Computational Model of Device-Induced Thrombosis and Thromboembolism

A numerical model of thrombosis/thromboembolism (T/TE) is presented that predicts the progression of thrombus growth and thromboembolization in low-shear devices (hemodialyzers, oxygenators, etc.). Coupled convection–diffusion-reaction equations were solved to predict velocities, platelet agonist (ADP, thromboxane A2, and thrombin) concentrations, agonist-induced and shear-induced platelet activation, and platelet transport and adhesion to biomaterial surfaces and adherent platelets (hence, thrombus growth). Single-platelet and thrombus embolization were predicted from shear forces and surface adhesion strengths. Values for the platelet-biomaterial reaction constant and the platelet adhesion strength were measured in specific experiments, but all other parameter values were obtained from published sources. The model generated solutions for sequential time steps, while adjusting velocity patterns to accommodate growing surface thrombi.Heparinized human blood was perfused (0.75 ml/min) through 580 μm-ID polyethylene flow cells with flow contractions (280 μm-ID). Thrombus initiation, growth, and embolization were observed with videomicroscopy, while embolization was confirmed by light scattering, and platelet adhesion was determined by scanning electron microscopy.Numerical predictions and experimental observations were similar in indicating: 1) the same three thrombotic locations in the flow cell and the relative order of thrombus development in those locations, 2) equal thrombus growth rates on polyethylene and silicon rubber (in spite of differing overall T/TE), and 3) similar effects of flow rate (1.5 ml/min versus 0.75 ml/min) on platelet adhesion and thrombosis patterns.     

The role of Fbg in platelet adhesion to polymeric materials in conditions of psychological stress.

The effect of psychological stress on platelet adhesion to five polymeric materials (polyurethane, polyurethane filled with BaSO4, polyethyleneterephthalate, silicone and low-density polyethylene) was studied. The platelets were obtained from non-stressed and stressed rabbits as platelet-rich plasma (PRP) and, once washed (Pw), were suspended in different media, i.e. in platelet poor plasma (Pw-PPP), in serum (Pw-S) and in Krebs-Ringer solution (Pw-KR). Scanning electron microscopy of platelet adhesion and morphology revealed differences in the platelet activating power of the various materials. The washing procedure and resuspension in PPP generally resulted in an increased number of adherent platelets, compared with the number of platelets adherent to the same material in PRP. However, platelets washed and suspended in Pw-KR or Pw-S showed the same shape distribution as in PRP. When platelets from stressed rabbits were used, there was very strong aggregation and activation of the platelets in both PRP and Pw-PPP, independent of the chemical nature and surface structure of the material. In contrast, in Pw-KR and Pw-S (in which Fbg is absent) a general picture of single, not very modified platelets was observed. Their number and shapes changed according to the nature of the different materials. On the whole, the present results confirm our original hypothesis of a key role of the psychological condition of the blood donor and strongly indicate Fbg as the determinant factor in the pattern of platelet adhesion.     

Thromboresistance of alkali- and heat-treated titanium metal formed with apatite

Fibrin deposition and platelet adhesion onto alkali- and heat-treated titanium metal (AH-Ti), alkali- and water-treated titanium metal (Wa-Ti), and alkali- and heat-treated titanium metal formed with apatite (Ap-Ti) in simulated body fluid (SBF) were evaluated by exposure to anticoagulated blood or washed platelet suspension (WPS) under static conditions and subsequent observation with scanning electron microscopy (SEM). The results were compared with those for commercially pure titanium metal (cp-Ti). Thrombus formation on AH-Ti and Wa-Ti, which were exposed to heparinized whole blood for 1 h, was significantly less than that on cp-Ti, on which pronounced depositions of fibrin-erythrocytes and lymphocytes were observed. No thrombus was observed on Ap-Ti, possibly because of a high adsorption of heparin. Morphological change of platelets attached to surfaces via adsorbed plasma proteins was found to a significant extent on AH-Ti and Wa-Ti exposed to WPS. However, there was almost no difference between cp-Ti and Ap-Ti in round morphology of adherent platelets. These findings suggested that Ap-Ti exhibits stronger antithrombogenic characteristics than cp-Ti and other materials examined in heparinized blood.     

Activation of platelets adhered on amorphous hydrogenated carbon (a-C:H) films synthesized by plasma immersion ion implantation-deposition (PIII-D)

Amorphous carbon films have attracted much attention recently due to their good biocompatibility. Diamond-like carbon (DLC), one form of amorphous carbon that is widely used in many kinds of industries, has been proposed for use in blood contacting medical devices. However, the blood coagulation mechanism on DLC in a biological environment is not well understood. Platelet adhesion and activation are crucial events in the interactions between blood and the materials as they influence the subsequent formation of thrombus. In this work, the behavior of platelets adhered onto hydrogenated amorphous carbon films (a-C:H) is investigated. Hydrogenated amorphous carbon films with different hydrogen contents, structures, and chemical bonds were fabricated at room temperature using plasma immersion ion implantation-deposition (PIII-D). The wettability of the films was investigated by contact angle measurements using several common liquids. Platelet adhesion experiments were conducted to examine the interaction of blood with the films in vitro and the activation of adherent platelets. The results show that the behavior of the platelets adhered on the a-C:H films is influenced by their structure and chemical bond, and it appears that protein interaction plays a key role in the activation of the adherent platelets.     

Effects of fibrinogen residence time and shear rate on the morphology and procoagulant activity of human platelets adherent to polymeric biomaterials

Fibrinogen readily adsorbs to the surface of biomaterials and, because of its demonstrated ability to support platelet adhesion and aggregation, plays a role in thrombotic events associated with the implantation of synthetic materials in the human body. Thus, understanding the factors influencing the interactions of fibrinogen with biomaterials, and how platelet responses are affected, is crucial for the development of synthetic materials exhibiting improved blood compatibility. In this study, the effects of fibrinogen residence time and shear rate on the procoagulant activity of adherent platelets, along with their morphologic status, as deduced from scanning electron microscopy, were investigated. To examine whether adherent platelets promoted the generation of thrombin, polymeric materials (polytetrafluoroethylene, polyethylene, and silicone rubber) preadsorbed with fibrinogen were exposed to platelet suspensions at different wall shear rates and then incubated with clotting factors for 5 minutes under static conditions. The amount of thrombin generated per platelet was calculated from the optical density of the color developed by adding substrate S-2238. Scanning electron microscopy images of the platelets revealed that the platelets exhibited different morphologies, depending on the shear rate and residence time of the adsorbed fibrinogen. Platelets ranged from their normal discoid shape observed primarily under static conditions, to that of fully spread platelets. Results from this study show that platelets, in the presence of shear forces, undergo activation on exposure to surfaces on which adsorbed fibrinogen has resided for short residence times rather than long residence times. Interestingly, studies examining the procoagulant responses of such adherent platelets demonstrated that the platelets attached to the fibrinogen coated materials did not promote significant thrombin generation. Such low prothrombinase activity of adherent platelets suggests that adsorbed fibrinogen, while capable of supporting platelet adhesion and spreading on biomaterials, does not necessarily enhance the procoagulant activity of adherent platelets.     

Interactions of thermally denatured fibrinogen on polyethylene with plasma proteins and platelets.

During the investigation of fibrin deposition onto hydrophobic polymers in contact with human blood, a model was developed in which fibrinogen was denatured and irreversibly coated onto a polyethylene surface by heating to 70 degrees C for 10 min. The denatured fibrinogen-polyethylene surface is resistant to fluid wall shear rates of up to 550 s-1 and the fibrinogen does not desorb in the presence of plasma proteins. Compared to uncoated polyethylene, little albumin or fibrinogen adsorbs to heat-denatured fibrinogen. Thrombin binds to the denatured fibrinogen-coated polyethylene with low affinity and also acts on the surface-bound denatured fibrinogen and cleaves fibrinopeptide A (FPA) quantitatively. Washed, 51Cr-labeled platelets do not adhere to the thermally denatured fibrinogen at either low or high shear rates compared to surfaces coated with undenatured fibrinogen (p < 0.01). These observations support the role of the D domain of fibrinogen in platelet adhesion because this is the region that is denatured by heating. In contrast, the E domain of fibrinogen is not altered by heating to 70 degrees C and hence remains susceptible to thrombin and/or plasmin cleavage. The characteristics of this surface are such that it can be used to develop fibrin-coated surfaces for use in studies of thrombus formation on artificial surfaces.     

Blood compatibility of hydrophilic polymers

Blood compatibility has been studied for hydrophilic polymers such as poly(vinyl alcohol) (PVA), its derivative, and polyethylene grafted with water-soluble monomers. The surfaces in contact with electrolyte solutions have been characterized by measuring the zeta potentials. The study of plasma protein adsorption on these polymers has revealed that bovine serum albumin as well as bovine serum fibrinogen adsorbs to a lesser extent as the hydrophilicity of the polymers increases. Platelet deposition and fibrin formation, examined using platelet-rich plasma, have been found to take place less significantly on PVA as well as sodium acrylate- and acrylamide-grafted polyethylene than on nongrafted and acrylic acid-grafted polyethylene. Ex vivo experiments with canine whole blood have shown that formation of thrombus on PVA is less than on siliconized glass but increases upon heat treatment which reduces the hydrophilicity. When PVA tubes of about 1 mm diameter are anastomosed to the carotid artery of rat, the patency rate is found to depend strongly on the anastomotic technique. From the results on the zeta potential and the experiments in vitro and ex vivo it can be concluded that the material having a surface from which solvated, neutral chains are extended into the outer aqueous phase may exhibit excellent resistance to thrombus formation.     

Effects of antithrombotic agents evaluated in a nonhuman primate vascular shunt model.

The effects of aspirin, cyproheptadine, dextran, dipyridamole, and sulfinpyrazone on thrombus deposition were determined. These antithrombotic agents were evaluated in a nonhuman primate model for thrombus generation that employed test devices exposed to blood in an arteriovenous shunt. Thrombus deposition on test devices was quantitated gravimetrically. Of the antithrombotic agents tested, cyproheptadine was found to be the most effective, and aspirin, dextran, and dipyridamole were each somewhat less effective. Sulfinpyrazone had only a slight antithrombotic effect. Ultrastructual studies of thrombus deposited in test devices showed that the various antithrombotic agents tested did not prevent completely the formation of fibrin, aggregation of platelets, or adhesion and spreading of platelets and leukocytes. This model for thrombus generation is felt to be a more efficient means for evaluating antithrombotic agents than previously described nonhuman primate models.     

Plasma-deposited tetraglyme surfaces greatly reduce total blood protein adsorption, contact activation, platelet adhesion, platelet procoagulant activity, and in vitro thrombus deposition

The ability of tetraethylene glycol dimethyl ether (tetraglyme) plasma deposited coatings exhibiting ultralow fibrinogen adsorption to reduce blood activation was studied with six in vitro methods, namely fibrinogen and von Willebrand's factor adsorption, total protein adsorption, clotting time in recalcified plasma, platelet adhesion and procoagulant activity, and whole blood thrombosis in a disturbed flow catheter model. Surface plasmon resonance results showed that tetraglyme surfaces strongly resisted the adsorption of all proteins from human plasma. The clotting time in the presence of tetraglyme surfaces was lengthened compared with controls, indicating a lower activation of the intrinsic coagulation cascade. Platelet adhesion and thrombin generation by adherent platelets were greatly reduced on tetraglyme-coated materials, compared with uncoated and Biospan-coated glass slides. In the in vitro disturbed blood flow model, tetraglyme plasma coated catheters had 50% less thrombus than did the uncoated catheters. Tetraglyme-coated materials thus had greatly reduced blood interactions as measured with all six methods. The improved blood compatibility of plasma-deposited tetraglyme is thus not only due to their reduced platelet adhesion and activation, but also to a generalized reduction in blood interactions.     

Preservation of platelet function on 2-methacryloyloxyethyl phosphorylcholine-graft polymer as compared to various water-soluble graft polymers.

The chemical structures of water-soluble polymers grafted onto PE surfaces affect platelet function when the platelets contact the polymer surfaces. To improve our understanding of this effect, this study sought to control the blood/materials interaction on the surfaces of polyethylene (PE) by grafting with various water-soluble polymers. Such polymers as poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC), poly(acrylamide) (PAAm), poly(N-vinylpyrrolidone) (PVPy), and poly[monomethacryloyl poly(ethylene glycol)] (PMPEG) were grafted on low-density PE sheets by photoinduced graft polymerization. Both the PE bags modified with water-soluble polymers and those nonmodified were prepared by heat processing. Activation of platelets after storage in the PE bags was evaluated by measuring the cytoplasmic free calcium ion concentration ([Ca(2+)]i). The concentration of [Ca(2+)]i of platelets in contact with the PE surface grafted with PMPC was the same as that of native platelets and significantly less than that in contact with other PE surfaces grafted with water-soluble polymers. The number of adherent platelets was effectively decreased on PE surfaces grafted with PMPC and PMPEG, as compared with nontreated PE. The aggregation ability of platelets was also measured after storage of platelet-rich plasma in the PE bags. The PE surface grafted with PMPC effectively maintained aggregation ability as compared with both the nontreated PE and with PE grafted with PAAm, PVPy, and PMPEG. It was concluded that for preserving platelet function, PMPC was the most effective of these water-soluble polymers used for surface modification.     

Blood compatibility of surfaces modified by plasma polymerization

Tubular blood-contacting polymeric materials were modified by plasma polymerization and evaluated in the baboon with respect to their capacity to induce both acute and chronic arterial thrombosis. Polymer surface composition was determined by electron spectroscopy for chemical analysis. Steady-state arterial thromboembolism was initiated by introducing tubular segments into chronic arteriovenous shunts. Rates of platelet destruction induced by the test materials were calculated from 111In-platelet survival measurements. Nine plasma polymers based on tetrafluoroethylene, hexafluoroethane, hexafluoroethane/H2, and methane, when deposited on silicone rubber, consumed platelets at rates ranging from 1.1-5.6 x 10(8) platelets/cm2-day. Since these values were near the lower detection limit for this test system, the plasma polymers were considered relatively nonthrombogenic. Acute thrombus formation was initiated by inserting expanded Teflon (Gore-Tex PTFE) vascular grafts into the shunt system. 111In-platelet deposition was measured by scintillation camera imaging over a 1-h exposure period. Standard PTFE grafts (10 cm x 4 mm i.d.) accumulated approximately 1 x 10(10) platelets over this interval. While modification of PTFE grafts with a plasma polymer based on hexafluoroethane/H2 did not alter graft surface morphology, platelet deposition was reduced by 87% as compared to the controls (p less than 0.001). We conclude that both the surface chemistry and texture of prosthetic materials influence thrombogenesis. The method of plasma polymerization may be useful for assessing the importance of these variables independently and, perhaps, for minimizing certain adverse blood-material interactions.     

Platelet adhesion and activation on a shielded plasma gradient prepared on polyethylene.

Contact of blood with foreign materials evokes thrombogenic effects to an extent determined partly by the wettability of the biomaterials surface. Tools to study blood response towards a variation in materials wettability with minimal variation in chemistry are "gradient surfaces". However, most gradients have been prepared by diffusion or density immersion techniques, which results in a limited gradient range. Through glow discharge with partial shielding, gradients on polymers were prepared over a length of 5 cm, which facilitated studies to platelet adhesion on separate gradient sections. On polyethylene, advancing water contact angles varied from 90 degrees to 40 degrees, with a hysteresis of 30 degrees. ESCA indicated an increasing incorporation of oxygen towards the hydrophilic end. To examine the role of materials wettability on the activation of adhering platelets, sections of shielded plasma gradients were incubated in anticoagulated whole human blood. Fewer platelets adhered to the hydrophobic end, but those platelets were more activated than those on the hydrophilic end, as judged from their morphology and exposure of GpIIb-IIIa complex. However, partly related to the increased binding of platelets, the clotting activation after platelet deposition was highest on the hydrophilic end. Concluding, this new technique results in a large gradient range, which facilitates studies of formed blood elements in relation to the wettability. Platelets are more activated on hydrophobic polyethylene, while on moderate hydrophilic polyethylene more platelet adhesion and activation of the clotting system occurs.     

Characterization of transient platelet contacts on a polyvinyl alcohol hydrogel by video microscopy.

Acridine orange labelled, washed human platelets were counted and tracked on polyvinyl alcohol (PVA), heparin-PVA and polyethylene (PE)-coated coverslips with a view to understand why transient contact on the PVA hydrogels lead to elevated platelet activation and consumption relative to polyethylene. Over the 4 min of initial contact that was studied, platelet adhesion was higher on PE than on PVA or heparin-PVA at both 40 and 200 s(-1), as expected, regardless of whether the surfaces were pre-treated with albumin or fibrinogen. Not all platelets appearing to make contact with the surface, actually attached. For example, less than 2% of the platelets contacting albumin pre-treated PVA (at 40 s(-1)) remained adherent at the end of the initial 60 s observation time, while the corresponding number for PE was greater than 9%. A greater fraction of the platelets remained adherent at the higher shear rate or with fibrinogen pre-treatment, but the difference between PVA and PE remained similar: for example, with fibrinogen pre-treatment at 200 s(-1), approximately 25% of the platelet contacts resulted in adhesion on PVA while 66% did so on PE. While net platelet adhesion was less for the hydrogels, than for PE, the total number of contacts (adherents + non-adherents) were more comparable and unexpectedly higher for albumin pre-treatment than for fibrinogen. Net platelet adhesion is but one component of the total platelet interaction with a material surface. Fluorescent video microscopy has been shown to be a useful, albeit not unequivocal, method for assessing the platelets that make contact with but do not adhere to a surface. reserved     

Surface properties and blood compatibility of polyurethaneureas

A series of polyurethaneureas of varying soft segment type and hard/soft segment ratio were synthesized, and their bulk and surface properties evaluated. A canine ex vivo arteriovenous series shunt was used to monitor initial thrombus deposition. Significant levels of surface hard segment components are apparent in these materials. Polymers with poly(tetramethylene oxide) and poly(propylene oxide) soft segments showed blood compatibility variations with changes in hard/soft segment ratios: the more well-phase-separated materials showing lower platelet and fibrinogen deposition levels. Those trends apparent in polymers synthesized with poly(dimethylsiloxane) or poly(ethylene oxide) soft segments, but poly(dimethylsiloxane)-based materials showed higher levels of thrombus deposition than the poly(ethylene oxide)-based polymers.     

Evaluation of the in vitro and ex vivo blood compatibility of primary reference materials

The blood compatibility of the primary reference materials, low density polyethylene and polydimethylsiloxane, was evaluated using human in vitro and human ex vivo test devices, and was compared with that of polyetherurethane and polyvinylchloride. The effect of the materials on in vitro platelet activation was studied by measurement of platelet factor 4 release by enzyme immunoassay. The adsorption of fibrinogen and platelets from human native blood onto the surface of the material was measured using enzyme immunoassay technique. The four materials tested exhibited significantly different effects on in vitro platelet activation. In addition, the materials adsorbed fibrinogen and platelets to a different extent under ex vivo test conditions. Materials, which induced strong in vitro platelet activation, e.g. low density polyethylene and polyvinylchloride, demonstrated high concentrations of fibrinogen and platelets on the surface when tested under ex vivo conditions. Polydimethylsiloxane and polyetherurethane, which induced slight in vitro platelet factor 4 release, absorbed significantly lower concentrations of fibrinogen and platelets from human native blood.     

Platelet deposition in a capillary perfusion model: quantitative and morphological aspects

The capillary perfusion model according to Cazenave and co-workers was characterized by investigating the effects of protein precoating, perfusion time and shear rate on platelet deposition using 111Indium labelling of human platelets and scanning electron microscopy (SEM). Compared with uncoated polyethylene, platelet deposition was increased after precoating with purified human von Willebrand factor, fibrinogen or fibronectin, and decreased by preadsorbed immunoglobulin G, albumin or whole plasma. Platelet aggregates were observed on immunoglobulin G-coated polyethylene, whereas all other surfaces showed single adherent platelets. Complete platelet spreading was only observed after precoating with fibronectin. The quantitative data concerning platelet deposition were evaluated by using the convective-diffusion theory. Our results indicate the applicability of this perfusion model for the in vitro testing of biomaterials.     

Platelet-derived microparticles on synthetic surfaces observed by atomic force microscopy and fluorescence microscopy.

Platelet activation on a thrombogenic surface includes the release of membrane-derived microparticles that provide catalytic sites for blood coagulation factors. Here, we describe a quantitative investigation on the production and dimensions of platelet-derived microparticles observed on glass and polyethylene under aqueous conditions, using atomic force microscopy (AFM) and complementary fluorescence microscopy. The results show that contact-activated platelet microparticles are not evenly distributed over a thrombogenic surface, but in clusters in close proximity to adherent platelets. The microparticles are localized near the platelet periphery, and in some cases appear to emanate from platelet pseudopodia, suggesting that formation may result from vesiculation of the pseudopodia. The microparticles measured 125 +/- 21 nm (n = 73) in the x-y dimensions and 5.2 +/- 3.6 nm in height. The results compared closely with 125 +/- 22 nm width and 4.1 +/- 1.6 nm height obtained for control preparations of thrombin activated microparticles, that were filtered and deposited on glass. Large differences between the measured widths and heights of adsorbed microparticles suggest that platelet microparticles may undergo spreading after attachment to a surface. The adsorbed microparticles expressed platelet membrane receptor GPIIb/IIIa, and many expressed the platelet activation marker P-selectin as determined by fluorescence microscopy. The high number distribution of procoagulant microparticles per unit area of surface compared with platelets suggests that platelet-derived microparticles provide a mechanistic route for amplifying thrombus formation on a thrombogenic surface.     

Series shunt evaluation of polyurethane vascular graft materials in chronically AV-shunted canines

Well characterized, laboratory-synthesized polymeric materials which have been extensively tested for biocompatibility via initial platelet and protein deposition in an acute ex vivo canine model were placed as interpositional series shunts in canines with chronically implanted iliac arteriovenous shunts ex vivo. Platelet deposition was measured on a base polyurethane block copolymer, a sulfonated ionic derivative, an alkyl grafted (C18) derivative, Biomer, polyethylene, and polydimethylsiloxane for 24 h using radiolabeled platelets. Platelet survival and in vitro aggregation were determined to investigate the effects of the shunting procedure on experimental animals. The viability of adopting a chronic arteriovenous (iliac) shunted canine model for use with series shunts to evaluate polyurethanes having applications as materials in vascular graft construction was investigated and the results compared with acute model data.     

In vitro and in vivo studies of PEO-grafted blood-contacting cardiovascular prostheses

The initial step of thrombus formation on blood-contacting biomaterials is known to be adsorption of blood proteins followed by platelet adhesion. Poly(ethylene oxide) (PEO) has been frequently used to modify biomaterial surfaces to minimize or prevent protein adsorption and cell adhesion. PEO was grafted onto a number of biomaterials in our laboratory. Nitinol stents and glass tubes were grafted with PEO by priming the metal surface with trichlorovinylsilane (TCVS) followed by adsorption of Pluronic and γ-irradiation. Nitinol stents were also coated with Carbothane® for PEO grafting. Chemically inert polymeric biomaterials, such as Carbothane, polyethylene, silicone rubber, and expanded polytetrafluoroethylene (e-PTFE), were first adsorbed with PEO-polybutadiene-PEO (PEO-PB-PEO) triblock copolymers and then exposed to γ-irradiation for covalent grafting. For PEO grafting to Dacron® (polyethylene terephthalate), the surface was sequentially treated with PEO-PB-PEO and Pluronics® followed by γ-irradiation. In vitro studies showed substantial reduction in fibrinogen adsorption and platelet adhesion to the PEO-grafted surfaces compared with control surfaces. Fibrinogen adsorption was reduced by 70-95% by PEO grafting on all surfaces, except for e-PTFE. The platelet adhesion corresponded to the fibrinogen adsorption. When the PEO-grafted surfaces were tested ex vivo/in vivo, however, the expected beneficial effect of PEO grafting was inconsistent. The beneficial effect of the PEO grafting was most pronounced on the PEO-grafted nitinol stents. Thrombus formation was reduced by more than 85% by PEO grafting on metallic stents. Only moderate improvement (i.e. 35% decrease in platelet deposition) was observed with PEO-grafted tubes of polyethylene, silicone rubber, and glass. For PEO-grafted heart valves made of Dacron, however, no effect of PEO grafting was observed at all. It appears that the extent of thrombus formation on PEO-grafted biomaterials was directly related to the extent of tissue damage during implantation surgery. Platelets can be activated and form aggregates in the bulk blood, and the formed platelet aggregates may be able to deposit on the PEO monolayer overcoming its repulsive property. Our studies indicate that the testing of in vitro platelet adhesion should include adhesion of large platelet aggregates, in addition to adhesion of individual platelets. Furthermore, the surface modification methods should be improved over the current monolayer grafting concept so that the repulsive force by the grafted PEO layers is large enough to prevent adhesion of platelet aggregates formed in the bulk blood before arriving at the biomaterial surface.     

Enhanced risk of infection with device-associated thrombi

Thrombosis and infection are two well-recognized risks with prosthetic devices that contact blood. Many of the currently used biomaterials may present an attractive surface for thrombus development as well as bacterial adhesion and colonization. Clinical experience with vegetative endocarditis patients has suggested that thrombosis may lead to enhanced risk of infection, and the possibility that adherent bacteria may enhance the risk of thrombosis has been noted by several investigators. To investigate the correlation between thrombosis and infection, a series of tests were conducted to assess the affinity of pathogen with surfaces in the absence and presence of blood components. Coronary stents were used as a model device to attract thrombi in a recirculating loop in vitro. Fresh heparinized blood was used to investigate thrombus development and bacterial interaction. (111)Indium-labeled Staphylococcus epidermidis and (111)Indium-labeled platelets were utilized to quantify bacterial interaction with thrombi under various test conditions. Anticoagulants, antiplatelet agents, and antibiotics were utilized in attempts to selectively influence bacteria, platelets, or thrombosis. The results suggest that under appropriate conditions, bacteria may preferentially adhere to platelet rich thrombus. These observations also suggest that by reducing the risk of thrombosis, the risk of device-associated infection may also be reduced.