Nitric oxide–releasing biopolymers inhibit thrombus formation in a sheep model of arteriovenous bridge grafts Paul S. Fleser, MD, Vijay K. Nuthakki,

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Nitric oxide–releasing biopolymers inhibit thrombus formation in a sheep model of arteriovenous bridge grafts Paul S. Fleser, MD, Vijay K. Nuthakki, MD, Lauren E. Malinzak, MD, Rose E. Callahan, MS, Marilyn L. Seymour, BS, Melissa M. Reynolds, PhD, Scott I. Merz, PhD, Mark E. Meyerhoff, PhD, Phillip J. Bendick, PhD, Gerald B. Zelenock, MD, Charles J. Shanley, MD Journal of Vascular Surgery Volume 40, Issue 4, Pages 803-811 (October 2004) DOI: 10.1016/j.jvs.2004.07.007 Copyright © 2004 The Society for Vascular Surgery Terms and Conditions

Fig 1 Schematic representation of nitric oxide (NO) release from polymer coating. At luminal surface of the NO-releasing graft is a thin layer of pure polymer outer coating consisting entirely of polyvinyl chloride (PVC) polymer. Beneath the outer coating is a PVC polymer suspension containing the NO-releasing compound (NO-RC). As water diffuses from the blood, it contacts the NO-releasing compound within the suspension. This enables release of free NO into the lumen of the vessel, where local activity on platelets is established. Systemic NO effects are averted, because NO is quickly scavenged by oxygen and hemoglobin of local red blood cells. Journal of Vascular Surgery 2004 40, 803-811DOI: (10.1016/j.jvs.2004.07.007) Copyright © 2004 The Society for Vascular Surgery Terms and Conditions

Fig 2 Representativegross photographs of explanted polyurethane vascular grafts. Grafts were opened longitudinally to display luminal thrombus. A, Uncoated control graft. B, Sham-coated graft without nitric oxide–releasing biopolymer. C, Graft incorporating nitric oxide–releasing polymer coating on luminal surface. Journal of Vascular Surgery 2004 40, 803-811DOI: (10.1016/j.jvs.2004.07.007) Copyright © 2004 The Society for Vascular Surgery Terms and Conditions

Fig 3 A, Schematic diagram demonstrating site of histologic sections of arteriovenous graft specimens. B, Hematoxylin-eosin–stained histologic sections from uncoated graft. Note abundance of thrombus at luminal surface of uncoated graft; arrowheads, red blood cell infiltration. Magnification ×40. C, Hematoxylin-eosin–stained histologic sections from nitric oxide–releasing graft. Luminal surface has thin fibrin coating in some specimens, but is free of attached thrombus. Cellular infiltration is not seen within the graft wall. Magnification ×40. Luminal surface toward top of photograph. Journal of Vascular Surgery 2004 40, 803-811DOI: (10.1016/j.jvs.2004.07.007) Copyright © 2004 The Society for Vascular Surgery Terms and Conditions

Fig 4 Explanted grafts were examined with scanning electron microscopy to show platelet adhesion and thrombus accumulation on graft surfaces. A-D, Magnification ×1000. A and B, Representative specimens from arterial anastomoses of 2 different nitric oxide–releasing grafts. Thin coating of fibrin is visible in specimen A as a mottled background of thin fibrils. Isolated platelets and 5% to 20% coverage of red and white blood cells are noted in both specimens. Most platelets appear inactivated when viewed at higher magnification (not shown). C and D, Representative specimens from arterial anastomoses of 2 sham-coated grafts. Specimen C shows approximately 50% coverage of red and white blood cells, isolated platelets, and platelet clumps. Some platelets appear activated when viewed at higher magnification (not shown). Specimen D shows complete coverage with complex thrombus consisting of red blood cells and occasional inflammatory cells in a heavy fibrin matrix. Journal of Vascular Surgery 2004 40, 803-811DOI: (10.1016/j.jvs.2004.07.007) Copyright © 2004 The Society for Vascular Surgery Terms and Conditions

Fig 5 In vitro nitric oxide (NO) release over 25 days from surface-coated polyurethane graft. Sample of the polyurethane graft coated with the NO-releasing compound was removed from the graft before implantation, and tested for NO release in vitro over 25 days. NO release is linear for approximately 1 week. Although kinetics of release appear to level off after approximately 12 days, NO surface flux level is still at or above that generated by endothelial cells in vivo. Journal of Vascular Surgery 2004 40, 803-811DOI: (10.1016/j.jvs.2004.07.007) Copyright © 2004 The Society for Vascular Surgery Terms and Conditions