DK175719B1 - Vævstransplantationsmateriale - Google Patents

Vævstransplantationsmateriale Download PDF

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DK175719B1
DK175719B1 DK198903405A DK340589A DK175719B1 DK 175719 B1 DK175719 B1 DK 175719B1 DK 198903405 A DK198903405 A DK 198903405A DK 340589 A DK340589 A DK 340589A DK 175719 B1 DK175719 B1 DK 175719B1
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tissue
graft
transplant
sis
grafts
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DK175719B2 (da
DK340589D0 (da
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Badylak Stephen F
Gary Lantz
Leslie A Gedees
Arthur C Coffey
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Purdue Research Foundation
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    • EFIXED CONSTRUCTIONS
    • E02HYDRAULIC ENGINEERING; FOUNDATIONS; SOIL SHIFTING
    • E02DFOUNDATIONS; EXCAVATIONS; EMBANKMENTS; UNDERGROUND OR UNDERWATER STRUCTURES
    • E02D5/00Bulkheads, piles, or other structural elements specially adapted to foundation engineering
    • E02D5/02Sheet piles or sheet pile bulkheads
    • E02D5/03Prefabricated parts, e.g. composite sheet piles
    • E02D5/04Prefabricated parts, e.g. composite sheet piles made of steel
    • E02D5/08Locking forms; Edge joints; Pile crossings; Branch pieces
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61FFILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2/00Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/02Prostheses implantable into the body
    • A61F2/04Hollow or tubular parts of organs, e.g. bladders, tracheae, bronchi or bile ducts
    • A61F2/06Blood vessels
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61KPREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K35/00Medicinal preparations containing materials or reaction products thereof with undetermined constitution
    • A61K35/12Materials from mammals; Compositions comprising non-specified tissues or cells; Compositions comprising non-embryonic stem cells; Genetically modified cells
    • A61K35/37Digestive system
    • A61K35/38Stomach; Intestine; Goblet cells; Oral mucosa; Saliva
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61LMETHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
    • A61L27/00Materials for grafts or prostheses or for coating grafts or prostheses
    • A61L27/36Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61LMETHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
    • A61L27/00Materials for grafts or prostheses or for coating grafts or prostheses
    • A61L27/36Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix
    • A61L27/3604Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix characterised by the human or animal origin of the biological material, e.g. hair, fascia, fish scales, silk, shellac, pericardium, pleura, renal tissue, amniotic membrane, parenchymal tissue, fetal tissue, muscle tissue, fat tissue, enamel
    • A61L27/3629Intestinal tissue, e.g. small intestinal submucosa
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61LMETHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
    • A61L27/00Materials for grafts or prostheses or for coating grafts or prostheses
    • A61L27/50Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
    • A61L27/507Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials for artificial blood vessels
    • YGENERAL TAGGING OF NEW TECHNOLOGICAL DEVELOPMENTS; GENERAL TAGGING OF CROSS-SECTIONAL TECHNOLOGIES SPANNING OVER SEVERAL SECTIONS OF THE IPC; TECHNICAL SUBJECTS COVERED BY FORMER USPC CROSS-REFERENCE ART COLLECTIONS [XRACs] AND DIGESTS
    • Y10TECHNICAL SUBJECTS COVERED BY FORMER USPC
    • Y10TTECHNICAL SUBJECTS COVERED BY FORMER US CLASSIFICATION
    • Y10T428/00Stock material or miscellaneous articles
    • Y10T428/13Hollow or container type article [e.g., tube, vase, etc.]
    • Y10T428/1352Polymer or resin containing [i.e., natural or synthetic]
    • Y10T428/139Open-ended, self-supporting conduit, cylinder, or tube-type article
    • YGENERAL TAGGING OF NEW TECHNOLOGICAL DEVELOPMENTS; GENERAL TAGGING OF CROSS-SECTIONAL TECHNOLOGIES SPANNING OVER SEVERAL SECTIONS OF THE IPC; TECHNICAL SUBJECTS COVERED BY FORMER USPC CROSS-REFERENCE ART COLLECTIONS [XRACs] AND DIGESTS
    • Y10TECHNICAL SUBJECTS COVERED BY FORMER USPC
    • Y10TTECHNICAL SUBJECTS COVERED BY FORMER US CLASSIFICATION
    • Y10T428/00Stock material or miscellaneous articles
    • Y10T428/24Structurally defined web or sheet [e.g., overall dimension, etc.]
    • Y10T428/24008Structurally defined web or sheet [e.g., overall dimension, etc.] including fastener for attaching to external surface

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  • Health & Medical Sciences (AREA)
  • Life Sciences & Earth Sciences (AREA)
  • Engineering & Computer Science (AREA)
  • Chemical & Material Sciences (AREA)
  • Biomedical Technology (AREA)
  • Veterinary Medicine (AREA)
  • Public Health (AREA)
  • General Health & Medical Sciences (AREA)
  • Animal Behavior & Ethology (AREA)
  • Epidemiology (AREA)
  • Medicinal Chemistry (AREA)
  • Transplantation (AREA)
  • Oral & Maxillofacial Surgery (AREA)
  • Dermatology (AREA)
  • Cell Biology (AREA)
  • Zoology (AREA)
  • Chemical Kinetics & Catalysis (AREA)
  • Vascular Medicine (AREA)
  • Structural Engineering (AREA)
  • Botany (AREA)
  • Pharmacology & Pharmacy (AREA)
  • Virology (AREA)
  • Nutrition Science (AREA)
  • Physiology (AREA)
  • Biotechnology (AREA)
  • Developmental Biology & Embryology (AREA)
  • Immunology (AREA)
  • Urology & Nephrology (AREA)
  • General Life Sciences & Earth Sciences (AREA)
  • Cardiology (AREA)
  • Molecular Biology (AREA)
  • Pulmonology (AREA)
  • Composite Materials (AREA)
  • Heart & Thoracic Surgery (AREA)
  • Gastroenterology & Hepatology (AREA)
  • Mining & Mineral Resources (AREA)
  • Paleontology (AREA)
  • Civil Engineering (AREA)
  • General Engineering & Computer Science (AREA)
  • Prostheses (AREA)

Description

I DK 175719 B1
Den foreliggende opfindelse angår et hidtil ukendt vævstransplantationsmateriale, som udviser styrke, åbenhed (eng: patency), infektionsresistens, ikke-immunogenicitet, ik-ke-thrombogenecitet og resistens overfor aneurismedannelse, hvilket overgår mange syntetiske transplantationsmaterialer. Den foreliggende opfindelse er nærmere bestemt 5 rettet mod vævstransplantationsmaterialer, som omfatter de submucosale og basil are mucosale dele af tyndtarmen.
Vævstransplantationsmaterialer har i dag opnået en betragtelig klinisk og økonomisk betydning. Det er beregnet, at der i 1986 blev brugt 130 millioner US dollars alene på 10 vaskulære transplantationer, herunder ikke medtaget kranspulsåreomløbstransplantationer (eng: coronary artery bypass grafts). Graden af succes for vaskulære transplantationsprocedurer er endnu svag i sammenligning med de fleste andre kirurgiske procedurer. F.eks. regnes en 5-års kumulativ åbenhed på 50% som fremragende for vaskulære transplantater med små diametre. Sådanne lave grader af succes er i stort 15 omfang resultat af en eller flere fysiske eller funktionelle mangler i transplantationsma-terialeme, der for tiden anvendes klinisk.
Identifikation af materialer, som er velegnede til vævstransplantationer, er særligt vanskeligt, fordi sådanne materialer skal udvise en varietet af uligeartede egenskaber.
20 F.eks. må vaskulære transplantationsmaterialer ikke kun udvise mekanisk stabilitet under kontinuerlig spænding, men de skal også have porøsitet, som er tilstrækkelig til ka- i pillarisation, eftergivenhed svarende til den for værtsvævet og høje negative Ze-ta-potentialer (således at de er ikke-thrombogene). Endvidere skal de være ik-ke-allergene, ikke-carcinogene og fortrinsvis billige at fremstille.
25 Få om overhovedet nogen vævstransplantationsmaterialer udviser alle de ønskelige egenskaber. Litteraturrapporter over forskning og udvikling inden for området af vaskulære transplantationer afspejler en betydelig igangværende anstrengelse for at overvinde de skavanker, som er almindelige for de for tiden værende kendte transplan-30 tationsmaterialer.
I DK 175719 B1
I 2 I
I Både syntetiske og autogene materialer er blevet anvendt til vaskulære transplantatio- I
I ner. Blandt syntetiske er ekspanderet polytetrafluorethylen (PTFE) et almindeligt an- I
I vendt vaskulært transplantationsmateriale, især til små kar-omløbskirurgier. Ekspande- I
rede PTFE-transplantater er imidlertid følsomme overfor neointimal hyperplasi og sen I
I 5 transplantationsthrombose (f.eks. 6-års åbenhedsgrader på ca. 50% for femoropoplitea- I
I le omløb). PTFE-transplantationer er rapporteret at have endnu lavere grad af succes I
I ved anvendelse i det venøse kredsløb. I
I Et andet syntetisk materiale, Dacron®, anvendes ofte til vaskulære transplantationspro- I
10 cedurer med store diametre (f.eks. inffarenale aortatransplantationer). Strikket (eng: I
I knitted) Dacron® har imidlertid en relativt høj porøsitet og skal præsammenklumpes I
forud for implantation for at undgå umådeholden blødning. Denne præsammenklump- I
ningsprocedure er ikke altid praktisk eller succesiuld. Vævet Dacron®, som er mindre j I
porøst, udviser en eftergivenhed på kun 20% af den, som findes i en normal aorta. En- I
15 delig fungerer Dacron®-transplantater dårligt i arterier eller vener med små diametre, ' I
hvor blodgennemstrømningen er relativt langsom. I
Et af de mere signifikante problemer i forbindelse med anvendelsen af syntetiske mate- I
rialer som vævstransplantationsmaterialer er den kendsgerning, at syntetiske materialer I
20 har lav infektionsmodstandsdygtighed. Infektionshyppigheder efter implantation af I
syntetisk transplantat, er forbundet med en dødelighedskoefficient på 66%. Syntetiske I
H materialer har tendens til at huse mikroorganismer i deres mellemrum, og ved kontami- I
H nering er de yderst modstandsdygtige over for antibakteriel terapi. Eksplantation af in- I
H ficerede, syntetiske transplantater er i realiteten uundgåeligt. I
H For nyligt har forskere rapporteret om fremstilling af syntetiske hud- og blodkarsækvi- I
H valenter under anvendelse af levende humanceller. Se US patentskrifter nr. 4.604.346, I
I 4.546.500,4.539.716,4.485.097 og 4.485.096. I
30 Blandt autogene materialer er den saphenøse vene, den humane navlevene, den inverte- I
rede tyndtarm og spolebensarterien alle blevet anvendt, men hvert af disse materialer I
I DK 175719 B1 har også udvist betydelige skavanker. Den saphenøse vene kan have en uhensigtsmæssig størrelse til visse procedurer eller kan være utilgængelig på grund af skade ved sygdom. Endvidere kan den saphenøse vene have uacceptable varikøsiteter og lide af accelereret atherogenese efter "arteriolisation”. Både navletransplantateme og transplan-5 taterne af inverteret tyndtarm er plaget af tidlig thrombose og sen aneurismedannelse.
Endvidere har spolebensarterien begrænset anvendelighed, fordi den er vanskelig at høste og kan forringes efter transplantatimplantation.
Det er derfor et formål med den foreliggende opfindelse at tilvejebringe et 10 vævstransplantationsmateriale, som ikke udviser mange af de skavanker, som er forbundet med mange transplantationsmaterialer, som nu anvendes klinisk.
. Tegningens figur viser delvis i snit en del af tyndtarmen.
15 Den foreliggende opfindelse er rettet mod et vævstransplantationsmateriale, som primært omfatter tunica submucosa af et segment af tyndtarmen hos et varmblodet hvirveldyr. Tunica submucosaen er delamineret fra tunica muscularis og mindst den lumi-nale del af tunica mucosaen af tyndtarmsdelen. Idet det omhandlede vævstransplantationsmateriale har vist sig at have fremragende funktionelle egenskaber i anvendelse 20 som vaskulære autotransplantater og vaskulære allotransplantater, forventes det, at vævstransplantationsmaterialer ifølge den foreliggende opfindelse vil finde bred anvendelse selv som heterotransplantater i både vaskulære og i andre vævstransplantationsanvendelser. Det har vist sig, at det pågældende vævstransplantationsmateriale udviser mangfoldige fysiske og biologiske egenskaber, som gør det særligt velegnet til 25 vævstransplantationsformål.
I en foretrukken udførelsesform for den foreliggende opfindelse omfatter vævstransplantationsmaterialet submucosavæv og basilar mucosavæv, som er delamineret fra et segment af tyndtarmen, mere foretrukket jenunum, en del af tyndtarmen, 30 der strækker sig mellem duodenum og ileum. Tyndtarmen er forud for dens manipulation (delaminering) til opnåelse af transplantationsmateriale i overensstemmelse med I DK 175719 B1 I 4
I den foreliggende opfindelse opbygget af en række adskilte vævslag. Fig. 1 viser delvis i I
I snit tyndtarmen, hvoraf fremgår dens adskilte vævslag, som er mærket A til G (hen- I holdsvis ydre til indre), og som tilsammen definerer tarmvæggen. Det yderste vævslag I A repræsenterer mesenterialvævene. Mesenterial vævene er afbildet som et adskilt lag I 5 kun til illustrationsfonnål. Sådanne væv forekommer almindeligvis ikke som et adskilt lag, men fremtræder snarere som diskontinuerlige vævssegmenter. Lag B og lag C re- præsenterer henholdsvis tunica serosa og tunica muscularis. Lag D, som repræsenterer I tunica submucosa, er et tæt, uregelmæssigt, kollagent bindevæv, der ofte huser adskil- I lige mastceller. Heparin, som hidrører fra disse mastceller, er sandsynligvis i det mind- 10 ste delvis ansvarlig for manglen på tidlig thrombogenecitet hos transplantationsmateria-
Lag E, F og G repræsenterer tilsammen den såkaldte tunica mucosa. Lag E er et lag af glatte muskelceller, der kendes som lamina muscularis mucosa. Lag F, stratum com- 15 pactum, består af acellulært kollagen og elastinfibre. Lag G består af lamina epithelialis mucosa og dens lamina propria, som tilsammen og arrangeret i villi udviser en række fingerlignende udvækster på den mukøse membran.
Efter den nedenfor detaljeret beskrevne manipulation af tarmvævssegmentet til frem- H 20 stilling af transplantationsmaterialet ifølge den foreliggende opfindelse viser histolo- H gisk undersøgelse, at lamina epithelialis mucosa og dens lamina propria er blevet fjer- net, ligesom tunica muscularis og tunica serosa. Det foretrukne transplantationsmateria- H le ifølge den foreliggende opfindelse omfatter således tunica submocosa D, sammen med basilare dele af tunica mucosa, især lamina muscularis mucosa E og stratum com- H 25 pactum D. Disse lag refereres i det efterfølgende samlet til som tyndtarmssubmucosa I ("SIS").
Et SIS-autotransplantationsmateriale ifølge den foreliggende opfindelse kan fremstilles f.eks. ved først at foretage resektion af et segment af autogen, proksimal jejunum efter-30 fulgt af en midtlinie-laparotomi-indskæring. Det operativt fjernede segment af jejunum indpakkes derefter i kirurgiske svampe (eng: sponges), som er blevet neddyppet i fysio- I DK 175719 B1 logisk saltvand. Efter afslutning på tarmanastomosen fremstilles det udskårne tarmsegment i overensstemmelse med den herefter beskrevne fremgangsmåde ifølge den foreliggende opfindelse til anvendelse som et vævstransplantationsmateriale. På tilsvarende måde fremstilles allotransplantationsmaterialer ud fra tarmvæv, der er fjernet fra 5 organ/vævs-donorer af den samme art. Heterotransplantationsmaterialer kan fremstilles f.eks. ud fra katte-, svine- eller oksetarmvæv, som er genvundet fra euthaniserede dyr ved si agteri operati oner. Indtil dato har der vist sig minimale morfologiske forskelle i tarmvæv fra forskellige arter. Den histologiske forekomst af humant transplantationsvæv i overensstemmelse med den foreliggende opfindelse viste sig faktisk at 10 være næsten identisk med det for hunden. Den eneste morfologiske forskel, som kunne erkendes, var en lidt mindre tæt stratum compactum i humanvævet.
Vævstransplantationsmaterialet ifølge den foreliggende opfindelse fremstilles ved afslidning af tarmvævet til fjernelse af de ydre lag, herunder både tunica serosa og I
15 tunica muscularis (lag B og C i fig. 1) og det indre lag omfattende mindst den luminale I
del (lag G) af tunica mucosa (lag E til G i fig. 1). Under milde afslidningsforhold I
delamineres tunica mucosa mellem stratum compactum (lag F) og lamina propria aflag I
G. Efter fjernelse af hvilke som helst mesenterialvæv fra tarmsegmentet under I
anvendelse af f.eks. Adson-Brown-pincetter og Metzenbaum-sakse, delamineres I
20 nærmere bestemt tunica serosa og tunica muscularis (det ydre vævslag) fra I
tarmsegmentet ved afslidning under anvendelse af en gnidende bevægelse på langs med I
et skalpelskaft (eng: scalpel handle) og fugtet gaze. Efter udkrængning af tarm- I
segmentet delamineres den luminale del af tunica mucosa fra det underliggende væv I
under anvendelse af den samme gnidende bevægelse. Der udvises forsigtighed for at I
25 forhindre perforation af submucosaen. Endvidere fjernes alle "vævsstumper" (eng: I
tissue "tags") fra det delaminerede lag, som forbliver på transplantatoverfladen. I
Tarmsegmentet kan eventuelt først udkrænges, derefter strippes for det luminale lag og I
derefter genindsættes i dets oprindelige orientation til fjernelse af tunica serosa og I
tunica muscularis. Transplantationsmaterialet er et hvidligt, gennemskinneligt rør af I
30 væv ca. 0,1 mm tykt og består typisk af tunica submucosa med den tilknyttede lamina I
muscularis mucosa og stratum compactum. Til fremstilling af vaskulære I
transplantationsmaterialer udkrænges det fremstillede transplantationsmateriale i dets I
IH
DK 175719 B1 I I
H
H
teriale i dets oprindelige orientation, således at stratum compactum tjener som trans- I
plantationsmaterialets luminale overflade. I
Det fremstillede transplantationsmateriale skylles typisk med saltvand og anbringes i I
5 en 10% neomycinsulfatopløsning i ca. 20 min., efter hvilket tidsrum transplantations- I
materialet er parat til anvendelse. Transplantationsmaterialeme anbringes under anven- I
delse af rutinemæssige kirurgiske procedurer, som sædvanligvis anvendes til I
vævstransplantationsformål. Til anvendelse til ikke-vaskulære vævstransplantations- I
formål kan det rørformede transplantationsmateriale skæres på langs og udrulles til I
10 dannelse af en "lap" af væv. Hele den ovenfor beskrevne vævsdelamineringsprocedure I
kan faktisk udføres på "lapper" af tarmvæv, som er fremstillet ved at skære tarmseg- I
mentet på langs og "udrulle" det til dannelse af en prætransplantationslap. De fremstil- I
lede transplantationsvævslapper kan f.eks. anvendes som et hudtransplan- I
tationsmateriale eller til reparation af andre legemsvævsdefekter, som er egnede til ki- I
15 rurgisk anvendelse af en vævstransplantationslap med de fysiske og funktionelle egen- I
skaber ifølge det foreliggende transplantationsmateriale. I
Til anvendelse i vaskulære transplantationer skal transplantationsmaterialets diameter I
være ca. den samme som diameteren hos det modtagende blodkar. Dette gennemføres I
20 ved at manipulere vævstransplantationsmaterialet til at definere en cylinder med en di- I
ameter, der ca. er den samme som den for det modtagende blodkar, og ved at foretage I
en sutur eller på anden måde fastgøre vævstransplantatet på langs til dannelse af det I
vaskulære transplantat. Således kan f.eks. et vaskulært transplantationsmateriale frem- I
stilles ved at udvælge en steril glasstang med en ydre diameter, som svarer til den for i I
25 det modtagende blodkar, og ved at indføre glasstangen i transplantatlumenet. Overflø- I
digt væv samles derefter, og den ønskede hulrumsdiameter opnås ved at foretage en su- I
tur langs transplantatets længde (f.eks. under anvendelse af to kontinuerlige sutursnore I
eller en enkelt afbrudt sutursnor) eller ved at anvende andre inden for området kendte I
vævsfastgøringsteknikker. I
I I
7 DK 175719 B1 1 overensstemmelse med formålene ifølge den foreliggende opfindelse udviser SIS-materialet mekaniske egenskaber, som er meget ønskelige for vævstransplanta-tionsmaterialer, herunder et lavt porøsitetsindeks, en høj eftergivenhed og et højt bristetrykspunkt. Vedrørende porøsitet vil en fagmand indenfor området forstå, at 5 vævstransplantationsmateriale skal have tilstrækkelig lav porøsitet til at forhindre in-traoperativ blødning og dog en tilstrækkeligt høj porøsitet til at muliggøre udvidelse af en nyudviklet vasa vasorum gennem transplantationsmaterialet til at nære neointima og den luminale overflade. Et transplantationsmateriales porøsitet måles typisk i antal ml vand, der passerer per cm2 per min. ved en trykhøjde på 120 mm Hg.
10 SIS-transplantationsmaterialets porøsitetsindeks er 10, hvilket er meget lavere end for andre transplantationsmaterialer, der for tiden er kendt inden for området. (Vævet Dacron® har f.eks. et porøsitetsindeks på 50). Trods dette lave porøsitetsindeks er SIS dog tilstrækkeligt porøst til at muliggøre, at neokapillarisation finder sted inden i SIS-transplantatet. Ved vaskulære transplantationsanvendelser muliggør SIS-materialer 15 dannelsen af blodfyldte kapillærer inden for transplantatvæggen, der strækker sig til den luminale overflade, så tidligt som fire dage efter kirurgi.
Angående transplantateftergivenhed er der inden for området blevet beskrevet eksistensen af et direkte forhold mellem eftergivenhed og åbenhed. Ideelt set skal et transplan-20 tationsmateriale være mindst lige så eftergivent som det væv, det erstatter. Eftergivenhed på langs hos SlS-transplantationsmaterialet blev målt ved anvendelse af en simpel trækprøve. En indledende målelængde blev dannet med to blækmærker 5,0 cm fra hinanden. Forlængelsen og den påførte kraft blev målt, idet prøverne blev belastet ved en trækhastighed på 32 cm/cm/min., hvilket gav de følgende resultater: 25
Eftergivenhed af SIS-transplantationsmateriale: 0,045 cm/N
per cm længde
Eftergivenhed af normal hundeaorta: 0,017 cm/N
per cm længde.
30
I DK 175719 B1 I
I I
I SIS-transplantationsmaterialeme udviser således aktuelt eftergivenhed, som er større I
I end den for den normale aorta. Dette er en betydelig fordel i forhold til tidligere teknik I
I inden for det vaskulære transplantationsområde. Alle for tiden værende tilgængelige I
I syntetiske transplantationsmaterialer er 3 til 10 gange mindre eftergivende end den na- I
I 5 turlige arterie og i tilsvarende grad mere udsat for thrombose end den naturlige arterie. I
Den tidligere kendte metode til at kompensere for denne ikke-sammenstemmende ef- I
tergivenhed er at anvende et transplantationsmateriale med større diameter end den til- I
I stødende naturlige arterie. Denne teknik har imidlertid ført til yderligere problemer. I
I Blodhastighed er langsommere gennem transplantatsegmenter med større diameter. Der I
10 er derfor mindre forskydningskraft på transplantatvæggen. Under sådanne betingelser I
er blodplade- og fibrinaflejring og efterfølgende thrombose mere sandsynlig. I mod- I
sætning hertil kan isodiametriske SIS-transplantater anvendes uden forekomst af så- I
danne problemer, idet SIS-materialet udviser sådanne høje eftergivenheder. I
15 Det foreliggende SIS-transplantationsmateriale har vist sig at have et bristetrykspunkt I
langt uden for, hvad man vil støde på fysiologisk. Et bristetryksforsøg blev udført ved I
at fastgøre et rørformet SIS-transplantationssegment til to cylindre med en diameter på I
25 mm og sætte transplantatet under tryk med nitrogengas ved en konstant strømnings- I
hastighed. To strømningshastigheder blev anvendt. Ved den lave strømningshastighed I
20 steg trykket indledningsvis og faldt derefter og blev stabilt, efterhånden som gas- I
udstrømningen gennem transplantatvæggen blev ækvilibreret med gasindstrømningen. I
Ved den højere strømningshastighed opbyggedes trykket øjeblikkeligt til bristeforhold I
ved ca. 400 mm Hg, hvilket indikerer, at transplantationsmaterialet let kan modstå de I
kontinuerlige, pulserende tryk, der findes ved normalt, fysiologisk, vaskulært trans- I
25 plantatbrug. I
DK 175719 B1 9
EKSEMPLER
Eksempel 1. Tvndtarmssubmucosa som et arterielt transplantat med stor diameter.
5 En række forsøg er blevet udført, hvori man undersøgte evnen hos tre forskellige konfigurationer af tyndtarm til at tjene som et vaskulært transplantat i den infrarenale aorta hos hunden. Ved det første forsøg anvendtes et ikke-inverteret segment af jejunum i fuld tykkelse, enten med en intakt mesenterial neurovaskulær forsyning eller med et frit, isoleret segment som transplantationsmaterialet. Tarmmucosa var blodtransplan-10 tatgrænsefladen. Alle fire hunde i dette forsøg døde inden for 18 timers kirurgi af thrombose i transplantatsegmentet og blødning fra sutursnorene.
Ved det andet forsøg anvendtes et isoleret og inverteret segment af jejunum som transplantatet, hvor tunica serosa tjener som blodtransplantatgrænsefladen. Der var to hunde 15 i dette forsøg. Transplantatet i den første hund blev thromboseret inden for 4 timers kirurgi, og den anden hund døde af akut blødning ved det proksimale anastomosested fire dage efter kirurgi.
I det tredje forsøg undersøgtes anvendelsen af kun en del af tarmvæggen som trans-20 plantationsmaterialet Et frit segment af autogent øvre jejunum blev høstet fra hver hund, og derefter blev størstedelen af mucosa fjernet ved ligefrem afskrabning af den luminale overflade med et skalpelskaft. Ved den samme metode fjernedes derefter serosa og tunica muscularis. Vævet, som blev tilbage efter denne tilsyneladende brutale manipulation af tarmsegmentet, var en 100 μ tyk del af submucosa og basilar mucosa.
25 Dette transplantationsmateriale blev derefter anbragt i den infrarenale aorta hos 15 hunde og har været bemærkelsesværdigt succesfuld. Resultaterne af dette tredje forsøg er opsummeret nedenfor.
Tretten af de femten hunde bevarede åbne transplantater, indtil tidspunktet for euthana-30 si. Elleve hunde døde ved euthanasi på forskellige tidspunkter efter kirurgi gående fra fire dage indtil et år. Dyrene viste ingen tegn på transplantatinfektion, aneurismedan- Η Η
I DK 175719 B1 I
I 10 I
I nelse eller thrombose. Det observerede uheldige udfald af transplantation hos to af I
I hundene var forårsaget af teknisk fejl, herunder fejlplacering af metalligaclips og dårlig I
I anastomoseteknik. To dyr var i live på tidspunktet for skrivning af nærværende beskri- I
I velse og krav og observeres for mere langsigtet transplantatåbenhed. I
I 5 I
I Transplantaternes åbenhed blev verificeret ved positiv kontrastradiografi inden for fire I
I til syv dage efter kirurgi og hver sjette til ottende uge derefter. Endvidere blev trans- I
plantatåbenhed overvåget klinisk ved observation af tilstedeværelsen af stærk lårpuls I
og manglen på bagbensødemer. I
I 10 I
I Elleve af de hunde, som bevarede åbne transplantater, blev aflivet med forskellige tid- I
I sintervaller efter kirurgi (4, 7,10 og 14 dage og 9, 11, 13, 17,26, 44 og 52 uger). Lige I
I forud for euthanasi fik dyrene optegnet et yderligere angiogram til bekræftelse af trans- I
plantatåbenhed og til tilvejebringelse af et sammenligningsradiografi til bedømmelse af I
15 transplantatdilatation, stenose og aneurismedannelse. Alle elleve dyr viste fuldstændig I
åbenhed uden noget tegn på skadelige luminale ændringer. I
Patologisk bedømmelse, som kan ses med det blotte øje, af disse transplantatsegmenter I
viste en glinsende luminaloverflade med tilfældigt arrangerede røde og hvide områder I
20 og ingen tegn på udbredelse af thrombedannelse. Der var en omsluttende fast binde- I
vævsakkumulering, som var sammenløbende med transplantatvæggen. Ingen arter, der I
blev undersøgt før 6 måneder efter kirurgi, viste tegn på endothelialcellevækst på I
transplantatets overflade. Disse transplantaters overflade var dækket med et fladt, mo- I
H derat tæt og organiseret lag af kollagen. I
I 25 I
Histopatologisk undersøgelse af 26-, 44- og 52-uge arterne viste en udfladet, "endothe- I
lial-lignende" celle, som delvis dækkede et tyndt (ca. 500 μ) lag af tæt organiseret fi- I
brin. Hele vævet var infiltreret med blodfyldte kapillærer, og den ydre grænse af det I
H oprindelige transplantationsmateriale kunne ikke skelnes fra det omsluttende bindevæv. I
H 30 Skanderende elektronmikroskopisk undersøgelse af luminaloverfladen viste et lag af I
H udfladede celler, som ikke kunne skelnes ffa endothelialceller, med udstrakt "pseudo- I
- I
DK 175719 B1 ; . i π i podia". Transmissionselektronmikroskopisk bedømmelse af disse transplantatsegmenter antydede også tilstedeværelsen af en endothelialcelletildækning af lu-minaloverfladen. Endvidere antydede tilstedeværelsen af faktor VIII: beslægtet antigen, som påvises ved immunofluoroscensfarvning, yderligere den endotheliale oprindelse af 5 disse transplantatluminaloverfladeceller. Transplantationsmaterialet blev også undersøgt for tilstedeværelse af endothelialceller ved undersøgelse af tilstedeværelsen af en-dothelafledt afslappende faktor. Acetylcholin blev påført overfladen af transplantatarter, og det udstrømmende materiale blev opsamlet. Det udstrømmende materiale blev ved observation af afslappelse af glatte muskler i et rotte aortapræparat vist at indehol-10 de endothel-afledt afslappende faktor.
Blodtrykket cephalt til, distalt til og inden i SIS-transplantatet blev bestemt i hver af de ti euthaniserede hunde. Trykkene var identiske på alle tre steder i hver af hundene, hvilket afspejler en mangel på uheldige hæmodynamiske virkninger som følge af an-15 vendelse af SIS-transplantationsmaterialet.
De følgende laboratorieparametre blev målt før kirurgi, en dag efter kirurgi og derefter på yderligere tidspunkter i de følgende måneder hos alle hunde: hæmatokritværdi, prothrombintid, aktiveret partiel thromboplastintid, blodpladetælling, fuldstændig blod-20 tælling og en forkortet serumkemiprofil. Resultater viste, at alle dyr var normale ved disse laboratoriemålinger på alle tidspunkterne. Disse dyr fik behandling med lave doser af heparin (600 enheder IV) under det kirurgiske indgreb, men fik ikke antikoagula-tionsbehandling under den post- operative periode. Manglen på enhver forandring i ko-. agulationsforsøgene og blodpladetællingeme var særligt opmuntrende i lyset af det re- 25 lativt hyperaktive koaguleringssystem hos hunden sammenlignet med mennesket.
Eksempel 2. Tvndtarmssubmucosa som arterielt transplantat med en lille diameter.
Dette forsøg involverede implantation i atten hunde af et total på 36 transplantater i bå-30 de lårbensarterien og halspulsåren. Treogtredive af de seksogtredive transplantater forblev åbne. Laboratoriemålinger blev foretaget hos disse dyr, hvilke målinger var identi-
I DK 175719 B1 I
I I
I ske med dem, der blev foretaget i den første undersøgelse, og der observeredes ingen I
I abnormiteter. Endvidere blev konventionel todimensional ultralydsbilleddannelse an- I
I vendt til måling af åbenhed og kartværsnitsdiameter. I
I 5 Patologisk undersøgelse af transplantatvæv fra en hund, der blev eutaniseret fire dage I
I efter kirurgi, viste en ikke-thrombotisk luminaloverflade og en svagt stenotisk proksi- I
I mal anastomose. Histologisk undersøgelse afslørede den tidlige tilstedeværelse af blod- I
fyldte kapillærer inden i transplantatvæggen, et potentielt naturligt legemsforsvar mod I
infektion. Fem af disse hunde forblev i live på tidspunktet for skrivning af nærværende I
I 10 beskrivelse og krav til yderligere bedømmelse. Den længst overlevende hund i dette I
I forsøg har nu overlevet syv måneder efter kirurgi. I
H Eksempel 3. Tvndtarmssubmucosa som et venetransplantat I
15 1 dette forsøg blev SIS-transplantatet anbragt i posterior vena cava (analog med "infe- I
I rior" vena cava i mennesket) i to hunde og i anterior vena cava (analog med "superior" I
vena cava i mennesket) i fem hunde. Selv om posterior vena cava-transplantateme kun I
forblev åbne i henholdsvis 11 og 14 dage, viste patologisk undersøgelse, at de uheldige I
udfald af transplantationerne kunne henføres til tekniske fejl, hvori inferior anastomo- I
20 sestedet var stenotisk (8 mm i diameter i modsætning til den naboliggende naturlige I
H vena cava med en diameter på 16 mm og det proksimale transplantat med en diameter I
på 16 mm). Endvidere var de luminale overflader af begge transplantater dækket med I
et ikke-thrombotisk "pseudoendothel", som var sammensat af tæt pakket fibren og I
umodent, kollagent bindevæv. I
I I
Anterior vena cava-transplantateme forblev åbne indtil euthanasi af tre af hundene I
henholdsvis 7, 14 og 21 dage efter kirurgi. To af disse hunde var i live på tidspunktet I
for skrivning af nærværende beskrivelse og krav med åbne transplantater syv uger efter I
kirurgi. Den proksimale sutursnor i alle tre hunde viste tegn på tidlig thrombose, hvor I
30 en klap af transplantatet var blevet inverteret og forårsagede turbulent blod- I
H gennemstrømning, men resten af transplantatet var ikke-thrombotisk. Endvidere viste I

Claims (1)

  1. 5 Eksempel 4. Tvndtarmssubmucosa som et arterielt allotransplantat I SIS er blevet anvendt som et allotransplantat med stor diameter i hundeaorta. Al- lotransplantateme blev konstrueret på samme måde som dem, der er beskrevet ovenfor I til undersøgelse af aortaautotransplantater. På tidspunktet for skrivning af nærværende I 10 beskrivelse og krav er testdyrene kun otte uger efter kirurgi, men de viser ikke noget I tegn på transplantatthrombose, infektion eller aneurismedannelse (som dokumenteret I ved angiogrammer). I Eksempel 5. Tvndtarmssubmucosa som et arterielt heterotransplantat. SIS er blevet anvendt som et heterotransplantat i hunden. Et SIS-transplantationsmateriale af katteoprindelse blev fremstillet i overensstemmelse med de tidligere heri beskrevne procedurer og anbragt i en hund. På tidspunktet for 20 skrivning af nærværende beskrivelse og krav var testdyret to uger postkirurgi og viste ikke nogen uønskede tegn.
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