Structural and Functional Consequences of Bypass Grafting with Autologous Vein

Abstract

An understanding of the consequences of autologous vein grafting reveals both the reasons why cryopreserved allogenic veins are being used clinically and how they are most likely to be expected to fail. Autologous vein bypass grafts are characterized by a series of distinct biological properties that influences their in vivo patency. Current surgical practice ensures that the endothelium of vein grafts is preserved at the time of implantation and that there is minimal damage to the smooth muscle cells. After implantation, the endothelial cells show varying degrees of morphological changes that are maximal within the first 3 days after grafting. In autografts, extensive endothelial denudation does not appear to occur. During the initial grafting period, the smooth muscle cells change from a contractile phenotype to a synthetic phenotype, migrate from the media, proliferate in the intima, and lay down connective tissue. Thereafter, endothelial cell changes regress and the smooth muscle cells return to their contractile phenotype. Perioperative manipulation of vein grafts results in decreased endothelial cell function but preservation of smooth muscle cell responsiveness. Postoperatively endothelial cell-mediated relaxation to acetylcholine is lost and smooth muscle cell contractility is decreased. Within 7 days after implantation, smooth muscle cell contractility returns and, with time, becomes markedly greater than that of the control vein. Endothelium-mediated relaxation to acetylcholine never returns in vein grafts and this loss of endothelial cell function appears to be related to receptor-coupled G-protein defects. Smooth muscle cell contractility remains abnormal. Many of the intimal hyperplastic lesions in vein grafts progress to stenosis or become sites of accelerated atherosclerosis. Control of intimal hyperplasia and the subsequent development of accelerated atherosclerosis remain important in the quest for long-term graft patency.