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Long-term experience in autologous in vitro endothelialization of infrainguinal ePTFE grafts  Manfred Deutsch, MD, Johann Meinhart, PhD, Peter Zilla,

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Presentation on theme: "Long-term experience in autologous in vitro endothelialization of infrainguinal ePTFE grafts  Manfred Deutsch, MD, Johann Meinhart, PhD, Peter Zilla,"— Presentation transcript:

1 Long-term experience in autologous in vitro endothelialization of infrainguinal ePTFE grafts 
Manfred Deutsch, MD, Johann Meinhart, PhD, Peter Zilla, MD, PhD, Norbert Howanietz, MD, Michael Gorlitzer, MD, Alexander Froeschl, MD, Andreas Stuempflen, MD, Deon Bezuidenhout, PhD, Martin Grabenwoeger, MD  Journal of Vascular Surgery  Volume 49, Issue 2, Pages (February 2009) DOI: /j.jvs Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

2 Fig 1 Immune-fluorescent live-dead stains of control samples taken immediately after seeding. Overall, 78% of the grafts showed complete confluence (a), 16% areas of preconfluence (b), and only 6% had minor endothelial-free areas (c). Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

3 Fig 2 Kaplan-Meier survivorship functions of all patients with femoropopliteal grafts broken down into primary patency, secondary patency, and limb salvage (a), and into stage I and II/III patients (b), showing patients at risk and standard errors at 1, 3, 5, and 10 years. The difference between stages was N.S. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

4 Fig 3 Patency rates in relation to the distal anatomical position of the femoropopliteal grafts. Although there was a trend towards better patency of below knee grafts, it was N.S. (a). When patencies were broken down into clinical stages for both above knee (b) and below knee (c) position differences were again N.S. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

5 Fig 4 Comparison of 6 mm with 7 mm grafts showed a significant difference in patency. Seven millimeter grafts were only commenced 38 months after the 6 mm group and were selected on the basis of larger popliteal artery diameters. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

6 Fig 5 (a) Stenosed mid-graft segment of an in-vitro endothelialized ePTFE graft. (b) One-year follow-up angiography of an endothelialized 6 mm graft used in a distal reconstruction. Smooth surface of the endothelialized prosthesis (→) and no distal anastomotic narrowing. An additional bridge-graft (B) reconstruction had been performed between the posterior tibial and the peroneal artery with the endothelialized graft inserted near the proximal bridge anastomosis. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

7 Fig 6 Midgraft segments explanted at the time of re-operation for graft failure 41 months (a) and (c) and 63 months (b) and (d) after implantation of an in vitro endothelialized ePTFE graft. Both specimens contained other areas of more significant stenoses but the displayed prestenotic regions were packed with large islands of foam cells (F) (c) and (d). Typically, the foam cells were wedged underneath pannus-like cell-poor tissue that occasionally showed stretches of complete acellularity (A) (c). Masson's Trichrome Stain; “stitched” images to represent objective magnifications of ×0.5 (a) and (b) and ×10 (c) and (d). Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

8 Fig 7 Different area of the same specimen as in Fig 6a and c of an endothelialized graft 41 months after implantation. Relatively extended areas were typically found in most explants where a confluent endothelium was resting on a layer of well-aligned α-SMC actin-positive cells (a) (Immunofluorescence α-SMC actin/CD31; Dapi nuclear counter stain/CD 31; ×10 objective) A delicate intima was demarcated from the actin positive cells by a well-defined elastic membrane. Orcein stain; ×10 and ×20 objectives. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

9 Fig 8 Areas of confluent endothelium (°) lying in direct proximity to densely packed inflammatory cells, which were directly resting on the ePTFE surface without any connective tissue cells. Explant samples of four different patients 27 months (a), 14 months (b), 29 months (c), and 63 months (d) after implantation. Foreign body giant cells (*) were regularly present, either directly attached to the ePTFE (a) or tucked underneath the endothelium (b). Some areas consisted almost exclusively of lymphocytes (c) while others were dominated by macrophages (d). Occasionally, macrophage debris (↔) was densely packed into the surface layer of the ePTFE (d). Double-immunofluorescence Ham56/CD68 and CD31; Dapi nuclear counter stain; ×10 (a), (c), and (d), and ×40 (b) objectives. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

10 Fig 9 Large surface thrombi (T) were sometimes attached to the areas of subendothelial inflammation shown in Fig 9. Typically, Foreign Body Giant Cells (FBGC) were much denser and more prominent in areas of thick thrombus coverage. The red actin-positive (Ac) cells within the top half of the thrombus indicate that it represents a chronic thrombus that was already partially organized at the time of explantation. CD 68/Ham56 and α-SMC actin; Dapi nuclear counterstain; ×10 objective magnification. Journal of Vascular Surgery  , DOI: ( /j.jvs ) Copyright © 2009 The Society for Vascular Surgery Terms and Conditions

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