title: The protective effect of vein cuffed anastomoses is not mechanical in origin.
abstract: OBJECTIVE
  Intimal hyperplasia (IH) is a proliferative process of vascular smooth muscle cells that occurs after an arterial injury, particularly at outflow anastomoses of prosthetic bypass grafts. IH causes stenosis that leads ultimately to graft flow reduction and thrombosis. We have demonstrated previously that vein cuff interposition between an expanded polytetrafluoroethylene (e-PTFE) graft and artery at distal anastomoses diminished IH formation in the arterial outflow as compared with noncuffed anastomoses. Improved long-term patency rates associated with the placement of an interposition vein cuff at the distal anastomosis of e-PTFE grafts to infrageniculate arteries have also been demonstrated clinically. This study examined the mechanical factors that may contribute to the protective effect of cuffed anastomoses. These factors include the expansibility of the vein cuff as compared with e-PTFE, as well as the angle of the cuffed anastomosis.
  
  
  METHODS
  Compatible animals were selected by use of platelet aggregation studies. Nine dogs, group A, received a 4 mm e-PTFE graft plus a 1 cm long interposition vein cuff at the distal anastomosis in the left carotid artery. The same procedure was done on the right side, and in addition the vein cuff was encircled by an e-PTFE jacket incorporated into the anastomosis to prevent the expansion of the vein cuff with arterial pulsation. To study the effect of distal anastomotic angle and geometry on the formation of IH, five dogs, group B, received a 4 mm e-PTFE graft in both sides. On the left, the distal anastomosis was performed between the graft and the artery at an acute angle as it is commonly done when a bypass graft is placed. On the right side a 1 cm long, 6 mm diameter e-PTFE segment was interposed between the artery and the graft at a perpendicular angle. This geometry mimicked the right angle of a vein cuff-to-artery anastomosis. After 10 weeks the grafts were harvested, and the thickness of IH was measured with an ocular micrometer under light microscopy.
  
  
  RESULTS
  In group A, one dog had bilateral graft thrombosis (12%), and these grafts were discarded. In the remaining eight dogs there was no statistically significant difference in the thickness of IH between the right (jacketed group) and the left side (nonjacketed/control group), showing that vein cuff expansibility did not play a role in protecting against the formation of IH. In group B, bilateral graft thrombosis occurred in four of five dogs (80%), suggesting that the perpendicular anastomotic angle was not protective.
  
  
  CONCLUSIONS
  These results suggested that the protective effect of the vein cuff is not mechanical in origin.
authors.affiliation: Department of Surgery, George Washington University, Washington, DC, USA.
authors.forename: J J
authors.initials: JJ
authors.lastname: Norberto
authors.forename: A N
authors.initials: AN
authors.lastname: Sidawy
authors.forename: K S
authors.initials: KS
authors.lastname: Trad
authors.forename: B A
authors.initials: BA
authors.lastname: Jones
authors.forename: R F
authors.initials: RF
authors.lastname: Neville
authors.forename: S F
authors.initials: SF
authors.lastname: Najjar
authors.forename: M K
authors.initials: MK
authors.lastname: Sidawy
authors.forename: R G
authors.initials: RG
authors.lastname: DePalma
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods*; D000818:Animals; D001807:Blood Vessel Prosthesis; D017536:Carotid Artery, Common / Q000473:pathology / Q000601:surgery*; D004285:Dogs; D004548:Elasticity; D006083:Graft Occlusion, Vascular / Q000473:pathology / Q000517:prevention & control; D006965:Hyperplasia; D009131:Muscle, Smooth, Vascular / Q000473:pathology; D010974:Platelet Aggregation / Q000502:physiology; D011138:Polytetrafluoroethylene; D011474:Prosthesis Design; D011673:Pulsatile Flow / Q000502:physiology; D013314:Stress, Mechanical; D013499:Surface Properties; D013927:Thrombosis / Q000209:etiology / Q000473:pathology; D017539:Tunica Intima / Q000473:pathology; D014654:Vascular Patency / Q000502:physiology; D014680:Veins / Q000473:pathology / Q000637:transplantation*
chemical_list: D011138:Polytetrafluoroethylene