(Circulation. 1999;99:1047-1053.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Arterial Flow Conditions Downregulate Thrombomodulin on Saphenous Vein Endothelium
From the Department of Vascular Surgery, Imperial College School of Medicine at Charing Cross, Charing Cross Hospital, London, UK.
Correspondence to Dr J.T. Powell, Imperial College School of Medicine at Charing Cross, Department of Vascular Surgery, Charing Cross Hospital, Fulham Palace Rd, London W6 8RF, UK. E-mail j.powell{at}ic.ac.uk
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Abstract |
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Background—The antithrombogenic properties of venous endothelium may be attenuated when vein is implanted in the arterial circulation. Such changes may facilitate thrombosis, which is the final common pathway for saphenous vein arterial bypass graft occlusion.
Methods and Results—Using human saphenous vein in a validated ex
vivo flow circuit, we investigated (1) the possibility that
arterial flow conditions (mean pressure, 100 mm Hg,
90 cpm, 
200 mL/min) alter the concentration of proteins involved in
regulating thrombosis at the vessel wall and (2) the influence of ion
channel blockade on such effects. Concentrations of thrombomodulin and
tissue factor were quantified by Western blotting (ratio of von
Willebrand factor staining) and immunohistochemistry (as a
percentage of CD31-staining area). Thrombomodulin concentrations after
90 minutes of venous and arterial flow conditions were
quantified by immunostaining (68.9±4.8% and
41.0±3.0% CD31, respectively; P<0.01) and by Western
blotting (1.35±0.20 and 0.15±0.03 ratio of von Willebrand
factor, respectively; P<0.01). The ability of
endothelial cells to generate activated protein
C also decreased from 62±14 to 19±10 ng ·
min-1 · 1000 cells-1
(P=0.01). The significant reduction in thrombomodulin
was attenuated if calcium was removed from the perfusate but
not by external vein stenting. Inclusion in the vein perfusate
of drugs that reduce calcium entry (including Gd3+, to
block stretch-activated ion channels, and
nifedipine) abolished the reduction in thrombomodulin
concentration observed after arterial flow conditions. In
freshly excised vein, negligible concentrations of tissue factor were
detected on the endothelium and concentrations did not
increase after 90 minutes of arterial flow conditions,
although the inclusion of nifedipine caused the
immunostaining to increase from 3.0±0.4% to
8.5±0.7% CD31 (P<0.02).
Conclusions—In saphenous vein endothelium exposed to arterial flow conditions, there is rapid downregulation of thrombomodulin, sufficient to limit protein C activation, by a calcium-dependent mechanism.
Key Words: veins • bypass • thrombosis • ions
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Introduction |
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In both the aortocoronary and infrainguinal circulations, thrombosis is the final common pathway leading to saphenous vein bypass graft occlusion. Normally, the endothelium provides an antithrombotic surface, with the expression of thrombomodulin and tissue plasminogen activator (tPA) on the endothelium contributing to this property. The preparation of vein for grafting causes considerable endothelial cell injury.1 In addition, the new hemodynamic forces placed on the endothelium, in vein grafts, have complex effects on gene expression.2 These hemodynamic forces may alter the expression of thrombomodulin, tPA, and tissue factor.3 4 5 6 In cultured bovine aortic endothelial cells, thrombomodulin protein concentration decreased 3- to 5-fold after 36 hours of exposure to high shear stress, with mRNA levels decreasing as early as 2 to 4 hours after the application of shear stress.6 In cultured human umbilical endothelial cells, both fluid flow and shear stress have been reported to stimulate mRNA levels and protein secretion of tPA.4 5 Similarly, although there is scant evidence for the expression of tissue factor in normal endothelium, in cultured cells the application of shear stress causes a transient increase in tissue factor procoagulant activity.6 In saphenous vein grafted into the arterial circulation, such changes could disturb the antithrombotic properties of endothelium in a manner that may predispose to bypass occlusion.
To facilitate investigation of the early adaptive responses of saphenous vein endothelium to arterial hemodynamics, we developed and validated an ex vivo arterial bypass circuit.7 External stenting of vein in vitro permits discrimination of effects attributable to increased flow and shear stress from effects attributable to circumferential deformation.7 Using this ex vivo circuit, we have been able to show rapid changes in the expression of endothelial proteins (eg, intercellular adhesion molecule–1, vascular cell adhesion molecule–1, and nitric oxide synthase) that participate in leukocyte adhesion.7 Here, we report on the changes in endothelial thrombomodulin and tissue factor expression, extending these studies to indicate the importance of ion channels in mechanotransduction events, when saphenous vein endothelium is subject to arterial flow conditions.
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Methods |
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Patients
Saphenous vein was harvested from patients undergoing aortocoronary or infrainguinal bypass, amputation, or high ligation of saphenous vein for correction of varicose veins, as approved by the local ethical committee. The vein segment was sected to provide 2 long lengths and a vein ring from the center. The vein ring was suspended in an organ chamber to confirm the presence of functional endothelium and smooth muscle, as described previously.8 Diseased vein that did not respond to phenylephrine (10 µmol/L) with a contraction of >2g and then relax in response to A23187 (1 µmol/L) was discarded. Samples from recent smokers and patients with diabetes were excluded.
Materials
Modified Krebs' solution (118.4 mmol/L NaCl, 4.7
mmol/L KCl, 1.2 mmol/L
KH2PO4, 1.2 mmol/L
MgSO4 · 0.7H2O,
11.1 mmol/L glucose, 24.9 mmol/L
NaHCO3, 2.5 mmol/L
CaCl2) was made fresh each day. Antibodies for
immunohistochemistry and Western blotting were obtained as follows:
platelet endothelial cell adhesion molecule–1
(CD31, monoclonal; R&D Systems), P-selectin and tPA (monoclonals;
Serotec), tissue factor (monoclonal was the kind gift from Dr John
McVey, Clinical Sciences Center, Royal Postgraduate Medical School,
London, UK W12; polyclonal was the kind gift from Prof Y. Nemerson,
Mount Sinai School of Medicine, New York), thrombomodulin (monoclonals
24FM and 3EZ were the kind gifts from Dr J. Amiral, Serbio
Research Laboratory, Gennevilliers, France), and polyclonal antibodies
to von Willebrand factor (vWF; DAKO). Antibodies for the
characterization of isolated endothelial cells included
vWF and CD31 (as above), anti–smooth muscle cell actin, and CD45
(DAKO). Enhanced chemiluminescence (ECL) Western blotting reagents were
obtained from Amersham UK. Unless specified, other reagents were
obtained from Sigma.
Flow Circuit
Saphenous vein (3 to 4 cm) was mounted in a retaining jig,
placed in an in vitro flow circuit, and perfused with
oxygenated Krebs' solution, and the internal diameter was
monitored as described previously.9 Veins were exposed
either to pulsatile flow (90 cpm) at a mean pressure of 100 mm Hg
(arterial flow) for 45 to 90 minutes (flow rate, 200 to 225
mL/min; shear stress, 0.26±0.09 N/m2) or to
nonpulsatile flow at 20 mm Hg (venous flow) for 90 minutes (flow
rate, 10 to 20 mL/min; shear stress, 0.021±0.011
N/m2). Some veins were placed inside a tube (2 to
4 cm in length) of externally supported polytetrafluorethylene, which
was nonrestrictive but sized to limit circumferential distention of the
vein during arterial flow (shear stress, 0.40±0.13
N/m2). In some experiments, the Krebs' solution
perfusing the vein was supplemented with ion channel blockers. After 45
or 90 minutes, the vein was removed, the ends were discarded, and the
remainder was divided for histology or immunohistochemistry or used for
harvesting of endothelial cells. The Krebs' solution
perfusing the vein was sampled at 15-minute intervals and later
concentrated 100-fold through an Amicon filter with a 3000-Da exclusion
limit, and the concentrates were stored at –70°C.
Immunohistochemistry
Vein specimens for immunohistochemical analysis were
fixed in Zamboni's solution and prepared, and serial cryostat sections
were stained through use of the ABC immunoperoxidase
method7 10 with the use of monoclonal antibodies at the
following dilutions: to endothelial nitric oxide
synthase (1:10 000), to P-selectin (1:1000), to tPA (
1:10), to
thrombomodulin 24FM (1:5000), and to CD31 (1:1000): Polyclonal
antibodies to tissue factor were used at 1:25 dilution. The area of
immunostaining was computed from serial sections as
described previously.7 To allow for the small
endothelium loss noted from CD31
immunostaining and the dilation that occurs in response
to arterial flow, the staining areas for P-selectin,
thrombomodulin, and tissue factor were expressed as a percentage of
CD31 staining.
Western Blotting
Endothelial cells were harvested from freshly
excised veins and veins exposed to the different flow conditions as
described previously.7 The yield of
endothelial cells, estimated with the use of a
hemocytometer, ranged between 5000 and 10 000 cells per vein and
contained >95% endothelial cells, <2% leukocytes,
and <2% smooth muscle cells. Cells were collected, as a pellet, and
dispersed in lysis buffer (10 mmol/L Tris, pH 8, 1 mmol/L
EDTA, 2.5% SDS, 5% mercaptoethanol) before SDS-PAGE (Phast System 8%
to 25% gradient acrylamide gel) as described
previously.7 The primary antibodies used were
thrombomodulin at 1:200 dilution, monoclonal to tissue factor at 1:500
dilution, tPA at 1:25 dilution, CD31 at 1:1000 dilution, and vWF at
1:1000 dilution. Proteins were visualized with ECL and quantified with
densitometric scanning. If possible, changes in thrombomodulin and
tissue factor staining were standardized with respect to vWF staining.
To minimize inconsistencies, paired samples always were processed
together, there was simultaneous development of
thrombomodulin or tissue factor and vWF, and only band densities within
the linear ECL signal range were assessed. For experiments using A23187
or veins perfused with calcium-free Krebs' solution, the staining of
CD31 and thrombomodulin or tissue factor was performed on separate gels
because of molecular weight similarities.
Activation of Protein C to Assess Thrombomodulin Activity
Endothelial cells were harvested through the use
of collagenase digestion,7 resuspended, and
washed 3 times in 50 mmol/L Tris buffer, pH 8.0, containing 2
mmol/L CaCl2, 0.1 mol/L NaCl, and 0.1% BSA. The
cell suspension was incubated with 1.0 µg protein C and 0.1 µg
thrombin (both from Enzyme Research Laboratories), and the activation
of protein C was measured as described previously.11 The
assay was calibrated using activated protein C (Enzyme Research
Laboratories). The endothelial cells used in these
assays were quantified using monoclonal antibodies to CD31. Briefly,
cells were incubated at 4°C with antibody CD31 (diluted 1:80 in PBS
containing 5% fetal calf serum, 1 µg/mL pepstatin,1 µg/mL
leupeptin, and 0.1 mmol/L phenylmethylsulfonyl fluoride).
Cells were harvested by centrifugation, washed 3 times
in the same PBS-based buffer as above, sequentially incubated, and
washed with biotinylated second antibody and a streptavidin-peroxidase
conjugate before the development of the peroxidase activity with a
chromogenic substrate. Cultured human saphenous vein
endothelial cells (1000 to 25 000) were used to
calibrate the assay, and cultured human aortic smooth muscle cells
(25 000) were used as a negative control. The results are given as
generation of activated protein C (ng ·
min-1 · 1000
cells-1).
Statistical Analysis
Immunostaining areas (mean±SEM) and staining of
Western blots were compared using Student's t test for
paired comparisons.
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Results |
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Expression of Thrombomodulin on Saphenous Vein Endothelium: Influence of Pulsatile Arterial Flow Conditions on Unstented and Stented Vein
The abundant immunostaining for thrombomodulin on the endothelium of freshly excised veins was unchanged after exposure to venous flow circuits for 90 minutes (Table 1
). After exposure to
arterial flow conditions for 45 or 90 minutes, there was
decreased thrombomodulin staining (Figure 1), with a significant 2-fold decrease in
the ratio of thrombomodulin to CD31 staining area (Table 1).
These changes were accentuated in Western blotting experiments (Figure 2a). The staining ratio of thrombomodulin
to vWF was similar in lysates of cells from freshly excised vein
(1.5±0.2) and cell lysates from vein subjected to venous flow
conditions (1.35±0.2) but decreased markedly after the vein had been
exposed to arterial flow conditions for 90 minutes (to
0.15±0.03, P<0.01, 6 paired samples, compared with venous
flow conditions). A reduction in thrombomodulin/vWF staining ratio also
was evident after 45 minutes of arterial flow conditions
(staining ratio, 0.60±0.1, P=0.02, 4 paired samples,
compared with freshly excised vein). The temporal changes in
thrombomodulin are summarized in Figure 3.
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There was no evidence of thrombomodulin in the concentrated vein perfusate after 90 minutes of arterial flow conditions by either Western blotting or dot-blotting (the minimum concentration that could be detected was 2 pg or 100 pg/mL), mitigating against surface shedding of thrombomodulin. External stenting of vein with polytetrafluorethylene to limit circumferential and radial deformation did not alter the reduction in thrombomodulin concentration observed after exposure to arterial flow conditions for 90 minutes. The immunostaining area for thrombomodulin in stented vein exposed to arterial flow conditions was 41.0±3.0 compared with 68.9±4.8 for stented vein subjected to venous flow conditions (P<0.01, 5 paired samples).
Activation of Protein C by Endothelial Cells
Harvested After Venous and Arterial Flow
Conditions
After 90 minutes of arterial flow conditions,
the ability of isolated endothelial cells to
activate protein C had decreased 3-fold compared with cells
isolated after 90 minutes of venous flow conditions (from 62±6 to
19±4 ng · min-1 · 1000
cells-1, respectively, 6 paired samples,
P=0.01; Figure 3
).
Expression of tPA and Tissue Factor in Saphenous Vein
Endothelium: Influence of Pulsatile Arterial
Flow
In freshly excised vein, there was scant
endothelial staining for either tissue factor (Figure 4a) or tPA, even at primary antibody
concentrations of 1:10. There was no evidence of altered
endothelial staining after exposure to
arterial flow conditions for 45 or 90 minutes or to venous
flow conditions for 90 minutes. In veins in which smooth muscle cells
were present in the intima, staining for tissue factor in the
intimal muscle cells was observed after exposure of veins to
arterial flow conditions for 90 minutes (Figure 4b).
Tissue factor was more readily detected in endothelial
cell lysates. There was no change in the tissue factor/vWF ratio, as
observed with Western blotting, after 90 minutes of
arterial or venous flow conditions (6 paired samples): the
results are shown in Table 2. Western
blotting failed to detect tPA in endothelial cell
lysates. Because tPA is secreted rapidly after synthesis, the presence
of tPA in the vein perfusate was investigated with both Western
blotting and dot blotting, but no tPA was detected. As reported
previously, arterial flow conditions for 90 minutes had no
effect on the endothelial concentration of
P-selectin7 : baseline results for
immunostaining area are given in Table 1.
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Ion Channel Blockade: Limitation of Flow Responses
First, it was necessary to establish whether the expression of the
selected endothelial proteins was altered by ion
channel blockers alone. In the absence of flow, the incubation of vein
for 90 minutes in oxygenated Krebs' solution supplemented
with 3 mmol/L tetraethylammonium
chloride (TEA) (to block K+ channels),
30 µmol/L glibenclamide (to block KATP
channels), 10 µmol/L Gd3+ (to block
stretch-activated cation channels), or 20 µmol/L
nifedipine (to block voltage-gated calcium channels) did
not alter the immunostaining area of any of the
selected endothelial proteins (data not shown). For
veins perfused under venous flow conditions for 90 minutes with Krebs'
with or without TEA, there were no changes in the
immunostaining area of thrombomodulin or tissue factor
(Table 1). For the other ion channel blockers, there usually was
insufficient length of vein to conduct venous flow condition controls,
and only arterial flow condition experiments are reported
in Tables 1 and 2, using vein incubated in Krebs' supplemented
with the appropriate channel blocker as the control. Inclusion of ion
channel blockers in the vein perfusate did not alter the
immunostaining area of P-selectin after 90 minutes of
arterial flow conditions. The reduction in thrombomodulin
concentration, after arterial flow conditions, was
abolished when either Gd3+ (10 µmol/L) or
nifedipine (20 µmol/L) was included in the vein
perfusate: the results for immunostaining are
shown in Table 1, and the results for Western blotting are shown
in Table 2. Inclusion of TEA in the vein perfusate did
not abolish the arterial flow–induced decreases in
immunostaining area or the thrombomodulin concentration
observed on Western blotting (Tables 1 and 2). Inclusion of
nifedipine in the vein perfusate resulted in a
significant increase in the endothelial concentration
of tissue factor, with clear evidence of endothelial
staining (Figure 4c and Table 1). These results were
confirmed by Western blotting. The tissue factor/vWF ratio in
endothelial cell lysates increased from 0.25±0.06 to
0.35±0.10 (5 paired samples, P=0.04) from control vein and
vein exposed to arterial flow conditions for 90 minutes,
respectively (Figure 2b and Table 2). The inclusion of
glibenclamide in vein perfusate did not abrogate the changes in
immunostaining area, observed after 90 minutes of
arterial flow conditions, for any of the
endothelial proteins assessed (Table 1). The
marked endothelial cell loss (>50%) after perfusion
of vein, under arterial flow conditions for 90 minutes,
with calcium-free solutions precluded the assessment of
immunostaining areas under these conditions. However,
remaining cells could be isolated for Western blotting and functional
assays. The Western blotting experiments showed no reduction in
thrombomodulin (n=3). The ability of cells, harvested after
arterial or venous perfusion in the absence of calcium, to
generate activated protein C was 84±14 and 60±8 ng ·
min-1 · 1000
cells-1, respectively (n=3).
Augmentation of Endothelial Cell Calcium
Concentrations With A23187
Perfusion under venous conditions or incubation of vein rings with
0.5 µmol/L A23187 for 90 minutes effected a 2-fold reduction in
immunostaining area for thrombomodulin. The staining
area for thrombomodulin decreased from 73.5±6.1 in the absence of
A23187 to 44.3±5.3 in the presence of 0.5 µmol/L A23187
(P<0.01, 5 paired samples, venous flow conditions for 90
minutes). Because A23187 stimulates the secretion of vWF, albeit at
concentrations >1 µmol/L,12 Western blotting
for CD31 was performed. Venous perfusion conditions with A23187
decreased the staining ratio (thrombomodulin/CD31) from 1.32±0.3 to
0.33±0.08 (4 paired samples, P<0.03). There also was a
2-fold reduction in the thrombomodulin/vWF staining ratio. After
experiments in the presence and absence of A23187, the ability of
isolated endothelial cells to generate
activated protein C was 15±4 and 49±9 ng ·
min-1 · 1000
cells-1, respectively (n=3).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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The prevention of thrombosis in saphenous vein bypass grafts is an important therapeutic goal that has provided the impetus for randomized trials of both antiplatelet and anticoagulant drugs after bypass surgery.13 14 15 16 The disappointing results of some of these trials, with respect to graft patency, emphasize the gaps in our understanding of how the antithrombotic surface of saphenous vein endothelium is altered when vein is implanted in the arterial circulation. Here, we show that the concentration of thrombomodulin on saphenous vein endothelium is downregulated rapidly in response to arterial flow conditions, whereas the changes in tissue factor expression are either slower or much more subtle. Our results also indicate that these changes in thrombomodulin concentration could be mediated by changes of calcium flux into the endothelium.
The antithrombogenic properties of thrombomodulin include the sequestration of thrombin and the activation of protein C by the thrombomodulin-thrombin complex.17 Protein C deficiency, traditionally associated with venous thrombosis, has been reported in association with peripheral arterial thrombosis,18 19 and recently, variations in the thrombomodulin gene have been associated with coronary artery thrombosis.20 In cultured cells, the thrombomodulin-protein C pathway has been shown to regulate the thrombogenic properties of endothelium under shearing conditions simulating both the venous and arterial circulation.21 Thrombomodulin is only 1 component of the antithrombogenic system of vascular endothelium: Other components include heparan sulfates, plasminogen activator, tissue factor inhibitor, and the endothelium-derived vasodilators nitric oxide and prostacyclin, many of which are regulated by shear stress. In addition, preparation of the vein for grafting injures the endothelium, which may expose underlying tissue factor or promote tissue factor synthesis. Nevertheless, downregulation of endothelial thrombomodulin may be an important factor predisposing to early vein graft occlusion.
We have shown downregulation of thrombomodulin on saphenous vein
endothelium within 45 to 90 minutes of exposure to
arterial flow conditions. This downregulation of
thrombomodulin appears to result from the increase in shear stress
rather than circumferential deformation because external vein stenting
did not alter the rapid reduction in thrombomodulin concentration. This
rapid reduction in thrombomodulin concentration by modest shear stress
(0.4 N/m2) contrasts with the findings in
cultured bovine aortic endothelial cells, in which
reductions in thrombomodulin mRNA concentrations were not observed at
comparable levels of shear stress.3 Even at higher levels
of shear stress (1.5 to 3.6 N/m2), a reduction in
thrombomodulin mRNA was not observed until after 6 to 9 hours, and a
reduction in protein concentration was not observed until after 36
hours.3
For most of this study, we used immunostaining as the primary technique to investigate thrombomodulin expression and confirmed the direction of all the important findings by Western blotting. Because we failed to detect any thrombomodulin in the vein perfusate, thrombomodulin may be recycled and degraded. This would be consistent with the findings in cultured endothelial cells, in which cytokines and phorbol esters stimulated internalization and degradation of thrombomodulin to reduce surface activity.22 Equally, it is possible that our techniques were not sufficiently sensitive to record circulating thrombomodulin. Unfortunately, we have not been able to explore whether the arterial flow–induced downregulation of thrombomodulin on saphenous vein endothelium diminishes the antithrombogenic properties of endothelium in situ. Although others have quantified thrombomodulin activity on saphenous vein using chromogenic assays,23 this method could not be used in our system with the problems of endothelial cell loss and increase in vein diameter in response to arterial flow conditions. However, we have shown that the ability of endothelial cells to activate protein C was markedly reduced after 90 minutes of arterial flow conditions.
The responses of endothelium to hemodynamic forces occur over a time frame ranging from minutes to days.2 In the intermediate-early period (0 to 90 minutes), we could find no evidence to support the altered expression of tissue factor, and tPA was not detected at all. These may be later changes, as they are in cultured endothelial cells exposed to shear stress.3 4 5 6 In only a single condition, nifedipine in the vein perfusate, was significant tissue factor staining observed on endothelium.
Potassium channels have been considered important in transducing
signals from increased shear stress into changes in
endothelial gene expression.24 25
Perfusion of vein with either the nonselective potassium channel
blocker TEA or the KATP channel blocker
glibenclamide did not alter the downregulation of thrombomodulin in
response to arterial flow conditions (Table 1). A
role for calcium in transducing signals from increased shear stress
also should be considered because the application of shear stress to
cultured endothelial cells increases intracellular
calcium concentrations.26 Low concentrations of the
calcium ionophore A23187 caused a significant reduction in
thrombomodulin concentration. In contrast, perfusion of vein with
gadolinium or nifedipine prevented the thrombomodulin
downregulation. Perfusion of vein with calcium-free Krebs' solution
also prevented the downregulation of thrombomodulin, with
endothelial cells retaining their full thrombomodulin
functional activity. The effect of nifedipine, which
selectively blocks L-type voltage-gated calcium channels, was
unexpected. Although these channels are present in vascular smooth
muscle, there is limited evidence for the presence of these channels in
endothelium.27 However, in arterioles,
electrotonic coupling from smooth muscle to endothelium
has been reported, with elevation of calcium concentrations in smooth
muscle, caused by vasoconstrictors, leading to increased
endothelial calcium concentrations.28 A
similar phenomenon may account for the effects of
nifedipine we observe.
In summary, we have shown that there is rapid downregulation of thrombomodulin concentration and functional activity in the endothelium of saphenous vein exposed to arterial flow conditions. These changes are a response to increased flow or shear stress rather than circumferential deformation. The relevance of these findings to vein bypass graft occlusion is a topic of current investigation.
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Acknowledgments |
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We thank all the cardiac and vascular surgeons who have provided us with saphenous vein, David Lane for constructive criticism, and the British Heart Foundation for research support.
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Footnotes |
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1 These authors contributed equally to this work.
Received August 13, 1998; revision received November 11, 1998; accepted November 11, 1998.
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