Conformational stress and anastomotic hyperplasia.

Late failure of synthetic vascular grafts to small-diameter arteries (less than or equal to 4 mm) is commonly due to anastomotic hyperplasia. Theoretic analysis suggests that conformational changes at the anastomosis lead to high localized arterial wall stress caused by increases in radius of curvature of the artery (law of Laplace: tension = pressure X radius). Nine 3 kg rabbits had a plastic insert implanted into the infrarenal aorta. The insert was designed to recreate the conformational changes caused by the anastomosis of a synthetic graft to a small-diameter artery, without significantly altering blood flow. The increase in arterial wall tension created by the insert was calculated to be 80% to 100% over baseline values. Aortography, real-time ultrasound, and computed tomography (CT) scanning were done to confirm the absence of luminal thrombus formation or migration of the insert. Ultrasound and CT scans also confirmed the desired conformational changes in the aorta at the site of the insert. Aortas, with the inserts in place, were removed from 3 days to 6 months after implantation. Implantation times of 1 to 6 months resulted in a hyperplastic subintimal lesion characterized by fibrous tissue deposition, spindle cells (which may have been fibroblasts), and/or smooth muscle cells covered by endothelium. In contrast, two rabbits that had the insert placed and then removed at 1 minute and were allowed to survive for 37 and 72 days, respectively, demonstrated complete healing of the aorta without anastomotic hyperplasia. The arterial wall conformational changes induced in this experiment led to the formation of a lesion consistent with anastomotic hyperplasia. An increase in wall tension may have been the stimulus for this response. Prevention of anastomotic hyperplasia may require a means of uniting a graft to an artery without increasing wall tension.