Development of a prostacyclin-agonist–eluting aortic stent graft enhancing biological attachment to the aortic wall Yoshiki Watanabe, MD, Shigeru Miyagawa,

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The Journal of Thoracic and Cardiovascular Surgery

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Development of a prostacyclin-agonist–eluting aortic stent graft enhancing biological attachment to the aortic wall Yoshiki Watanabe, MD, Shigeru Miyagawa, MD, PhD, Satsuki Fukushima, MD, PhD, Takashi Daimon, PhD, Yukitoshi Shirakawa, MD, PhD, Toru Kuratani, MD, PhD, Yoshiki Sawa, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 148, Issue 5, Pages 2325-2334.e1 (November 2014) DOI: 10.1016/j.jtcvs.2014.04.024 Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, ONO-1301 release curve of ONO-1301 microspheres synthesized with PLA polymers. The drug-eluting capacity was sustained even at 3 months after the initiation of degradation. B, The stent grafts were handmade and composed of stainless-steel Z stent and woven polyester graft. C, The canine abdominal aorta was exposed via the retroperitoneal approach. D, The stent graft was introduced into the thoracic aorta under fluoroscopic guidance, followed by post-balloon dilatation. E, Stent materials were removed from the extracted specimen and sectioned for assessments. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2325-2334.e1DOI: (10.1016/j.jtcvs.2014.04.024) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, ONO-1301 concentration in the aortic wall in the ONO(+) group. Although the drug concentration at the graft attachment site decreased over time, it remained in the effective range over 3 months (*P < .05 vs 1 month). B, Plasma ONO-1301 levels in the ONO-1301(+) group. The drug concentration remained below the safety level. C, Macroscopic view of the inner lumen. Neointimal formation and thrombus degradation progressed, and this process was observed earlier in the ONO(+) group. D, The exposed stent length decreased over time and was shorter in the ONO(+) group (†P < .05 vs 1 month of the corresponding group). ANOVA, Analysis of variance. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2325-2334.e1DOI: (10.1016/j.jtcvs.2014.04.024) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, Tensilon RTC-1150A (Orientec, Tokyo, Japan). B, Tension was applied to the specimen placed into the metallic cylinder of the machine using mosquito clamps. C, The maximal load required to displace the graft from the aortic wall was evaluated by the load-deformation plot. D, The maximum load needed to displace the graft fabric from the aortic wall increased over time and was greater in the ONO-1301(+) group than in the ONO(−) group, especially 2 months after surgery (*P < .05 vs ONO(−) group, †P < .05 vs 1 month of the corresponding group, ‡P < .05 vs 2 months of the corresponding group). ANOVA, Analysis of variance. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2325-2334.e1DOI: (10.1016/j.jtcvs.2014.04.024) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 A-C, Neointimal tissue was observed on the graft fabric; new tissue also was seen between the aortic wall and the graft fabric (HE staining: A, ONO(+); B, ONO(−) at 2 months; C, The scheme). D, Fibrotic area was assessed using Masson's trichrome staining. The % fibrotic area increased in a time-dependent manner and was greater in the ONO treatment group, especially at 2 and 3 months (% fibrotic area [%] = [fibrotic area]/[total tissue area]). Scale bar = 200 μm. E, Migrating cells into the graft fabric were assessed by HE staining. The cell density was greater in the ONO(+) group at both 1 and 2 months after the procedure (cell density = [cell counts]/[area of graft fabric]). Scale bar = 50 μm (*P < .05 vs ONO(−) group, †P < .05 vs 1 month of the corresponding group, ‡P < .05 vs 2 months of the corresponding group). ANOVA, Analysis of variance. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2325-2334.e1DOI: (10.1016/j.jtcvs.2014.04.024) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 A, Messenger RNA expressions of VEGF and SDF-1 were analyzed in the neointimal tissue (ie, area stained red). The expressions of VEGF and SDF-1 tended to be upregulated at 1 month and 3 months. B, Immunohistochemically, the IP receptor in the aortic wall was coexpressed with CD31-positive, αSMA-positive, and fibroblast-specific antigen-1–positive cells. Scale bar = 50 μm. C, The expressions of VEGF and SDF-1 were upregulated when ONO-1301 was added to the culture medium of aortic smooth muscle cells and aortic fibroblasts (*P < .05 vs 0 nM). FSP, Fibroblast specific antigen; SDF, stromal cell-derived factor; SMA, smooth muscle actin; VEGF, vascular endothelial growth factor; IP, prostacyclin; CD, cluster of differentiation. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2325-2334.e1DOI: (10.1016/j.jtcvs.2014.04.024) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 A and B, Adventitia of the aorta at 2 months in the ONO(+) group (A) and ONO(−) group. B, Solid line: stent graft implantation area, dotted line: nonimplantation area. C-F, CD31-positive capillary networks increased, and αSMA-positive components were denser in the neointimal tissues in the ONO(+) group than in the ONO(−) group (C and E, ONO(+); D and F: ONO(−) at 2 months). Scale bar = 500 μm. SMA, Smooth muscle actin; CD, cluster of differentiation. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2325-2334.e1DOI: (10.1016/j.jtcvs.2014.04.024) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions