Vein graft adaptation and fistula maturation in the arterial environment

Abstract

Veins are exposed to the arterial environment during two common surgical procedures, creation of vein grafts and arteriovenous fistulae (AVF). In both cases, veins adapt to the arterial environment that is characterized by different hemodynamic conditions and increased oxygen tension compared with the venous environment. Successful venous adaptation to the arterial environment is critical for long-term success of the vein graft or AVF and, in both cases, is generally characterized by venous dilation and wall thickening. However, AVF are exposed to a high flow, high shear stress, low-pressure arterial environment and adapt mainly via outward dilation with less intimal thickening. Vein grafts are exposed to a moderate flow, moderate shear stress, high-pressure arterial environment and adapt mainly via increased wall thickening with less outward dilation. We review the data that describe these differences, as well as the underlying molecular mechanisms that mediate these processes. Despite extensive research, there are few differences in the molecular pathways that regulate cell proliferation and migration or matrix synthesis, secretion, or degradation currently identified between vein graft adaptation and AVF maturation that account for the different types of venous adaptation to arterial environments.

Keywords: Arteriovenous fistula; Environment; Hemodynamic forces; Remodeling; Vein graft.

Figure 1

Schema of vein graft adaptation and AVF maturation. AVF adapt largely through outward remodeling in response to supra-arterial flow, whereas vein grafts adapt largely through intimal/medial thickening in response to arterial pressure.

Figure 2

Diagram depicting molecular pathways mediating venous adaptation to the arterial environment.