
Regardless of the therapeutic strategy selected for each cular approach (Table 43.1) [11].
case, there is a resulting systemic inflammatory response The endovascular aortic approach is not free of complica-
mediated by many factors, such as as cytokines, cellular tions, particularly inflammation. In an attempt to prove this,
adhesion molecules, and interleukins. In this setting, it is Gabriel et al. [12] developed clinical research whose main
relevant to remember that the massive presence of intralu- focus was to try to determine the magnitude, intensity, and
minal thrombus is a strong determinant for an intense correlations of the inflammatory response theoretically spec-
inflammatory response postoperatively with both therapeu- ulated for the setting of endovascular procedures. The main
tic approaches. In case of endovascular treatment, this outcomes of this study are illustrated in Figs. 43.1, 43.2,
inflammatory response is called postimplantation syndrome 43.3, 43.4, 43.5, 43.6, and 43.7. Concerning these figures,
[5–7]. we must bear in mind that there is something like an
The most striking difference, in terms of the surgical prin- inflammatory response pattern following the deployment of
ciple, is that the open approach requires the use of aortic aortic endoprostheses. This pattern is represented by a profile
clamping; thus, some complications resulting from ischemia- of inflammatory markers as well as “inflammatory time
reperfusion injury are inevitable. Although ischemic injury courses” for each marker [12].
is a time-dependent process, the resulting inflammatory To meticulously address the issue of the inflammatory
response takes place even in short procedures. In the response in the endovascular treatment of aortic aneurysms,
Gabriel et al. [13] used data obtained from their previous
clinical research to propose the first model of an inflammatory
E.A. Gabriel, MD, PhD (*) risk score for the endovascular approach. These authors
Department of Cardiovascular Surgery, employed classic methodology based on a step-by-step tech-
University Nove de Julho, São Paulo, Brazil nique, Spearman’s test, and logistic regression and ROC
e-mail: edag@uol.com.br
curve analysis in order to determine the final variables and
S.A. Gabriel, MD their possible cutoff values (Fig. 43.8 and Tables 43.2, 43.3,
Department of Vascular Surgery,
43.4, and 43.5). It is important to emphasize that this is a
Pontifical Catholic University of Campinas,
São Paulo, Brazil “developing” inflammatory risk score by Gabriel et al. [13],
who were trying to meet a need, but the scoring method still
Department of Vascular Surgery,
Celso Pierro Hospital and Maternity, needs to be investigated additionaly by new trials.In sum-
Campinas, São Paulo, Brazil mary, this risk score model is not definitive and should not be
e-mail: sthefanogabriel@yahoo.com.br considered as such.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 369
DOI 10.1007/978-1-4471-4429-8_43, © Springer-Verlag London 2013
370 E.A. Gabriel and S.A. Gabriel

Table 43.1 Complications from meta-analysis of 2006 and 2007 national inpatient sample cohorts at only those institutions performing both
TEVAR and open repair
2006 2007
Variable Open repair (%) TEVAR RR 95 % CI p value Open repair (%) TEVAR (%) RR 95 % CI p value
In-hospital mortality 9.79 1.16 % 8.48 (3.03–23.75) <0.01 1.35 1.91 0.71 (0.12–4.24) 0.7
Cardiac complications 7.13 1.22 % 5.5 (1.34–25.48) 0.02 10.85 2.02 5.36 (1.82–15.81) <0.01
Transfusion 32.52 15.77 2.06 (1.22–3.48) <0.01 29.36 20.68 1.42 (0.77–2.63) 0.26
Hematoma 0 2.91 0 – – 1.35 3.85 0.35 (0.07–2.63) 0.22
Hemorrhage 7.13 3.45 2.07 (0.41–10.46) 0.38 5.28 1.69 3.12 (0.43–22.71) 0.26
Respiratory complications 23.37 8.29 % 2.82 (1.27–6.25) 0.01 16.01 6.92 2.31 (0.96–5.56) 0.06
Prolonged ventilation 13.41 1.98 % 6.78 (1.51–30.51) 0.01 10.70 2.32 4.61 (0.99–21.46) 0.05
Tracheostomy 0.00 0 – – – 7.51 1.91 3.92 (0.79–19.53) 0.09
Acute renal failure 8.35 3.52 2.37 (0.75–7.46) 0.14 6.53 5.16 1.26 (0.29–5.44) 0.75
Postop stroke/TIA 3.66 2.66 % 1.38 (0.31–6.14) 0.67 0.30 2.05 0.14 (0.02–1.36) 0.09
PVC 2.44 4.61 % 0.53 (0.07–4.28) 0.55 0.25 1.78 0.14 (0.01–1.29) 0.08
Sepsis 0.00 0.00 % – – – 0.00 0.34 0 – –
Graft problem 2.85 4.76 % 0.60 (0.09– 4.01) 0.60 4.05 6.96 0.61 (0.12–3.17) 0.55
CI 95 % confidence interval, PVC peripheral vascular complication, RR estimated relative risk, TEVAR thoracic endovascular aortic repair, TIA
transient ischemic attack

SV CRP
90 90
80 25
70
60 20
mm/dl
mm/h

50 15
40
30 10
20 5
10
0 0
h

h
h

m
e

h
tiv

tiv

24

48
1

24

48

7
1

6
1

3
ra

ra
pe

pe

Time p < 0.0001 Time p < 0.0001

eo

eo
Pr

Pr

Fig. 43.1 Values of SV and CRP in a period of 3 months

IL - 6 IL - 8
900 600
800 500
700
600 400
pg/ml

pg/ml

500 300
400
300 200
200 100
100
0 0
h

m
h

d
e

m
h

h
e
tiv

7
24

48

24

48
tiv

7
1

3
ra

ra
pe

p < 0.0001
pe

Time Time p = 0.237

eo

eo
Pr

Pr

Fig. 43.2 Values of IL-6 and IL-8 in a period of 3 months

43 Inflammatory Response in Open and Endovascular Treatment 371

ICAM L - selectin
1800 4000
1600 3500
1400 3000
1200 2500

pg/ml
pg/ml

1000 2000
800
600 1500
400 1000
200 500
0 0
h

m
h

m
h

h
e

e
1

7
tiv

24

48

7
tiv

24

48
1

3
ra

ra
pe

p = 0.533 p = 0.352

pe
Time Time
eo

eo
Pr

Pr
Fig. 43.3 Values of ICAM-1 and L-selectin in a period of 3 months

TNF-alpha Fever
10

Number of subjects
1800 9
1600 8
1400 7
1200 6
pg/ml

1000 5
800 4
600 3
400 2
200 1
0 0
h

m
h

m
h

h
e

e
1

7
24

48
tiv

7
24

48
tiv
1

3
ra

ra
pe

p = 0.846 p < 0.0001

pe
Time Time
eo

eo
Pr

Pr

Fig. 43.4 Values of TNF-alpha and frequency of fever episodes in a period of 3 months

Leukocytes Lymphocytes
20000 3000
2500
Cell number

Cell number

15000
2000
10000 1500
1000
5000
500
0 0
h h h h d m m m
h

m
e

1 6 24 48 7 1 2 3
iv

iv

24

48

3
at

at
r

r
pe

pe

Time p < 0.0001 Time p < 0.0001

eo

eo
Pr

Pr

Fig. 43.5 Values of leukocytes and lymphocytes in a period of 3 months

Creatinine Platelets

26 400000
Number of platelets

350000
2 300000
250000
mg/dl

1.5
200000
1 150000
100000
0.5
50000
0 0
h h h h d m m m
h

m
e
e

1 6 24 48 7
tiv
tiv

1 2 3
1

24

48

3
ra
ra

pe
pe

Time p = 0.233 Time p = < 0.0001

eo
eo

Pr
Pr

Fig. 43.6 Values of creatinine and platelets in a period of 3 months

372 E.A. Gabriel and S.A. Gabriel

a b
50 20
45 18
40 16
35 14
30 12
mm/h

mm/dl
25 10
20 8
15 6
10 4
5 2
0 0
Pre 1h 6h 24 h 48 h 7d 1m 2m 3m Pre 1h 6h 24 h 48 h 7d 1m 2m 3m
Time Time
SV CRP
c d
350 2000
1800
300 1600
250 1400

pg/ml
pg/ml

200 1200
1000
150 800
150 600
400
50 200
0 0
Pre 1h 6h 24 h 48 h 7d 1m 2m 3m Pre 1h 6h 24 h 48 h 7d 1m 2m 3m
Time Time
IL-6 IL-8 ICAM L-selectin TNF-alpha

Fig. 43.7 (a–d) Inflammatory response curves. (a) SV. (b) CRP. (c) IL-6, IL-8. (d) ICAM-1, L-selectin, TNF-alpha

a b
1.0 1.0

0.8 0.8

0.6 0.6
Sencificity
Sencificity

0.4 0.4

0.2 0.2

0.0 0.0
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0
Specificity Specificity

Fig. 43.8 (a) Analysis of the ROC curve for the volume of crystalloid solution; (b) Analysis of the ROC curve for the pre-operative values of
IL-8
43 Inflammatory Response in Open and Endovascular Treatment 373

Table 43.2 Inflammatory variables and period of greatest prevalence References

Variable Time
Total neutrophil count 24 h 1. Adams JD, Angle JF, Matsumoto AH, Peeler BB, Arslan B, Cherry
KJ, et al. Endovascular repair of the thoracic aorta in the post-FDA
Total lymphocyte count 1 month approval era. J Thorac Cardiovasc Surg. 2009;137:117–23.
a
Volume of crystalloid solution – ml 2. Gopaldas RR, Dao TK, LeMaire SA, Huh J, Coselli JS. Endovascular
a
Volume of contrast material – ml versus open repair of ruptured descending thoracic aortic aneu-
Transfusion of red blood cells a rysms: a nationwide risk-adjusted study of 923 patients. J Thorac
Presence of intraluminal thrombi b Cardiovasc Surg. 2011;142:1010–8.
b 3. Ferrero E, Ferri M, Viazzo A, Robaldo A, Zingarelli E, Sansone F,
Material of endoprosthesis
a
et al. Is total debranching a safe procedure for extensive aortic-arch
Number of endoprostheses disease? A single experience of 27 cases. Eur J Cardiothorac Surg.
Velocity of blood sedimentation – mm/h 7 days 2012;41(1):177–82.
C-reactive protein (CRP) – mm/dl 48 h 4. Hughes GC, Lee SM, Daneshmand MA, Bhattacharya SD, Williams
Interleukin 6 (IL-6) – pg/ml 24 h JB, Tucker Jr SW, et al. Endovascular repair of descending thoracic
Interleukin 8 (IL-8) – pg/ml Preoperative aneurysms: results with “on-label” application in the post food and
drug administration approval era. Ann Thorac Surg. 2010;90: 83–9.
Tumoral necrosis factor alpha (TNF-a)-pg/ml Preoperative
5. Patel HJ, Nguyen C, Diener AC, Passow MC, Salata D, Deeb GM.
Intercellular adhesion molecule (ICAM-1)-pg/ml 1 month Open arch reconstruction in the endovascular era: analysis of 721
L-selectin – pg/ml 1 month patients over 17 years. J Thorac Cardiovasc Surg. 2011;141(6):
a
Parametric variables related to the intraoperative period 1417–23.
b
Non-parametric variables 6. Preventza O, Bavaria J, Ramaiah V, Moser GW, Szeto W, Wheatley
III G, et al. Thoracic endografting is a viable option for the octoge-
Table 43.3 Candidate variables for the risk score model narian. Ann Thorac Surg. 2010;90(1):78–82.
7. Cheng D, Martin J, Shennib H, Dunning J, Muneretto C, Schueler
Variable Level of significance (P)a C, et al. Endovascular aortic repair versus open surgical repair for
Volume of crystalloid solution 0.04 descending thoracic aortic disease: a systematic review and meta-
Material of endoprosthesis 0.04 analysis of comparative studies. J Am Coll Cardiol. 2010;55(10):
Volume of contrast 0.02 986–1001.
8. Goodney PP, Travis L, Lucas FL, Fillinger MF, Goodman DC,
Preoperative IL-8 0.10
Cronenwett JL, et al. Survival after open versus endovascular tho-
ICAM-1 1 month 0.03 racic aortic aneurysm repair in an observational study of the
L-selectin 1 month 0.06 Medicare population. Circulation. 2011;124(24):2661–9.
ICAM intercellular adhesion molecule 9. Matsagkas MI, Kirou IE, Kouvelos G, Arnaoutoglou EM,
a
Spearman test, P £ 20 % Papakostas JC, Katsouras C, et al. Stenting of the descending tho-
racic aorta: a six-year single center experience. Interact Cardiovasc
Thorac Surg. 2011;12(5):789–93.
Table 43.4 Numeric intervals and risk categories 10. Coselli JS, Gopaldas RR. Ruptured thoracic aneurysms: to stent or
Volume of crystalloid not to stent? Circulation. 2010;121(25):2705–7.
solution (ml) IL-8 pre (pg/ml) Risk Probability (%) 11. Walker KL, Shuster JJ, Martin TD, Hess Jr PJ, Klodell CT, Feezor
RJ, et al. Practice patterns for thoracic aneurysms in the stent graft
Up to 1,850 Up to 33.53 Mild Up to 70
era: health care system implications. Ann Thorac Surg.
1,850–3,250 33.54–53.37 Moderate 71–82 2010;90:1833–9.
>3,250 >53.37 Severe >82 12. Gabriel EA, Locali RF, Romano CC, Duarte AJS, Palma JH,
3,500 38.7 Severe 86.59a Buffolo E. Analysis of the inflammatory response in endovascular
a
Maximum probability of risk treatment of aortic aneurysms. Eur J Cardiothorac Surg.
2007;31:406–13.
13. Gabriel EA, Locali RF, Matsuoka PK, Romano CC, Duarte AJS,
Table 43.5 Inflammatory risk score
Buffolo E. First inflammatory risk score for aortic endoprostheses.
Volume of crystalloid IL-8 pre Clinical Rev Bras Cir Cardiovasc. 2008;23(4):512–8.
solution (ml) (pg/ml) Risk manifestations
Up to 1,850 Up to 33.53 Mild Fever/leukocytosis
1,850–3,250 33.54–53.37 Moderate Fever/leukocytosis/
hypotension
>3,250 >53.37 Severe SIRS/sepsis
SIRS systemic inflammatory response syndrome
 Surgical Treatment of Aortic Aneurysm
in Patients with Aortitis 44
Maqsood M. Elahi and Kenton J. Zehr

Introduction Given this, the most common causes of noninfectious aor-

titis are the large-vessel vasculitides GCA and Takayasu
The most common causes of aortitis are the large-vessel arteritis. Although the epidemiological and clinical features
vasculitides [giant cell arteritis (GCA) and Takayasu arteritis], of these two disorders are distinct (see Clinical Presentation),
although aortitis also is associated with systemic lupus ery- there may be significant overlap in histopathological findings
thematosus, rheumatoid arthritis, the HLA-B27-associated (Fig. 44.1). Both GCA and Takayasu arteritis are associated
spondyloarthropathies, anti-neutrophil cytoplasmic antibody- with an inflammatory cellular infiltrate of the aortic media,
associated vasculitides, Behçet’s disease, Cogan syndrome, adventitia, and vasa vasorum that contains a predominance
and sarcoidosis. Infectious causes include tuberculosis, of lymphocytes, macrophages, and multinucleated giant cells
syphilis, salmonella, and other bacteria. Acute presentation [4, 6]. Over time, scarring of the aortic media and destruction
includes aneurysm rupture, Stanford type A dissection with of the elastic lamina occur [6].
severe aortic regurgitation, stroke, and myocardial infarction A few pathological features can be used to distinguish
[1, 2]. Isolated aortitis (IA) is a newly recognized condition Takayasu arteritis and GCA. Takayasu arteritis is more
(i.e., no associated rheumatologic or infectious disease is commonly associated with extensive intimal and adven-
present), but its differentiation from Takayasu arteritis (TA) titial fibrosis or scarring with resultant luminal narrowing,
is still a challenge. whereas GCA is more commonly associated with extensive
Most cases of aortitis are non-infectious; however, the medial inflammation and necrosis and the formation of aortic
possibility of an infectious nature exists, and the treatment aneurysms [5, 7]. GCA also is characterized by focal arterial
regimens widely diverge. In bacterial aortitis, a segment of inflammation, and “skip lesions” are common, a finding that
the aortic wall with preexisting pathology, such as an athero- can lead to false-negative findings on temporal artery biopsy
sclerotic plaque or aneurysm sac, is seeded by bacteria via in patients with associated temporal artery aortitis.
the vasa vasorum [3]. Similarly, tuberculous aortitis, a com- The pathogenesis of both GCA and Takayasu arteritis is
mon problem in the developing world, may occur as a result unknown. Both are thought to be antigen-driven cell-medi-
of direct seeding of the thoracic aorta from adjacent infected ated autoimmune processes, although the specific antigenic
tissues such as infected lymph nodes or lung lesions or by stimuli have not been identified [6]. Both GCA and Takayasu
miliary spread [4]. arteritis have been associated with specific HLA-linked anti-
gens and a resultant genetic predisposition. In a significant
percentage of cases, the diagnosis of aortitis is an incidental
M.M. Elahi, MD, PhD histopathological finding because no rheumatologic disor-
Department of Cardiothoracic Surgery, der, infection, or symptoms are attributable directly to the
Glenfield Hospital, Groby Road, aortitis [7, 8]. Such cases of idiopathic isolated aortitis typi-
Leicester LE3 9QP, UK
cally are localized to the ascending thoracic aorta and occur
K.J. Zehr, MD (*) in association with ascending aortic aneurysm. Patchy necro-
Division of Cardiothoracic Surgery and Center for Aortic Disease,
Scott & White Clinic, Texas A & M Health Sciences
sis of the aortic media is the primary histological finding,
Center College of Medicine, 2401 S. 31st Street, along with an inflammatory cellular infiltrate, which may
Temple, TX 76508, USA include multinucleated giant cells (Fig. 44.2).

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 375
DOI 10.1007/978-1-4471-4429-8_44, © Springer-Verlag London 2013
376 M.M. Elahi and K.J. Zehr

1.0 mm

Fig. 44.1 (a) Giant cell aortitis shows more active aortitis with similar antigen is unknown. The accepted theory is that the small vasa vasorum
(but less advanced) medial damage and a punched out area seen in the that supplies the medial smooth muscle cells (thought to be the caretakers
elastic stain (top left). This area corresponds to an area of inflammation for the elastic scaffolding) are damaged by autoantibodies or self-attack-
(blue cells) in the H&E slide (bottom left). The right side image shows ing T cells leading to ischemia in the media and death of the smooth
what type of inflammation this is (lymphocytes, macrophages multinucle- muscle cells. The giant cell inflammation comes in to clean it up, and then
ated giant cells). (b) Takayasu arteritis. The pathogenesis of this disease is collagen scar tissue replaces the elastic tissue in the media causing dilata-
not well understood. It’s generally thought to be autoimmune, but the tion and wall thinning. The mechanism is described by Weyand et al. [5]
44 Surgical Treatment of Aortic Aneurysm in Patients with Aortitis 377

Fig. 44.2 The left hand side is taken from the better-preserved or more normal part of the specimen showing the medial layer with a relatively
intact elastic scaffolding

Epidemiology The epidemiology of Takayasu arteritis is not as well

characterized as that of GCA. Data from Olmstead County,
Arteritis was first described clinically in 1890 by Hutchinson Minnesota, based on a very small number of cases, estimated
[9] and histologically by Horton and associates in 1932 [10] an incidence of 2.6 per 1 million residents per year, which is
after biopsy of a patient presenting with a swollen, painful higher than that reported in any other epidemiological series
temporal artery. The general population prevalence has been [16]. Although originally described by the Japanese ophthal-
reported to be 1 % in a large autopsy series [11], whereas an mologist Dr. Mikoto Takayasu, no data support an increased
average annual incidence of 17/100,000 person-years in the incidence of this disorder in Japan [17]. In a Cleveland Clinic
local population has been described [12, 13]. Although com- case series of 1,204 consecutive pathological specimens
parable data on the incidence of aortitis in Western popula- taken from patients who underwent aortic surgery over
tions or adults are not available, the epidemiology of the 20 years, the prevalence of aortitis on surgical pathology
large-vessel vasculitides GCA and Takayasu arteritis, the specimens was 4.3 % [8]. Most of the surgeries were per-
most common causes of aortitis, has been studied in some formed for aortic aneurysmal disease. In nearly 70 % of
depth. patients with evidence of aortitis, no underlying systemic
Reports have suggested that in the Olmsted County, disease was found, and vascular inflammation was a truly
Minnesota, population, the average age- and sex-adjusted incidental finding in most of these cases of isolated idio-
incidence of GCA among individuals ³50 years during a pathic aortitis [8].
50-year period was 18.8 per 100,000 per year [14]. The over-
all incidence of GCA increased substantially during the
50-year follow-up period of the study, perhaps because of Clinical Presentation
advances in diagnostic modalities. In this cohort, the inci-
dence of GCA was > twofold higher among women than Clinically, presentation of aortitis varies from back or abdom-
men (24.4 versus 10.3 per 100,000 per year, respectively), inal pain with fever to acute severe aortic insufficiency and to
and the mean age at the time of diagnosis was 75 years [14]. an incidentally identified large thoracic aortic aneurysm.
Few published data are available on the epidemiology of Acute aortic syndromes, including aortic dissection and rup-
GCA in non-Western countries, although one Japanese study ture, can occur in persons with aortitis [18]. Inflammation-
reported a very low prevalence of 1.5 per 100,000 individu- associated thrombus formation in the aortic lumen with
als ³50 years of age [15]. peripheral embolization also has been reported [19]. The
378 M.M. Elahi and K.J. Zehr

location of aortic inflammation (e.g., ascending thoracic ver- its clinical presentation. Nearly all patients with Takayasu
sus abdominal aorta) and the presence of coexisting arteritis arteritis either present initially or ultimately develop large-
in other blood vessels also determine the clinical presenta- vessel manifestations of the disease, including hypertension
tion. Because of the varied presentations of aortitis and the caused by suprarenal aortic or renal artery occlusive dis-
often nonspecific nature of its symptoms and signs, the index ease, pulse deficits and/or vascular bruits, and upper- and/or
of suspicion of the evaluating clinician must be high to estab- lower-extremity claudication [22]. A comprehensive vascular
lish an accurate diagnosis in a timely fashion. GCA clinically examination, including measurement of blood pressure in
presents as headache, temporal artery abnormalities on phys- both arms and palpitation and auscultation of pulses in all
ical examination, and elevated markers of inflammation in an major vascular regions, is a critical component of the clinical
older adult. Common manifestations of GCA include poly- evaluation of all patients with suspected Takayasu arteritis. In
myalgia rheumatica, scalp tenderness, jaw claudication addition, we recommend measuring blood pressure in all four
(resulting from involvement of the branches of the external extremities for such patients. Aortic involvement in Takayasu
carotid artery), visual field changes (caused by involvement arteritis is very common, with angiographic abnormalities
of the ophthalmic, posterior ciliary, or retinal arteries), and demonstrated on aortography in nearly all patients [22, 23].
mononeuropathy or polyneuropathy [20]. Coronary GCA, The abdominal aorta is the most common site of involvement,
manifest as tapering lesions in the coronary arteries and myo- followed by the descending thoracic aorta and aortic arch [22,
cardial infarction, also has been reported [21]. The frequency 23]. At the time of aortography, stenotic lesions in the aorta
of aortic involvement in GCA is not known. It is suggested are most frequently detected, although aortic aneurysm also
that all patients with temporal GCA who present with symp- is common and has been reported in up to 45 % of patients in
toms suggestive of extracranial vascular involvement undergo published case series [22, 23]. Case series also have reported
an imaging study to evaluate the aorta and large vessels [20]. rapid aortic aneurysm expansion, aortic rupture, and the devel-
An association has been found between a history of GCA and opment of aortic aneurysm at the site of anastomoses of prior
the development of aortic aneurysm, particularly thoracic reconstructive surgery among patients with Takayasu arteri-
aortic aneurysm, as a manifestation of extracranial involve- tis [24, 25]. Nearly 40 % of patients with Takayasu arteritis
ment [18]. In the Olmsted County cohort, it is reported that develop cardiac abnormalities, including acute myocardial
18 % of patients with GCA and aortic aneurysm were diag- infarction, angina pectoris, and acute aortic insufficiency. In
nosed with thoracic aortic aneurysm at the time of diagnosis these cases, the cardiac pathology is related directly to the
in this population, and most developed aneurysm during fol- aortic inflammation, including aortic insufficiency as a result
low-up a median of 5.8 years after the initial diagnosis. More of aortic root dilatation and coronary ostial stenoses resulting
than half of the patients with GCA-associated thoracic aneu- from aortitis (Fig. 44.3).
rysm died of acute aortic dissection. In this cohort, GCA also
was associated with a >twofold increased (relative risk, 2.4)
risk of developing abdominal aortic aneurysm a median of Diagnostic Testing
2.5 years after initial presentation with GCA [13].
Risk factors for the development of aortic and large-vessel When the diagnosis of aortitis is suspected on the basis of clini-
complications in GCA have been identified, including the pres- cal presentation, expedient imaging of the entire aorta with an
ence of a murmur of aortic insufficiency at diagnosis, con- appropriate modality is critical to establish the diagnosis.
comitant hyperlipidemia, and coronary artery disease [18]. Modern imaging tools for the aorta include CTA, MRA, and
Presentation with classic cranial symptoms and signs of tempo- ultrasonography. CTA and MRA have the advantage of imag-
ral arteritis (i.e., headache, scalp tenderness, abnormal temporal ing the components of the aortic wall and periaortic structures
artery pulsations, elevated erythrocyte sedimentation rate) was rather than the lumen only, as is the case of conventional
a negative predictor of an aortic complication [18]. Evidence of angiography. Invasive aortography generally is reserved for
GCA also has been identified on histopathological specimens cases in which diagnosis of an acute aortic syndrome is uncer-
of patients undergoing thoracic aortic aneurysm repair, includ- tain despite noninvasive imaging or for performance of cathe-
ing those not known to have aortic involvement [7]. ter-based revascularization procedures in select patients.
In contrast to GCA, Takayasu arteritis is observed to be a Positron emission tomography (PET) scanning has emerged
much rarer disorder with a predilection for young women. The for targeted imaging of vascular inflammation and may be par-
average age at diagnosis is 25–30 years, and anywhere from ticularly useful when combined with traditional cross-sectional
75 to 97 % of patients are female [22, 23]. The most common imaging modalities. CT in the setting of acute aortitis may
presentation of Takayasu arteritis includes symptoms result- demonstrate thickening of the aortic wall and periaortic
ing from arterial occlusive disease of the aorta, aortic arch, and inflammation, although milder degrees of inflammation or wall
large vessels. Other common names for Takayasu arteritis, edema may not be apparent. MRA, generally with gadolinium
including pulseless disease and aortic arch syndrome, reflect contrast enhancement, is emerging as a noninvasive imaging
44 Surgical Treatment of Aortic Aneurysm in Patients with Aortitis 379

a b

Fig. 44.3 A 7-cm ascending aortic aneurysm involved with giant cell involvement who was prepared for a valve-preserving aortic root recon-
aortitis. Note the glistening cobblestone appearance. Inside view of the struction. The inflammatory process is grossly evident in the residual
coronary buttons and residual involved aorta in a patient with aortic root aorta, but the morphology of the valve cusps is preserved

modality of choice for aortitis, particularly aortitis associated aortitis should include markers of inflammation, namely
with GCA and Takayasu arteritis. MR imaging (MRI) may be erythrocyte sedimentation rate and C-reactive protein, a
used to image the entire aorta without radiation exposure or complete blood count, assessment of kidney and liver func-
iodinated contrast, and it provides excellent resolution of the tion, and blood cultures, to exclude the unlikely but critical
aortic wall. Recently, the use of 18-fluorodeoxyglucose (18F- diagnosis of infectious aortitis. Additional laboratory testing
FDG) PET, either alone or in combination with contrast- should be based on the clinical assessment of the patient and
enhanced CTA or MRA, has emerged as a potential tool for the the differential diagnosis of the underlying cause. A rheuma-
initial diagnosis and assessment of disease activity of aortitis tologic panel, including anti-nuclear antibodies, antineutro-
caused by either GCA or Takayasu arteritis. Recent imaging phil cytoplasmic antibodies, and rheumatoid factor, may be
series have reported a sensitivity of 60–92 % and a specificity helpful in the appropriate clinical setting. Skin testing for
of 88–100 % of 18F-FDG PET for diagnosing active tuberculosis and serological testing for syphilis should be
inflammation in arteritis, but these studies have been limited by completed.
small sample size, heterogeneous patient population, and Although the erythrocyte sedimentation rate and
inconsistent choice of a reference standard [26, 27]. C-reactive protein typically are markedly elevated in cases of
Although generally not used as a primary diagnostic aortitis caused by GCA and other systemic vasculitides,
modality for aortitis, abdominal ultrasound or transthoracic these inflammatory markers may be unreliable for the pre-
or transesophageal echocardiography may demonstrate cir- diction of disease activity among patients with Takayasu
cumferential thickening of the aortic wall. Abdominal ultra- arteritis [31]. Recent clinical investigation has focused on the
sonography is useful for the diagnosis of abdominal aortic identification of novel and more sensitive laboratory markers
aneurysm occurring as a complication of aortitis or in asso- for disease activity among patients with Takayasu arteritis,
ciation with chronic periaortitis or inflammatory aneurysm. with interleukin-6, interleukin-18, and certain matrix metal-
In addition, echocardiography plays a key role in the assess- loproteinases showing promise in small studies [32, 33].
ment of the aortic root and aortic valve in the setting of aor-
titis of the ascending thoracic aorta associated with aortic
insufficiency and aneurysm formation [28–30]. Surgical Management

In our experience, GCA commonly presents as an ascending

Laboratory Measurements aortic aneurysm involving the ascending aorta at and above
the sinotubular junction and frequently extends into the aor-
Although the diagnosis of aortitis generally is based on clini- tic arch. There is often associated central aortic insufficiency
cal presentation and aortic imaging, key laboratory tests are related to effacement of the sinotubular junction. The aortic
helpful. The initial evaluation of a patient with suspected valve tissue appears to be spared from the vasculitic process.
380 M.M. Elahi and K.J. Zehr

A surgical strategy of tailoring the operation to address the anterograde cerebral perfusion. The diagnosis is nearly
aortic disease and aortic valve insufficiency can be done with always made by histologic examination. As we gained expe-
low morbidity and mortality. We advocate that treatment rience with the clinical entity, a high index of suspicion could
with steroids alone based on assessment of the acute be obtained by the gross appearance of the aorta at the time
inflammatory process does not seem to protect from aortic of surgery (Fig. 44.3). If the aneurysm extends into the aortic
involvement. The high incidence of involvement of other arch, then replacement is extended to include a partial or
parts of the aorta portends close surveillance of the remain- complete arch reconstruction. All complete arch reconstruc-
ing aorta. tions are and should be done as an elephant trunk procedure
Earlier we reported in our published series [34] that a in anticipation of the possible need for future descending aor-
large proportion of patients were asymptomatic at presenta- tic replacement. In the younger adult patients, valve-sparing
tion with the aneurysm discovered incidentally on routine aortic root reconstruction should be considered. In our expe-
physical examination or during workup of an unrelated rience, in patients who had their native valves excised, the
pathologic process. The question arises whether to serially valve cusps showed no histologic evidence of an inflammatory
monitor all patients with temporal arteritis or polymyalgia process [34]. Therefore, the valve can safely be preserved in
rheumatica for the development of a thoracic aneurysm or patients with functionally normal valves.
not. In our study [34], evidence of a past history of temporal There is no consensus on the dose and duration of steroid
arteritis or polymyalgia rheumatica was found in 10 of the 37 treatment after a histologic diagnosis of giant cell arteritis.
(27 %) patients. All were treated with steroids for variable Most surgeons recommend treatment with steroids in the
periods (6 months to 3 years) depending on the response active phase of disease. The active phase is determined by
based on inflammation markers. The mean duration of the either symptomatic vasculitis or elevated markers of
diagnosis of temporal arteritis to aortic surgery was inflammation. Our practice is to start prednisolone at a dose
8.9 ± 3.9 years, although most patients had silent vasculitis. of 40–60 mg/day in adults and continue for 6 months to
In symptomatic patients, the symptoms were related to the 2 years depending on the response. Cyclophosphamide, aza-
aneurysm or the associated aortic regurgitation. This was thioprine, or dapsone may be used with steroids if the eryth-
true even for patients who were previously treated for symp- rocyte sedimentation rate does not respond. In our reported
tomatic temporal arteritis. This suggests that patients with a series [34], 13 patients received steroid therapy as per the
history of temporal arteritis should be serially assessed for guidelines mentioned. Of these 13 patients, 5 had developed
the development of large vessel disease [13]. Evans and col- or had progression of an aneurysm in the remaining aorta
leagues [13] found 11 of 96 (11.5 %) patients had (2 patients) despite steroid therapy. Of the eight patients who died during
or developed a thoracic aneurysm (9 patients) during a follow-up, only one had received steroids after surgery. All
median time of 5.8 years after the diagnosis of temporal three patients who had fatal complication of a thoracic aortic
arteritis. On the other hand, Lie [35] made some interesting aneurysm during follow-up had not received steroids.
findings in 72 patients with extracranial giant cell arteritis Whether aneurysmal dilatation of the remaining aorta and
described to have evidence of temporal arteritis, 67 by biopsy great vessels can be prevented by an aggressive regimen of
before, concurrent with, or after the diagnosis of aortic and steroids or antineoplastic agents is unclear. Nevertheless, we
extracranial large vessel giant cell arteritis and 5 by clinical recommend a continued aggressive treatment approach in
criteria. Lie’s study provides evidence that cranial symptoms patients with evidence of active disease and computed tomo-
are often absent in patients with aortitis despite biopsy- graphic scanning on a yearly basis with surgical consider-
proven giant cell involvement of the temporal arteries. ation given at smaller dimensions similar to patients with
Therefore, the presence of symptoms is a suboptimal end- connective tissue disorders.
point to initiate a screening process for aortitis. We recom-
mend that all patients with temporal arteritis be screened for
large vessel disease. Survival
Our surgical results have so far been similar to surgery for
aneurysms caused by other etiologies when the same algo- Patients with aneurysms caused by giant cell aortitis carry
rithm concerning surgery is applied. The usual indication is a high incidence of catastrophic complications. In the
an ascending aneurysm greater than 5.5 cm or severe aortic Olmstead County population, a study has suggested an inci-
regurgitation. The aortic arch or ascending aneurysm is usu- dence of sudden death in 44 % of patients from aortic dis-
ally cannulated, and femoral cannulation is occasionally per- section [13]. Liu and co-workers [2] reported on a series of
formed in patients with tenuous aneurysmal walls. In 23 patients with GCA presenting with dissection; 46 % of
retrospect, we do not believe there is any contraindication to patients presented catastrophically. Of these, the 2-week
axillary artery cannulation, and this procedure is preferred in mortality was 80 %. Our earlier series [34] corroborates
patients in whom arch reconstruction is required to facilitate these data. We reported [34] that in our series 17 patients
44 Surgical Treatment of Aortic Aneurysm in Patients with Aortitis 381

Fig. 44.4 Photomicrograph of a

cross-section through the aortic
wall showing near-complete
disruption of the elastic fibers
and media by the inflammatory
giant cell process

100
Expected
had aneurysmal involvement of the descending or thora-
coabdominal aorta. Out of these, five patients died. Three 80
were caused by complications of a thoracic aortic aneurysm, Observed
two had documented rupture, and one had a localized rupture 60
with a thoracic hematoma that contributed to the develop- %
ment of disseminated intravascular coagulation. All three 40
patients had aneurysms of less than 6 cm in diameter. One
patient died suddenly, and an autopsy was not performed. 20
The histology of this disease suggests that patients often P = 0.019
have a near-complete disruption of the elastic medial layer, 0
0 1 2 3 4
as outlined in Fig. 44.4. This may predispose patients to rup- Years
ture and dissection before the aneurysm achieves the stan- NO. at risk 27 21 15 11
dard sizes for usual intervention.
Eklund and coworkers [36] reported on a patient who Fig. 44.5 Survival curve of patients undergoing surgical repair com-
pared with the expected survival of our age- and sex-matched regional
presented with an aortic rupture 3 cm above the valve annu-
population (Adapted from Ref. [34] with permission)
lus with a normal-sized aorta but marked thinning of the aor-
tic media. The patient had been treated for 5 years with a
maintenance dose of 5 mg/day of prednisolone after achiev- Conclusion
ing a normal erythrocyte sedimentation rate. There is no Most of the factors predictive of large-artery stenosis are
doubt that close surveillance of the remaining aorta in this identified in this chapter. Diminished pulse or blood pres-
patient population is necessary. However, the overall sur- sure and/or claudication of an arm, TIA or stroke, and
vival rate in a cohort of patients undergoing aneurysm oper- diplopia are all predictive of large-artery stenosis, and an
ation on the proximal thoracic aorta has been reported to be aortic insufficiency murmur could be predictive of aortic
90.6 % with a median follow-up time of 15.4 months [37]. aneurysm and/or aortic dissection. The presence of any of
This is similar to the 87 % 1-year survival rate from a these symptoms should prompt further evaluation for pos-
Swedish population-based study [38]. We have so far dem- sible large artery complication. The negative association
onstrated an overall survival of 97.2 % with a mean follow- of cranial symptoms and a higher ESR at the time of diag-
up of 2.8 ± 2.3 years [34]. Our actuarial survival in 37 patients nosis of GCA with large-artery stenosis, and the border-
at 4 years is 74 % (95 % confidence interval, 57–94 %; line association of polymyalgia rheumatic-type symptoms
Fig. 44.5) at a mean follow-up of 3.8 ± 2.3 years [34]. No with large-artery stenosis, might somewhat help in risk
patients from the surviving cohort required aortic value stratifying patients with GCA for the development of
replacement. large-artery complications. Surgical tailoring to address
382 M.M. Elahi and K.J. Zehr

the aortic disease and aortic valve insufficiency and ste- patients with giant cell arteritis: a population-based study over
roid therapy based on assessment of the acute inflammatory 50 years. Arthritis Rheum. 2003;48:3522–31.
19. Silver AS, Shao CY, Ginzler EM. Aortitis and aortic thrombus in
process can be implemented with low morbidity and mor- systemic lupus erythematosus. Lupus. 2006;15:541–3.
tality. However, a standardized, prospective, large-scale 20. Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia
study is needed to better determine factors and outcomes rheumatic and giant-cell arteritis. N Engl J Med. 2002;347:
predictive of such anomaly. 261–71.
21. Jang JJ, Gorevic PD, Olin JW. Images in vascular medicine: giant
cell arteritis presenting with acute myocardial infarction. Vasc Med.
2007;12:379.
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a descriptive study of 41 cases. Arthritis Rheum. 1994;37:1539–47. characteristics and outcomes of Takayasu’s arteritis: analysis of
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 Part XIV
Heart and Lung Transplantation
 Cytokine Profile in Heart
Transplantation 45
Ahmet Ruchan Akar, Serkan Durdu, Bahadır Inan,
and Mustafa Sırlak

Brief Historical Review and antilymphocyte globulin [12, 13]. Dr. Barnard [12]
pointed out that “one day this problem will be solved, we will
The founder of modern organ transplantation is Alexis Carrel be able to induce tolerance in our patients and organ trans-
(1873–1944) because of his extensive work on vascular anas- plantation will be a curative and not a palliative procedure.”
tomosis and accomplishment of the first successful heart Between 1968 and1970, a total of 166 (102, 48, and 16 annu-
transplantation (HT) in a canine model using carotid artery ally) HTs were performed worldwide with unacceptably high
and jugular vein anastomosis in 1905 [1]. The realization of mortality rates due to either rejection or infection [14]. These
the first human-to-human HT was closely related to the work unfavorable outcomes led to the investigation of new immu-
of Norman Shumway and Richard Lower at Stanford nosuppressive regimens, and most centers have stopped prac-
University, who described the technique for orthotopic canine ticing HT. Another milestone in immunosuppression was
HT [2, 3]. Shumway and colleagues not only worked exten- reached in 1972 when cyclosporine was discovered in Basel,
sively on an efficient surgical technique for HT, but also per- Switzerland, and subsequently approved for clinical use in
formance characteristics of the allograft and control of 1983 [15–19]. During that period, only Shumway and his
allograft rejection [2, 4–10]. However, Christiaan N. Barnard team continued using HT at Stanford University and per-
(1922–2001) performed the world’s first successful human- formed 227 HT procedures between 1968 and 1981 [20].
to-human HT in Groote Schuur Hospital, Cape Town, in 1967 Today, HT provides the gold standard treatment modality for
[11]. The immunosuppressive regimen of Barnard and patients with end-stage heart failure [21]. Since 1967, over
colleagues in their first three patients included corticoster- 100,000 HTs have been performed worldwide. In the last
oids, azathioprine, local irradiation to the transplanted heart, decade, between 3,600 and 3,850 HTs have been performed
in 388 countries registered with International Society of Heart
and Lung transplantation (ISHLT) Registry [21, 22].
According to the ISHLT Registry, the 30-day and 1-year
mortality after HT are 8 and 14 %, respectively. The UK
A.R. Akar, MD, FRCS CTh (*) • S. Durdu, MD, PhD transplant registry reported that 20 % of patients who get the
Department of Cardiovascular Surgery, chance to have HT die within the first year of transplantation.
Heart Center, Ankara University School of Medicine,
Dikimevi, Ankara 06340, Turkey Following the first year, there is a constant mortality rate of
3–4 % per year. Moreover, it has been generally agreed that
Department of Multi-disciplinary Stem Cell and
Regenerative Medicine, Stem Cell Institute, Ankara University, the 5-year survival rate for heart transplantation is around
Ankara, Turkey 65–70 % [23]. Median survival is 11 years for the entire
e-mail: akarruchan@gmail.com; akar@ankara.edu.tr cohort of adult and pediatric heart recipients in the ISHLT
B. Inan, MD Registry. Major complications following HT are periopera-
Department of Cardiovascular Surgery, tive ischemic injury, allograft rejection, infection, lymphop-
Heart Center, Ankara University School of Medicine, roliferative disease, and cardiac allograft vasculopathy.
Dikimevi, Ankara 06340, Turkey
Cell-to-cell communication via cytokine networks has an
M. Sırlak, MD active role in immune responses following heart transplanta-
Department of Cardiovascular Surgery, Heart Center,
Ankara University School of Medicine, tion. Furthermore, the correlation between the cytokine profile
Ankara, Turkey and clinical outcomes after HT is under intense research.

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 385
DOI 10.1007/978-1-4471-4429-8_45, © Springer-Verlag London 2013
386 A.R. Akar et al.

Cytokine Release During Donor Brain Death by recipient “natural” antibodies activates the complement
and coagulation cascades, resulting in rapid graft thrombosis
Acute brain death is associated with the release of cate- and ischemia. B cell maturation, proliferation, activation,
cholamines and substantial decreases in free thyroxine and and survival require particular cytokines (TNF superfamily
T3, cortisol, insulin, and antidiuretic hormone levels, leading cytokines, BLyS and APRIL).
to diabetes insipidus. Furthermore, change from aerobic to
anaerobic metabolism and increases in inflammatory cytok-
ines are common [24]. Recently, de Vries and colleagues Acute Cellular Rejection
demonstrated that donor brain death is associated with
inflammatory cytokine release upon reperfusion [25]. In this Within the first year, approximately 20–40 % of heart trans-
study, the investigators showed prompt release of inflammatory plant recipients experience at least one episode of acute cel-
cytokines, including G-CSF, IL-6, IL-9, IL-16, and MCP-1 lular rejection (ACR) [31, 32]. In a recent cohort between
after reperfusion of kidneys from brain-dead donors in con- 2001 and 2009, hospitalization for rejection treatment was
trast to kidneys from living and cardiac dead donors [25]. required in 26 % of patients within 1 year and in 44 % of
patients within 5 years after HT [21]. Younger and female
recipients were at a higher risk of rejection [21]. Alloreactivity
Early Postoperative Systemic Inflammatory in retransplant candidates, blood product recipients, previous
Response LVAD recipients, and multiparous women is increased
because of repeated B- and T-cell exposure to alloantigens.
Heart transplantation is associated with systemic inflammatory The major histocompatibility complex (MHC) proteins
response triggered by oxidative stress and enhanced produc- (human leukocyte antigens in humans) and ABO blood anti-
tion of glycoprotein messengers, namely cytokines [26]. The gens are the primary targets of the allogeneic immune
cytokine milieu in the early postoperative period is triggered response. The rejection of transplanted heart is mainly a
by several factors, including surgical trauma, exposure of T-lymphocyte (T-cell)-mediated event, although humoral
blood to extracorporeal artificial surfaces, ischemia/reperfu- (B-cell) responses may also contribute [33]. T cells, B cells,
sion injury, sheer stress, and release of endotoxin [27, 28]. and antigen-presenting cells (APCs) all participate in the
Cell-to-cell contact, immune complexes/autoantibodies, local production of cytokines. Indeed, cytokines play a critical
complement activation, microorganisms, reactive oxygen role in orchestrating acute cellular rejection. Furthermore,
species, and donor DNA also promote cytokine expression non-immune endothelial cells via lymphokines further mod-
after HT. The release of cytokines (IL-1, IL-6, and IL-8) and ulate the immune response.
complement fragments (C3a, C5a, membrane attack com- CD34+ T helper (Th) cells and their committed Th counter-
plex) during cardiopulmonary bypass (CPB) activates the parts, namely Th1, Th2, and Th17 subsets, and regulatory T
vascular endothelium via endothelial cell adhesion molecules cells (Tregs) are the active actors of acute cardiac cellular
and causes functional changes in endothelial cells. IL-1, rejection (Fig. 45.1) [34]. Figure 45.1 shows the principal fea-
tumor necrosis factor-alpha (TNF-a), and IL-6 have significant tures of the APC/CD34+ Th cell interaction and recognition of
roles in driving the acute-phase response. Frering and col- alloantigens by CD34 T cells. The Th1 subset preferentially
leagues showed that normothermic CPB is associated with produces IL-2, IFN-g, and TNF-a. Th1 cytokines activate
IL-6 and IL-8 production, which is similar to hypothermic macrophages, promoting delayed-type hypersensitivity (DTH)
CPB; however, plasma levels of TNF-a and IL-1-b remained reactions. The Th2 subset produces IL-4, IL-5, IL-10, and
undetectable after normothermic CPB [29]. IL-1-b and IL-13. Both subsets contribute to the production of IL-3,
TNF-a stimulate procoagulant activity of endothelial cells. TNF-a, and granulocyte-macrophage colony-stimulating fac-
Both inhibit the thrombomodulin/protein C anticoagulant tor (GMCSF). In contrast, Tregs have an antiinflammatory role
pathway and stimulate production of type I plasminogen acti- and are responsible for self-tolerance. Although several stud-
vator inhibitor. The cardiac allograft is a major source of ies [35] have highlighted the link between IL-17 and allograft
cytokines after HT associated with activated T lymphocytes rejection, the impact of Th17 cells on transplant outcomes
and macrophages and elevated coronary sinus levels of TNF- requires further investigation. Through their developmental
alpha, IL-6, and high soluble IL-2 receptor levels [30]. stages, T cells require cytokine release. These steps include
bone marrow stem cell differentiation and proliferation, thy-
mic education leading to central tolerance [36], and matura-
Hyperacute Rejection tion after primary or secondary antigen exposure. In brief,
direct allorecognition by T cells mediates acute rejection.
The major blood group (ABO) antigens are the targets of a Initially, donor’s antigen-presenting cells (APC) recog-
dramatic hyperacute rejection process. Recognition of blood nize donor-derived antigens located on the cells of the
group antigens on the endothelial surface of the graft vessels allograft. APCs migrate from the allograft to the recipient
45 Cytokine Profile in Heart Transplantation 387

Fig. 45.1 Immature dendritic

cells mature into antigen-present- Th1
ing cells (APCs) within
IL-2
recipients’ lymph nodes and
IFN-γ
spleen. APCs present donor TNF-α
alloantigens on their class II APC
MHC molecules. CD4 helper T Dendritic cells
CD4 T cell
cells recognize alloantigens with macrophages
the use of their surface immuno- Stimulation Cytokine Th2
globulins and MHC class II release
B7 IL-4
molecules. Activated subgroups CD28
IL-5
of helper T cells have distinct IL-10
cytokine profiles to promote IL-13
rejection or tolerance. APC IgE
antigen-presenting cell, MHC
major histocompatibility
complex, TCR T-cell receptor, IL MHC Ag TCR Th17
Interleukin, IFN-g interferon-g,
IL-17
Treg regulatory T cell, TGF-b
IL-21
transforming growth factor b IL-22
IFN-γ

Treg
IL-10
TGF-β

lymphoid tissue and present donor major histocompatibility wild-type and IFN-g-deficient mice, while the rejection
complex class II and B7 complex to the recipient’s T-cells process in IFN-g-deficient mice did not show increased
for direct allorecognition [32, 33]. Allorecognition is medi- expressions of CXCL9 and CXCL10 [42].
ated by the recognition of foreign MHC molecules on the IL-12 and -23 share the p40 subunit and are crucial for
surface of donor cells by recipient dendritic cells [37]. T cell- the development of T helper (Th) 1 and Th17 cell responses
dendritic cell interaction requires local cytokine expression. in acute graft rejection [43]. Th17 cells, a recently identified
Intracellular activation of calcineurin leads to production of CD4+ effector T cell subset, produce proinflammatory
IL-2. In fact, blockade of IL-2R has been used as an effective IL-17 in both mice and humans [44]. Furthermore, Xie and
therapeutic strategy promoting allograft survival [38]. colleagues [43] demonstrated effective inhibition of Th1
Active APCs produce IL-12. IL-12 initiates CD4+Th1 and Th17 cell responses after treatment with an anti-IL-
activation and stimulates the development of activated CD8+ 12/23p40 antibody in vivo mouse model of acute cardiac
cells and interferon (IFN)-g production both in vivo and allograft rejection. Recently, Wang and colleagues [45]
in vitro [39, 40]. IFN-g activates macrophages, upregulates demonstrated that the levels of Th1, Th17, and FoxP3+
the expression of MHC class II antigen, and promotes CD4+ T cells and their specific transcription factors
allograft rejection [41]. In their enlightening study, Saiura increased in patients with acute rejection after HT and were
and colleagues have revealed a distinct upregulating effect associated with rejection grades.
on the genes that are involved in the inflammatory process T-helper 1 (Th1)-type cytokines (e.g., IL-2, IFN-g, IL-12,
after HT, while failing to document any conclusive findings TNF-a) are closely linked in the elimination of intracellular
on the regulation of chemokine ligand 9 and chemokine infections and mediating allograft rejection [46]. TNF-a
ligand 10 in mice. They also reported upregulation of -308 SNP is associated with acute cellular rejection follow-
allograft inflammatory factor-1 throughout the investigated ing HT [47]. In contrast, the Th2 cytokine profile (IL-4, -5,
time points (days 3, 5, and 7) following HT. Most impor- and -10) is associated with allograft tolerance. For example,
tantly, samples taken from patients with acute graft rejection IL-10 promoter at positions −1,082, −819, and −592 corre-
displayed the central role of IFN-g in inducing several lates with increased IL-10 production [48]. Allograft rejec-
chemokines. Macrophage inflammatory protein 1 alpha tion is characterized by CXCR3 carrying T cells and, more
expression is shown to increase during rejection in both importantly, release of Th1-related cytokines and expression
388 A.R. Akar et al.

of CXC chemokines that are inducible by IFN-g, for exam- researchers to determine specific proteins, genes, metabolites
ple, monokine induced by interferon gamma Mig/CXCL9, and pathways that are involved in normal and dysfunctional
interferon-inducible T-cell alpha chemoattractant I-TAC/ processes [66]. These major methodological developments
CXCL11 and interferon and IFN-g -inducible protein-10 create the possibility for discovery of new markers, while also
IP-10/CXCL10 [49]. In brief, allograft rejection is related to presenting novel targets for therapy. Human biopsy materials
Th1 cell trafficking caused by CXCR3-binding chemokines. obtained from ailing tissue are being used to investigate the
CXCL9 and CXCL10 are documented to be involved in the etiology of diseases; a good example would be cardiac biop-
development of acute allograft rejection [50]. While CXCL10 sies used for tetralogy of Fallot [67] and atrial fibrillation
mediates the congregation of leukocytes, it also acts as an [68]. New biomarkers can be developed by utilizing such
initiator of the alloimmune response against the antigen, tak- methodologies and provide stepping stones for new therapy
ing a critical part in the initiation of an inflammatory loop, options. DNA microarray experiments involving animal mod-
which fuels the immune response in graft rejection [51]. els have been performed to understand the Brown Norway to
Interestingly, high levels of pre-transplant CXCL10 in serum Lewis heterotopic heart transplant model [69]. A recent study
have been proposed to serve as a biomarker for predicting has documented a correlation between endomyocardial
the risk of acute allograft rejection in the first 3 months after biopsy material and whole blood by using microarray analy-
the transplantation [52]. Recently, Sathya and colleagues sis. A new biomarker panel from whole blood samples is pro-
[53] showed a significant correlation with post-transplant posed for detection of rejection, which was claimed to have as
circulating endothelial progenitor cell (EPC) function, efficient results as biopsy microarray [70].
namely colony-forming units and rejection episodes.
MicroRNAs (miRs) have recently emerged non-coding
RNAs that can regulate gene expression at the posttranscrip- Cardiac Allograft Vasculopathy
tional level and key regulators for the immune system
[54–56]. MiRs have been demonstrated to play important Despite the major improvements that have been achieved in
roles in regulating dendritic cell function, B cell and T cell- the prevention and treatment of acute transplant rejection,
mediated rejections, and Treg activities [57]. A recent study long-term survival following HT has not improved. Cardiac
showed a significant correlation with MHC class I-related allograft vasculopathy (CAV) is the major long-term limita-
gene A (MICA) upregulation and histological evidence of tion of HT survivors [71, 72]. Despite a 2–4 % recent decrease
severe rejection after HT in 44 patients [58]. in the cumulative incidence of CAV, the prevalence of CAV
still remains high. CAV is detectable by angiography in 8 %
of the patients within the first year, 20 % at 3 years, 32 % at
Diagnosis of Rejection 5 years, and 45 % at 8 years following HT [21]. Briefly, CAV
is the leading cause of late morbidity and mortality in HT
Endomyocardial biopsy (EMB) is currently the gold standard patients, accounting for 30 % mortality in the first 5 years
method for detection and confirmation of the allograft rejec- [21]. The pathogenesis of CAV is not fully elucidated. Indeed,
tion. Several methods have been proposed for an accurate CAV is a complex, multifactorial phenomenon. Immunologic
diagnosis, yet none so far has proven to be adequate or specific (indirect allorecognition, upregulation of cytokines and
enough to replace the status quo [59]. The necessity to replace cytokine-related adhesion molecules, focal inflammation, and
endomyocardial biopsy is to avoid an invasive method and to vasculitis) and nonimmunologic factors (repetitive vascular
provide the clinician with a tool with fast and accurate results. injury) may play critical roles in the process [32, 73–75].
In current practice, major adjunct methods are used for moni- EMB and coronary angiography provide effective but inva-
toring rejection, such as electrocardiography, electrophysiol- sive monitoring methods for CAV in cardiac transplantation
ogy, radio-isotopic techniques, cyto-immunologic monitoring, recipients. Histologically CAV is characterized by a concentric
and magnetic resonance imaging [60, 61]. Among the pro- and diffuse intimal thickening composed of T cells, mac-
posed biochemical markers are urinary polyamines [61], rophages, and modified smooth muscle cells beneath an acti-
neopterins [62], prolactin [63], beta-2-microglobulins [64], vated endothelium in epicardial and intramural coronary arteries
and brain natriuretic peptide (BNP) [65], none of which had along their entire lengths [76–83]. The disease begins as con-
fulfilled the need for sensitivity. centric fibrous intimal thickening caused by myofibroblast pro-
New high-throughput analyses that utilize protein or gene liferation and fibrosis mainly in the proximal region of epicardial
expression analysis techniques, cell-mediated immune assays, arteries [80]. Following the first year of HT, intermediate lesions
and fluorescence-activated cell sorter analysis of cellular sub- with intimal lipid-filled cell accumulation can be detected. In
populations have the potential to provide the clinicians with long-term survivors, fibrous and fibrofatty intimal lesions often
more accurate markers of allograft rejection. Advancements diffusely involve large and small epicardial and intramural
in microarray technologies and bioinformatics allow arteries [80–83]. Late increase in TNF-a and IFN-g in endomyo-
45 Cytokine Profile in Heart Transplantation 389

cardial biopsies precedes the development of CAV [84]. van 16. White DJ, Calne RY. The use of cyclosporin a immunosuppression
Loosdregt and colleagues demonstrated abundant CD4+ T cells in organ grafting. Immunol Rev. 1982;65:115–31.
17. Jamieson SW, Burton NA, Bieber CP, Reitz BA, Oyer PE, Stinson
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Conflicts of Interest There is no undisclosed ethical problem or Kirk R, et al. The Registry of the International Society for Heart
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 Platelet Activation After Lung
Transplantation 46
David Sternberg and Joshua Sonett

Introduction of proinflammatory cytokines, such as interleukin-1, which

further upregulates endothelial adhesion receptors, as well as
Initially recognized for their central role in thrombosis, there the powerful immune chemoattractants, interleukin 8,
has been an emerging understanding that platelets also play MCP-1, and RANTES [10–14]. Release of ADP, serotonin,
an important role in both the innate as well as the adaptive and thromboxane A2 further upregulates local inflammatory
immune response. The profound impact and putative role of processes and induces endothelial permeability and vasocon-
platelet activation in both acute and chronic allograft failure striction [15–17].
after lung transplant are just beginning to be truly appreci-
ated. To understand this multifactorial interaction, one must
first understand the basics of platelet physiology. Produced Platelet Activation
through a budding process by megakaryocytes in the bone
marrow, platelets have an average lifespan of 5–10 days. During platelet activation, the conformational status and
Normally, there are approximately 200–400 × 103 circulating concentration of a variety of surface receptors are altered by
platelets per microliter. The average volume of each platelet activation of endogenous biochemical circuits and by the
is approximately 7 fl, giving each anucleate cell an average exocytic process itself. The most abundant surface receptor,
surface area of 8 mm2. This important fact implies that the integrin aIIbb3, undergoes a conformational change during
total surface area of platelets outnumbers that of all other platelet activation that is referred to as “inside out” when
circulating leukocyte types combined [1]. initiated by intracellular ligand binding or “outside in” when
Each platelet is composed of an open canalicular system mediated by engagement of external signaling domains [18–
as well as three biochemically distinct cellular compart- 20]. Activated aIIbb3 binds fibrinogen, which crosslinks acti-
ments, alpha granules, dense granules, and lysozomes. vated platelets, forming platelet aggregates, and also mediates
During platelet activation, an exocytosis process causes the adhesion to intercellular adhesion molecules (ICAMS),
release of over 300 proteins, many of which directly modu- which are expressed on endothelial surfaces [21, 22]. Platelets
late the immune system [2, 3]. Alpha granules, in particular, also express integrin a2b1, which is a collagen receptor that
contain high concentrations of platelet factor 4 (PF4) and mediates platelet activation upon co-stimulation by GPVI
b-thromboglobulin [4–7]. These platelet-derived CXC [23, 24]. This is an important nexus between the thrombotic
chemokines bind chemokine receptor CXCR1 and CXCR2, and inflammatory pathways. Similarly, GP1b-IX binds von
and, in the presence of TNF-a, induce neutrophil adhesion to Willebrand factor, which induces platelet activation, cross-
endothelium [8, 9]. Platelets simultaneously release a variety linking, and aggregate formation [25, 26]. P-Selectin is an
important transmembrane receptor nominally stored in
a-granules whose concentration on the platelet surface rap-
D. Sternberg, MD (*)
Lung Transplant Program, Henry Ford Health System, idly increased after exocytosis. P-selectin binds P-selectin
K-14 2799 West Grand Blvd, Detroit, MI 48202, USA glycoprotein ligand-1 (PSGL-1), which is expressed on leu-
e-mail: dsternb1@hfhs.org kocytes and represents an important mechanism by which
J. Sonett, MD activated platelets initiate and form aggregates with leuko-
Lung Transplant Program, General Thoracic Surgery, cytes [27–29]. Recently, relatively high concentrations of
Columbia University Medical Center,
Toll-like receptors (TLRs), types 2, 4, and 9, have also been
PH Room 104, 14th Floor, 622 West 168th St,
New York, NY 10032, USA reported on platelets [30, 31]. These ancient receptors are
e-mail: js2106@columbia.edu expressed on immune cells and recognize common conserved

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 393
DOI 10.1007/978-1-4471-4429-8_46, © Springer-Verlag London 2013
394 D. Sternberg and J. Sonett

microbial motifs; they thus represent a form of innate non- from asthmatic bronchial biopsy specimens [47]. Indeed,
self recognition. This discovery supports a role for platelets allergen challenging of asthmatic patients increases periph-
upstream in the innate immune response [32]. Thus, platelet eral circulating activated platelet leukocyte complexes while
activation is a key early event that links, recruits, and ulti- transfusing thrombocytopenic murine models of asthma
mately upregulates both leukocytes and endothelial cells in restored pulmonary inflammation [48]. Multiple lines of evi-
both the thrombotic as well as the immune pathways. dence, including increases in platelet-derived soluble CD40L,
Circulating platelets form immunologically active aggre- also suggest that platelets participate in the chronic pulmo-
gates with leukocytes, particularly monocytes [25]. Other nary inflammatory processes that are the hallmark of cystic
than aggregate formation, however, the presence of these fibrosis (CF) [49, 50]. Platelets have also been implicated in
activated platelets strongly affects leukocyte function. After the pathophysiology of primary pulmonary hypertension
binding, NF-kappa B translocates to the monocyte nucleus, (PPH), although the exact mechanism remains unclear [51].
signifying that the master cellular control switch has been set Many patients with PPH have chronic levels of thrombocy-
to a proinflammatory setting [33]. Interleukin-8, tumor topenia, and clinical studies suggest 87 % of adult patients
necrosis factor-a, and MCP-1 production are all strongly with PPH have abnormal platelet aggregration [52]. Indeed,
upregulated, as is surface expression of PSGL-1 and CD-16, high concentrations of platelet-derived soluble CD40L have
which increases the adhesive capacity of monocytes to the been reported in PPH patients [53]. Injured pulmonary arte-
vascular endothelium [34–37]. Platelets also directly bind rial endothelium is a central thesis in this disease, but plate-
and interact with endothelial cells in a highly reflexive man- lets also seem to be recruited and operative within this
ner. Activated endothelial surfaces express PSGL-1, process [51]. Reports of platelet activation as a contributory
P-selectin, ICAM-1,GP-1b, as well as the important co- event in the pathophysiology of sepsis have been suggestive,
stimulatory CD-40 receptor, which mediate stable platelet but far from conclusive. Reports of increased platelet aggre-
and platelet-leukocyte aggregate adhesion to the endothe- gation in sepsis have been inconsistent, although more recent
lium [38, 39]. CD40 ligand is stored in platelet granules and evidence seems to support the case for diffuse platelet activa-
released shortly after aIIbb3 ligand engagement [40, 41]. tion and aggregate formation with pulmonary trapping [54–
Platelet factor 4 release has also been shown to stimulate 57]. Furthermore, inhibition of platelet neutrophil binding
NF-kappa B nuclear migration, activating a proinflammatory mitigates sepsis, at least in animal models of abdominal sep-
endothelial phenotype that is hallmarked by the release of sis [58]. It seems highly likely then, especially since the dis-
P-selectin-laden Weibel-Palade bodies [42]. A multidirec- covery of Toll-like receptors on their surface, that platelets
tional relationship among the platelets, leukocytes, and participate in the physiology of sepsis, although the exact
endothelium thus exists whereby any participant can recruit role has yet to be fully elucidated.
and stimulate the other party and thus induce or propagate
local inflammatory signals.
Platelet Activation After Transplant

Clinical Consequences of Platelet Activation A putative role for platelet activation during acute post-
transplant graft dysfunction after solid organ transplant has
The clinical consequences of platelet activation have long also been scrutinized. Ischemia and reperfusion injury (I/RI)
been recognized for their importance in thrombotic vascular is thought to injure the vascular endothelium and induce a
disease. Recently, however, recognition that platelet activa- global “activated” phenotype. Injured endothelium expresses
tion may be important in inflammatory disease is gaining platelet receptors that mediate platelet as well as leukocyte
traction as well. Platelets have been implicated in the devel- adhesion and could be an important injury mechanism. After
opment of acute lung injury (ALI) and acute respiratory dis- liver transplant in a rat model, platelets have been shown to
tress syndrome (ARDS). Analysis of lung biopsy specimens mediate endothelial apoptosis in hepatic sinusoids [59–61].
in these patients shows platelet aggregate deposition in both Another interesting observation from this model was the dis-
ARDS patients and those with ALI after acid aspiration [43, covery that thrombocytopenia inversely correlated strongly
44]. Idell and Niewiarowski have shown that the degree of with ischemic time. Additionally, after reperfusion injury in
platelet activation, inferred from the concentration of platelet a clinical study, increased concentrations of activated plate-
a-granule specific proteins in bronchial lavage fluid, correlated lets can be detected in the circulation for days, unlike control
well with clinical severity scores [45]. Furthermore, murine transplants without reperfusion injury [62]. Platelet deposi-
models of ALI have shown that inhibiting P-selectin-mediated tion has been reported in livers, kidney, intestine, and pan-
platelet neutrophil interactions abrogate lung injury after creas grafts and in rat cardiac allografts [63–66]. Platelet
intrapulmonary acid instillation [46]. Support for a patho- deposition has also now been linked with overall graft func-
logical role in pulmonary leukocyte trafficking is also derived tion. For example, increased platelet deposition correlated
46 Platelet Activation After Lung Transplantation 395

with elevated post-transplant creatinine after kidney trans- immunosuppressed prior to transplant, and this may effect
plantation [65]. Thrombocytopenia has been observed after platelet leukocyte interaction in the graft during reperfusion
liver transplant and correlates poorly with survival. injury. Sixth, it is impractical to obtain lung biopsies at
Platelet activation also seems to be a key injury mecha- meaningful time frames after transplant, as these patients
nism during allo- or xenograft hyperacute rejection [67–69]. have already been transported to the intensive care unit.
It is known that both complement and humoral mechanisms Despite these limitations, much has been learned, both
strongly activate platelets and co-injure vascular endothe- from animal studies and from clinical investigations. Platelet
lium during hyperacute rejection. Vascular permeability, deposition was first reported in a careful pathological study
tissue edema, and leukocyte infiltration all ensue. of canine lung grafts as early as 1978 by Hoyer et al. [77].
Simultaneous platelet-mediated activation of the coagula- This observation was later repeated in humans when Zenati
tion cascade causes a microthrombotic failure of organ per- performed post-mortem analysis of five lung transplant
fusion and graft loss. Platelet activation lies at the fulcrum recipients who succumbed to primary graft failure in 1990
of these events and has thus served as an appealing thera- [78]. In 1997, Okada observed increasing platelet deposition
peutic target, given its key role in both pathways. Multiple in rat lung grafts with incrementally prolonged ischemic
groups have reported prolonged graft function and therefore times [79]. He also made the important observation that isch-
partial success with the use of aIIbb3 antagonists in cardiac emia time correlated with the severity of reperfusion injury,
xenograft models [70, 71]. Similarly, blockade of GP1b- determined functionally and via histological severity scores.
mediated platelet aggregation, inhibition of ADP-mediated When the platelet inhibitor, beraprost sodium, was adminis-
platelet activation, and platelet-activating factor antagonism tered prior to lung transplant in rats, reperfusion injury –
have all prolonged cardiac xenograft failure [72–74]. measured morphologically by the severity of capillary
Platelet antagonism with GP1b and aIIbb3, inhibitors has congestion, tissue edema, and graft flow – were all improved
also been favorably evaluated in rabbit to dog and guinea in comparison to untreated control animals [80]. This led to
pig to rat lung xenotransplant models as well as isolated a specific focus on P-selectin-mediated signaling because it
guinea pig lungs perfused with whole heparinized human is critical for platelet adhesion to endothelial surfaces as well
blood [75, 76]. as the recruitment of leukocytes into immunologically active
aggregates with platelets. In 1997, Naka et al. used an anti-
body to abrogate P-selectin signaling and P-selectin-deficient
Platelet Activation and Pulmonary lines of Lewis rats to study reperfusion injury after trans-
Reperfusion Injury plant. He reported improved oxygenation, pulmonary vascu-
lar resistance, and overall survival in isogenic animals in
Lung grafts, in particular, are a cogent model to study plate- lung grafts in animals without intact P-selectin signaling
let endothelial cell interaction because of the high degree of [81]. These results were supported by Roberts who also
vascularity, low pressure/high flow perfusion characteristics, blocked P-selectin binding and then directly observed a
and exquisite organ sensitivity to edema. Reperfusion injury decrease in platelet rolling and adhesion in sub-pleural arte-
can be studied in situ after cross-clamping the pulmonary rioles after 2 h of warm ischemia in rabbits [82]. In 2004,
artery for a variable period of time and then permitting rep- Colombat directly observed platelet aggregation and
erfusion for further periods of time, or it can be studied after increased surface P-selectin expression in human lung grafts
transplantation. Although studied directly in humans after after 15–30 min of reperfusion [83]. Furthermore, Colombat
lung transplant, this has proven to be exceedingly hard to do noted that increased P-selectin expression correlated with
directly for a variety of reasons. First, all grafts used in clini- clinical markers of primary graft dysfunction, such as pro-
cal lung transplant are exposed to variable periods of a longed mechanical ventilation, decreased oxygenation, and
severely deranged hormonal and neuroendocrine environ- pulmonary edema assessed by chest radiograph [83]. In
ment after brain death that could stimulate endothelial dys- 2008, we reported increased concentrations of two circulat-
function and predispose to platelet activation well before the ing markers of platelet activation, soluble P-selectin and
transplant is contemplated. Second, since no two transplants soluble CD40 ligand, as well as increased concentrations of
have exactly the same periods of ischemia, consistent data circulating platelet-monocyte aggregates 6 h after clinical
collection is challenging. Third, the use of cardiopulmonary lung transplantation [84]. In 2009, Kawut reported a correla-
bypass itself causes platelet activation and deposition in the tion between increased soluble P-selectin levels and primary
lungs. Fourth, patients that come to lung transplant them- graft dysfunction at both 6 and 24 h after lung transplant
selves suffer a variety of ailments, some of which are thought [85]. Thus, a significant body of evidence in both clinical
to involve variable degrees of platelet activation, such as lung transplant and a variety of animal models supports a
primary pulmonary hypertension. Fifth, some patients, central critical role for platelet activation in pulmonary rep-
such as those with interstitial lung disease, are heavily erfusion injury.
396 D. Sternberg and J. Sonett

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 Role of BNP in Pediatric Heart
Transplantation 47
Marcelo Biscegli Jatene and Estela Azeka

Introduction It has been identified in the brain and subsequently in the

heart, mainly in the myocytes of the ventricle. Studies have
The role of hormonal changes and biomarkers has been shown low plasma concentrations under physiological set-
studied after heart transplantation; they include B-type natri- tings, with a significant increase in pathological situations,
uretic peptide (BNP), atrial natriuretic peptide (ANP), such as ventricular hypertrophy and heart failure [9].
adrenomedullin (ADM), cardiac troponin T (cTnT), C-reactive It has been shown that the concentration of BNP is less
protein (CRP), endothelial growth factor, glycoprotein 130, than 20 % of the levels of ANP in normal individuals, but can
and cytokines, such as tumor necrosis factor a (TNF), inter- equal or exceed these levels in patients with congestive heart
leukin 1 beta (IL-1ß), and interleukin 6 (IL-6) [1]. failure [10].
Studies with electron microscopy of atrial and ventricular NT pro-BNP is an inactive metabolite of the pro-BNP
muscle cells made by Kisch in 1963 [2] and Jamieson and peptide, and it has been described to be useful for the evalu-
Palade in 1964 [3] marked the beginning of the research on ation of heart failure and the prognostic outcome of heart
polypeptide hormones called natriuretic factors and the atrial transplant candidates [11] because of its greater serum stabil-
natriuretic factor (ANF). In 1981, Bold [4] experimentally ity and not being metabolized by neuropeptidase. Furthermore,
tested the actions of these polypeptides. They had a charac- it seems to have a longer half-life than BNP [7].
teristically high biological natriuretic response, drop in blood A study conducted in healthy subjects showed increased
pressure, and increased hematocrit values [4–7]. levels of BNP with age and in females. The authors con-
Natriuretic peptides are a family that consists of three main cluded that 90 % of healthy young adults present BNP values
components: atrial natriuretic peptide (ANP), brain natriuretic smaller than 25 pg/ml and NT pro-BNP smaller than or equal
peptide (BNP), and C-type natriuretic peptide (CNP), in addi- to 70 pg/ml [7].
tion to urodilatin, a peptide found in the urine [4–7]. In 2006, Soldin et al. evaluated 808 persons for –21 years,
In 1983, de Bold and Flynn [8], after isolating and with a significant number of subjects in each age group, show-
sequencing BNP, started their studies on the correlation ing high levels of BNP in neonates (1,585 pg/ml) and in chil-
between serum levels of circulating BNP and the diagnosis dren up to 6 months (263 pg/ml), with little variation in the other
and treatment of heart failure. age groups. In this study, no difference was observed between
Brain natriuretic peptide (BNP) is homologous to ANP genders, and the 95th percentile was around 100 pg/ml [12].
hormone (neurohormone released by atrial myocytes and to The secretion of BNP is regulated by the myocardial wall
a lesser extent in the ventricles), and the physiologically tension, and its plasma levels are elevated in systolic and/or
active portion consists of 32 amino acids [9]. diastolic heart failure and in cases of volume overload, pro-
viding a predictor of the development of heart failure and
cardiovascular mortality [13–19].
M.B. Jatene, MD (*)
Pediatric Cardiothoracic Surgery Unit, Heart Institute (InCor), Elevated serum levels of BNP (greater than 200 pg/ml)
University of Sao Paulo Medical School, showed 100 % sensitivity and specificity of 97.1 %, a posi-
Av. Eneas de Carvalho Aguiar, 44, 2nd Floor – Block 2, tive predictive value of 97.3 %, and a negative predictive
Room 5, 05403-000 Sao Paulo, Brazil
value of 100 % for diagnosing decompensated heart failure
e-mail: mbjatene@uol.com.br
in adult patients, and 80 % sensitivity and specificity of 86 %
E. Azeka, MD, PhD
as a predictor of mortality. In some studies, BNP is related to
Pediatric Cardiology and Adult Congenital Heart Disease Unit,
Heart Institute (InCor), University of Sao Paulo Medical School, increased central venous pressure and pulmonary capillary
Sao Paulo, Brazil wedge pressure [20–22].

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 399
DOI 10.1007/978-1-4471-4429-8_47, © Springer-Verlag London 2013
400 M.B. Jatene and E. Azeka

BNP is present in high levels in children with congenital echocardiogram, elevated pulmonary capillary wedge pres-
heart disease with volume overload and/or myocardial dys- sure, reduction of the cardiac index score, and presence of
function and in patients with cardiomyopathies [23–26]. symptoms of fatigue and dyspnea [33].
Ationu et al. [34] studied the gene expression of ventricu-
lar and atrial natriuretic peptide in patients undergoing heart
BNP and Heart Transplantation transplantation and found that these peptides may be involved
in ventricular remodeling after transplantation.
Heart transplantation has been a therapeutic option in patients Studies evaluating blood levels of BNP and endomyocar-
with heart failure refractory to conventional therapy and in dial biopsy showed accuracy in the detection of rejection epi-
patients with complex congenital heart disease [27, 28]. sodes, increasing according to the degree of rejection, with
The first heart transplant in humans was performed by values ranging from 101 to 194 pg/ml in rejection grade 0–3
Barnard et al. in 1967, and Kantrovitz et al. performed the A and levels of 1,144–1,843 pg/ml in more severe degrees of
first transplantation in a newborn in the same year [29, 30]. rejection, negative predictive value of 98 %, and a cutoff
The absence of immunosuppressive drugs effective in the value of 130 pg/ml [35].
prophylaxis, treatment of rejection, and the difficulty in diag- In the adult population, studies show that blood levels of
nosis resulted in a decrease in the number of procedures BNP remain high in the first 2 months after transplantation,
before 1980. The introduction of cyclosporine as an immu- preventing the diagnosis of rejection, with its levels reducing
nosuppressive drug in the 1980s [31] as well as increased progressively over a 6-month period, at which point correla-
survival has led many centers to re-initiate their programs. tion with the histological rejection can be observed [36].
Despite the significant improvement in survival, rejection Martinez et al. evaluated BNP levels measured consecu-
[hyperacute, acute humoral (vascular), acute cellular, and tively 9–12 months after transplantation in relation to the fol-
chronic (allograft vasculopathy)] has been described up to lowing events: death, late rejection (after first year), and graft
70 % of deaths within 5–10 years after transplant [1]. dysfunction. The authors found a higher number of events in
Hyperacute rejection is less frequent and may occur the group with BNP levels that had increased by more than
immediately after extracorporeal circulation. It is caused by 20 % [36].
antibodies to the ABO system and to histocompatibility Lan et al. [37] reported a study conducted in 44 children
antigens (HLA). This is a serious event that can lead to graft who underwent orthotopic heart transplantation. The peptide
loss [1]. levels remained high after the transplants, with decreased
Acute rejection is observed, especially in the first 6 months levels to lower values of 100 pg/ml at 14 weeks in a fol-
post-transplant. It is mediated by T cells. The patient may be low-up period of 171 months.
asymptomatic or have nonspecific symptoms to low cardiac Claudius et al. [38] found that serum levels of BNP are
output due to graft failure. Endomyocardial biopsy is the elevated in children after heart transplantation with symp-
gold standard for the diagnosis and determines the intensity tomatic ventricular dysfunction because of rejection or coro-
and distribution of the cellular infiltrate in the myocardium nary artery disease after transplantation.
as well as whether myocardial necrosis is present [1]. Rousseau et al. [39] compared blood levels of BNP and
The humoral or vascular rejection is mediated by antibod- histological findings of endomyocardial biopsy, showing a
ies against the T cells and antibodies directed against the correlation between elevated natriuretic peptide levels above
HLA antigens and endothelial cells of the donor. It is more 100 pg/ml and the presence of rejection.
common in already sensitized patients who have received Sylos et al. [32] studied the role of BNP after pediatric
blood products prior to transplantation or have a history of transplantation and concluded that children could be asymp-
pregnancy or use of mechanical ventricular assist support tomatic at allograft rejection episodes. The BNP level was
before transplantation. These patients may present with statistically different in patients in the allograft rejection
severe hemodynamic compromise related to ventricular dys- group, and its evaluation could be an additional method to
function due to diffuse ischemia [1]. assess the diagnosis of allograft rejection.
Some biological markers such as BNP have been com- Coronary heart disease after transplantation, called graft
pared with the findings of endomyocardial biopsy in the vascular disease, is one of the main factors affecting the sur-
diagnosis of cellular rejection; however, the results are still vival of adults and children undergoing heart transplantation
controversial, especially in pediatric patients [32]. [1]. Studies show that the incidence of graft vascular disease
The blood level of BNP has been shown to be a factor varies from 30 to 50 % depending on the post-transplant
indicative of rejection and appears to be related to ventricular period of evolution examined and on the immunosuppressive
remodeling after orthotopic cardiac transplantation. In multi- regimen. Factors associated with a higher incidence of coro-
variate analysis, independent predictors of elevated BNP nary artery disease and graft loss are older age of the recipi-
were changes in the diastolic function and/or systolic ent, a greater number of rejections, and the presence of late
47 Role of BNP in Pediatric Heart Transplantation 401

rejection and moderate to severe coronary artery disease 17. Tang WH, Girod JP, Lee MJ, Starling RC, Ypung JB, Van Lente F,
detected by angiography and intravascular ultrasound [1]. et al. Plasma brain natriuretic peptide levels in ambulatory patients
with established chronic symtomatic systolic heart failure.
The evaluation of graft coronary artery disease by angiog- Circulation. 2003;208(24):2964–6.
raphy is recommended after the first year of transplantation 18. Wang TJ, Larson MG, Levy D, Benjamin E, Leip EP, Omland T,
and in the presence of symptoms of heart failure, arrhythmia, et al. Plasma natriuretic peptide levels and the risk of cardiovascular
chest pain, or syncope [1]. There are reports of a correlation events and death. N Engl J Med. 2004;350(7):655–63.
19. Groenning B, Raymond I, Hildebrandt PR, Nilsson JC, Baumann M,
between graft coronary artery disease and increased serum Pedersen F. Diagnostic and prognostic evaluation of left ventricular
levels of BNP in the adult population [1]. systolic heart failure by plasma N terminal pro-brain natriuretic
In conclusion, BNP has potential beneficial effects and peptide concentration in a large sample of general population.
prognostic value after heart transplantation; however, future Heart. 2004;90(3):297–303.
20. Villacorta H, Duarte NM, Carrano A, Mesquita ET, Dohmann HJ,
investigations are needed to better understand its role and Ferreira FE. The role of B-type natriuretic peptide in the diagno-
relation to the inflammatory process. sis of congestive heart failure in patients presenting to an emer-
gency department with dyspnea. Arq Bras Cardiol. 2002;79(6):
564–8.
21. Akioka K, Takeuchi K, Yanagi S, Hirota K, Sakamoto K,
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 Nutritional Factors, Oxidative Stress
and Lung Transplantation 48
Janet Madill, Bianca Arendt, Chung-Wai Chow,
and Johane Allard

Introduction oxidants and antioxidant studies in relation to lung disease

and lung transplantation.
Transplantation is the only treatment of choice for end-stage
lung disease patients. This procedure is labor-intensive,
expensive, and driven by the availability of organ donation. Oxidative Stress
Considering the ongoing significant organ donor shortage, it
is important to ensure that each transplant candidate will sur- The role of oxygen is double-edged. It is utilized in the meta-
vive and achieve the maximum long-term outcome. bolic processes that provide energy for cell functions and in
Unfortunately, there are still challenging long-term compli- this process generates toxic free radicals [13]. Under normal
cations associated with lung transplant recipients, and conditions, these free radicals, which include reactive oxy-
research is ongoing to maximize medical treatment. gen species (ROS) and reactive nitrogen species (RNS), are
In lung transplantation, the long-term outcome is ham- efficiently scavenged by the antioxidant defense system [14].
pered by the development of bronchiolitis obliterans syn- However, there are a number of chronic inflammatory condi-
drome (BOS). Although the survival rate at 1 year is 80 %, tions, such as aging [15], atherosclerotic heart disease [16],
this rapidly decreases to 50 % at 5 years post-transplant Alzheimer’s disease [17], as well as a variety of lung [18]
because of BOS [1]. Medical and pharmacological approaches and liver diseases [19, 20] whereby the production of free
to prevent these long-term complications are improving, but radicals overwhelms the antioxidant defense system, leading
the success is limited. The main reason for this limited suc- to a condition known as oxidative stress (Fig. 48.1).
cess is the complex pathogenesis of BOS, which can be asso- Physiological levels of free radicals are essential for cell
ciated with ischemia-reperfusion injury [2], immunological differentiation, cell growth, cell apoptosis, and immunity
reactions [3], acute and chronic rejection [4–9], inflammation against invading microorganisms [21–23]. However, when
[10], and concomitant infections [11]. Oxidative stress may
contribute to BOS pathogenesis and induce further tissue PUFA* Antioxidant
injury and inflammation. Oxidative stress can be influenced defense
Superoxide radicals
by several factors, including nutrition.
We have previously reported that oxidative stress may Hydroxyl radicals
play a role in the pathogenesis of BOS in lung transplant Peroxyl radicals
recipients [12]. Considering that oxidative stress can be asso-
Hydrogen peroxide
ciated with nutritional factors, this chapter will focus on anti-
Singlet oxygen
J. Madill, PhD, RD (*)
Assistant Professor, Brescia University College, Vitamin E
Western University, London, Ontario Vitamin C
e-mail: jmadill7@uwo.ca Carotenoids
C. Chow, MD Glutathione
Lung Transplant Program, University of Toronto, Selenium
Toronto, ON, Canada
B. Arendt, PhD • J. Allard, MD *PUFA, Poly unsaturated fatty acides
Department of Medicine, University Health Network (UHN),
Toronto, ON, Canada Fig. 48.1 Oxidative stress

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 403
DOI 10.1007/978-1-4471-4429-8_48, © Springer-Verlag London 2013
404 J. Madill et al.

Fig. 48.2 Effects of oxidative IRI Injury/infection/rejection

stress

Active neutrophils

Reactive oxygen species Reactive nitrogen species

(ROS) (RNS)

Oxidative stress

Inactivation of
Lipid Transcription of
proteases Neutrophil
peroxidation proinflammatory
sequestration
cytokines

Depletion of antioxidant
defenses

Epithelial permeability
Inflammation Immunological
process
Lung injury

BOS

these free radicals overwhelm the antioxidant defense sys- The antioxidant system can also be assessed by measur-
tem, oxidative stress occurs. ROS/RNS are increased during ing antioxidant enzymes such as glutathione peroxidase
processes such as immunological reactions, inflammation, (GPx), superoxide dismutase (SOD), and catalase (CAT) or
infections, and ischemia-reperfusion injury. Excess by analysis of micronutrients such as antioxidant vitamin E,
production of ROS/RNS can cause oxidative damage to DNA C, or carotenoids.
as well as modify proteins, carbohydrates, and lipids, result-
ing in cellular injury (Fig. 48.2). On the other hand, antioxi-
dant levels can be reduced by the chronicity and magnitude Evidence of Oxidative Stress in Lung
of these processes and can be influenced by dietary intake of Transplantation
certain types of fat and antioxidant micronutrients, such as
vitamin E, ascorbic acid, carotenoids, and selenium. Oxidative stress is a condition whereby prooxidants over-
whelm the antioxidant defense system, and this may contrib-
ute to the pathogenesis of BOS by inducing increased tissue
Measuring Oxidative Stress injury and inflammation.
Three studies have reported antioxidants in lung transplant
Oxidative stress can be assessed by various laboratory analy- recipients and measured oxidative stress parameters. In a small
ses, for example, by measuring by-products of lipid, protein, cross-sectional study, Madill [29] reported that lung recipients
and DNA oxidation. These include, lipid peroxidation with severe stages of BOS were more oxidatively stressed
metabolites such as plasma/tissue malondialdehyde (MDA) compared to those patients with a milder stages of BOS and
and 8-isoprostanes [24], protein oxidation parameters, such non-BOS lung recipients. This was indicated by increased
as protein carbonyls, total thiols, advanced oxidation protein BALF levels of LPO and oxidized glutathione. However, there
products, and nitrotyrosine [25, 26], and measures of DNA were no significant differences in nutritional intake of vitamin
damage, such as DNA strand breaks and guanine oxidation A, C, or E or plasma antioxidant vitamin levels of retinol, vita-
products (8-OHdG) [27, 28]. min C, or a- and g-tocopherol among the three groups.
48 Nutritional Factors, Oxidative Stress and Lung Transplantation 405

Williams et al. [30] in a prospective study also reported Obesity is associated with a heightened state of
increased BALF MDA levels in lung recipients 2 weeks and inflammation [34, 35], resulting in oxidative stress. Increased
12 months post-transplant when compared to non-transplant body weight is positively associated with inflammation,
controls (p < 0.05). The authors reported no significant measured by C-reactive protein levels (a biomarker of
improvement in antioxidant status (serum or BALF) from inflammation) in obese compared to non-obese individuals
2 weeks to over 1 year post-lung transplant, indicating that [36, 37].
lung recipients remain oxidatively stressed. Obesity is also prevalent in other solid organ transplant
Another study [31] performed in 15 cystic fibrosis recipients [38–41]. However, in the lung transplant popula-
patients taking vitamin supplements, including 8,000 IU tion, there is minimal information on the association of obe-
(1,200 mg) vitamin A and 300 IU (248 mg) vitamin E, sity and the development of BOS.
assessed antioxidant vitamin levels. Serum vitamin A and Kanasky et al. [42] examined 85 post-lung transplant
vitamin E levels were determined pre-transplant and again recipients (34 % were overweight/obese) and determined that
at approximately 15 months post-transplant. Pre-transplant obesity had a negative effect on post-transplant survival. The
serum vitamin A levels were within the normal range, most powerful predictor of mortality was BMI, with an
whereas post-transplant, they significantly increased. increased risk of death of 7 % for each 1.0 unit (kg/m2)
Similar results were seen regarding serum vitamin E levels. increase. These authors also reported that there was no differ-
No measurements were conducted in BALF to assess lung ence in the development of BOS and/or infection in the obese
antioxidant status or oxidative stress. Supplementation in compared to the non-obese group. Another study also reported
these lung transplant patients with both vitamin A and E a negative impact of high pre-transplant BMI [43]. Culver
(8,000 IU, 300 IU, respectively) remained the same pre- and examined 46 lung transplant patients with BMI >30 kg/m2
post-transplant to prevent vitamin deficiencies. The increase and reported a significant increase in 90-day mortality in
in vitamin E and A serum vitamin levels post-transplant obese lung transplant patients when compared to non-obese
may have been due to increased compliance or reduced oxi- [OR 3.16 (CI: 1.05–9.48)]. Previously, we have reported that
dative stress post-transplant due to lower lung infectious high body mass index (BMI) pre-transplantation was shown
rates related to CF. to increase morbidity and/or mortality within 90 days post-
In summary, only three studies have been conducted lung transplantation [44]. A retrospective chart review [45] of
examining oxidative stress and lung transplantation. Two 826 lung transplant recipients from 12 international transplant
studies documented an increase in lipid peroxidation along centers reported that substantial weight gain occurred within
with a weakened antioxidant status in lung transplants recipi- the first year post-transplant. In this study, higher weight gain
ents not taking vitamin supplementation. The third study was associated with better subsequent survival [45].
examining CF patients indicated that antioxidant vitamin Taken together, these studies indicate that there is a high
supplementation helps maintains vitamin levels. prevalence of obesity post-lung transplantation and that this
In addition to ischemia-reperfusion injury and inflam- may affect survival, although the results are mixed. Only one
mation associated with rejection and infection, nutritional small retrospective study looked at the relationship between
factors may contribute to oxidative stress by either creating a obesity and BOS and did not find any increased risk of BOS
prooxidant status or affecting the antioxidant defense sys- in obese subjects.
tem. Prooxidant nutritional factors include obesity and/or
malnutrition, as well as intake of dietary fat, particularly
polyunsaturated fatty acid (PUFA). Conversely, nutritional Malnutrition
factors contributing to the antioxidant defense systems are
antioxidant micronutrients such as vitamins E, C, and carote- In addition to obesity, malnutrition can also be associated
noids. In addition, antioxidant enzymes and trace elements with oxidative stress because of possible micronutrient
such as selenium may also play a role. deficiencies due to inadequate intake and/or malabsorption
[46]. In the pre-transplant lung literature, the effect of mal-
nutrition and oxidative stress has been reported mainly in
Nutritional Factors and Oxidative Stress cystic fibrosis (CF) patients [47]. CF patients have malab-
sorption of fat-soluble vitamins A, E, and carotenoids
Obesity [48, 49]. In addition, repeated or chronic infections as well as
respiratory failure can increase catabolism and anorexia,
We are currently encountering an obesity epidemic [32]. contributing to malnutrition. Furthermore, chronic
Recent studies have indicated that decreased energy intake inflammation generates more ROS/RNS via neutrophil and
resulted in decreased oxidative stress, measured by decreased macrophage activation and ‘respiratory burst’ [50, 51].
plasma MDA levels in non-obese subjects compared to obese Therefore, the effect of reduced intake and increased malab-
participants [33]. sorption of micronutrient antioxidants, combined with
406 J. Madill et al.

greater demand of antioxidants for scavenging free radicals, E. High fat requirements lead to increased intake of PUFA,
will enhance oxidative stress in this patient population [50]. which leads to increased oxidative stress.
Some studies reported on malnutrition, malabsorption, Because of its antiinflammatory effect, omega-3 PUFA is
and low micronutrient levels pre-transplantation, particularly often given to cystic fibrosis (CF) patients as a supplement.
the CF population. In general, in the studies reported, oxida- Omega 3 supplements contain vitamin E to prevent LPO. In
tive stress was shown to be elevated. However, there is a pau- a Cochrane systematic review [59], results indicated that CF
city of studies reporting on nutritional status, dietary intake, patients supplemented with w-3 had (1) improved lung func-
and plasma levels of antioxidant micronutrients in post-lung tion, (2) improved clinical status, (3) reduced volume of spu-
transplant patients. Nutritional intake also influences oxida- tum, and (4) increased essential fatty acids (efa) in neutrophil
tive stress. membranes. Few minor adverse effects were reported.
Another study in CF patients found no change in oxidative
stress with fish oil supplementation [60], suggesting that
Nutrition Intake vitamin E from supplementation was sufficient to prevent
lipid peroxidation. Studies on the effect of w-3 PUFA sup-
Polyunsaturated Fatty Acid (PUFA) plementation have not been reported in the lung transplant
The type of PUFA ingested in the diet can influence oxidative population. Antioxidant intake and/or supplementation can
stress and the demand for antioxidants. It can also influence also influence oxidative stress.
underlying inflammation. Long-chain PUFAs are more prone
to lipid peroxidation (LPO) because they have more double Antioxidants
bonds. The greater the number of double bonds in the PUFAs, Observational studies examining a possible protective role of
the more susceptible they are to LPO [52–54]. antioxidants in lung diseases have been summarized in sev-
Hydroxyl radicals produced by activated neutrophils initi- eral review articles [61–63]. Dietary studies form the bulk of
ate a free radical chain reaction by attacking the double these reports.
bonds of PUFA within the membrane phospholipids. Current dietary guidelines from Health Canada Eating
Omega-6 PUFAs, such as arachidonic acid, and omega-3 Well with Canada’s Food Guide recommend seven food
PUFAs, such as eicosapentaenoic acid (EPA) and docosa- guide servings of fruit and vegetables per day (HC Pub:4651;
hexanoic acid (DHA), are prone to LPO, particularly in an Cat: H164-38/1-2007E SSBN:0-662-44467-1). Consuming
environment deficient in vitamin E. Both PUFA and vitamin foods based on this recommendation will provide a diet rich
E are influenced by diet. in antioxidants, including vitamins C, E, and b-carotene,
In addition, the type of PUFA influences inflammation. among others. Many dietary antioxidants work synergisti-
Omega-3 PUFAs, such as a-linolenic acid, eicosapentaenoic cally [64] to promote their protective effects as they exist in
acid (EPA), and docosahexaenoic acid (DHA), contained in a natural environment and are biochemically balanced [65].
walnuts, soybeans, flax seed oil, and fish [55], have To our knowledge, there are no studies examining fruit and
antiinflammatory effects by decreasing the production of vegetable intake in lung transplant recipients. However, in the
eicosanoids and leukotrienes [56]. However, omega-6 PUFAs, patients with lung disease, diets rich in antioxidants have
such as linoleic acid found in vegetable oils and arachidonic shown beneficial effects on lung function described as high
acid found in animal fat sources, are classified as maximal forced expired ventilation in 1 s (FEV1). Cross-
proinflammatory [57] as they produce two potent inflammatory sectional studies have been conducted on 12,000 subjects with
mediators, eicosanoids and leukotrienes [56]. Therefore, the various lung etiologies, indicating that intake of fruits and veg-
type of PUFA can influence oxidative stress depending on its etables improves lung function [61–63, 66]. As well, large
predisposition to lipid peroxidation and its effect on longitudinal studies have also reported a positive association
inflammation. Both PUFA and vitamin E levels can be between overall dietary intake of fruits and vegetables and
influenced by dietary intake. FEV1 [67–71]. Furthermore, fruit and vegetable consumption
The University of Toronto Lung Transplant Program con- has shown beneficial effects on decreasing respiratory symp-
ducts about 100 lung transplants/year, and patients with cys- toms and disease severity [72]. Even low intake of fruit and
tic fibrosis (CF) represent 25 % of this population (UHN vegetables compared to no consumption achieved a positive
lung transplant data statistics; December 2011). These effect on lung function [61]. Similarly, one longitudinal study
patients generally require high-calorie and high-fat nutrition [67] reported an inverse association (RR = 0.73) between fruit
care plans to optimize their nutritional status [58], along with intake and the incidence of chronic non-specific lung disease.
pancreatic enzymes and vitamin supplementation to correct Studies on the intake of fruits and vegetables and the
for malabsorption. In addition to the underlying disease, this effect on oxidative stress measurements have been con-
regimen will influence oxidative stress depending on the pro- ducted. In a crossover study [73], increased consumption of
portion and type of fat absorbed and the ratio of PUFA:vitamin ten servings of fruits and vegetables resulted in a significant
48 Nutritional Factors, Oxidative Stress and Lung Transplantation 407

reduction of oxidative stress measured as oxygen radical to ischemia-reperfusion injury (IRI). However, oxidative stress
absorbance capacity (ORAC) from baseline to post- in long-term lung recipients is not well studied [29, 30].
consumption [73]. It is important to keep in mind that, in the broader context,
Dietary studies examining the association between lung research studies examining antioxidant supplementation in
function (described as high maximal FEV1) and intake of patients with a variety of disease conditions such as athero-
individual antioxidants provide conflicting results. Indeed, sclerosis [92] and Alzheimer’s disease [93] have also been
while some cross-sectional studies found a positive associa- disappointing, underlying the difficulties regarding decisions
tion between vitamin C and lung function [74–77], along for the dosing, timing, type and combination of supplements,
with two longitudinal studies [69, 70], others failed to find duration of the intervention, and outcome measures. Results
any such association [67, 78]. from primary and secondary intervention trials with 400 IU
The evidence for intake of vitamin E is also conflicting. vitamin E every other day plus 500 mg vitamin C daily have
Cross-sectional studies [74, 75, 78] and one longitudinal reported increased mortality in both healthy controls and
study [69] report a positive association between intake of patients with diseases [94–96]. The evidence is even more
vitamin E and lung function, whereas one cross-sectional convincing that antioxidant supplementation with the goal of
[76] and one longitudinal study report no association [79]. reducing the risk of cardiovascular disease is not supported
Although less well studied, research indicates that intake by the findings from current randomized controlled studies
of b-carotene shows similar trends. Two cross-sectional stud- [97, 98]. Similarly, 400 IU vitamin E every other day along
ies [76, 80] along with a longitudinal study [69] indicate a with daily 500 mg vitamin C supplementation, neither alone
beneficial association, whereas one cross-sectional study nor together, reduced the risk of prostate or total cancers
reports no benefit [67]. [99–101]. However, some of these studies have been criti-
Studies involving patients with a variety of lung diseases have cized for not examining an oxidative stress biomarker, thus
reported positive associations between plasma vitamin E, vita- making it difficult to identify individuals who may have
min C, and b-carotene antioxidant levels and FEV1 [79, 81]. benefited from supplementation [102]. Therefore, based on
Supplementation studies in patients with lung diseases these past studies, optimal antioxidant vitamin supplementa-
have reported very disappointing results. The Alpha- tion studies may be very challenging to design.
Tocopherol, Beta-Carotene Cancer Prevention (ATBC) study Another potential intervention would be a dietary
[82, 83] describes a RCT of 28,000 male smokers who were modification [103]. Initiating nutrition strategies to improve
supplemented with a daily dose of 50 IU of vitamin E, 20 mg the total antioxidant capacity (TAC) of lung recipients’ diets
b-carotene, both, or placebo for 5–8 years. Unexpected represents a possible dietary alteration. Some authors agree
results indicated that vitamin E supplementation, increased that improving the patients’ overall nutrition intake may
the risk of death from hemorrhagic stroke, and b-carotene prove more beneficial than antioxidant supplementation
increased lung cancer mortality and ischemic heart disease. [104]. As well, some authors have reported that high TAC
The CARET study [84] tested effects of combined treat- foods (consisting of red berries, spinach, coffee, olive oil,
ment of b-carotene (30 mg/day) and retinyl palmitate among others) can minimize inflammation [105–109]. More
(25,000 IU/day) in 18,000 men and women with a history of recently, Giuseppe reported that subjects consuming higher
smoking. Results from this study found increased risk of TAC foods demonstrated a significant improvement in FEV1
both lung cancer and coronary artery disease in treated when compared to those with lowered intakes of TAC foods
patients compared to controls. [110]. These types of diets may be more beneficial than con-
Therefore, most of these epidemiological studies showed suming additional pills and may have other beneficial com-
some beneficial effect from antioxidants on various respira- pounds that have not yet been identified [111].
tory diseases. However, intervention studies were disap- However, before recommending antioxidant supplemen-
pointing. Presently, minimal studies examining antioxidant tation in lung transplant recipients, we should assess its
status in lung transplant patients have been undertaken. One benefit and determine what appropriate dose and combina-
study [85] reported low BALF ascorbic acid and glutathione tion would be most successful, as well as the duration of
levels in BOS lung recipients when compared to non-BOS treatment [112, 113]. We may also want to determine if we
recipients. The second study [30] indicated elevated plasma could identify the ‘more oxidized’ lung transplant patient at
and BALF MDA levels and low serum and BALF ascorbic an earlier stage for supplementation with extra antioxidants
acid levels up to 12 months after lung transplantation. No [114]. Furthermore, we will need to examine if supplementa-
dietary intake assessment was performed, and no interven- tion leads to minimization of the inflammatory process evi-
tion studies were conducted. dent in chronic rejection, a condition that significantly
In the lung disease population, increased oxidative stress decreases long-term outcomes in lung transplant patients. If
has been adequately documented in pre-transplant patients [47, so, would this reduce oxidative stress and, as a result, have a
50, 86–91] as well as early post-lung transplantation in relation clinical impact on FEV1 and the development of BOS?
408 J. Madill et al.

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 Part XV
Ventricular Assist Device
 Mechanical Unloading and Heart
Remodeling Features 49
Nikolaos A. Diakos, Omar Wever-Pinzon,
Anthony S. Zannas, and Stavros G. Drakos

Introduction Effects of LVAD-Induced Unloading

on Myocardial Structure
Left ventricular assist devices (LVADs) are increasingly used
in the everyday clinical practice to either ‘bridge’ end-stage Key changes that have been described in the failing myocar-
heart failure (HF) patients to heart transplantation or as a dium after LVAD unloading include alterations in cardio-
permanent (‘destination’) therapy. Myocardial remodeling myocyte hypertrophy, extracellular matrix, microvasculature,
driven by excess pressure and volume load is believed to be and adrenergic pathways-sympathetic innervation, among
responsible for the vicious cycle of progressive myocardial others. These effects are summarized in Table 49.1 and will
dysfunction in chronic HF [1]. This mechanistic model led to be described in this section.
the hypothesis that LVAD support would disrupt this cycle
and, by providing profound volume and pressure unloading,
allow for a reversal of stress-related compensatory responses Cardiac Hypertrophy – Atrophy
of the overloaded myocardium [2–4]. This in turn would lead
to subsequent structural and functional “reverse remodeling” Hypertrophic growth of cardiomyocytes is the common mech-
at organ and tissue levels [2–4]. anism by which the heart reduces stress on the failing ven-
Limited clinical data have suggested that LVAD therapy tricular wall. Pulsatile LVAD unloading has been repeatedly
can occasionally reverse the complex process of chronic shown to induce regression of cardiac myocyte hypertrophy –
myocardial remodeling to the point where a subset of patients cell length, width, and thickness [10]. This is in agreement
can be successfully weaned from the LVAD (“bridge to with data showing that pulsatile LVAD unloading reverses the
recovery”) [5–8]. Achieving sustained myocardial recovery altered cardiac production of natriuretic peptides along with
after LVAD explantation in a patient with chronic HF is one parallel reductions in myocardial mass and myocyte size [4].
of the most desirable goals in the treatment of heart disease Regarding the exact mechanisms governing hypertrophy
[9]. Consequently, the mechanisms that might facilitate regression during pulsatile LVAD support, reviewed in detail
LVAD unloading-induced myocardial reverse remodeling elsewhere, ongoing investigations examining the complex role
have become the subject of intensive research [2–4], and this of Akt kinase/cyclooxygenase-2, mitogen-activated protein
has been favored by the fact that the LVAD patient popula- kinases (MAPK)/extracellular signal-related kinases (Erks),
tion possesses a series of significant research advantages.
However, fundamental questions at the basic science, trans- Table 49.1 Cardiac remodeling parameters favorably altered with
lational, and clinical level remain unanswered. LVAD unloading
Hypertrophy
N.A. Diakos, MD (*) • O. Wever-Pinzon, MD Contractile dysfunction
S.G. Drakos, MD Calcium cycling
Heart Failure Program (Division of Cardiology) Cytoskeletal proteins (sarcomeric, non-sarcomeric, membrane)
and Molecular Medicine Program Beta-adrenergic signaling
(Eccles Institute of Human Genetics), Metabolism and bioenergetics
University of Utah, Salt Lake City, UT, USA
e-mail: ndiakos@u2m2.utah.edu Myocyte death (apoptosis, autophagy, stress)
Endothelium and microvasculature
A.S. Zannas, MD, MSc
Sympathetic innervation
Department of Psychiatry, Duke University Medical Center,
Durham, NC 27710, USA Circulating neurohormones, cytokines

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 413
DOI 10.1007/978-1-4471-4429-8_49, © Springer-Verlag London 2013
414 N.A. Diakos et al.

and Akt kinase/glycogen synthase kinase 3b (GSK3b) under- reenter the cell cycle during regenerative processes. Of
score their importance in the pathogenesis and regulation of course, this hypothesis requires further confirmation.
cardiac hypertrophy. Whether the primary stimulus for the
regression of hypertrophy is directly related to mechanical
unloading/stretch or to circulating systemic factors needs to be Extracellular Matrix
further investigated. Interestingly, a study from the Harefield
group examining myocytes from pulsatile LVAD patients with Remodeling of extracellular matrix, specifically an increase
and without myocardial functional recovery demonstrated that in fibrosis, is a hallmark feature of myocardial remodeling in
myocytes from both groups had similar reductions in cell size, chronic HF. Altered collagen metabolism is responsible for
suggesting that hypertrophy regression might not be specifically ventricular dilatation and for changes in systolic and dia-
related to the structural signature of LVAD-induced myocar- stolic function. Investigations of the effect of mechanical
dial recovery [11]. unloading on extracellular matrix have shown conflicting
Animal models of prolonged unloading in nonfailing, non- results: one group of investigators has reported decreased
hypertrophic myocardium by means of heterotopic transplanta- fibrosis, while others found an increase in fibrosis associated
tion or LVAD or severing the chordae tendinae of the mitral with an increase in cross-linked collagen and myocardial
papillary muscle suggested that mechanical unloading could stiffness [2, 3, 10]. The explanation for the contradictory
lead to cardiac myocyte atrophy. Whether this phenomenon observations is not clear, with some attributing the inconsis-
applies only to nonfailing and nonhypertrophic or also to hyper- tent results to differences in the methodology employed [2,
trophic and failing myocardium unloaded by LVAD is contro- 3]. Applying recent advances in whole-field digital micros-
versial. One animal study of hypertrophic failing hearts indicated copy, we addressed this issue using digital histopathology
that unloading by means of heterotopic transplantation resulted and advanced image analysis techniques, an approach that
in a decrease of cardiac myocyte size beyond normal values reduces observer bias, increases the amount of myocardial
[12]. However, in two human HF studies, unloading by means tissue analyzed, and permits comprehensive endocardium-
of pulsatile LVAD support also revealed a decrease of cardiac to-epicardium evaluation [14]. This eliminates the confound-
myocyte size, but not beyond the size of normal donor cardiac ing effect of endocardial or epicardial sampling known to be
myocytes [13, 14]. In a later study from our group in which light associated with different degrees of fibrosis. In failing hearts,
microscopy findings were complemented by ultrastructural and interstitial and total fibrosis was higher compared with nor-
metabolic data, we did not identify any evidence suggesting car- mal myocardium, and the collagen content increased further
diac myocyte atrophy or degeneration during pulsatile LVAD after LVAD unloading [14].
support [14]. More research needs to be performed to clarify Changes in the neurohormonal milieu seen after LVAD
whether prolonged mechanical unloading with the currently uti- implant support the above findings. While older studies indi-
lized continuous flow LVADs affects basic protein degradation cated that circulating levels of many neurohormones (plasma
pathways (calcium-dependent calpain system, ubiquitin protea- epinephrine, norepinephrine, arginine, vasopressin, renin,
some system, and lysosomal proteolysis) and/or fetal gene pro- and angiotensin II) decrease after LVAD implant, the effects
gram overexpression, which have been implicated in cardiac of LVAD unloading on the myocardial tissue renin-angio-
hypertrophy and atrophic remodeling . tensin-aldosterone system (RAAS) components (including
Finally, a recent study examined cardiomyocyte DNA the profibrotic and prohypertrophic angiotensin II) seem to
content, nuclear morphology, and the number of nuclei per be more complicated. Klotz et al. recently published results
cell before and after LVAD support [15]. After unloading, of the first study that systematically analyzed the different
the number of polyploid cardiomyocytes and cardiomyocyte components of RAAS in paired myocardial tissue samples
DNA content declined, whereas an increase in binucleated obtained before and after LVAD implantation [16]. Renin
cardiomyocytes was observed. The authors hypothesized levels in the pre-LVAD myocardium were the highest ever
that the vast polyploidy of cardiomyocytes in the failing reported in human cardiac tissue (100× normal), and the
human heart was a result of hypertrophic growth associated myocardial aldosterone level was also elevated (250× nor-
with repeated rounds of DNA synthesis that despite comple- mal). After LVAD support, myocardial renin and aldosterone
tion of DNA replication did not result in cell division. The levels markedly decreased, but, in contrast with this finding,
increase in binucleated cardiomyocytes could suggest that myocardial angiotensin I and II levels increased five to ten
reduction of noxious hypertrophic stimuli through LVAD fold [16]. The increase in the myocardial level of angiotensin
unloading might have led to beneficial cardiomyocyte dupli- II during LVAD support was accompanied by a seven fold
cation and regeneration. These findings suggest that there is rise in myocardial norepinephrine content [16]. Increased
a dynamic and plastic regulation of cardiomyocyte content in norepinephrine levels are also known to lead to cardiac
HF, which strengthens the notion that at least a proportion of fibrosis. The same group of investigators reported an increase
cardiomyocytes are not terminally differentiated and could in the ratio of matrix metalloproteinases (MMPs) to tissue
49 Mechanical Unloading and Heart Remodeling Features 415

inhibitors of metalloproteinases (TIMP-1) in end-stage HF, and time to 50 % relaxation [23]. In isolated trabecular mus-
which normalized after LVAD unloading, favoring decreased cles of failing human hearts with and without LVAD support,
collagen degradation and hence increased fibrosis [17]. Ogletree-Hughes et al. found that unloading restores the den-
Collectively, these post-LVAD myocardial biomarker altera- sity of b-AR in cardiomyocytes [24]. They also found that
tions are compatible with the structural findings, suggesting muscle from hearts that had been supported with LVAD pro-
increased post-LVAD fibrosis. Whether the observed increase duced an inotropic response to isoproterenol similar to non-
in fibrosis is a manifestation of further progression of cardiac failing hearts, significantly stronger than that observed with
remodeling that LVAD unloading failed to reverse or a direct muscles from failing hearts that had not been mechanically
result of LVAD actively inducing an increase in fibrosis war- supported. However, the receptor density alone did not pre-
rants further investigation. dict the magnitude of the inotropic response [24]. Similarly,
in another study, an increase in b-adrenergic density and a
prominent normalization in the location of the receptors in
Endothelium and Microvasculature the myocardium were observed following ventricular unload-
ing [25]. The potentially important role of b-AR signaling in
Myocardial microvascular density is reduced in patients with the reverse remodeling process that occurs in mechanically
HF. LVAD unloading has been shown to lead to changes in assisted failing hearts is also supported by experimental
the expression of genes involved in the regulation of vascular observations showing that b2-AR stimulation results in ino-
organization and migration. In agreement with these findings, tropic support of the heart and decreases apoptosis, while
our group demonstrated that pulsatile LVAD unloading b1-AR causes progressive cardiomyopathy and HF.
resulted in increased microvascular density in failing human Altogether, these observations suggest that it might be
hearts [14]. We also found strong evidence of endothelial cell beneficial to combine ventricular unloading with an augmen-
activation by both immunohistochemistry (the endothelial tation of b2-AR signaling to enhance reverse remodeling. In
activation marker major histocompatibility complex class-II, this direction, in order to maximize the efficiency of LVAD as
MHC-II) and by electron microscopy (ultrastructure analysis) a bridge to recovery, M.H. Yacoub combined mechanical
[14]. The findings of a post-LVAD increase in microvascular unloading with the selective b2 agonist clenbuterol to take
density and endothelial cell activation were also accompanied advantage of the therapeutic effects of b2-AR signaling on
by increased interstitial and total myocardial fibrosis [14]. the heart as well as of the antiatrophic effects of clenbuterol
This suggests that the recently described mechanistic link on the mechanically unloaded myocardium and on skeletal
between the endothelium and cardiac fibrosis during the car- muscles [26]. According to the Harefield protocol, clenbuterol
diac remodeling process – “endothelial to mesenchymal tran- is added to standard medical treatment for HF, including b1-
sition” via pathways directly implicated in cardiomyocyte blockade, angiotensin-converting enzyme, or angiotensin-II
hypertrophy [18, 19] – might also apply to human myocar- inhibition, spironolactone and digoxin, when maximal regres-
dium. Obviously, direct proof for such a mechanism requires sion of the LV end-diastolic and end-systolic diameters has
lineage tracing possible only in genetically manipulated ani- been reached, usually after approximately 2 months of LVAD
mal models [18, 19]. Of note, work done in our laboratory has support, and when they have remained stable for at least
shown that endothelial proliferation and migration, hallmarks 2 weeks. Using this strategy, Yacoub’s group was able to
of angiogenesis, must be balanced by mechanisms that stabi- remove LVAD successfully from 11 out of 15 patients suffer-
lize the endothelium so that a functional vascular network ing from non-ischemic cardiomyopathy, and excellent cardiac
may be established and maintained [20–22]. An imbalance in function was preserved during long-term follow-up [7].
these competing signals after LVAD implantation may con- Whether stimulation of b2-AR with clenbuterol best takes
tribute to the increase in microvascular density, endothelial advantage of the beneficial effects of b2-AR signaling
activation, and cardiac fibrosis. described earlier in order to enhance the effectiveness of
chronic mechanical unloading, with myocardial recovery as
a target, certainly needs further investigation.
Beta-Adrenergic Signal Transduction

The changes in the b-adrenergic receptor (AR) system in the Effects of LVAD-Induced Unloading
failing heart are well known. Typically, the b1-AR density is on Myocardial Function
selectively reduced, and the remaining b1- and b2-AR are
desensitized. The response of cardiomyocytes to b-adrener- Ventricular remodeling is associated with a rightward shift of
gic stimulation with isoproterenol after long-term LVAD the pressure-volume loop toward larger volumes, while pul-
support was characterized by an increase in the magnitude of satile LVAD unloading results in a leftward shift in the direction
contraction and shortening of the time to peak contraction of a normal physiological relationship. Both continuous flow
416 N.A. Diakos et al.

Table 49.2 LVAD bridge to recovery studies

Adjuvant drug therapy Unloading
Study design N protocol duration (m) Recoverya N, (%)
US LVAD Working group 2007 [5] P 67 Not standardized 4.5 6 (9)
Berlin group 2008 [6] R 188 Not standardized 4 35 (19)
Harefield group 2006 [7] P 15 Yes 11 11 (73)
Harefield group 2011 [8] P 20 Yes 9 12 (60)
University of Athens-Harefield group 2007 [4] P 8 Yes 7 4 (50)
Vancouver group 2011 [28] P 17 Not standardized 7 4 (23)
Gothenburg group 2007 [29] P 18 Not standardized 7 3 (17)
Osaka group 2005 [30] R 11 Not standardized 15 5 (45)
Pittsburgh group 2010 [31] R 18 Not standardized 8 6 (33)
Multicenter 2002 [32] R 271 N/A 2 22 (8)
Columbia group 1998 [33] R 111 N/A 6 5 (4.5)
HF heart failure, LVAD left ventricular assist device, m months, N number of patients, N/A not applicable, P prospective studies, R retrospective
studies
a
Defined as LVAD explantation due to functional myocardial recovery

and pulsatile flow LVADs are associated with significant vol- Experience from “Bridge to Recovery Studies”
ume unloading and subsequent decrease in LV end-diastolic
diameter. However, pulsatile LVADs seem to have a more The main results of key clinical outcome studies investigating
pronounced volume unloading effect compared with contin- LVAD used as a bridge to recovery are summarized in
uous flow LVADs [10]. Continuous flow LVADs, in addition Table 49.2 [4–8, 28–33]. Most of the clinical outcome studies
to LV unloading, have also been associated with significant that addressed myocardial recovery during LVAD support
left atrial volume unloading and improved left atrial function were retrospective, and the results, as far as the success of
at 3–6 months after LVAD implantation [10]. LVAD weaning and of achieving sustained myocardial recov-
LVAD unloading results in increased cardiac output and ery, varied significantly (Table 49.2). These inconsistencies
near normalization of pulmonary artery pressures and LV can be explained by numerous limitations in the study design,
systolic and diastolic pressures. These changes are compa- such as (1) absence of a pre-specified protocol to monitor
rable regardless of the etiology of HF and are similar in mag- functional myocardial recovery, (2) absence of a pre-specified
nitude in pulsatile and continuous flow LVADs. Etz et al. protocol for the use of adjuvant pharmacotherapy with poten-
reported that continuous flow LVADs implanted in patients tial anti-remodeling effects, (3) variable duration of LVAD
with medically refractory pulmonary hypertension resulted support, (4) lack of standardized LVAD explantation criteria,
in a significant reduction in mean pulmonary artery pressures and (5) diversity of the populations studied in their propensity
and pulmonary vascular resistance, and these patients were for recovery. With the exception of three recent studies from
subsequently successfully transplanted [27]. Berlin, Harefield, and Vancouver [8, 28, 34], the majority of
Left ventricular unloading by LVAD also has significant the devices utilized in the bridge to recovery studies have so
effects on the right ventricle (RV). LVAD unloading will typi- far included first generation, pulsatile LVADs. The most
cally result in a decrease in RV afterload and improved RV effective approach aimed at recovery of myocardial function
geometry and systolic function [4]. However, higher than reported so far is that of the Harefield protocol, which tested
optimal continuous flow LVAD unloading can result in a left- mechanical unloading combined with aggressive anti-remod-
ward shift of the interventricular septum with a resulting eling drug therapy, including the beta-2 agonist clenbuterol,
compromise in RV systolic function and RV failure [4]. in advanced non-ischemic cardiomyopathy patients [4, 7, 8].
Exercise intolerance in patients with chronic HF is associ- Reproducibility of these results in larger patient cohorts and
ated with respiratory muscle weakness and poor outcomes in a randomized fashion would be of great importance.
[10]. In a study where cardiopulmonary exercise testing was
done before and after continuous flow LVAD placement, we
observed that all patients had a restrictive ventilatory pattern Future Directions
before LVAD implantation. This improved during LVAD
support and was associated with a significant increase in the The impact of the etiology of HF on the potential for myocar-
anaerobic threshold, peak work rate, and exercise duration, dial recovery is not well understood (Table 49.3, target 2).
findings consistent with other investigations [10]. Direct comparisons between ischemic and non-ischemic
49 Mechanical Unloading and Heart Remodeling Features 417

Table 49.3 LVAD unloading and myocardial recovery: unsolved ‘HF history duration’ can be viewed as a surrogate of poten-
issues – future directions tial irreversibility of chronic remodeling, it may be argued
Unsolved issues-ongoing research targets that a more direct research target would be the identification
Target 1: Correlate structural and functional findings of the degree of pre-LVAD structural or molecular remodel-
Target 2: Impact of HF etiology on the potential of myocardial recovery ing beyond which there is ‘no return.’ Indeed, Bruckner et al.
Target 3: Role of HF duration on prospect of cardiac reverse remodeling have reported that patients with worse hypertrophy and
Target 4: Extent of pre LVAD remodeling higher degrees of fibrosis at baseline (the time of LVAD
Target 5: Type of unloading: pulsatile vs. continuous vs. counterpulsation implantation) were by far less likely to show recovery of LV
Target 6: Targeted adjuvant therapies
systolic function during LVAD unloading [35]. More research
Target 7: Functional and structural evaluation protocols
needs to be done to determine what degree of pre-LVAD
Target 8: Optimal duration of mechanical unloading
myocardial remodeling changes preclude unloading-induced
Target 9: Determinants of myocardial recovery
reversibility and thus provide useful guidance for patient
selection (Table 49.3, target 4).
patients were performed in only a few studies. The likely can- Another important issue in need of further investigation is
didates for reverse remodeling induced by LVAD unloading the definition of the specific type of mechanical unloading
usually include patients with non-ischemic cardiomyopathy that best promotes reverse remodeling (Table 49.3, target 5).
of different etiologies: idiopathic, hypertensive, peripartum, Various LVAD types have been tested in the experimental
familial, alcoholic, etc. However, ischemic cardiomyopathy and clinical arenas during the last half century: pulsatile, non
patients who have suffered myocardial infarction and have pulsatile/continuous flow, and counterpulsatile. Mainly for
large areas of non-infarcted myocardium that ‘remodeled’ engineering reasons, the clinical field has recently shifted
over the years could also be considered candidates [4]. This from pulsatile to continuous flow LVADs. Whether these
latter concept deserves further investigation and could com- devices also have different effects on the biological outcomes
bine the excision of scarred myocardium, using LV recon- needs to be further investigated. Consequently, whether the
struction techniques (e.g., Dor operation) with LVAD prospects of LVAD-induced reverse remodeling are better
unloading. It can be argued that with this approach the index served by pulsatile, non-pulsatile, or counterpulsation
event that triggered the cascade of cardiac remodeling pro- devices, and by full or partial unloading, is unknown. Future
gression – the post-myocardial infarction scar– has been studies must be designed targeting the identification of
eliminated [4]. In contrast, in most non-ischemic cardiomyo- specific ventricular-assist device properties that would best
pathy cases, the index event that caused progressive ventricu- promote reverse remodeling.
lar remodeling and HF often remains undetermined, most The potential impact of the following important issues also
likely persists despite an initially successful reversal of the needs to be clarified: the concept of targeted adjuvant drug
process by mechanical unloading, and might recur and cause therapies (introduced by Sir Magdi H. Yacoub) [26], the opti-
further progression of HF after the termination of LVAD sup- mal duration of mechanical unloading, and the development
port. This might explain why long-term freedom from recur- of advanced protocols to monitor the unloaded myocardium
rent HF in the largest bridge to recovery series in non-ischemic during LVAD support (Table 49.3, targets 6, 7, 8). These latter
cardiomyopathy patients was 74 and 66 % at 3–5 years, imaging protocols could include either conventional imaging
respectively [6]. techniques (echocardiography, nuclear imaging, computed
The importance of the duration of HF on the prospect for tomography) or molecular imaging techniques. They will need
cardiac reverse remodeling also needs further study. Data to address the challenging issue of reliable testing of the heart’s
from two series of patients that were successfully bridged to performance under both decreased and increased loading con-
sustained recovery have identified ‘duration of HF history’ ditions – the so-called ‘off-pump’ or ‘turn-down’ studies.
(i.e., time from HF symptoms onset) as an important predic- These monitoring protocols should also evaluate the short- and
tor of favorable response [6, 8]. In terms of the cardiac long-term impact of LVAD support on the right ventricle (RV).
remodeling trajectory, the time from the index event that trig- The published studies gave conflicting results on this issue.
gered the HF syndrome, rather than the time from symptom Some investigations have shown evidence of improved RV
onset, would be an even more meaningful target (Table 49.3, structure and function after LVAD support, suggesting that the
target 3). However, we need to acknowledge that in the clini- normalization of both the hemodynamic status and the neuro-
cal research arena this may be a target too hard to achieve. hormonal milieu also has favorable effects on the RV. On the
The index event can often be determined in ischemic cardio- contrary, Klotz et al. found that biventricular assist device sup-
myopathy patients, but it may be hard to identify in non- port resulted in significant reverse structural and functional
ischemic patients. Even in ischemic cardiomyopathy, other remodeling of both the RV and the LV, while RV reverse
factors such as ischemia induced by non-culprit lesions, remodeling was not seen during LVAD support alone [36]. The
repetitive stunning, etc., add to the complexity. Insofar as the authors concluded that a lesser degree of volume unloading
418 N.A. Diakos et al.

provided to the RV during LVAD support may not be sufficient 17. Klotz S, Foronjy RF, Dickstein ML, et al. Mechanical unloading
to result in significant reverse structural and functional remod- during left ventricular assist device support increases left ventricular
collagen cross-linking and myocardial stiffness. Circulation. 2005;
eling of the RV. In fact, it is not uncommon after LVAD implant 112:364–74.
to find the net effect on the RV to be the one of overloading, 18. Zeisberg EM, Tarnavski O, Zeisberg M, et al. Endothelial-
rather than unloading, a result of the higher cardiac output off- to-mesenchymal transition contributes to cardiac fibrosis. Nat Med.
setting the benefit derived from the LVAD-induced decrease of 2007;13:952–61.
19. Towbin JA. Scarring in the heart – a reversible phenomenon?
pulmonary pressures. N Engl J Med. 2007;357:1767–8.
20. Whitehead KJ, Chan AC, Navankasattusas S, et al. The cerebral
cavernous malformation signaling pathway promotes vascular
integrity via Rho GTPases. Nat Med. 2009;15:177–84.
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process. Prog Biophys Mol Biol. 2008;97:479–96. unloading restores beta-adrenergic responsiveness and reverses
4. Drakos SG, Terrovitis JV, Anastasiou-Nana MI, Nanas JN. Reverse receptor downregulation in the failing human heart. Circulation.
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5. Maybaum S, Mancini D, Xydas S, et al. Cardiac improvement dur- ing with an assist device results in receptor relocalization as well as
ing mechanical circulatory support: a prospective multicenter study increased beta-adrenergic receptor numbers: are these changes
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6. Dandel M, Weng Y, Siniawski H, et al. Prediction of cardiac stability 26. Yacoub MH. A novel strategy to maximize the efficacy of left ven-
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 Part XVI
Stem Cells in Cardiovascular Surgery
 Cytokine Profiles in Cardiac Diseases
and Marrow Stromal Cells Therapy 50
Nasser Alkhamees, Alice Le Huu,
and Dominique Shum-Tim

Introduction for intercellular communication, these molecules are respon-

sible for propagating damage sustained during an MI, even-
Worldwide, it has been estimated that cardiac surgeons tually culminating in the development of congestive heart
perform over 800,000 coronary artery bypass graft (CABG) failure (CHF) [2–4]. Paradoxically, recent studies demon-
procedures per year [1]. With the advent of percutaneous strate that cytokines are paramount to stem cell therapy
coronary intervention (PCI), the number of patients under- [5, 6]. Research is increasingly focused on cytokines in the
going CABG has declined in recent years. PCI presents a hope of developing new therapeutic modalities aimed at the
rapid, non-invasive technique for revascularization, but treatment and prevention of ischemic heart disease.
has also created several daunting tasks for cardiac sur- Consequently, comprehension of the inflammatory cascade
geons. Surgeons are increasingly faced with patients suf- is increasingly indispensable.
fering from acute myocardial infarction (MI) who have
failed PCI and are suffering from advanced heart failure.
These patients are often hemodynamically unstable, and Myocardial Infarction and the Inflammatory
the challenge is further confounded by a full-fledged Reaction
inflammatory response from an evolving MI. As surgeons,
the tendency is to focus on the clinical and technical The sudden rupture of an atherosclerotic plaque leads to the
aspects of patient care. However, on a biochemical level, formation of a thrombus within a coronary artery. As the
the inflammatory process encompasses every facet of a thrombus occludes the vessel and blood flow is interrupted,
cardiac surgeon’s practice. Understanding the biochemical cardiomyocyte death quickly ensues [7]. Rapid revascular-
basis of the inflammatory response allows for a greater ization can decrease the proportion of cell death and thus
appreciation of physiopathological mechanisms responsi- preserve heart function. However, cardiomyocytes damaged
ble for heart disease. by the initial insult will release chemotactic factors and
In addition, the basis of the inflammatory process is an cytokines that will provoke an intense inflammatory
intricate interaction between cytokines. Acting as mediators response. Rapid recruitment of leucocytes to the affected
area is essential for healing and subsequent scar formation
after an MI. Unfortunately, the inflammatory response is
non-specific and continued propagation of this process dam-
ages healthy, viable myocardium untouched by the initial
N. Alkhamees, MD • A. Le Huu, MD, MSc insult [8].
Divisions of Cardiac Surgery and Surgical Research, The inflammatory response is controlled by cytokines,
Department of Surgery, McGill University Health Center,
which are soluble proteins produced by damaged cells.
Montreal, QC, Canada
Following an MI, cytokines may be classified into two
D. Shum-Tim, MD, CM, MSc, FRCSC, FACS, FAHA (*)
distinct categories: pro- and antiinflammatory cytokines.
Divisions of Cardiac Surgery and Surgical Research,
Department of Surgery, McGill University Health Center, Proinflammatory cytokines frequently found in ischemic
Montreal, H3G 1A4 QC, Canada heart disease consist of TNF-a, interlukin-1b, IL-6, and IL-8
The Montreal Children’s Hospital, The Montreal General Hospital, [9, 10]. They are primarily responsible for the stimulation and
Montreal, QC, Canada enhancement of inflammation. In contrast, antiinflammatory
Department of Surgery, McGill University, Montreal, QC, Canada cytokines are responsible for tempering the inflammatory
e-mail: dshumtim@yahoo.ca response, the most important being IL-10, which is a powerful

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 421
DOI 10.1007/978-1-4471-4429-8_50, © Springer-Verlag London 2013
422 N. Alkhamees et al.

inhibitor of proinflammatory cytokines IL- a, IL-1b, TNF-a, injection. Upon termination of the study, the heart tissue was
and IL-8 [11]. An important caveat when classifying cytok- harvested, and histopathological analysis was completed.
ines into distinct categories is that the molecules often have Rats injected with mesenchymal stem cells had
multiple functions and may exert pro- and antiinflammatory significantly lower ratios of pro-/antiinflammatory cytokines
roles depending on their milieu. compared with control groups. Although levels of both pro-
and antiinflammatory cytokines were upregulated, the actual
ratios were lower than the control groups because of
significantly higher levels of IL-10 (antiinflammatory)
The Cytokines Cascade cytokine. In addition, rats injected with mesenchymal cells
had a decreased ratio of MMP-2/tissue inhibitor of metallo-
Proinflammatory cytokines TNF-a, IL-1b, IL-6, and IL-8 proteinases-1 (TIMP-1).
upregulate the inflammatory cascade and induce myocardial Functionally, the results were equally impressive. After
damage. Clinically, increased levels of these cytokines are 12 h, rats injected with mesenchymal stem cells demon-
directly proportional to the risk of future ischemic events [12]. strated improved ejection fractions compared to control
TNF-a, released early after an MI, stimulates the expression groups. This improvement was sustained up to 2 weeks after
of other proinflammatory cytokines. It is also responsible the MI. Histological examination showed significantly lower
for upregulation of chemokines, stimulating the degradation levels of extracellular matrix deposition, reduced tissue
of the extracellular matrix by reducing collagen synthesis injury, and decreased inflammatory cell infiltration.
and enhancing matrix metalloproteinase (MMP) activity Consequently, at a cellular level, decreased ratios of pro-/
in cardiac fibroblasts [12]. Concurrently, TNF- a enhances antiinflammatory cytokines led to significantly less cellular
cardiomyocyte apoptosis. TNF- a also promotes end organ destruction following an MI. The cellular improvements cul-
dysfunction by suppressing cardiac contractility though minated in clinically improved ventricular function [20].
inhibition of intracellular calcium during systole, leading This experiment couples mesenchymal cell implantation
to decreased contractility [3, 4]. A potent proinflammatory with the production of inflammatory cytokines and suggests
cytokine, TNF- a may also have antiinflammatory proper- that the paracrine function of cells is crucial to the regenera-
ties. Specifically, studies suggest that TNF-a may exert a tive process. Another study by Guo et al. found that implan-
cytoprotective function by preventing or delaying myocyte tation of mesenchymal cells resulted in lower levels of
apoptosis following MI [13, 14]. proinflammatory cytokines TNF-a, IL-1b, and IL-6. These
IL- 1b and IL-6 are proinflammatory cytokines that func- results were correlated with clinical parameters that demon-
tion as acute phase reactants. Both of these cytokines demon- strated decreased ventricular dilatation and thickening [21].
strate elevated levels early after an MI and remain elevated Following the acute event, IL-1 and IL-6 continue to contrib-
after the initial insult [8, 11, 15]. They are found to cause ute to organ dysfunction by inducing myocyte hypertrophy
myocyte hypertrophy in vitro [16, 17]. IL-8 is released upon [16, 17]. This cellular change is a crucial contributor to the
myocardial injury [18]. It appears to function as a chemoat- pathophysiological changes culminating in the development
tractant, acting on neutrophils and T-lymphocytes, leading to of heart failure.
increased myocardial destruction [19]. Proinflammatory cytokines may also be useful prognos-
The most prominent antiinflammatory cytokine is IL-10, tic indicators, by providing measures of clinical outcome.
produced by Th2 lymphocytes. It appears to inhibit the pro- Upregulation of IL-8 has been associated with increased
duction of proinflammatory cytokines IL-1 a, IL-1b, TNF-a, myocardial damage measured through higher levels of tro-
and IL-8 by monocytes [11]. Consequently, increasing the ponin release [19]. Similarly, in patients with chronic heart
production of IL-10 may reduce the damage inflicted on the failure, increased plasma levels of proinflammatory cytok-
myocardium by a pronounced proinflammatory reaction. ines correlate with increased severity and poor clinical out-
In patients suffering from an MI or in CHF, studies show come [22–24]. In addition, patients in end-stage heart failure
that lower ratios of pro-/antiinflammatory cytokines were produce abundant levels of proinflammatory cytokines [25].
associated with improved ventricular function. Chen et al. Torre-Amione et al. demonstrated that implanting a left ven-
demonstrated that the pro-/antiinflammatory ratio might be tricular assist device in patients with heart failure resulted in
crucial to ventricular remodeling. Following induction of a significant reduction of TNF-a levels [26]. This suggests
acute myocardial infarction in 88 Lewis rats, the animals that high ventricular pressures and hemodynamic volume
were subsequently injected with culture medium or mesen- may play a role in TNF-a activation. It is thought that TNF-a
chymal stem cells. PCR analysis was used to determine the induces myocardial dysfunction by inhibiting the increase
ratio of IL-1b/IL-10, IL-6/IL-10, and IL-8/10 produced at of intracellular calcium during systole and by induction of
24 h, 1 week, and 2 weeks. A baseline echocardiography was nitric oxide [3].
performed before the study and at intervals after stem cell
50 Cytokine Profiles in Cardiac Diseases and Marrow Stromal Cells Therapy 423

Cellular Cardiomyoplasty mechanism. Urbanek et al. found that growth factors

(HGF, IGF-1) attract cardiac stem cells to infarcted myo-
Heart failure is the end result of histopathological and structural cardium and stimulate them to proliferate [44]. In addi-
changes to the myocardium resulting in left ventricular (LV) tion, MSCs exposed to hypoxic conditions express
remodeling. The core component of this process is cardiomyo- vascular endothelial growth factor (VEGF) [45–47].
cyte death and the resultant loss of myocardial cell mass. Secretion of VEGF enhances cell survival, and up-
Conventional management of ischemic heart disease has focused regulation of VEGF results in angiogenesis within isch-
on palliation of symptoms without addressing the inadequate emic myocardium [48–50]. In a similar manner, Rehman
regenerative capabilities possessed by the myocardium. et al. demonstrated that the secretion of another molecule,
However, in the last two decades, research has been increasingly HGF, also resulted in angiogenesis and a significant
focused on cell-based therapy to recruit, regenerate, and prevent reduction in endothelial cell apoptosis [51]. Currently,
further cell loss while promoting angiogenesis. this hypothesis is the most widely accepted mechanism of
Cellular cardiomyoplasty consists of transplanting stem action for cardiomyoplasty.
cells to sites of cardiac injury, restoring blood flow and con-
tractility to areas previously infarcted or scarred myocardium Conclusion
[27]. Studies have shown that stem cell transplantation can Proinflammatory cytokines play a central role in the prop-
limit scar expansion, ventricular dilation, and improve ven- agation of an MI and subsequent development of heart
tricular function after myocardial injury [28–31]. The process failure. However, because of the pleiotropic and redun-
by which stem cell therapy repairs damaged myocardium, dant nature of cytokines, further studies are required to
leading to significant recovery of cardiac function, is unknown. fully elucidate the cellular and molecular events associ-
To date, the following mechanisms have been proposed: ated with the inflammatory cytokine cascade. It is evident
• Trans-differentiation: Studies have shown that injection that cytokines, through network modulation, may alter the
of MSCs into infarcted myocardium resulted in mesen- outcome of the disease, and influence patient prognosis.
chymal stem cells (MSC) undergoing trans-differentiation Therefore, extensive comprehension of the inflammatory
into cardiomyocytes [32]. Injected MSCs expressed car- cascade is essential to the development of therapeutic
diomyocyte markers and aligned with host cardiomyo- modalities aimed at ischemic heart disease.
cytes, forming intercalated discs [33–35]. However, the Despite incomplete knowledge about the inflammatory
quantity of stem cells presented at the site of injury was cytokine cascade, clinical trials involving cardiomyoplasty
disproportionately lower than the functional recovery already have debuted. Early data published from the Stem
obtained solely on the basis of neo-myocardial regenera- Cell Infusion in Patients with Ischemic Cardiomyopathy
tion. Consequently, MSC trans-differentiation into cardi- (SCIPIO) phase 1 trial are encouraging [52]. Patients who
omyocytes remains controversial [36–39]. received autologous cardiac stem cells by intracoronary
• Angiogenesis: Many studies have demonstrated that stem infusion 4 months post-coronary bypass grafting demon-
cells promote angiogenesis. In vivo, endothelial progeni- strated a 24 % reduction in infarct size and 8.2 % improve-
tor cells have been successfully used for neovasculariza- ment in ejection fraction. These clinical gains are indisputable
tion of ischemic myocardium [40]. Similar results were and demonstrate that further research focused on under-
achieved in humans using endothelial progenitor cells standing the mechanisms of stem cell therapy, proper selec-
(EPC) and bone marrow mononuclear cells [41, 42]. It tion of cell type, optimization of cell delivery, and survival
remains unclear if angiogenesis alone can result in the will bring cellular cardiomyoplasty to the forefront of treat-
significant functional improvement. ments aimed at eradicating congestive heart failure.
• Cell fusion: This mechanism is a derivative of stem cell
plasticity. Orlic et al. demonstrated that bone marrow-
derived cells (BMDCs) transplanted into acute myocardial References
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2. Jacobs M et al. Tumor necrosis factor-alpha at acute myocardial
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infarction in rats and effects on cardiac fibroblasts. J Mol Cell
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enon, with no BMDCs observed within damaged myocar- 3. Yokoyama T et al. Cellular basis for the negative inotropic effects
dium 28 days post-implantation [43]. of tumor necrosis factor-alpha in the adult mammalian heart. J Clin
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 Hypoxic Preconditioning of Cardiac
Progenitor Cells for Ischemic Heart 51
Shiyue Xu and Gangjian Qin

Introduction diac muscle and makes it stiff and resistant to distension.

However, collagen deposition also occurs in the uninfarcted
Ischemic heart disease is the leading cause of morbidity and remote myocardial region, particularly in the interstitium.
mortality in western countries. According to the data from These changes, collectively, result in adverse remodeling of
the American Heart Association, coronary artery disease ischemic heart, which contributes to ventricular stiffness and
causes about one of every six deaths in the United States. dysfunction [5]. Furthermore, due to the loss of cardiomyo-
Each year, an estimated 785,000 Americans will have a new cytes and adverse remodeling, ischemic heart often shows
coronary attack, about 470,000 will have a recurrent attack, both systolic (decreased contraction) and diastolic (decreased
and an additional 195,000 will have a silent first myocardial relaxation) dysfunction and ultimately fails; a large portion
infarction. Thus, approximately every 25 s, an American will of patients who suffer from myocardial infarction die from
have a coronary event; approximately every minute, some- heart failure [1, 6].
one will die of one [1]. In the past decade, a tremendous amount of scientific
The pathophysiological process underlying most isch- knowledge about the pathophysiology and molecular mecha-
emic heart disease is atherosclerosis of coronary arteries. nisms of myocardial infarction and heart failure has been
Atheroma formation, with or without thrombus, can lead to learned; nevertheless, therapeutic options for these devastat-
stenosis in coronary arteries, resulting in a reduction in coro- ing diseases remain limited. Traditional therapies, such as
nary blood flow and oxygen supply. A sudden and significant angioplasty and thrombolytic agents, can relieve only the
reduction in coronary blood flow, most commonly from rup- cause of infarction; no existing medication or procedure can
ture of plaques in the coronary arteries, can cause myocar- effectively replace cardiac scarring (i.e., fibrotic tissue) with
dial infarction. A large number of cardiomyocytes die, and functional contractile tissue. Newer therapies that incorpo-
cardiac muscles in the infarcted area lose their striations. The rate recently identified populations of stem/progenitor cells
death of cardiomyocytes invokes the recruitment of may regenerate cardiac tissue directly by inducing neovascu-
inflammatory cells at the infarct border, which remove the logenesis and cardiogenesis [7–15]. Resident cardiac stem/
necrotic cell debris by phagocytosis [2]. As a result, the progenitor cells (CSPCs) may be particularly suitable for
infarct area becomes thin and non-contractile and may lead resurrecting dead myocardium because they are endogenous
to infarct rupture, which accounts for 15–30 % of deaths in components of the adult heart and appear to be responsible
the first week after infarction [3, 4]. for the physiologic and pathologic turnover of cardiac myo-
The acute phase of infarction is always followed by cytes and other cardiac cells [16]. In this chapter, we will
a chronic phase of remodeling related to fibroblast prolif- introduce different types of CSPCs identified and various
eration and collagen deposition. In the chronic phase, col- strategies to enhance the effectiveness of these cells for car-
lagen deposition is the primary determinant of structural diac regeneration, with a particular focus on the treatment of
and mechanical changes. A rapid increase of the collagen cells with hypoxic preconditioning.
amount in the infarcted zones strengthens the necrotic car-

S. Xu, MD • G. Qin, MD (*) Cardiac Stem/Progenitor Cells

Department of Medicine, Cardiology,
Feinberg Cardiovascular Research Institute,
For a long time, the human heart has been considered a ter-
Northwestern University Feinberg School of Medicine,
303 E Chicago Ave, Tarry 14-721, 60611 Chicago, IL, USA minally differentiated, postmitotic organ. The number of car-
e-mail: g-qin@northwestern.edu diomyocytes was determined on the day of birth, and there

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 427
DOI 10.1007/978-1-4471-4429-8_51, © Springer-Verlag London 2013
428 S. Xu and G. Qin

was not regeneration of these cells throughout life. However, humans [12]. These cells were capable of renewal and fully
in the past decade, a population of multipotent undifferenti- differentiation into cardiomyocytes.
ated cells termed “cardiac stem/progenitor cells (CSPCs)”
was found in adult human hearts as well as other mammalian
animals [17]. Evidence suggests that CSPCs can give rise to Sca-1+ Cells
cardiomyocytes, vascular endothelial cells, and smooth mus-
cle cells and contribute to cardiomyocyte turnover and myo- Stem cell antigen-1 (Sca-1) is a member of the Ly-6 family
cardial recovery following injury [16]. Studies focusing on and was initially suggested as a surface marker of hematopoi-
the biology and therapeutic potential of CSPCs are growing etic stem cells [21]. Oh et al. identified a group of cells in the
exponentially. Like any other types of stem/progenitor cells, adult heart that express Sca-1 and possess cardiac progenitor
the true identity of CSPCs remains debated. cell properties [8]. Using a magnetic cell sorting system,
Katsuhisa Matsuura et al. isolated Sca-1+ cells from adult
murine hearts and induced these cells to express cardiac tran-
Lin–c-kit+ Cells scription factors and contractile proteins, form sarcomeric
structure, and beat spontaneously in vitro following oxytocin
The Lin–c-kit+ CSPCs were first reported by Beltrami et al. in treatment [10]. Recently, several subpopulations of Sca-1+
2003 [7]. They found that this population of cells in the adult cardiac progenitor cells have been further characterized
rat hearts are self-renewing, clonogenic, and multipotent, [22, 23]. Like other CSPCs, Sca-1+ cells are able to home to
giving rise to at least three differentiated cell types including the infarcted myocardium, differentiate into cardiomyocytes,
cardiomyocytes, vascular endothelial and smooth muscle and integrate with host cells in the infarcted myocardium of
cells. When injected into ischemic heart of animals, these animals [8, 10, 22, 23].
cells regenerated well-differentiated myocardium and encom-
passed a significant portion of the ventricle [7]. Subsequently,
Lin–c-kit+ CSPCs were extensively characterized by many Side Population (SP) Cells
laboratories across different species of animals including
mice and humans [17]. In a recent clinical trial conducted by SP cells were first described by Margaret et al. when they
Bolli et al., one million autologous CSPCs were adminis- stained murine bone marrow cells with the Hoechst 33342
tered via coronary artery in patients with post-infarction left [24]. They found that these cells resisted Hoechst staining,
ventricular dysfunction at a mean of 113 days after coronary had phenotypic markers of multipotent hematopoietic stem
artery bypass grafting (CABG). After a 4-month follow-up in cells, and contributed to the bone marrow reconstitution in
23 patients (16 cardiac stem cell-treated patients, 7 control- lethally irradiated mice. Recently the concept of SP cells has
treated patients), the investigators found that the left ventric- been introduced to identify stem/progenitor cells in the adult
ular ejection fraction (LVEF) and the quality of life in the heart. In a study from Hierlihy et al., a resident side popula-
CSPCs-treated patients were significantly better than those tion was found in the post-natal mouse heart [25]. They
in control-treated patients [18]. showed that the cardiac SP cells were capable of forming
cardiomyocytes when co-cultured with primary cardiomyo-
cytes. Pfister et al. further demonstrated that only CD31–
Isl1+ Cells Sca1+ cardiac SP cells exhibit the potential of cardiomyogenic
differentiation [26]. These investigators also reported that
The LIM-homeodomain transcription factor islet-1 (isl1)- Abcg2, one of the ATP-binding cassette (ABC) transporter
positive cells were initially identified as a population of superfamily members, plays an important role in regulating
embryonic progenitors that contribute to the embryonic heart the proliferation, differentiation, and survival of cardiac SP
formation, comprising most of the cells in the right ventricle, cells [27]. Furthermore, cardiac SP cells have been shown to
both atria, the outflow tract, and specific regions of the left be involved in both early heart development and the repair of
ventricle [19]. By using genetic fate-mapping techniques, adult hearts [9].
Moretti et al. identified a subset of primordial isl1+ cardio-
vascular progenitors with the transcriptional signature of
isl1+/Nkx2.5+/flk1+, which are multipotent and play a critical Cardiosphere Cells
role in embryo heart development [20]. They found that
those isl1+ cells isolated from the second heart field of the Cardiosphere is a cluster of self-adhering undifferentiated
embryonic heart can give rise to cardiomyocytes, endothelial cells grown from subcultures of postnatal atrial or ven-
and smooth muscle cells in vitro and are essential for cardio- tricular biopsy specimens [11]. In vitro study showed that
genesis. Subsequently, isl1+ cardiac progenitors were cardiosphere cells express stem and endothelial progenitor
identified also in postnatal myocardia of rats, mice, and cell antigens; they are clonogenic and capable of self-renewal
51 Hypoxic Preconditioning of Cardiac Progenitor Cells for Ischemic Heart 429

and diverse differentiation including myocytes and vascular ischemic heart after permanent coronary artery ligation
cells [11]. Smith et al. demonstrated that cardiosphere-derived resulted in the formation of new myocytes in the infarcted
cells developed from cardiospheres exhibited biophysical zone through activating the proliferation and differentiation
features of cardiomyocytes when co-cultured with neona- of endogenous cardiac c-kit+ progenitor cells [34]. Smart
tal rat ventricular myocytes and that engraftment of human et al. used a small protein called thymosin b4 to re-activate
cardiosphere-derived cells in immunodeficient mice can the expression of a key embryonic epicardial gene, Wilm’s
increase the percentage of viable myocardium in the infarct tumor 1 (Wt1), in the endogenous CSPCs in the ischemic
zone and improve left ventricular ejection fraction [15]. In a heart and induced de novo cardiogenesis [35]. Boni et al.
recent clinical trial conducted by Makkar et al., autologous demonstrated that Notch1 can regulate the differentiation
cardiosphere-derived cells were administrated at escalat- ability of cardiac progenitor cells through Notch1 intracel-
ing doses (12.5–25 million cells) by intracoronary infusion lular domain (N1ICD), and RBP-J; inhibition of Notch1 in
in 17 patients at 1.5–3 months after myocardial infarction. infarcted mice impaired the differentiation of resident CSPCs
After a 6-month follow-up in 25 patients (17 patients receiv- into the myocyte lineage [36] (Fig. 51.1). In addition, a num-
ing cardiosphere-derived cells, 8 patients receiving standard ber of growth factors and signaling molecules involved in
treatment), these investigators reported that patients treated cell growth and survival, including Akt, c-kit, and insulin-
with cardiosphere-derived cells showed a reduction in scar like growth factor-1 (IGF-1), have been shown to play impor-
mass and increase in viable heart mass, regional contrac- tant roles in the differentiation and expansion of CSPCs
tility, and regional systolic wall thickening as compared [37–39].
with control patients. However, there were no significant
changes in end-diastolic volume, end-systolic volume, and
LVEF between groups by 6 months [28]. Toward enhanc- Survival
ing the therapeutic index of these cells, we further purified
CSPCs from the cardiosphere-derived cells by depleting the Survival of stem cells is one of the main barriers to effective
cells that express hematopoietic lineage markers (Lin–) and cell therapy. The hostile myocardium environment, such as
enriching c-kit+ cells; these cardiosphere-derived, Lin–c-kit+ persistent ischemia and inflammation, challenge the survival
cells (CLK cells) demonstrate an enhanced regenerative of all types of cells. It has been observed that within a day of
capacity [29]. myocardial infarction, 40 % of resident cardiac progenitor
In summary, although many different types of CSPCs cells are depleted [13], emphasizing the importance of
have been identified, their regenerative capacity, long-term enhancing the survival of CSPCs. Lu et al. demonstrated that
engraftment in the ischemic heart tissue, and benefit to car- pretreatment of Sca-1+ cells with IGF-1 can promote cell sur-
diac function have been modest in various pre-clinical ani- vival both in vitro and in vivo [40]. The survival rate of the
mal models and, more recently, in clinical studies [30]. pre-conditioned Sca-1+ cells was 5.5 fold higher than that of
Methods to maximize their therapeutic potential are becom- the non-preconditioned cells. In addition, Konstantinos et al.
ing the focus of research in the field. reported that transplantation of bone marrow-derived mesen-
chymal stem cells (MSCs) can stimulate the survival of the
host endogenous c-kit+ CSPCs after infarction, and the
Enhancement of the Cardiac improvements of CSPC survival lead to amelioration of car-
Stem/Progenitor-Cell Function diac function [41].

Cardiac regeneration by CSPCs involves a series of inte-

grated steps, including homing, proliferation, differentiation, Homing and Recruitment
and survival. Thus, enhancing CSPC function through these
steps would aid in the design of better strategies for cardiac When administered intravenously or through coronary
cell therapy. artery, the CSPCs need to home to the damaged cardiac
tissue, whereas at local tissue, the densely packed cardiac
cells, extracellular matrix, and replacement fibrotic tissues
Expansion and Differentiation impose a significant physical barrier to the cell recruitment.
Compelling evidence now suggests that enhancement of
CSPC expansion and differentiation are the foundation of CSPC migration can enhance the repair of ischemic heart.
cardiac regeneration. Several laboratories have reported that Goichberg et al. demonstrated that Ephrin A1, through
Wnt/b-catenin signaling plays a key role in promoting interacting with EphA2 receptor, promotes the motility of
expansion and self-renewal of CSPCs, including isl+ cells cardiac stem cells in vitro and their migration to the area
[31–33] (Fig. 51.1). Limana et al. reported that administra- of damage in vivo [42]. Liang et al. found that upregulation
tion of high-mobility group box 1 protein (HMGB1) to the of SDF-1 in the infarcted myocardium induces migration
430 S. Xu and G. Qin

a
sVCAM

SDF-1
CXCR4

c-kit SCF

b Cardiomyocytes
Notch1
TGF-β1

NICD
HIF-1α
Smooth muscle cells
c-kit
RBP-J
Cardiac stem/progenitor cells

c Endothelial cells
Wnt
IGF-1

β-catenin
nuclear Akt

Fig. 51.1 Mechanisms that regulate CSPC migration (a), differentia- domain, RBP-J J kappa-recombining binding protein, TGF-b1 trans-
tion (b), and proliferation (c). CXCR4 C-X-C chemokine receptor type forming growth factor beta 1, HIF-1a hypoxia-inducible factor 1a,
4, SDF-1 stromal cell-derived factor-1, sVCAM soluble vascular cell IGF-1 insulin-like growth factor 1 (see text for detailed discussions)
adhesion molecules, SCF stem cell factor, NICD Notch1 intracellular

of Sca1+CD31− cardiac SP cells [43]. In addition, the sol- dependent on the O2 level, time of exposure, and specific tis-
uble VCAM-1 (sVCAM-1) has also been shown to exert a sue microenvironment [46]. Hypoxic preconditioning of
positive effect on the migration of cardiac stem cells [44]. stem cells can induce a series of protective responses that
Short exposure to hypoxia has also been shown to increase adapt these cells to the hostile environment of damaged tis-
the migration of CSPCs [45]. All of these studies suggest sues; therefore, it can be employed as a strategy to enhance
the importance of homing and recruitment of the CSPCs in the effectiveness of cell therapy.
cardiac repair and may provide a therapeutic strategy in the
treatment of ischemic heart diseases.
General Mechanisms of Hypoxic
Preconditioning in the Regulation
Hypoxic Preconditioning of Cardiac of Stem/Progenitor-Cell Function
Stem/Progenitor Cells
It is well established that preconditioning of hearts with mild
Hypoxia is the most common pathological state of ischemic ischemia/hypoxia stimuli can significantly limit the damage
diseases including ischemic heart disease, and severe hypoxia from a subsequent serious cardiac ischemia such as myocar-
causes cardiac cell death. However, accumulating evidence dial infarction. However, how hypoxic pre-treatment of stem/
now suggests that hypoxia has a variety of effects on embry- progenitor cells affects their functional capacity is incom-
onic and adult stem cells, from proliferation and pluripotency pletely understood, and a number of molecules and signaling
maintenance to adaptive stress response, which are largely pathways have been reported to be involved in the process.
51 Hypoxic Preconditioning of Cardiac Progenitor Cells for Ischemic Heart 431

Hypoxia-Inducible Factor-1 (HIF-1) pre-conditioned myocardium and exert a protective effect

The HIF-1 transcription factor is known as a master regulator through NOS expression [63].
for cells to sense O2 levels in the tissue microenvironment
and mount an appropriate cellular response to hypoxia [47]. Iron Channels
Its pivotal role in the hypoxic preconditioning is well sup- Hu et al. demonstrated that hypoxic preconditioning can
ported by a large body of literature [48]. Hypoxia results in a increase the migratory capacity of bone marrow mesenchy-
reduced degradation of HIF-1a via the proteasome pathway; mal stem cells via upregulation of Kv2.1 expression and
the accumulated protein induces the expression of a diverse FAK activity [64]. The importance of calcium was also noted
range of target genes, including erythropoietin, vascular by another study in which Yu et al. found that calcium/calm-
endothelial growth factor, and Bcl-2 family members, which odulin-dependent protein kinase II is critical for the beneficial
augment stem cell function [49, 50] and markedly enhance effect of intermittent hypoxic preconditioning in the isch-
stem cell survival under severe hypoxia, oxidative stress, or emic-reperfusion-induced cardiac dysfunction [65]. Thus,
in the inflammatory environment [51–53]. iron channels may participate in the hypoxic preconditioning
in ischemic heart diseases.
Akt Taken together, these experimental findings provide a
Akt is a hub of several important survival pathways in many general understanding of the mechanisms involved in hypoxic
types of cells. Recently, it has been shown to participate in preconditioning of stem/progenitor cells. However, more in-
hypoxic preconditioning of stem cells. Phosphorylation depth investigations are warranted to unravel the molecular
(activation) of Akt is significantly increased in adipose- details.
derived stem cells during hypoxic preconditioning, and inhi-
bition of Akt abolishes the protective effect of the hypoxic
preconditioning [54]. Similarly, hypoxic treatment of mesen- Hypoxic Preconditioning of Cardiac
chymal stem cells (MSCs) results in an upregulation of sev- Stem/Progenitor Cells (CSPCs)
eral pro-survival and angiogenic factors, including HIF-1a,
VEGF, and the phosphorylated Akt [55, 56]. These data sug- Compared with other types of stem/progenitor cells, CSPCs
gest that Akt is critical for the protective effect of hypoxic seem to be the obvious choice for cell-based cardiac repair.
preconditioning [57]. However, the success of this approach is determined in part
by the same factors that cause the endogenous cardiac repair
Mitogen-Activated Protein (MAP) Kinases system to fail. Within a day of myocardial infarction, 40 % of
It has been shown that the intermittent hypoxia-induced resident CSPCs are depleted [13], and the barriers imposed
delayed cardioprotection is mediated by p38 MAPK and by cardiac damage may limit the proliferation and self-renewal
ERK 1/2 and blocked by p38 MAPK inhibitor [58]. This of the remaining resident cells, thereby preventing restora-
indicates that the protective effect of hypoxic precondition- tion of the progenitor-cell pool. At present, these limitations
ing may be, at least partially, dependent on MAPK path- are often addressed by using ex vivo expansion protocols to
ways. In addition, JNK and ERK have been reported to exert generate a sufficient number of cells for transplantation into
an anti-apoptotic effect of ischemic/hypoxic precondition- the ischemic heart. However, only a very small number of
ing on stem cells and regulate cell function by interacting transplanted stem/progenitor cells are retained in the isch-
with additional molecular pathways [59]. Furthermore, inhi- emic myocardium [66], and poor cell retention is one of the
bition of ERK attenuates the beneficial effect of ischemic primary barriers to the effectiveness of cell therapy [67].
preconditioning on the pig myocardium [60]. In addition to Thus, techniques that enhance the recruitment and retention
Akt and MAPKs, protein kinase C (PKC) has also been of transplanted stem/progenitor cells are crucial to adequately
shown to play a role in ischemic preconditioning in the rat replenish the resident progenitor cell pool and to maximize
heart [61]. its regenerative potential. Toward this goal, we have initiated
a series of studies investigating the effect of hypoxic precon-
Endothelial Nitric Oxide Synthase (eNOS) ditioning on the recruitment of intravenously administered
eNOS is an important regulator of stem/progenitor cell cells to ischemic heart tissue and the preservation of heart
biology as well as vascular function. Uemura et al. found that function in murine models of myocardial infarction.
hypoxic treatment significantly increases the level of eNOS To enrich potent CPSCs, we selected the hematopoietic-
in bone marrow stem cells. When injected into the infarcted lineage-negative (Lin−) and c-kit-positive (c-kit+) cells (CLK
myocardium in mice, the hypoxic pretreated bone marrow cells) from cardiospheres grown from explants of adult
cells exhibit better survival than control non-treated cells mouse hearts [29]. Because CXCR4 plays a critical
[62]. Interestingly, Ii et al. demonstrated that endothelial role during SDF-1-mediated recruitment of circulating
progenitor cells (EPCs) are recruited to the ischemic stem/progenitor cells to ischemic myocardium [68, 69], we
432 S. Xu and G. Qin

evaluated the expression of CXCR4 in CLK cells. When greater, and infarct size was significantly smaller, in hearts
cultured under normoxic conditions, CXCR4 expression from mice administered hypoxic-preconditioned cells
was rather modest; however, both the number of cells than from mice treated with normoxia-cultured cells, and
expressing CXCR4 and the amount of CXCR4 protein hypoxic-preconditioned cells were also associated with
expressed increased rapidly after just 4 h in hypoxic culture lower heart weights and a lower heart-weight:body-weight
[29]. The elevation in CXCR4 expression was preceded by ratio. Collectively, these results indicate that the therapeutic
an increase in the expression of HIF-1a, and transfection benefits of CLK-cell administration after myocardial infarc-
of CLK cells with a HIF-1a small-interference RNA tion are enhanced by hypoxic preconditioning.
(siRNA) diminished hypoxia-induced CXCR4 expression. The ischemic myocardium is known to produce an abun-
Furthermore, the hypoxia-induced CXCR4 expression is dance of chemo-active, -attractive, or -repulsive, agents [70,
associated with a markedly increased CLK-cell migration 71], and these chemotactic signals, along with specific cell-
toward SDF-1, and when CXCR4 expression was knocked matrix and cell-cell interactions, modulate the regenerative
down by infecting CLK cells with a lentiviral vector encod- capacity of progenitor cells [67]. Accordingly, we performed
ing CXCR4 shRNA, the hypoxia-induced enhancement of protein array experiments to compare the levels of more than
CLK-cell migration was abolished. Collectively, these 300 mouse cytokines released from hypoxia- and normoxia-
observations indicate that the migratory activity of CLK treated CLK cells into the culture medium. Hypoxic treat-
cells is increased by hypoxia and that the mechanism of ment was associated with higher levels of numerous factors,
enhancement is dependent on an HIF-1a-mediated increase including chemokines (e.g., TCA-3, SDF-1, 6Ckine), vas-
in CXCR4 expression. cular growth factors (e.g., VEGF, Osteopontin, bFGF, EPO,
To determine whether hypoxia-induced CLK-cell migra- SCF), and factors involved in cardiac differentiation (e.g.,
tion was accompanied by enhanced CLK-cell recruitment to Activin A, TGF-b, and Dkk-1), which also contribute to the
ischemic myocardium, and to assess the differentiation of cardiac repair (Fig. 51.2). The increase in SDF-1 secretion
the recruited CLK cells, CLK cells were transduced with ret- by CLK cells is particularly interesting. Recent studies have
roviral vector pCL-MFG-LacZ (CLK-LacZ cells). Hypoxic shown that SDF-1 is cardioprotective and that pretreatment
preconditioning was associated with a ~2.5-fold increase in of BM-derived mesenchymal stem cells (MSCs) with SDF-1
CLK-cell recruitment to ischemic myocardium as assessed enhances cell survival, proliferation, and engraftment, and
24 h after CLK cell injection. Importantly, pretreatment of improves cardiac function after myocardial infarction in
CSPCs with CXCR4 antagonist AMD3100 during the course animals [72–74]. Our results indicate that SDF-1 is one of
of hypoxic preconditioning diminished the increase in CLK- the chemokines and growth factors secreted by hypoxia-
cell recruitment, suggesting that the SDF-1/CXCR4 axis preconditioned CLK cells, which suggests that the apparent
plays a pivotal role (Fig. 51.2). Our observation is supported benefit associated with systemically administered hypoxia-
by studies reported by van Oorschot et al., which also dem- preconditioned CLK-cells evolves, at least in part, through
onstrated that short-term hypoxia increased the migratory paracrine mechanisms.
and invasive capacities of CSPCs [45]. In addition, we
assessed CLK cell differentiation at 4 weeks after injection
of lacZ-transgenic CLK cells; histological analyses revealed Outlook
that the lacZ+ cells in the ischemic myocardium co-expressed
cardiac troponin I, von Willebrand factor, and smooth muscle Ischemic heart disease and consequent heart failure remain
actin, indicating that the transplanted CLK cells had differ- the leading cause of morbidity and mortality worldwide; tra-
entiated into cardiomyocytes, endothelial cells, and vascular ditional therapies can only relieve symptoms and slow the
smooth muscle cells, respectively. Therefore, hypoxic pre- disease progress. In the past decade, stem/progenitor cells
conditioning enhances CLK cell migration, recruitment, and have emerged as an optimal strategy of treatment, and
differentiation. CSPCs, in particular, can directly regenerate cardiac tissue
After observing the dramatic hypoxia-induced increase in by inducing neovasculogenesis and cardiogenesis. At pres-
CLK-cell recruitment to ischemic myocardium, we investi- ent, the regenerative capacity of CSPCs is rather limited, and
gated whether hypoxic preconditioning enhanced the thera- their clinical uses are still at infancy. One of the major barri-
peutic benefit of CLK cells. At week 4, functional analyses ers to the successful CSPC therapy is the hostile environment
indicated that both left ventricular fractional shortening and of the infarcted cardiac tissue, which quickly depletes endog-
the ejection fraction were better preserved in mice admin- enous CSPCs and limits the expansion and differentiation of
istered hypoxic-preconditioned CLK cells than in mice the exogenously administered cells.
treated with normoxia-cultured CLK cells. Histological Recently, hypoxic preconditioning has emerged as a
analyses indicated that peri-infarct capillary density and promising strategy to improve CSPC therapy. Studies
infarct wall thickness in the left ventricle were significantly from our laboratory and others have shown that hypoxic
51 Hypoxic Preconditioning of Cardiac Progenitor Cells for Ischemic Heart 433

Fig. 51.2 Hypoxic a Normoxia

preconditioning of CLK cardiac
stem cells enhances repair of the Homing / recruitment
infarcted myocardium. (a)
Hypoxic pretreatment of CLK
cardiac stem cells upregulates the
expression of CXCR4 and SDF-1
through HIF-1 and augments the
recruitment of CLK cells to the
ischemic myocardium. (b)
Hypoxic pretreatment also b Hypoxia pre-conditioning
increases the secretion of
paracrine factors that promote CXCR4 Homing / recruitment
chemotaxis, vascular growth, and
cardiac differentiation. TCA-3, HIF-1
also named chemokine (C-C
motif) ligand 1, CCL1, or I-309;
6Ckine, also named chemokine Paracrine effect
(C-C motif) ligand 21A,
CCL21A, secondary lymphoid-
tissue chemokine (SLC), or
Exodus-2; Epo, erythropoietin
Chemokines: SDF-1, TCA-3, 6Ckine
Vascular growth factors: VEGF, Osteopontin, bFGF, Epo, SCF
Cardiac differentiation factors: Activin A, TGF-β, Dickkopf homolog-1

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 Index

A Adrenal glucocorticoids, 5–6

Abdominal aortic aneurysms (AAAs), 57, 63, 199, 215, 218 b-adrenergic receptor, 248, 414
aortic wall degradation, 47, 49 b-adrenergic signal transduction, 415
biology, 47–49 Adrenocorticotropic hormone (ACTH), 4, 5, 335
Brazil, stents in, 63 AGEPC. See Acetyl-glyceryl-ether-phosphorylcholine
Anaconda®, 64 (AGEPC)
Aorfix®, 64–65 Akt kinase, 413, 414, 431
Apollo®, 65 Allograft rejection, 388
Braile®, 65–66 Anaconda® stent, 64
E-Evita®, 68 Anemia, 51, 196, 322, 351
Ella®, 66 Aneurysm, definition of, 47
Endofit®, 66–67 Aneurysmal disease, of TA, 198
Endurant®, 67 coronary lesions, 199
Excluder®, 68–69 extracranial supraaortic aneurysm, 199
Hercules®, 69 thoracic and abdominal aortic aneurysms, 199
Powerlink®, 69, 70 Ang2 expresssion, 109
Talent®, 69–70 Angiogenesis, 423
Zenith®, 70–71 Angiography, 196
complication, 47 Angioplasty, 98–100
definition, 47 aortic coarctation, 356
elective aneurysm repair, 47 coronary, 97
endovascular treatment, 63 cutting ballons, 223
future perspectives, 49 PTA, 222
genetics, 49 renal, 98
Hp in, 53–54 subintimal angioplasty, 223
MMP, 48, 49 Ankle-brachial index (ABI), 94
pathogenesis, 47–49 Anti-atherogenic T cell subsets, 11
ruptured AAA, 47 regulatory CD4+T cells, 12
sandwich technique, 71 Th2 cells, 11–12
stents, characteristics of, 63 Antiendotoxin therapy, in CPB, 238–239
surgical mortality in, 60 Antifibrinolytic therapy, in pediatric congenital
Abdominal compartment syndrome, 74 heart surgery
ABO blood antigens, 386 aprotinin, 342–343
Acetylcholine, 5, 83, 336 developmental hemostasis, 341
Acetyl-glyceryl-ether-phosphorylcholine EACA, 343
(AGEPC), 181 endogenous thrombin potential, reduction of, 341
ACS. See Acute coronary syndrome (ACS) fibrinolysis
ACTH. See Adrenocorticotropic clot formation, 341–342
hormone (ACTH) coagulation system, 342
Activated protein C, 147, 164, 175, 179, 281–282, 349 definition, 341
Activation genes, 245 plasminogen activator inhibitor-1 and-2, 342
Acute cellular rejection (ACR), 386–388 tissue-type plasminogen activator, 342
Acute coronary syndrome (ACS), 11, 12, 37, 91, 92, 175 indications, 343
Acute lung injury (ALI), platelet activation, 394 risk and side effects, 344–346
Acute respiratory distress syndrome timing, 344
(ARDS), 394 TXA, 343–344
Acute vein graft thrombosis, Antigen-presenting cells (APCs), 9–10, 19, 386–387
MMPs in, 147–149 Anti-inflammatory cytokines, 247–248
Acute venous thrombosis. See Matrix Antimediator therapy, in CPB, 238–239
metalloproteinases (MMPs) Antioxidants, 237
Adaptive immunity, 15, 19–21 dietary studies, 406–407
Adenosine, 279, 282, 285 oxidative stress assessment, 404–405

E.A. Gabriel, S.A. Gabriel (eds.), Inflammatory Response in Cardiovascular Surgery, 437
DOI 10.1007/978-1-4471-4429-8, © Springer-Verlag London 2013
438 Index

Antiphospholipid syndrome (APS) Apollo® stent, 65

cardiac surgery Aprotinin
aggressive intraoperative management, 326 metabolic response, in CPB, 279
clinical experience, 326 pediatric congenital heart surgery
decision-making process, 326 blood-saving effect, 343
issues, 326 dosage regimes, 342–343
organ involvement, 324, 325 mechanism of action, 342
valve replacement, 324, 326, 327 risks and side effects, 344, 345
catastrophic, 322, 323 serine protease inhibitors, 237
clinical manifestation, 322 APS. See Antiphospholipid syndrome (APS)
definition, 321 Arachidonic acid cascade, 278
heart valve lesions, 322–324 Arginine, 6, 239
prevalence, 322 Argyle shunt, 133
revised classification criteria, 322 Arterial transplantation, for limb salvage, 117
Anti-platelet therapy, 225, 396 cold ischemia time, 119
Antithrombin (AT), 141, 164 frequency, 120, 121
Antithrombin III (ATIII), 127, 128, 179, 351 graft description and documentation, 118–119
Antithrombotic therapy, 119 graft implantation, 119
Aorfix® stent, 64–65 graft procurement, 118
Aortic aneurysms graft rejection, 119
abdominal (see Abdominal aortic aneurysms (AAAs)) immunosuppressive therapy, 119
endovascular complications, 369 organ donor selection, 118
etiology, 49 patient selection, 118
health problem, 47 postoperative follow-up, 119
open (conventional) complications, 369 problems, 119–120
pathogenesis, 48 results, 120
surgery/endovascular repair, 202 Arterial wall remodeling, 101–102
Aortic coarctation Arteriogenesis, and shear stress, 109–110
history, 355 Arteriosclerosis, 81, 82, 86
indications, 355–356 Assisted venous drainage (AVD)
patient selection, 355 KAVD, 255
procedural risks/complications, 360, 362, 366 VAVD
procedural success, 362 advantages, 255–257
surgical correction, 355 disadvantages, 257–258
technique AT. See Antithrombin (AT)
angioplasty, 356 Atherectomy, 98, 224–225
covered and uncovered stents, 359, 361 Atherosclerosis, 15, 37, 91, 98
endovascular approach, 356–358 and AAAs, 57, 59
stenting, 356, 359, 360 anti-atherogenic T cell subsets, 11
treatment, 359–360, 363–365 regulatory CD4+T cells, 12
Aortic stenosis Th2 cells, 11–12
AVIC, 318, 319 classical, 9
BMP-2, 318 Hp role in, 52
clinical risk factors, 317 immune response in, 9
IL-1RA, 318–319 immunotherapy in, 12–13
inflammation mechanisms, 317 lymphocytes, 9–12
interleukin-1b, 318 pathophysiology, 31
toll-like receptors, 318 proatherogenic T cell subsets
Aortic valve interstitial cells (AVICs), 318, 319 CD4+CD28null T cells, 10–11
Aortic wall degradation, in AAAs, 47, 49 Th1 cells, 10
Aortitis Th17 cells, 11
causes, 375 T-cell-mediated immune responses, 9
clinical presentation, 377–378 Atherosclerotic aneurysms, 215
diagnostic testing, 378–379 ATIII. See Antithrombin III (ATIII)
epidemiology, 377 Atorvastatin, 33, 34
histopathological findings, 376 Atrial natriuretic peptide (ANP), 399, 400
infectious, 375 Autologous vein grafts, 110, 112, 294
laboratory measurements, 379 AVICs. See Aortic valve interstitial cells (AVICs)
noninfectious, 375 Azathioprine, 200, 380, 385
patchy necrosis, 377
pathological features, 375
patient survival, 380–381 B
surgical management, 379–380 Bacterial aortitis, 375
APCs. See Antigen-presenting cells (APCs) Balloon injury, 100–101
Apixaban, 162 Baloon angioplasty, aortic coarctation, 356
Apolipoproteins (apos), 29, 30 Bare metal stent (BMS), 97, 98
Index 439

B-cells, 19, 195 decision-making process, 326

Behçet’s syndrome (BS), 207–208 issues, 326
Bile acid sequestrants, 34 organ involvement, 324, 325
BioLine coating, 246 valve replacement, 324, 326, 327
Biomarkers VAVD
allograft rejection, 388 advantages, 255–257
inflammatory, 41–42 disadvantages, 257–258
Blood and vasculature, MMPs in, 145–146 Cardiopulmonary bypass (CPB)
B lymphocytes, 17, 18 in children
BMS. See Bare metal stent (BMS) biocompatible surfaces, 246
BNP. See Brain natriuretic peptide (BNP) complement system and inflammation, 246, 247
Bone marrow-derived cells (BMDCs), 423 cytokines (see Cytokines)
Bone morphogenetic proteins (BMP), 318 endothelium, 245
canonical smad signaling pathways, 308, 309 hypothermia, 249–251
and post-natal valve dysfunction, 313 platelet activation, 249
valve formation steroid pretreatment, 248–249
growth factor regulation, 310–312 endotoxemia reduction strategies
spatial and temporal localization, 308–310 antimediator and antiendotoxin
transcriptional regulation, 312–313 therapies, 238–239
Braile® stent, 65–66 enteral nutrition, 239
Brain natriuretic peptide (BNP), 337–338 immunonutrition, 239
elevated serum levels, 399–400 SDD, 239
and heart transplantation, 400–401 erythrocytes, 278
properties, 399 humoral response
secretion, 399 arachidonic acid cascade, 278
Brazil, stents in, 63 cellular factors, 275, 276
Anaconda®, 64 coagulation system, 277–278
Aorfix®, 64–65 complement system, 275–277
Apollo®, 65 complexity, 275, 276
Braile®, 65–66 cytokines, 277
E-Evita®, 68 endotoxins, 277
Ella®, 66 fibrinolytic cascade, 278
Endofit®, 66–67 free oxygen radicals, 277
Endurant®, 67 kallikrein-bradykinin system, 277
Excluder®, 68–69 metabolic response
Hercules®, 69 adenosine, 279
Powerlink®, 69, 70 anti-inflammatory strategies, 278–279
Talent®, 69–70 aprotinin, 279
Zenith®, 70–71 corticosteroids, 279
Bronchiolitis obliterans syndrome (BOS), 403 heparin-coated circulation, 279
BS. See Behçet’s syndrome (BS) leukocyte filter, 279
Buerger’s disease. See Thromboangiitis obliterans (TAO) off-pump cardiac surgery technique, 279
Bypass surgery, 98, 99, 110, 111, 113, 117, 119, 222, 265 sodium nitroprusside, 279
neutrophil activation, 278
OPCAB surgery, 231
C randomized controlled trials, 232–234
CABG. See Coronary artery bypass uses, 232
grafting (CABG) pharmacologic strategies
Calcific aortic stenosis, 317–319 antioxidants, 237
Capillary leak syndrome, 247, 248 C5 complement inhibitors, 237–238
Cardiac allograft vasculopathy (CAV), 388–389 corticosteroids, 236–237
Cardiac hypertrophy–atrophy, 413–414 COX inhibitors, 238
Cardiac stem/progenitor cells (CSPCs) phosphodiesterase inhibitors, 238
cardiosphere cells, 428–429 serine protease inhibitors, 237
expansion and differentiation, 429 platelet response, 278
homing and recruitment, 429–430 polymorphonuclear leukocytes, 278
hypoxic preconditioning, 430–433 SIRS, 231
isl1-positive cells, 428 technical strategies
Lin–c-kit+ cells, 428 centrifugal pumps, 236
Sca-1, 428 HBCs, 232, 234
SP cells, 428 hemofiltration, 234–235
survival, 429 leukocyte depletion, 235–236
Cardiac surgery MECC, 232
and APS temperature, 236
aggressive intraoperative management, 326 Cardiovascular diseases (CVDs), 15
clinical experience, 326 Carmeda bioactive surface (CBAS), 246
440 Index

Carotid arterial disease, lipoproteins in Coagulation system, 277–278

atherosclerosis, pathophysiology of, 31 fibrinolysis, in pediatric patients, 342
carotid atherosclerosis, 31–33 Fontan circulation and thromboembolism, 350–351
endogenous lipid metabolism, 30–31 Coarctation, of aorta. See Aortic coarctation
exogenous (dietary) lipid metabolism, 30 Collagen, 57, 58, 185
prevention strategies, 33–34 Complement system, 275–277
Carotid artery stenosis, 37, 38 Compression ultrasonography (CUS), 155, 156
Carotid artery stenting, 41–42 Computed tomography angiography (CTA), 206, 378
Carotid atherosclerosis Computer tomography (CT), 59, 155, 156
inflammatory cytokines in, 38 inflammatory peripheral arterial aneurysms, 218
lipoproteins to Connective tissue growth factor (CTGF), 102
HDL, 32 Conventional extracorporeal circulation (cECC), 259–262
IDL, 32 Coronary angioplasty, 97
LDL, 31–32 Coronary artery bypass grafting (CABG), 21
lipoprotein (a), 32 Coronary artery disease, 92, 153, 248, 289, 299, 317, 355, 378,
lipoprotein ratios, 32–33 400–401, 407
Lp-PLA2, 32 Coronary heart disease (CHD), 29, 33
triglycerides, 32 Coronary lesions, 199
Carotid balloon injury model, 101 Corticosteroids, 200, 236–237, 248, 249, 279
Carotid disease, endovascular treatment of, 41 Corticotrophin, 6
inflammation and in-stent restenosis, 42–43 Cortisol, 5, 6
inflammatory biomarkers and carotid artery stenting, 41–42 Cortisone, 119
Carotid echo-Doppler imaging, 196 Co-stimulatory molecules, 20
Carotid endarterectomy (CEA), 37 Counter-regulatory hormones, 336
carotid atherosclerosis, inflammatory cytokines in, 38 Covered/uncovered stents, 359, 361
carotid plaque(s) COX inhibitors. See Cyclooxygenase (COX) inhibitors
formation and vulnerability, 37–38 CPB. See Cardiopulmonary bypass (CPB)
gender differences in, 38–40 C-reactive protein (CRP), 17, 21, 37, 41, 42, 91, 196, 247
Cascade amplification, 237 Creatinine, 371
Catastrophic APS, 322, 323 Critical limb ischemia (CLI)
Catecholamines, 5 with forefoot gangrene, 93
CBAS. See Carmeda bioactive surface (CBAS) inflammatory markers in
CCHD. See Cyanotic congenital heart disease (CCHD) and invasive treatment, 93–94
C5 complement inhibitors, 237–238 mortality, 94
CDC. See Center for Disease Control and Prevention (CDC) and peripheral arterial disease, 92–93
CD4+CD28null T cells, 10–11 prognosis, 94
CD40 ligand (CD40L), 92, 300, 301 molecular-cellular basis for
CD14 receptor, 18, 23 endothelial cell physiology, 107–108
CD-40 receptor, 394 hypoxic physiology, 108–109
CD204 receptor, 18 shear stress and arteriogenesis, 109–110
CD4+ T cells, 19, 22. See also Atherosclerosis surgical solutions for
CD8+ T cells, 10, 22 autologous vein grafts, 110
CD34+ T helper (Th) cells, in heart transplantation, 386 endothelial cell seeding, 113–114
CEA. See Carotid endarterectomy (CEA) graft characteristics and long-term patency, 111–112
cECC. See Conventional extracorporeal circulation (cECC) prostheses, 112–113
Cellcept®. See Mycophenolate mofetil vein graft adaptation, physiology of, 110–111
Cell fusion, 423 venous endothelial cells response to shear stress, 111
Cell migration, mechanisms in, 16 CRP. See C-reactive protein (CRP)
Cell seeding, 113–114 Cryoplasty, 222–223
Cellular cardiomyoplasty, 423 CT. See Computer tomography (CT)
Cellular immunity, 194 CTA. See Computed tomography angiography (CTA)
Cellular rejection, acute, 386–388 CTGF. See Connective tissue growth factor (CTGF)
Center for Disease Control and Prevention (CDC), 21 CTL. See Cytotoxic T lymphocytes (CTL)
Centrifugal pumps, 236 Cutting balloons, 223
CHD. See Coronary heart disease (CHD) CXCL9 and CXCL10, in heart transplantation, 387, 388
Chemokines, 15, 17, 126, 195 CXCR4, 431–432
Chlamydia pneumoniae, 58 Cyanotic congenital heart disease (CCHD), thromboembolism in,
Chronic inflammation, 275 349–352
Chronic thromboembolic pulmonary hypertension, 176 Cyclooxygenase (COX) inhibitors, 238
Chronic vasculitis, 193 Cyclophosphamide, 200
Chronic venous diseases (CVDs), 185 Cyclosporin A, 119
Chylomicrons, 29–30, 32 Cysteine C, 57
Circulating progenitor cells, and platelets, Cystic fibrosis, vitamin supplements in, 405
301–302 Cytokines, 6, 15, 17, 20, 21, 126, 195, 277
CLI. See Critical limb ischemia (CLI) anti-inflammatory, 247–248, 422
CLK cells, 431, 432 cellular cardiomyoplasty, 423
Index 441

in heart transplantation (see Heart transplantation, cytokines in) EMB. See Endomyocardial biopsy (EMB)
myocardial infarction and the inflammatory reaction, 421–422 Endarterectomy, 98, 100, 163. See also Carotid
proinflammatory, 246–247, 422 endarterectomy (CEA)
Cytomegalovirus, 59 Endarteritis obliterans, 79
Cytotoxic T cells, 194 Endofit® stent, 66–67
Cytotoxic T lymphocytes (CTL), 10 Endogenous lipid metabolism
HDLs, 31
IDLs, 30
D LDLs, 30–31
Dabigatran etexilate, in VTE, 162 VLDLs, 30
Dacron, 113, 114 Endomyocardial biopsy (EMB), 388, 400
Daflon (flavonoid), 187, 189 Endoscopic vein harvesting (EVH), 296
Damage control surgery (DCS), 131 Endothelial cells, 125
Damage/danger-associated molecular patterns (DAMPs), 18, 23 dysfunction, 9
DCS. See Damage control surgery (DCS) hypoxic physiology, 109
DCs. See Dendritic cells (DCs) LVADs effects on, 415
DC-SIGN. See Dendritic cell-specific intercellular adhesion molecule- physiology, 107–108
3-grabbing non-integrin (DC-SIGN) and platelets
D-dimer test, 165–166 adhesive properties, 299, 300
Deep vein thrombosis (DVT), 175. See also Pulmonary embolism atherosclerotic lesion formation, 300
(PE); Venous thromboembolism (VTE) CD40 ligand, 300, 301
dietary intake, role of, 154 chemotactic properties, 299, 300
low-molecular-weight heparin, 161 IL-1b, 299, 300
MMPs in, 146–147 monocyte chemoattractant protein-1, 299, 300
pathophysiology, 154 nuclear factor kappa B, 300
post-thrombotic syndrome, 157, 160 proteolytic properties, 299, 300
treatment goals, 161 RANTES, 300
Wells score, 155 reperfusion, responses to, 109
Degenerative aneurysmatic process, 57 retention, 114
Dendritic cells (DCs), 10, 19, 194, 387 seeding, 113–114
Dendritic cell-specific intercellular adhesion molecule-3-grabbing and VTE, 176, 178
non-integrin (DC-SIGN), 19 Endothelial nitric oxide synthase (eNOS), 108, 111, 431
DESs. See Drug-eluting stents (DESs) Endothelins, 181, 234, 334
Developmental hemostasis, 341 Endotoxemia reduction strategies, in CPB
Dexamethasone, 248 antimediator and antiendotoxin therapies, 238–239
DIC. See Disseminated intravascular coagulation (DIC) enteral nutrition, 239
Dietary lipid metabolism. See Exogenous lipid metabolism immunonutrition, 239
Diffuse endothelial dysfunction, 245 SDD, 239
Disseminated intravascular coagulation (DIC), 125 Endotoxins, 236, 238, 239, 277, 386
coagulation, 125–127 Endovascular aneurysm repair (EVAR) treatment, for RAAAs
fibrinolysis, 125, 127 abdominal compartment syndrome, 74
mechanisms, 127–128 anesthesia and catheter guidewire placement, 73–74
in vascular trauma endograft type and configuration, 74
impact, 127 fluid restriction, 73
management strategies for, 128–129 standard approach/protocol, 73
Docosahexaenoic acid, 34 supraceliac aortic sheath placement and balloon control, 74
Doppler ultrasound, 84–85 treatment site, 73
Doxycycline, 58 worst risk patients, EVAR for, 74
Drug-coated balloons, 224 Endovascular approach, for aortic coarctation, 356–358
Drug-eluting stents (DESs), 97, 102, 103, 224 Endovascular repair, for aortic aneurysm, 202
Duplex ultrasound, 206 Endovascular treatment
Duraflo II heparin-coated circuits, 232, 234, 246 of carotid disease, 41
DVT. See Deep vein thrombosis (DVT) inflammation and in-stent restenosis, 42–43
inflammatory biomarkers and carotid artery stenting, 41–42
of RAAAs (see Ruptured abdominal aortic aneurysms (RAAAs))
E of stenotic lesions, 209–210
EACA. See e-aminocaproic acid (EACA) Endurant® stent, 67
e-aminocaproic acid (EACA), 342, 343 eNOS. See Endothelial nitric oxide synthase (eNOS)
ECM. See Extracellular matrix (ECM) Enteral nutrition, 239
E-Evita® stent, 68 EPA. See Eicosapentaenoic acid (EPA)
Ehlers-Danlos syndrome, 49, 58 Epinephrine, 5, 334, 336, 414
Eicosapentaenoic acid (EPA), 34, 406 ePTFE. See Expanded polytetrafluoroethylene (ePTFE)
Eisenmenger syndrome, 334, 349–351 Erythrocytes, 278, 351
Elastin, 47–49, 57, 58. See also Specific entries E-selectin, 17, 21, 92, 176, 232, 260, 300
Elastolysis, 47, 48, 147 Euthyroid sick syndrome, 6, 265
Ella® stent, 66 EVAR treatment. See Endovascular aneurysm repair (EVAR) treatment
442 Index

EVH. See Endoscopic vein harvesting (EVH) inflammation and atherosclerosis, Hp role in, 52
Excluder® stent, 68–69 polymorphism, 51–52
Exogenous lipid metabolism, 30 protein structure, 51–52
Expanded polytetrafluoroethylene (ePTFE), 113, 117 HBCs. See Heparin-bonded circuits (HBCs)
Extracellular matrix (ECM), 98, 102, 141, 187 HDLs. See High-density lipoproteins (HDLs)
degradation, 49 Heart failure (HF), LVAD. See Left ventricular assist devices (LVADs)
LVADs effects on, 414–415 Heart transplantation
Extracranial supraaortic aneurysm, 199 brain natriuretic peptide, 400–401
Ex vivo lung perfusion, 282 cytokines in
Ezetimibe, 34 acute cellular rejection, 386–388
cardiac allograft vasculopathy, 388–389
cytokine release during donor brain death, 386
F history, 385
FDPs. See Fibrin degradation products (FDPs) hyperacute rejection, 386
Fenofibrate, 34 rejection, diagnosis of, 388
FFP. See Fresh frozen plasma (FFP) Helper T (Th) cells, 10
Fibric acid derivatives (fibrates), 34 Hematoma, 74, 200, 295, 326, 381
Fibrilin-1 gene, 49 Hemofiltration, 234–235
Fibrin degradation products (FDPs), 180, 341 Hemorrhagic shock, 74, 127
Fibrinolysis, in pediatric patients Hemostasis, 125
clot formation, 341–342 extrinsic pathway, 126
coagulation system, 342 intrinsic pathway, 126
definition, 341 primary, 127
plasminogen activator inhibitor-1 and-2, 342 secondary, 126, 127
tissue-type plasminogen activator, 342 Henoch-Schönlein syndrome (HSS), 207
Fibrinolytic cascade, 278 Heparin, 101, 127, 134, 179, 181, 246, 259, 275, 278, 311, 326, 344
Fibrinolytic therapy, contraindications to, 161 Heparin-bonded circuits (HBCs), 232, 234
Fibronectin, 114, 185, 186, 195, 302 Heparin-coated circulation, 279
Fontan circulation, and thromboembolism Hercules® stent, 69
coagulation system, 350–351 Herpes (simplex) virus, 18, 59
endothelium, 351 hHSP60. See Human heat shock protein 60 (hHSP60)
platelets, 351 HIF. See Hypoxia-inducible factor (HIF)
prevalence, 350 HIF-1. See Hypoxia-inducible factor-1 (HIF-1)
Free oxygen radicals, 237, 276, 277 High-density lipoproteins (HDLs), 29, 31, 32
Fresh frozen plasma (FFP), 128, 344 High-sensitivity C-reactive protein (hsCRP), 91–94, 110
HLA. See Human leukocyte antigen (HLA)
HLA-DR. See Human leukocyte antigen-DR (HLA-DR)
G HMGCoA. See Hydroxymethylglutaryl-coenzyme
Gamma-delta T cells, 194 A (HMGCoA)
GCA. See Giant cell arteritis (GCA) Horton’s arteritis. See Giant cell arteritis (GCA)
Gemfibrozil, 34 Hp. See Haptoglobin (Hp)
GH. See Growth hormone (GH) HPA axis. See Hypothalamic-pituitary-adrenal (HPA) axis
GHRP. See Growth hormone-releasing hsCRP. See High-sensitivity C-reactive protein (hsCRP)
peptide (GHRP) HSS. See Henoch-Schönlein syndrome (HSS)
Giant cell arteritis (GCA), 194, 206–207 Human heat shock protein 60 (hHSP60), 11
clinical presentation, 378 Human leukocyte antigen (HLA), 19, 118, 400
epidemiology, 377 Human leukocyte antigen-DR (HLA-DR), 22, 58, 218
histopathological findings, 376 Humoral immunity, 23, 194, 195
pathogenesis, 375 Hyaluronan (HA), 102
vs. Takayasu arteritis, 375 Hydrocortisone, 6, 335
Glenn procedure, for thrombosis management, 351–352 Hydroxymethylglutaryl-coenzyme A (HMGCoA), 33
Glucagon, 5, 336 Hyperacute rejection, 386, 395, 400
Glucocorticoids, 5–6, 236 Hypertension, and AAAs, 59
Glycogenolysis, 5 Hypofibrinogenemia, 127
Glycoproteins, 19, 176, 302–303 Hypotensive hemostasis, 73
Gravity siphon drainage, 255 Hypothalamic-pituitary-adrenal (HPA) axis, 4, 333, 335
Growth hormone (GH), 4, 6, 299, 335, 336 Hypothermia, 128, 249–251
Growth hormone-releasing peptide (GHRP), 4, 7 Hypovolemia, 3, 4
Hypoxia, 3, 108–109, 430
Hypoxia-inducible factor-1 (HIF-1), 109, 431
H Hypoxia-inducible factor (HIF), 109, 188, 431
HA. See Hyaluronan (HA)
Haemorrhage, MMPs in, 146
Hageman factor, 275, 276, 278 I
Haptoglobin (Hp) ICAM-1. See Intercellular adhesion molecule-1 (ICAM-1)
in AAA, 53–54 Idiopathic venous thrombosis, 153. See also Venous
anti-inflammatory plasma protein, 51 thrombotic events
Index 443

Idiopathic venous thrombotic events Kolmogorov-Smirnov test, 216

anticoagulation strategies, 167 Mann-Whitney U test, 216
cancer-related consideration, 167 pathogenesis, 217
occult malignancy, incidence of, 167–169 revascularization, 217–218
recurrence rate, 162, 165–166 Infliximab, 200
residual venous thrombus, 166–167 Infrainguinal peripheral artery disease, 98
treatment algorithms, 167, 170–171 Inhibitors
IDLs. See Intermediate-density lipoproteins (IDLs) C5 complement inhibitors, 237–238
IGF-1. See Insulin-like growth factor-1 (IGF-1) cyclooxygenase, 238
IL-1RAcP. See Interleukin-1 receptor accessory protein (IL-1RAcP) phosphodiesterase, 238
IL-1 receptor antagonists (IL-1RA), 246, 247, 318–319 serine protease inhibitors, 237
Immature DCs, 194 Innate immunity, 15, 17–20
Immune dysfunction, on perioperative period, 21–23 Innate receptors, 18–19
Immune response, in atherosclerosis, 9. See also T-cell-mediated In situ vein grafts, 112
immune responses In-stent restenosis, 42–43
Immunity Insulin-like growth factor-1 (IGF-1), 6
cellular, 194 Insulin resistance, 5
humoral, 195 Integrin aIIbb3, 393
Immunological mechanisms, of inflammation. See Inflammation Intercellular adhesion molecule-1 (ICAM-1), 19, 21, 186, 300, 301,
Immunonutrition, 23, 239 371, 372, 394
Immunotherapy, in atherosclerosis, 12–13 Interferon (IFN)-g, 10, 11, 18, 20, 38, 386–388
Inducible NOS, 49 Interferon regulatory factor (IRF), 18
Inflammation Interleukin-1 (IL-1), 4, 17, 91, 127, 128, 234, 236, 238, 277
cell activation, 17 Interleukin-2 (IL-2), 277
evidence, 15–16 Interleukin-3 (IL-3), 195, 386
forms, 16 Interleukin-4 (IL-4), 10, 11, 22, 38, 48
and haptoglobin, 52 Interleukin-5 (IL-5), 11, 48
immunological mechanisms, 15 Interleukin-6 (IL-6), 5, 10, 11, 17, 37, 38, 41, 91, 127, 128, 232, 234,
adaptive immunity, 19–21 236–239, 246–248, 250, 260, 277, 370, 422
immune dysfunction, on perioperative period, 21–23 Interleukin-8 (IL-8), 17, 38, 232, 234, 236, 237, 277, 370, 422
innate immunity, 17–19 Interleukin-9 (IL-9), 386
perioperative immune modulation, 23–24 Interleukin-10 (IL-10), 5, 22, 38, 48, 232, 236, 246, 247, 250
inflammatory mediators, 17 Interleukin-12 (IL-12), 10, 17, 18, 387
and in-stent restenosis, 42–43 Interleukin-13 (IL-13), 11, 22
and VTE, 176–177, 179–180 Interleukin-16 (IL-16), 386
Inflammatory AAA Interleukin-17 (IL-17), 11
aneurysmatic degeneration, 57 Interleukin-18 (IL-18), 5, 17, 37, 41
atherosclerosis, 57, 59 Interleukin-23 (IL-23), 11
clinical features, 59 Interleukin-33 (IL-33), 24
collagen, 57, 58 Interleukin-1b (IL-1b), 260, 299, 300, 318, 422
cysteine C, 57 Interleukin-1 receptor accessory protein (IL-1RAcP), 24
diagnosis, 59 Intermediate-density lipoproteins (IDLs), 29, 30, 32
elastin, 57, 58 International Society for Heart and Lung Transplantation, 333
etiology, 57 International Working Group on Acute Heart Failure, 333
hypertension, 59 Intimal hyperplasia, 100–101
MMPs, 57 IRF. See Interferon regulatory factor (IRF)
surgical management, 59–60 Iron channels, 431
Inflammatory biomarkers, 41–42 Ischemia, 128–129
Inflammatory cytokines, 38, 422 Ischemic injury, 15, 108, 369, 385
Inflammatory markers Islet-1 (isl1)-positive cells, 428
in critical limb ischemia Isolated aortitis (IA), 375
mortality, 94 Isolated valve surgery, 21
and peripheral arterial disease, 92–93 Isoprostanes, 91–92
prognosis, 94
PAD and CLI, invasive treatment of, 93–94
in vascular disease, 91 J
CD40L, 92 Javid shunt, 133
CRP, 91
IL-6, 91
isoprostanes, 91–92 K
MMPs, 92 Kallikrein-bradykinin system, 277
neopterin, 91 KAVD. See Kinetic-assisted venous drainage (KAVD)
TNF-a, 91 72-kDa gelatinase, 57, 58
Inflammatory peripheral arterial aneurysms 92-kDa gelatinase, 57, 58
case study Kinetic-assisted venous drainage (KAVD), 255
clinical and morphological characteristics, 215, 216 Kolmogorov-Smirnov test, 216
histological features, 216, 217 Kringles, 32
444 Index

L nonpharmacologic therapies, 34
Laminin, 147, 185, 307 pharmacologic therapies, 33–34
Langerhans cells, 51 Listeria monocytogenes, 18
Laparotomy, 74 LMWH. See Low-molecular-weight heparin (LMWH)
Large-vessel vasculitides. See Giant cell arteritis (GCA); Takayasu’s Low-density lipoproteins (LDLs), 9, 29–32
arteritis (TA) Low-molecular-weight heparin (LMWH), 161
Large-vessel vasculitis, 205, 375, 377 Lp-PLA2. See Lipoprotein-associated phospholipase A2 (Lp-PLA2)
LDLs. See Low-density lipoproteins (LDLs) L-selectin, 21, 176, 371
Left ventricular assist devices (LVADs) Lumbar sympathectomy, 87
adjuvant drug therapies, 417 Lumen narrowing, structural basis of, 98
myocardial function, 415–416 arterial wall remodeling, 101–102
myocardial recovery, 416–417 intimal hyperplasia, 100–101
myocardial structure Lung protection
beta-adrenergic signal transduction, 415 adenosine, 282, 285
cardiac hypertrophy–atrophy, 413–414 arterial oxygen pressure, 282, 283
endothelium and microvasculature, 415 CD11b expression, 282, 285
extracellular matrix, 414–415 implementation strategies, 281
recovery studies, 416 interferon gamma, tissue level of, 282, 285
reverse remodeling, 417 low edema formation rates, 282, 285
Leishmania, 18 peak airway pressure, 282, 283
Leptin, 7, 294 protein C, 281
Leucine, 6 tissue concentration, 282, 284
Leukocyte(s), 265, 266, 268 Lung transplantation
depletion, in CPB, 235–236 nutritional factors
filters, 279 antioxidants, 406–407
and lymphocytes values, 371 malnutrition, 405–406
and platelets, 301 obesity, 405
Leukocytosis, 196 PUFA, 406
Leukotriene, 277 oxidative stress
Limb salvage, arterial transplantation for, 117 clinical evidence, 404–405
cold ischemia time, 119 effects of, 404
frequency, 120, 121 free radicals, 403
graft description and documentation, 118–119 measurement, 404
graft implantation, 119 platelet activation (see Platelet activation, after lung transplantation)
graft procurement, 118 Lymphocytes, in atherosclerosis pathogenesis. See Atherosclerosis
graft rejection, 119
immunosuppressive therapy, 119
late problems, 119–120 M
organ donor selection, 118 Macrophages, 10, 18, 19, 48, 57, 194
patient selection, 118 Major histocompatibility complex (MHC), 10, 18, 19, 194, 386
postoperative follow-up, 119 Major histocompatibility complex class I chain-related gene A
results, 120 (MICA), 193
Lin–c-kit+ cells, 428 Malnutrition, 405–406
Lipid peroxidation (LPO), 406 Malondialdehyde (MDA), 405
Lipoprotein-associated phospholipase A2 (Lp-PLA2), 32 Mann-Whitney U test, 216
Lipoproteins, in carotid arterial disease MAPK. See Mitogen-activated protein kinase (MAPK)
affinities, 29 Marcoumar®. See Phenprocoumon
atherosclerosis, pathophysiology of, 31 Marfan syndrome, 49
carotid atherosclerosis, lipoproteins to (clinical evidence), 31 Matrilysn, 57
high-density lipoprotein, 32 Matrix metalloproteinases (MMPs), 9, 38, 40, 41, 57, 92, 102, 141, 186
intermediate density lipoprotein, 32 in AAAs, 48, 49
lipoprotein (a), 32 activation, 143–144, 187
lipoprotein ratios, 32–33 in acute vein graft thrombosis, 147–149
low-density lipoprotein, 31–32 acute venous thrombosis, 141
Lp-PLA2, 32 in blood and vasculature, 145–146
triglycerides, 32 in DVT resolution, 146–147
characteristics, 30 endothelial and SMC venous function, effects on, 187–188
classification, 29 in haemorrhage, 146
endogenous lipid metabolism, 30–31 localization, 187
exogenous lipid metabolism, 30 modulation, by flavonoid, 187
function, 30 in peripheral blood, 145
lipid metabolism, 29 production, 143–144
location, 30 significance, 187
plasma lipoproteins, 29 substrates, 143–144
prevention strategies in varicose veins, 147
medications, 33 and venous hypertension, 187
Index 445

MECC system. See Minimized extracorporeal circulation (MECC) MUF. See Modified ultrafiltration (MUF)
system MV. See Mesenteric vasculitis (MV)
Medical therapy Mycophenolate mofetil, 119, 200
for mesenteric vasculitis, 208 Myeloid differentiation factor 88 (MyD88), 18, 23
for TA, 200 Myeloperoxidase (MPO), 37, 38, 251
for TAO, 87–88 Myocardial function, LVADs effects on, 415–416
Medium-sized-vessel vasculitis, 205 Myocardial infarction, and inflammatory reaction, 421–422
Mesenchymal stem cells (MSC), 422, 423, 429, 431, 432 Myocardial structure, LVADs effects on
Mesenteric vasculitis (MV), 205 b-adrenergic signal transduction, 415
Behçet’s syndrome, 207–208 cardiac hypertrophy–atrophy, 413–414
clinical presentation, 205 endothelium and microvasculature, 415
diagnostic imaging, 206 extracellular matrix, 414–415
differential diagnosis, 207
endovascular treatment, 209–210
GCA, 206–207 N
HSS, 207 National Heart, Lung, and Blood Institute, 47
medical treatment, 208 Natriuretic peptide system, 336–338
microscopic polyangiitis, 207 Natural killer (NK) cells, 11, 17, 18, 194
open surgical reconstruction, 208–209 Neointima, 98–103, 111
PAN, 207 Neopterin, 91, 94
SLE, 207 NETs. See Neutrophil extracellular traps (NETs)
Takayasu’s arteritis, 206 Neuroendocrine response and shock, 3
TAO, 208 adrenal glucocorticoids, 5–6
Wegener’s granulomatosis, 207 definition, 3
Methotrexate, 200 growth hormone, 6
Methylprednisolone, 236, 248, 279 historical aspects, 3
MHC. See Major histocompatibility complex (MHC) leptin, 7
MICA. See Major histocompatibility complex class I chain-related peripheral hormonal environment, 5
gene A (MICA) shock mediators, 3
MicroRNAs (miRs), in heart transplantation, 388 signal integration and effector mechanisms, 4–5
Microscopic polyangiitis (MP), 207 systemic inflammatory response, neuroendocrine axis role in, 4
Microvasculature, LVADs effects on, 415 thyroid hormones, 6
Miniaturized extracorporeal circulation (MECC) system, 261 trauma response, signs triggering, 3–4
arterial and venous filters, 260 Neurohormonal factors, in pediatric heart surgery
vs. cECC, 260 counter-regulatory hormones, 336
cell-saver device, 260 endothelins, 334
centrifugal pump, 260 growth hormone, 335
circuit coating, 259 homeostasis, 333
vs. off-pump surgery, 260 HPA axis, 335
advantages, 262 natriuretic peptide system, 336–338
IL-6 levels, 261 RAAS, 334–335
in-hospital mortality, 261 SNS, 334
neurocognitive disturbance/cerebrovascular events, 261 thyroid hormones, 335–336
perioperative blood transfusions, 262 tri-iodothyronine treatment, 335, 336
plasmin-antiplasmin complex levels, 261 vasopressin system, 335
postoperative atrial fibrillation, 261–262 Neurotripsy, 87, 88
revascularization, 262 Neutrophil(s), 265, 266, 268
serum S-100 protein levels, 261 activation, 278
oxygenators, 260 dysfunction, 21
SIRS, 260 and MMPs, 145
tubing length, 259 Neutrophil extracellular traps (NETs), 180
Minimized extracorporeal circulation (MECC) system, 232 NF-kB. See Nuclear factor kappa B (NF-kB)
Mitogen-activated protein kinase (MAPK), 23, 413, 431 Nicotinic acid (niacin), 33–34
MMPs. See Matrix metalloproteinases (MMPs) Nitinol stents, 224
Modified ultrafiltration (MUF), 234, 235 Nitric oxide synthase (NOS), 6, 49, 109, 111, 248
Molecular-cellular basis, for CLI NK cells. See Natural killer (NK) cells
endothelial cell physiology, 107–108 NKT lymphocytes, 18
hypoxic physiology, 108–109 Non-heparin coatings, 246
shear stress and arteriogenesis, 109–110 Nonpharmacologic therapy. See Lipoproteins, in carotid arterial disease
Monocytes Nonreversed vein grafts, 111–112
and MMPs, 145–146 Nonsteroidal antiinflammatory drug (NSAID), 238
and thrombus resolution, 181 Norepinephrine, 5, 334, 414
5’ monodeiodinase, 6 Normothermia, 236, 248, 251
MP. See Microscopic polyangiitis (MP) NOS. See Nitric oxide synthase (NOS)
MRA, and aortitis diagnosis, 378 No-touch saphenous vein harvesting technique, 295.
Msx1/Msx2 expression, 312 See also Saphenous vein (SV)
446 Index

Nuclear factor kappa B (NF-kB), 17–19, 246, 300, 318 Percutaneous coronary intervention (PCI), 97, 103
Nutritional factors, and oxidative stress Percutaneous transcatheter embolization (PTE), 210
antioxidants, 406–407 Percutaneous transluminal angioplasty (PTA), 209, 222
malnutrition, 405–406 angioplasty, alternative modalities for
obesity, 405 cryoplasty, 222–223
polyunsaturated fatty acid (PUFA), 406 cutting balloons, 223
drug-coated balloons, 224
stents (see Stents)
O subintimal angioplasty, 223
Obesity, in lung transplants, 405 Periinterventional serum inflammation markers, 42
Off-pump beating heart technique, 279 Perioperative immune modulation, 23–24
Off-pump coronary artery bypass grafting (OPCABG) surgery, 259 Peripheral arterial aneurysms. See Inflammatory peripheral arterial
Off-pump coronary artery bypass (OPCAB) surgery, 231 aneurysms
randomized controlled trials, 232–234 Peripheral arterial disease (PAD), 91, 117, 118
uses, 232 American Heart Association/American College of Cardiology
Omega-3 fatty acids, 23, 34, 239 guidelines, 221
OPCAB. See Off-pump coronary artery bypass (OPCAB) surgery inflammatory markers in, 92–93
OPCABG surgery. See Off-pump coronary artery bypass grafting invasive treatment, 93–94
(OPCABG) surgery medical management, 225
Open (conventional)/endovascular complications pathophysiology, 221–222
aortic aneurysms, 369 percutaneous transluminal angioplasty, 222
creatinine and platelets values, 371 PTA, 222
ICAM-1 and L-selectin values, 371 restenosis, 222
IL-6 and IL-8 values, 370 risk factors, 221
inflammatory response curves, 372 Peripheral blood, MMPs in, 145
ischemic injury, 369 Peripheral hormonal environment, 5
leukocytes and lymphocytes values, 371 Perivascular fat (PVF), 291, 293, 294
patient variables, 373 Phagocytes, 18
prevalence period, 373 Pharmacologic therapy. See Lipoproteins, in carotid arterial disease
ROC curve analysis, 372 Phenprocoumon, 119
SV and CRP values, 370 Phosphodiesterase inhibitors, 238
TEVAR and open repair meta-analysis, 370 Phosphorylcholine inert surface (PHISIO), 246
TNF-alpha values, 371 Plasma lipoproteins, 29
Open surgery, for mesenteric vasculitis, 208–209 Plasma thrombomodulin level, 349–351
OPN. See Osteopontin (OPN) Plasmin, 128
Organ donation legislation, in Austria, 120 Plasminogen activator inhibitors (PAIs), 125, 127, 128, 180–182, 342
Osteopontin (OPN), 41 Platelet(s), 125, 128, 265, 266, 268
Oxidative modification of LDL (oxLDL), 31 activation (see Platelet activation)
Oxidative stress, 49, 92 atheroprogression, 302
lung transplantation and circulating progenitor cells, 301–302
clinical evidence, 404–405 and endothelium
effects of, 404 adhesive properties, 299, 300
free radicals, 403 atherosclerotic lesion formation, 300
measurement, 404 CD40 ligand, 300, 301
nutritional factors, 405–407 chemotactic properties, 299, 300
oxLDL. See Oxidative modification of LDL (oxLDL) IL-1b, 299, 300
monocyte chemoattractant protein-1, 299, 300
nuclear factor kappa B, 300
P proteolytic properties, 299, 300
Packed red blood cells (pRBCs), 128 RANTES, 300
PAD. See Peripheral arterial disease (PAD) glycoprotein VI, 302–303
PAF. See Platelet-activating factor (PAF) and leukocytes, 301
PAIs. See Plasminogen activator inhibitors (PAIs) and MMPs, 145
PAMPs. See Pathogen-associated molecular patterns (PAMPs) response, 278
PAN. See Polyarteritis nodosa (PAN) Platelet-activating factor (PAF), 181, 277
PAPP-A. See Pregnancy-associated plasma protein-A (PAPP-A) Platelet activation, 249
Paracrine effect, 423 after lung transplantation
Partial thromboplastin time (PTT), 128 aggregate formation, 393–394
Pathogen-associated molecular patterns (PAMPs), 18 allo/xenograft hyperacute rejection, 395
Pattern-recognition molecules (PRMs), 18 anti-platelet therapy, 396
Pattern-recognition receptors (PRRs), 18 clinical consequences, 394
PCI. See Percutaneous coronary intervention (PCI) cytokines releases, 393
PDGF. See Platelet-derived growth factor (PDGF) graft dysfunction, 394
PE. See Pulmonary embolism (PE) granules releases, 393
Pediatric congenital heart surgery. See Antifibrinolytic therapy, in integrin aIIbb3 changes, 393
pediatric congenital heart surgery and pulmonary reperfusion injury, 395
Index 447

Fontan circulation, 351 R

thrombosis in CCHD, 349–350 Radial artery (RA), 289
Platelet-derived growth factor (PDGF), 109 RANTES, 195, 300, 393
Polyarteritis nodosa (PAN), 207 Reactive oxygen species (ROS), 102, 108, 237
Polyethylene terephthalate. See Dacron Regulatory CD4+T cells, 12
Polymorphonuclear leukocytes, 278 Regulatory T (Treg) cells, 10, 12
Polytetrafluoroethylene (PTFE), 113, 114 Rejection, transplanted heart
Polyunsaturated fatty acid (PUFA), 406 acute cellular, 386–388
Post-thrombotic syndrome, 176 diagnosis of, 388
Powerlink® stent, 69, 70 hyperacute, 386
pRBCs. See Packed red blood cells (pRBCs) Remodeling, of arterial wall. See Arterial wall remodeling
Prednisolone, 380 Renal angioplasty, 98
Prednisolone-21-sodium-hydrosuccinate, 119 Renin-angiotensin-aldosterone system (RAAS), 334–335, 414
Pregnancy-associated plasma protein-A (PAPP-A), 38 Restenosis, 97
Primarily DCs, 10 BMS, 97, 98
Primary hemostasis, 127 carotid revascularization, 98
Primary pulmonary hypertension (PPH), 394 clinical progress, 102–103
PRMs. See Pattern-recognition molecules (PRMs) coronary angioplasty, 97
Proatherogenic T cell subsets DESs, 97
CD4+CD28null T cells, 10–11 in extracoronary vascular beds, 97–98
Th1 cells, 10 infrainguinal peripheral artery disease, 98
Th17 cells, 11 PCI, 97
Proinflammatory cytokines, 246–247, 422 recurrent lumen narrowing, structural basis of, 98
Prolactin, 4 arterial wall remodeling, 101–102
Prostacyclin (PGI1), 108, 179 intimal hyperplasia, 100–101
Prostheses, of CLI, 112 renal angioplasty, 98
Dacron, 113 Revascularization, 217–218
PTFE, 113 Reverse cholesterol transport, 31
Protein and albumin, 265, 267, 269 Reversed vein grafts, 111
Protein C, 179, 281 Rivaroxaban, 162
Protein S, 154, 164, 165, 175, 179, 180, 351 ROS. See Reactive oxygen species (ROS)
Prothrombin time (PT), 128 Ruptured abdominal aortic aneurysms (RAAAs), EVAR treatment for
PRRs. See Pattern-recognition receptors (PRRs) abdominal compartment syndrome, 74
Pruitt-Inahara shunt, 133 anesthesia and catheter guidewire placement, 73–74
P-selectin, 21, 176, 249, 349–352 endograft type and configuration, 74
P-selectin glycoprotein ligand-1 (PSGL-1), 176, 179, 393 fluid restriction, 73
Pseudoaneurysms, 120 standard approach/protocol, 73
PSGL-1. See P-selectin glycoprotein ligand 1 (PSGL-1) supraceliac aortic sheath placement and balloon control, 74
PT. See Prothrombin time (PT) treatment site, 73
PTA. See Percutaneous transluminal angioplasty (PTA) worst risk patients, EVAR for, 74
PTE. See Percutaneous transcatheter embolization (PTE)
PTFE. See Polytetrafluoroethylene (PTFE)
PTT. See Partial thromboplastin time (PTT) S
Pulmonary embolism (PE), 146, 175. See also Deep vein thrombosis SAA. See Serum amyloid A (SAA)
(DVT); Venous thromboembolism (VTE) Salicylic acid, 119
chronic thromboembolic hypertension, 157 Sandimmun®. See Cyclosporin A
complications, 157 Sandwich technique, for isolated aneurysms, 71. See also Abdominal
CW Doppler, 157, 158 aortic aneurysms (AAAs)
dietary intake, role of, 154 Saphenous vein (SV), 147
echocardiography, 157 adventitia, 289–291, 293
fondaparinux doses, 161 conventional harvesting technique, 294–295
Geneva scores, 155 endothelium, 289–291
hemodinamic unstable PE, 157–159 EVH, 296
LMWH doses, 161 graft performance, 296
mortality, 157, 161 intima, 289–290
pathophysiology, 154 media, 289, 290, 292
preserved systolic function no-touch technique, 295
using pulsed tissue doppler, 157, 159 PVF, 291, 293, 294
using tricuspid annular plane systolic motion, 157, 160 structure, 289, 290
pulmonary angiography, 155 vasa vasorum, 290, 293
signs and symptoms, 155 vascular damage, 295–296
thrombolytic doses, 161 Scavenger receptors, 18
Wells score, 155 sCD40L. See Soluble CD 40 ligand (sCD40L)
Pulmonary reperfusion injury, platelet activation, 395 SDD. See Selective digestive decontamination (SDD)
Pulseless disease. See Takayasu’s arteritis (TA) sdLDLD. See Small, dense LDL (sdLDLD)
PVF. See Perivascular fat (PVF) Secondary hemostasis, 126, 127
448 Index

Selectins, 176 Suppressor T cells. See Regulatory T (Treg) cells

Selective digestive decontamination (SDD), 239 Surface-modifying additive (SMA), 246
Self-made shunts, 133 Surgical site infections, 21
Serine protease inhibitors (SERPIN), 179, 237 Surgical solutions, for CLI
Serum amyloid A (SAA), 37, 42 autologous vein grafts, 110
Shear stress, 107 endothelial cell seeding, 113–114
and arteriogenesis, 109–110 graft characteristics and long-term patency, 111
high, 107 nonreversed vein grafts, 111–112
low, 107, 108 reversed vein grafts, 111
oscillary, 108 in situ vein grafts, 112
venous endothelial cells response to, 111 prostheses, 112
Shock Dacron, 113
definition, 3 PTFE, 113
mediators, 3 vein graft adaptation, physiology of, 110–111
and tissue hypoperfusion, 3 venous endothelial cells response, to shear stress, 111
sICAM-1. See Soluble intercellular adhesion Surgical therapy
molecule 1 (sICAM-1) for TA, 200–201
Side population (SP) cells, 428 for TAO, 87–88
Signal transducer and activator of the transcription SV. See Saphenous vein (SV)
(STAT)-3 pathway, 250 Sympathetic nervous system (SNS), 334
Signal transduction process, 245 Systemic inflammatory response syndrome
SIRS. See Systemic inflammatory response (SIRS), 4, 231, 260
syndrome (SIRS) Systemic lupus erythematous (SLE), 207, 322–324
SLE. See Systemic lupus erythematous (SLE)
SMA. See Surface-modifying additive (SMA)
Small, dense LDL (sdLDLD), 31 T
Small-vessel vasculitis, 205 Takayasu’s arteritis (TA), 86, 206
SMCs. See Smooth muscle cells (SMCs) aneurysmal disease, 198
Smooth muscle cells (SMCs), 98 coronary lesions, 199
dysfunction, 186 extracranial supraaortic aneurysm, 199
immunohistochemical studies, 186 thoracic and abdominal aortic aneurysms, 199
of varicose veins, 186 clinical presentation, 195, 378
venous function, 187–188 imaging study, 196–197
SNS. See Sympathetic nervous system (SNS) laboratory tests, 196
SOD. See Superoxide dismutase (SOD) diagnostic criteria and classification, 197–198
Sodium nitroprusside, 279 epidemiology, 193
Soluble CD 40 ligand (sCD40L), 260 vs. GCA, 375
Soluble intercellular adhesion molecule 1 (sICAM-1), 41 histopathological findings, 376
Soluble P-selectin (sP-sel), 176 history, 193
Solu-Dacortine®. See Prednisolone-21-sodium-hydrosuccinate management, 199–201
Sox9, 312 medical treatment, 200
SPARCL. See Stroke Prevention by Aggressive Reduction in pathogenesis, 375
Cholesterol Levels Study (SPARCL) pathophysiology, 193
sP-sel. See Soluble P-selectin (sP-sel) cellular immunity, 194
Squeeze-to-release approach, 68 humoral immunity, 195
Stainless-steel stents, 223 surgery/endovascular repair, for aortic aneurysm, 202
Statins, 33 surgical treatment, 200–201
Stem cell antigen-1 (Sca-1), 428 Talent® stent, 69–70
Stent-grafts, 224 TAO. See Thromboangiitis obliterans (TAO)
Stents/stenting, 98 Tbx20, 313
aortic coarctation, 356, 359–361 T-cell-mediated immune responses, 9
in Brazil (see Brazil, stents in) T-cells, 194. See also Specific entries
characteristics, 63 g:d T cells, 18. See also Specific entries
DES, 224 TEG. See Thromboelastogram (TEG)
nitinol, 224 Temporary intravascular shunt, in complex vascular injury
stainless-steel, 223 anticoagulation administration, 134–135
stent-grafts, 224 Argyle shunt, 133
Steroid treatment complications, 136
aortitis, 380 DCS, 131
in CPB, 248–249 dislodgment, 136
Stroke Prevention by Aggressive Reduction in Cholesterol Levels expanded shunt usage, 136
Study (SPARCL), 33 hemorrhage control, 131
Subintimal angioplasty, 223 heparin-bonded polyvinylchloride, 134
Sundt shunt, 133 history, 131, 132
Superoxide dismutase (SOD), 102 indications, 135
Suppressor of cytokine signaling (SOCS)-3, 250 intestinal circulation, 133, 134
Index 449

Javid shunt, 133 thrombin antithrombin complex III (TAT), 350

patency duration, 133–134 thrombus formation mechanism, 349
Pruitt-Inahara shunt, 133 endothelial thrombomodulin, 349
self-made shunts, 133 Fontan circulation
shunt occlusion, 136 coagulation system, 350–351
shunt size, 133 endothelium, 351
silver tubes, 131 platelets, 351
Sundt shunt, 133 prevalence, 350
thrombosis, 136 Thrombogenesis, and VTE, 176–177, 179–180
trauma center, patient transfer to, 136 Thrombolysis, and VTE, 180–181
upper/lower extremities, 135–136 Thromboxane A2, 277
Tenascin, 185 Thrombus resolution, and VTE, 181–182
Tetracyclines, 49 Thyroid hormones, 6, 335–336
TF. See Tissue factor (TF) clinical research, 265
TFPI. See Tissue factor pathway inhibitor (TFPI) leukocytes, 265, 266, 268
TGF-b. See Transforming growth factor-b (TGF-b) neutrophils, 265, 266, 268
Th1 cells, 10 perioperative hormone levels, 265, 270
Th2 cells, 11–12 perioperative VO2 levels, 265, 273
Th17 cells, 11 platelets, 265, 266, 268
T helper (Th) cells, 5, 194 protein and albumin, 265, 267, 269
in heart transplantation, 386–387 thyroxine, 265, 267, 271
Th1 lymphocytes, 20 triiodothyronine, 265, 267, 271
Thoracic aortic aneurysms, 199 TSH, 265, 267, 271
Thoracic sympathectomy, 87 Thyroid-stimulating hormone (TSH), 4, 6, 265, 267, 271
Thrombin time (TT), 128 Thyrotropin, 4
Thromboangiitis, 82 Thyroxin (T4), 6
Thromboangiitis obliterans (TAO), 79, 208 Thyroxine (T4), 265, 267, 271
arteriosclerosis, 82 TIMPs. See Tissue inhibitors of MMPs (TIMPs)
coagulation, 83, 84 Tissue factor (TF), 125, 128
diagnosis, 85–86 Tissue factor pathway inhibitor (TFPI), 141, 179
differential diagnosis, 85–86 Tissue hypoxia, 3
epidemiology, 83 Tissue inhibitors of MMPs (TIMPs), 41, 186
etiology, 82–83 Tissue-type plasminogen activator (t-PA), 108, 125, 127, 180, 342
gender, 83 TLR2 expression, 22
genetic predisposition, 83 TLR4 expression, 22
immunology, 83 TLRs. See Toll-like receptors (TLRs)
clinical aspects, 84 T lymphocytes, 19, 20, 38
laboratory aspects, 83–84 TNF-a. See Tumor necrosis factor-a (TNF-a)
radiological aspects, 84–85 Toll-like receptors (TLRs), 18, 19, 23, 318
inflammatory and histopathological factors, 79–82 Total antioxidant capacity (TAC), 407
medical treatment, 87–88 t-PA. See Tissue-type plasminogen activator (t-PA)
pathogenesis, 83 Tranexamic acid (TXA)
prognosis, 88 pediatric congenital heart surgery
smoking, 82–83 clot stability, 343
surgical treatment, 87–88 dosage and infusion schemes, 343–344
thromboangiitis, 82 fibrinolysis prevention, 343
vasodilation, 83 mechanism of action, 342
ThromboASS®, 119 risks and side effects, 345–346
Thrombocytopenia, 127 Trans-differentiation, 423
Thromboelastogram (TEG), 128 Transforming growth factor-b (TGF-b), 10–12, 102
Thromboembolism Trauma response, signs triggering, 3–4
CCHD Treg cells. See Regulatory T (Treg) cells
cerebrovascular thrombosis, 350 TRIF, 18
Eisenmenger syndrome, 351 Triglycerides, 32
endothelial dysfunction, 350 Triiodothyronine (T3), 6, 265, 267, 271
endothelial function, 349 Tri-iodothyronine treatment, 335, 336
erythrocytosis, 351 Trillium bio-passive surface, 246
Fontan procedure, 351–352 TSH. See Thyroid-stimulating hormone (TSH)
Glenn procedure, 351–352 TT. See Thrombin time (TT)
incidence, 349 Tuberculous aortitis, 375
laboratory tests, 352 Tumor necrosis factor-a (TNF-a), 5, 11, 17, 22, 38, 91, 127, 128, 232,
organ infarction, 350 234, 236–239, 245–247, 249, 250, 260, 277
platelet activation, 349–350 on myocardial infarction, 422
prophylactic administration, 351 in period of 3 months, 371
P-selectin, 349–352 Twist1, 312–313
systemic-to-pulmonary shunt, 351 TXA. See Tranexamic acid (TXA)
450 Index

U Vasodilation, 83, 334, 351

Ultrafiltration, 234–235 Vasopressin, 335
Urokinase type plasminogen activator (u-PA), 180 VAVD. See Vacuum-assisted venous drainage (VAVD)
VEGF. See Vascular endothelial growth factor (VEGF)
Vein grafts
V adaptation, 110–111
Vacuum-assisted venous drainage (VAVD) autologous, 110
advantages nonreversed, 111–112
air block elimination, 256–257 reversed, 111
arterial perfusion flow and blood levels, 255–256 in situ, 112
cardiopulmonary support, 256 Vein wall remodeling, and VTE, 181–182
IVC anastomosis, 256 Venography, 156, 157
smaller venous cannulae, 255–256 Venous dilation, 186–187
tubing, 255–256 Venous endothelial cells response, to shear stress, 111
disadvantages Venous hypertension, and MMPs, 187
accidents, 257–258 Venous thromboembolism (VTE), 175. See also Deep vein thrombosis
blood trauma, 257 (DVT); Pulmonary embolism (PE)
gaseous microemboli transmission, 257 complications, 176
pump flow rate, 257 endothelium, 176, 178
schematic representation, 255, 256 genetic predisposition, 175
Valve formation, by BMP incidence, 175
growth factor regulation, 310–312 inflammation, 176–177, 179–180
spatial and temporal localization, 308–310 mortality, 175
transcriptional regulation, 312–313 plasminogen activators, 180
Valvulogenesis recurrence, 175–176
AV remodeling, 307–308 risk factors, 175
BMP role (see Bone morphogenetic proteins (BMP)) thrombogenesis, 176–177, 179–180
cardiac jelly, 307 thrombolysis, 180–181
cushions, 307 thrombus resolution, 181–182
epithelial-mesenchymal transition, 307 vein wall remodeling, 181–182
looping process, 307 Venous thrombotic events. See also Deep vein thrombosis (DVT);
semilunar valve morphogenesis, 308 Pulmonary embolism (PE)
Varicose veins, 185 bleeding risk, 163
drugs, for treatment, 188–189 chest x-rays, 155
MMPs, 147, 186–187 classic atherosclerotic cascade, 153
activation, 187 complications, 157, 160, 161
endothelial and SMC venous function, effects on, 187–188 compression ultrasonography, 155, 156
localization, 187 diagnosis, 155–160
modulation, by flavonoid, 187 endothelial injury/dysfunction, 155
significance, 187 HASBLED score, 163
and venous hypertension, 187 hypercoagulability anomalies, 154–155
primary vein wall changes, 185–186 idiopathic
SMC dysfunction, 186 anticoagulation strategies, 167
vein wall inflammation, 186 cancer-related consideration, 167
venous dilation, 186–187 occult malignancy, incidence of, 167–169
Vascular disease, inflammatory markers in, 91 recurrence rate, 162, 165–166
CD40L, 92 residual venous thrombus, 166–167
CRP, 91 treatment algorithms, 167, 170–171
IL-6, 91 incidence, 153
isoprostanes, 91–92 inflammation, 154
MMPs, 92 pathophysiology, 154–155
neopterin, 91 predisposing factors, 153, 154
TNF-a, 91 recurrence
Vascular endothelial growth factor (VEGF), 103, 109, 423 hazard ratio, 164
Vascular endothelium, 17, 82, 107, 108, 113, 125, 179, 238, 245, 299, hereditary thrombophilia, 164–165
301, 386, 394, 395 predictors, 164
Vascular injury, intravascular shunt in. See Temporary intravascular risk factors, 153–154
shunt, in complex vascular injury single-/multi-detector computer tomography, 155, 156
Vascular smooth muscle cells (VSMCs), 9, 10, 41, 146, 176, 188 treatment
Vascular trauma, DIC in chronic, 162–163
hemorrhage control, 128 goals, 161
impact, 127 intermediate phase, 162–163
management strategies for, 128–129 venography, 156, 157
Vasculitis ventilation-perfusion scintigraphy, 155
classification, 205 Vienna prediction model, 165, 166
mesenteric (see Mesenteric vasculitis (MV)) Versican, 102, 307, 313
Index 451

Very-low-density lipoproteins (VLDLs), 29, 30, 32 Weibel-Palade body (WPB), 176

Vitamin K antagonists (VKAs), 162 WG. See Wegener’s granulomatosis (WG)
Vitamins, and cystic fibrosis, 405 White blood cells (WBCs), 21
VLDLs. See Very-low-density lipoproteins (VLDLs) WPB. See Weibel-Palade body (WPB)
von Willebrand factor (vWF), 125, 148, 176
VSMCs. See Vascular smooth muscle cells (VSMCs)
vWF. See von Willebrand factor (vWF) X
Xenograft hyperacute rejection, 395

W
WBCs. See White blood cells (WBCs) Z
Wegener’s granulomatosis (WG), 207 Zenith Flex® stent, 70–71