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Review Article

Biomechanics and Mechanobiology of Saphenous Vein Grafts

[+] Author and Article Information
Keith J. Gooch

Department of Biomedical Engineering,
The Ohio State University,
290 Bevis Hall 1080 Carmack Drive,
Columbus, OH 43210;
Davis Heart Lung Research Institute,
The Ohio State University,
Columbus, OH 43210
e-mail: gooch.20@osu.edu

Michael S. Firstenberg

Surgery and Integrative Medicine,
Northeast Ohio Medical Universities,
Akron, OH 44309

Brittany S. Shrefler

Department of Internal Medicine,
The Ohio State University,
Columbus, OH 43210

Benjamin W. Scandling

Department of Biomedical Engineering,
The Ohio State University,
Columbus, OH 43210

1Corresponding author.

Manuscript received July 1, 2017; final manuscript received November 10, 2017; published online January 12, 2018. Editor: Victor H. Barocas.

J Biomech Eng 140(2), 020804 (Jan 12, 2018) (16 pages) Paper No: BIO-17-1288; doi: 10.1115/1.4038705 History: Received July 01, 2017; Revised November 10, 2017

Within several weeks of use as coronary artery bypass grafts (CABG), saphenous veins (SV) exhibit significant intimal hyperplasia (IH). IH predisposes vessels to thrombosis and atherosclerosis, the two major modes of vein graft failure. The fact that SV do not develop significant IH in their native venous environment coupled with the rapidity with which they develop IH following grafting into the arterial circulation suggests that factors associated with the isolation and preparation of SV and/or differences between the venous and arterial environments contribute to disease progression. There is strong evidence suggesting that mechanical trauma associated with traditional techniques of SV preparation can significantly damage the vessel and might potentially reduce graft patency though modern surgical techniques reduces these injuries. In contrast, it seems possible that modern surgical technique, specifically endoscopic vein harvest, might introduce other mechanical trauma that could subtly injure the vein and perhaps contribute to the reduced patency observed in veins harvested using endoscopic techniques. Aspects of the arterial mechanical environment influence remodeling of SV grafted into the arterial circulation. Increased pressure likely leads to thickening of the medial wall but its role in IH is less clear. Changes in fluid flow, including increased average wall shear stress, may reduce IH while disturbed flow likely increase IH. Nonmechanical stimuli, such as exposure to arterial levels of oxygen, may also have a significant but not widely recognized role in IH. Several potentially promising approaches to alter the mechanical environment to improve graft patency are including extravascular supports or altered graft geometries are covered.

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Stooker, W. , Niessen, H. W. , Wildevuur, W. R. , van Hinsbergh, V. W. , Fritz, J. , Jansen, E. K. , Wildevuur, Ch., R. , and Eijsman, L. , 2002, “ Perivenous Application of Fibrin Glue Reduces Early Injury to the Human Saphenous Vein Graft Wall in an Ex Vivo Model,” Eur. J. Cardiothorac. Surg., 21(2), pp. 212–217. [CrossRef] [PubMed]
Liu, S. Q. , 1998, “ Prevention of Focal Intimal Hyperplasia in Rat Vein Grafts by Using a Tissue Engineering Approach,” Atherosclerosis, 140(2), pp. 365–377. [CrossRef] [PubMed]
Barra, J. A. , Volant, A. , Leroy, J. P. , Braesco, J. , Airiau, J. , Boschat, J. , Blanc, J. J. , and Penther, P. , 1986, “ Constrictive Perivenous Mesh Prosthesis for Preservation of Vein Integrity. Experimental Results and Application for Coronary Bypass Grafting,” J. Thorac. Cardiovasc. Surg., 92(3 Pt. 1), pp. 330–336. https://www.ncbi.nlm.nih.gov/pubmed/3528676 [PubMed]
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Figures

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Fig. 1

Histology of typical human SV freshly harvested from the venous circulation (a) and harvested 6 months after CABG (b). Note in the grafted vein significant neointima formation above the internal elastic lamina and medial thickening. Figure modified from Ref. [27].

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Fig. 2

Effects of preparation technique on vein structure. Relative to SV isolated using the no touch technique (a), the conventional technique (b) removes significantly more of the adventia. In conventional technique, manual distension using a syringe to exert hydrostatic pressure is used. (Reproduced with permission from Souza et al. [47]. Copyright 2006 by Elsevier.)

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Fig. 3

Summary of stresses on a vessel with an inner radius ri and outer radius ro due to a volumetric flow Q with viscosity μ, transmural pressure P, and axial force F

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Fig. 5

Computationally modeled stress distribution in an end-to-side Dacron graft to artery anastomosis. Stresses are concentrated at suture attachment points, and are up to eight times greater than stresses within the host artery. (Reproduced with permission from Ballyk et al. [70]. Copyright 1998 by Elsevier.)

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Fig. 6

Computationally modeled average wall shear stress profiles for rigid (a) and distensible (b) end-to-side anastomoses. Shear stress magnitude is represented by the length of lines on the vessel wall, and lines on the outside of the wall represent positive shear stress resulting from flow toward the outlet of the vessel. The differences between the rigid and distensible cases are also plotted (c) where lines on the inside of the vessel represent shear stress in the distensible case being less than in the rigid case. (Reproduced with permission from Steinman et al. [71]. Copyright 1994 by ASME.)

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Fig. 7

Pressure–diameter relationship for human SV with (filled symbols) and without (open symbols) prior manual distension (Reproduced with permission from Zhao et al. [41]. Copyright 2007 by Elsevier.)

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Fig. 4

Compliance pressure curves for human SV, iliac artery, and three vascular graft materials (poly(carbonate)polyurethane, Dacron, and expanded polytetrafluorethylene) (Reproduced with permission from Tai et al. [44]. Copyright 2000 by John Wiley and Sons.)

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Fig. 8

Wall thickness as a function of longitudinal position in vein graft with diameter mismatch. Total wall thickness was the greatest in the region downstream from the flow expansion (region B), where localized IH was also present. (Reproduced with permission from Sunamura et al. [117]. Copyright 2007 by Elsevier.)

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Fig. 9

Porcine SV perfused ex vivo. (a) Intimal area/medial area (a marker of intimal area that accounts for different size vessels) as a function of calculated flow-induced shear stress. The horizontal dotted line represents the value for SV freshly isolated from the animal. (b) Medial area as a function of average transmural pressure. (Reproduced with permission from Gusic et al. [42]. Copyright 2005 by Elsevier.)

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Fig. 10

(a) Histological appearance of porcine SV cultured ex vivo with venous (40 mmHg) pO2 is indistinguishable from freshly isolated SV and has intact internal elastic lamina and thin intima. (b) SV cultured ex vivo with arterial (95 mmHg) pO2 exhibits disrupted internal elastic lamina, apparent invasion of cells and tissues from media to intima, and intimal thickening. Oxygen levels have a dose-dependent effect on (c) intimal thickening and cellular proliferation (d) in the media (filled bars) and intima (open bars) [161].

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