Paclitaxel coating of the luminal surface of hemodialysis grafts with effective suppression of neointimal hyperplasia Insu Baek, MS, Cheng Zhe Bai, PhD,

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Paclitaxel coating of the luminal surface of hemodialysis grafts with effective suppression of neointimal hyperplasia Insu Baek, MS, Cheng Zhe Bai, PhD, Jinsun Hwang, MS, Hye Yeong Nam, PhD, Jong-Sang Park, PhD, Dae Joong Kim, MD Journal of Vascular Surgery Volume 55, Issue 3, Pages 806-814.e1 (March 2012) DOI: 10.1016/j.jvs.2011.09.012 Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 1 Diagrams show the graft–venous anastomosis. A, Neointimal hyperplasia can easily build up at the junction of expanded polytetrafluoroethylene (ePTFE) graft and vein. Serial sections were taken to obtain cross-sections around the center of the graft–venous anastomosis, and three of these sections were analyzed to find the mean percentage of luminal stenosis. One section was obtained at the center of the anastomosis; the others were obtained 2 mm to the proximal side and 2 mm to the distal side from the center of the anastomosis. B, Intragraft and venous region of the cross-section is shown. Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 2 Gradient loading of paclitaxel from the inner to the outer wall, according to the various acetone/water ratios (v/v) of coating solutions: 7:3, 8:2, 9:1, and only acetone. After centrifugation of the unseasoned expanded polytetrafluoroethylene (ePTFE) graft wrapped with PTFE tape, the amount of paclitaxel loading in the PTFE tape was considered the index for in-depth penetration of the coating solution from the luminal surface to the graft wall. The outer ratio of paclitaxel was calculated as the paclitaxel amount on the PTFE tape divided by the total amount of paclitaxel (ie, on both the ePTFE graft and the PTFE tape). Data are the means of five experiments, and the bars represent the standard error. Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 3 Scanning electron microscope images of expanded polytetrafluoroethylene (ePTFE) grafts (A) before and (B) after drug coating. After paclitaxel coating, no significant difference was observed in the surface morphology of the ePTFE graft. Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 4 Cumulative in vitro release profiles from the paclitaxel-coated grafts made by the dipping method and by the inner-coating method of low dose and high dose (P < .001 by repeated measures analysis of variance). Data are the means of five experiments, and the bars represent standard error. Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 5 Representative cross-sections of the graft–venous anastomosis from (A and B) control grafts and from (C and D) low-dose and (E and F) high-dose paclitaxel inner-coated grafts (Masson's trichrome stain). Neointima can be recognized as the pale blue stained area in the intragraft and venous region of the cross-section. Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 6 Comparison of the (A) percentage of luminal stenosis and the (B) neointimal area between the control (n = 6) and the paclitaxel inner-coated groups (low dose, n = 6; high dose, n=6). *Mean value of each group. All differences between the control and paclitaxel inner-coated groups were statistically significant (P < .05 with unpaired Student t-test). Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 7 The cellular phenotypes of surrounding tissue outside the graft are shown in sequential sections of (A-C) control and (D-F) low-dose paclitaxel inner-coated grafts, immunohistochemically stained for (A and D) α-smooth muscle actin (α-SMA), (B and E) vimentin, and (C and F) desmin. Arrow a indicates spindle-shaped myofibroblasts, which were SMA-positive, vimentin-positive, and desmin-negative. Arrow b indicates fibroblasts, which were SMA-negative, vimentin-positive, and desmin-negative. Arrow c indicates contractile smooth muscle cells, which were SMA-negative, vimentin-negative, and desmin-positive (original magnification, ×400). Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Fig 8 Semiquantitative scores of cellular phenotypes in surrounding tissue outside the graft wall, the site of which is indicated in Fig 1, B. SMA, Smooth muscle actin. The error bars show the standard error. Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions

Light photomicrographs of implanted grafts and surrounding tissues in (A) the control grafts and (B) low-dose and (C) high-dose paclitaxel inner-coated grafts. The distributions and the numbers of inflammatory cells, such as leukocytes, were similar between two groups, which suggested that paclitaxel inner-coated expanded polytetrafluoroethylene grafts did not affect the inflammation compared with the noncoated control graft (hematoxylin and eosin staining, original magnification ×400). Journal of Vascular Surgery 2012 55, 806-814.e1DOI: (10.1016/j.jvs.2011.09.012) Copyright © 2012 Society for Vascular Surgery Terms and Conditions