Role and importance of biological research in Vascular Surgery Centers. Personal experience:

the theoretical research and engineering application in vascular surgery

Prof. Domenico PalomboDirettore U. O. C. Chirurgia Vascolare ed Endovascolare

Ospedale Policlinico San MartinoUniversità degli Studi di Genova

Patras, 24th May 2018

Introduction

The value of research in vascular surgery: from the Vascular Surgeon to the Vascular Specialist

Introduction

School of Medical and Pharmaceutical Sciences –Genova (Italy)

VASCULAR SURGERY TOPICS:

- Thoracic and Thoracoabdominal aortic diseases.

- Abdominal aortic diseases

- Carotid diseases

- Peripheral vascular disease

Introduction

Introduction

Thoracic and Thoracoabdominalaortic diseases.

Abdominal aortic diseases

Introduction

Carotid diseases

Introduction

Peripheral Arterial Obstructive Disease

Introduction

Research Laboratory of Experimental and Clinical Vascular Biology

Department of Surgical and Integrated Diagnostic Sciences (DISC)University of Genoa

Introduction

Research topics

Biological and biochemical research:

- vascular biology (polyphenols and inflammation and PPARγ agonist);- vascular bioprosthesis: functionalized electrospun scaffold;- nanoparticles as innovative targeted therapy in atherosclerosis.

In vivo medical image analysis and biomechanical simulations:

- endovascular implants: from medical images to patient specific structural simulations;- impact of peripheral endovascular repair on femoral popliteal artery kinematics;- assessment of FU geometry changes of TAAAs treated with MFM stent;- geometrical remodeling of the aortic arch after hybrid treatment.

Clinical research:- risk of rupture;- AAA screening.

Civil, Chemical and Environmental Engineering Department

Surgical and Integrated Diagnostic Sciences

Vascular biology

Chemical engineering

Engineering for medicine and longevity

Several partnership:CardiologyAnatomyPathological AnatomyNuclear Medicine

Vascular surgery, vascular biology and…chemical engineering

Research topics

- vascular biology (polyphenols and inflammation and PPARγ agonist);

- vascular bioprosthesis: functionalized electrospun scaffold;

- nanoparticles as innovative targeted therapy in atherosclerosis.

Biological and biochemical research1

nucleus

TNF α receptor

TNF α

Akt

p38MAPK

Endothelial cell membrane

apigenin

apigenin

Vascular biology – Polyphenols and inflammation

TNF α receptor

TNF α

Akt

p38MAPK

Endothelial cell membrane

apigenin

apigenin

apigenin

Mura M. et al «Simultaneous ultrasound-assisted water extraction and β-cyclodextrin encapsulation of polyphenols from Mangifera

indica stem bark in counteracting TNFα-induced endothelial dysfunction». Nat Prod Res. 2015;29(17):1657-63. doi:

10.1080/14786419.2014.996753. Epub 2015 Jan 15.

Palmieri D. et al «Effects of polyphenol extract from olive pomace on anoxia-induced endothelial dysfunction». Microvasc Res. 2012

May;83(3):281-9. doi: 10.1016/j.mvr.2012.02.010. Epub 2012 Feb 23.

Aliakbarian B. et al «Antioxidant activity and biological evaluation of olive pomace extract». Nat Prod Res. 2012;26(24):2280-90. doi:

10.1080/14786419.2012.660692. Epub 2012 Feb 15.

Palmieri D. et al «Apigenin inhibits the TNFα-induced expression of eNOS and MMP-9 via modulating Akt signalling through

oestrogen receptor engagement». Mol Cell Biochem 2012 Dec;371(1-2):129-36. doi: 10.1007/s11010-012-1429-1. Epub 2012 Aug 17.

Palmieri D. et al «Effects of polyphenol extract from olive pomace on anoxia-induced endothelial dysfunction». Microvasc Res. 2012

May;83(3):281-9. doi: 10.1016/j.mvr.2012.02.010. Epub 2012 Feb 23.

Vascular biology – Polyphenols and inflammation

Monocyte activation, macrophage infiltration, vascular oxidative stress and matrix proteolysis are

inflammatory key steps contributing to abdominal aortic aneurysm (AAA) development. Resveratrol

counteracted the CD62L-monocyte subset expansion, CD143 monocyte expression, and circulating levels of MMP-9 activity and TNFa associated to AAA induction.

Vascular biology – Polyphenols and inflammation (in vivo)

Vascular biology

30 Sprague Dawley male rats

15 treated with Resveratrol (10 mg / kg / day, in ethanol)15 placebo-treated (ethanol only)

Pancreatic elastase infusion

Vascular biology

• MMP-9 levels are down-modulated by treatment with Resveratrol

• TNF levels are down-modulated by treatment with Resveratrol

Plasma levels of MMP-9 and TNF-α

Gelatin zymography ** P <0.01 vs Ct

ELISA assay * P <0.05 vs Ct

Vascular biology

The number of macrophages infiltrated in aneurysmatic tissue is lower in Resveratrol treated sections than untreated rats

MACROPHAGOUS INFILTRATION

Vascular biology

Expression of MMP-9 in aortic wall is lower in rats treated with Resveratrol than control group

Immunohistochemistry for MMP-9

MMP-9 TISSUE EXPRESSION

Vascular biology

The expression of VEGF and TNF-α is lower in rats treated with Resveratrol than in the control group

VEGF

TNFα

TISSUE EXPRESSION OF VEGF AND TNF-α

Pane B. et al “Inflammatory modulation through a PPARγ agonist during surgically

induced visceral ischemia in animal model”.

Several reports describe the anti-inflammatory effects of PPARγ agonists about their role as modulators of theperi-vascular inflammatory response. PPARγ agonists, such

as pioglitazone, are able to modulate the inflammatoryresponse and consequently the ischemia/reperfusion injuryespecially on the renal parenchyma

Annals of Vascular Surgery

2018

Vascular biology – PPARγ agonist

Modulation of inflammatory response during surgical induction of visceral and renal ischemia in an animal model by pioglitazone vs placebo.

WHAT’S NEW? – OUR EXPERIENCE

Vascular biology – Thoracoabdominal aneurysm

Bianca Pane-Ospedale Policlinico San Martino Genova, Università degli Studi diGenova

1° prize“TOP ten Abstract” XV Congresso SICVE 2016

Carbone F. et al “Serum Levels of Osteopontin predict major adverse cardiovascular

events in patients with severe carotid artery stenosis”.

Inflammatory mediators in the blood stream and within plaques are keydeterminants in atherogenesis.High circulating Osteopontin (OPN) levels were strongly correlated withvulnerability parameters within plaques and predict Major AdverseCardiovascular Events in patients with severe carotid artery stenosis. OPNcould be a promising clinical tool to assess atherosclerotic outcomes

International Journal of Cardiology

2018

Vascular biology – Inflammation and Atherosclerosis

Research topics

- vascular biology (polyphenols and inflammation and PPARγ agonist);

- vascular bioprosthesis: functionalized electrospun scaffold;

- nanoparticles as innovative targeted therapy in atherosclerosis.

Biological and biochemical research1

1. Fabrication of biodegradable electrospun

vascular prosthesis functionalized with

quercetin as anti-inflammatory agent;

2. external coating with gelatin to reduce

permeability;

3. scaffolds characterization in terms of

physico-chemical, mechanical and

biological properties;

4. in vivo suturability test.

Functionalized electrospun scaffold

5 mm of diameter

PCL:PGS + quercetin

PCL:PGS

Scanning Electron Microscopy analysisC

PCL:PGS + quercetinPCL:PGS

Ferrari PF, Aliakbarian B, Lagazzo A, Tamayol A, Palombo D, Perego P, 2017. Tailored electrospun small-diameter graft for vascular prosthesis, International Journal of Polymeric Materials and Polymeric Biomaterials 66, 635-643.Ferrari PF, Aliakbarian B, Palombo D, Perego P, 2017. Small diameter vascular grafts coated with gelatin. Chemical Engineering Transactions 57.Aliakbarian B, Ferrari PF, Bagnato P, Palombo D, Perego P. Engineered small diameter vascular grafts with anti-inflammatory properties. The Journal of Cardiovascular Surgery, abstract book, Vol. 58 –Suppl. 2 to n° 3, 14.

Functionalized electrospun scaffold - Mechanical properties

0

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0 2 4 6 8 10 12 14 16 18 20 22 24

Sw

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%)

Time (h)

PCL:PGS 1:1

PCL:PGS 1:1 + gelatina

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PCL:PGS 1:1

PCL:PGS 1:1+

gelatina

Degradation

Swelling

Gelatin release

0.00

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1.00

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492 n

m)

Time (days)

PCL:PGS 1:1 Q GQ

MTS assay zymography

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NT TNF-α PCL:PGS PCL:PGS

Rel

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of

MM

P-9

(%

)

+ TNF-α + quercetin

+ TNF-α

Functionalized electrospun scaffold

Evaluation of cytotoxicity and anti-inflammatory activity in human vascular endothelial cell line EAhy 926

Q: scaffold with quercetinGQ: scaffold with quercetin and gelatin

Biocompatibility Anti-inflammatory activity

Implantation of electrospun PCL:PGS prostheses

Feasibility study

• number of rats: 2

• technical success: 100 %

Functionalized electrospun scaffold

Research topics

- vascular biology (polyphenols and inflammation and PPARγ agonist);

- vascular bioprosthesis: functionalized electrospun scaffold;

- nanoparticles as innovative targeted therapy in atherosclerosis.

Biological and biochemical research1

Nanodelivery system to carryactive compounds directly on the plaque…

…in order to counteract the inflammation

A NEW TARGETED THERAPY IN ATHEROSCLEROSIS

Nanoparticles, a new targeted therapy in atherosclerosis

Antibody-engineered nanoparticles allow us to introduce the concept of targeted therapy. CaCO3

nanoparticle containing therapeutic antibodies.

oxLDLLDL

Atherosclerotic plaque is enriched of oxidizedlow-density-lipoproteins (oxLDL). Site directed andibodyY

YY

Ferrari PF, Aliakbarian B, Zattera E, Pastorino L, Palombo D, Perego P, 2017. Engineered CaCO3 nanoparticles with targeting activity: a simple approach for a vascular intended drug delivery system. The Canadian Journal of Chemical Engineering 95: 1683-1689. Ferrari PF, Aliakbarian B, Bagnato P, Palombo D, Perego P. An innovative drug delivery system for atherosclerosis. The Journal of Cardiovascular Surgery, abstract book, Vol. 58 - Suppl. 2 to n° 3, 6.

20 nm

Results – Morphology studies

TEM analysis SEM analysis Fluorescence

microscopy

analysis

ESCVS 2017 YOUNG SURGEON AWARD 2nd PLACE

P.F. Ferrari, B. Aliakbarian, P. Bagnato, D. Palombo, P. Perego. An innovative drug delivery system for atherosclerosis.

Research topics

- endovascular implants: from medical images to patient specific structural simulations;

- impact of peripheral endovascular repair on femoral popliteal artery kinematics;

- assessment of FU geometry changes of TAAAs treated with MFM stent;

- geometrical remodeling of the aortic arch after hybrid treatment.

In vivo medical image analysis and biomechanical simulations2

Computational Mechanics &

Advanced Materials Group

Vascular and Endovascular Surgery Unit

IRCCS San Martino IST

University of Pavia University of Genoa

Alice Finotello

PhD Fellow

Team:Ferdinando Auricchio, Michele Conti,

Simone Morganti, Elena Faggiano

Team:Domenico Palombo, Giovanni Spinella,

Bianca Pane

Engineering support to vascular surgery clinical practice

Research topics

- endovascular implants: from medical images to patient specific structural simulations;

- impact of peripheral endovascular repair on femoral popliteal artery kinematics;

- assessment of FU geometry changes of TAAAs treated with MFM stent;

- geometrical remodeling of the aortic arch after hybrid treatment.

In vivo medical image analysis and biomechanical simulations2

Computed Tomography

Angiography

Dicom images

Endovascular implants: from medical images to patient specific structural simulations

1 2

4

Endograft models

5

Post-processing

3

Abaqus

Simulation results

3D reconstruction

ZTA P 36 161

Label FE model

ZTA P 36 113Quantify apposition to the wall: less prone to

endoleak

6

ESCVS 2018 YOUNG SURGEON AWARD 1st PLACE

A. Finotello, G. Spinella, M. Conti, B. Pane, F. Auricchio, and D. Palombo. Toward the use of patient-specific structural simulations of

endovascular repair in the clinical practice.

Endovascular implants: from medical images to patient specific structural simulations

AbaqusESCVS 2018 YOUNG SURGEON AWARD 1st PLACE

A. Finotello, G. Spinella, M. Conti, B. Pane, F. Auricchio, and D. Palombo. Toward the use of patient-specific structural simulations of

endovascular repair in the clinical practice.

Facing a real case: predictive value of simulations

Pre-operative Post-operative

6 months

Type IB endoleak

Could these complicationsbe predicted?

Endovascular implants: from medical images to patient specific structural simulations

AbaqusESCVS 2018 YOUNG SURGEON AWARD 1st PLACE

A. Finotello, G. Spinella, M. Conti, B. Pane, F. Auricchio, and D. Palombo. Toward the use of patient-specific structural simulations of

endovascular repair in the clinical practice.

Facing a real case: predictive value of simulations

Pre-operative Post-operative

6 months

Type IB endoleak

Could these complicationsbe predicted?

Simulation results: good agreement with the reality…

Bad device apposition to the wall: Endoleak prediction

Research topics

- endovascular implants: from medical images to patient specific structural simulations;

- impact of peripheral endovascular repair on femoral popliteal artery kinematics;

- assessment of FU geometry changes of TAAAs treated with MFM stent;

- geometrical remodeling of the aortic arch after hybrid treatment.

In vivo medical image analysis and biomechanical simulations2

Complex arterial kinematics due to leg bending

Challenging structural stentsolicitation

Engineering point of view 3 levels of analysis

1. Understanding arterial kinematics loads acting on the stent

2. Structural analysis of stent solicitation under the loads

3. Fatigue analysis expected structural life of the devices

Impact of peripheral endovascular repair on femoral poplitealartery kinematics: from clinical experience to in vivo biomechanical modeling

Open issues

• Preliminary results on a clinical case (Viabahn device)

STENT ZONE

SFA-PA

Vessel diameters in the stented zone (light blue)Nominal stent diameter (red)

Impact of peripheral endovascular repair on femoral popliteal artery kinematic: from clinical experience to in vivo biomechanical modeling

Dia

met

ers

[mm

]

Stent length [mm]

Vessel diameters in the stented region vs stent length

Research topics

- endovascular implants: from medical images to patient specific structural simulations;

- impact of peripheral endovascular repair on femoral popliteal artery kinematics;

- assessment of FU geometry changes of TAAAs treated with MFM stent;

- geometrical remodeling of the aortic arch after hybrid treatment.

In vivo medical image analysis and biomechanical simulations2

Medical image analysis to measure the FU geometry changes of TAAAs treatedwith Cardiatis Multilayed Flow Modulator stent

From CTs, verify, through geometrical analysis:

● perfusion of side branches;

● centerline changes induced by the Cardiatis MFM;

● presence/absence of blood flowing in the aneurysm sac;

● morphological changes of the aneurysm sac.

Segmentation of Lumen, MFM and

Aneurysm

Surface Registration

Principal Lumen Extraction

Geometrical Analysis

CTs selection

G. Spinella, A. Finotello, E. Faggiano, B. Pane, M. Conti, B. Pane, V. Gazzola, F. Auricchio, and D. Palombo. Mid-term follow-up geometrical analysis of thoraco-

abdominal aortic aneurysms treated with multilayer flow modulator. Annals of Vascular Surgery. IN PRESS

Research topics

- endovascular implants: from medical images to patient specific structural simulations;

- impact of peripheral endovascular repair on femoral popliteal artery kinematics;

- assessment of FU geometry changes of TAAAs treated with MFM stent;

- geometrical remodeling of the aortic arch after hybrid treatment.

In vivo medical image analysis and biomechanical simulations2

Image acquisition

• 22 patients

• Zones 0,1 and 2

• Pre-op and 1-month FU CTs

3D surface generation

• Lumen

• Endograft

Centerline distances

Outerline curvature at

endograft landing zones

Analysis Workflow: from CT scans to 3D geometric analysis

L

DAR-LSA

Assessment of geometrical remodeling of the aortic arch and descending thoracic

aorta after hybrid treatment

Aim: Analyze the geometric changes of the aortic arch after hybrid treatment, with a particular focus on the endograft landingzones, attempting to enhance the understanding on the possible reasons for the development of device-related complications

Our experience suggests that the physiological curvature of the aortic arch was altered after hibrid treatment,

probably due to spring-back force (SBF) exerted by the stent-graft at both ends of the stent-grafts.

Research topics

- risk of rupture;

- AAA screening.

Clinical research3

RISK OF RUPTURE

2014

2013

Vascular surgery – Abdominal Aortic Aneurysm

2016

RISK OF RUPTURE

Vascular surgery – Abdominal Aortic Aneurysm

Biomechanical indices are a promising tool in the assessment of AAA rupture risk as they incorporate several factors, including geometry, tissue properties, and patient-specific risk factors. However, clinical implementation of biomechanical AAA assessment remains a challenge owing to a lack of standardization.

2008

RISK OF RUPTURE

Vascular surgery – Abdominal Aortic Aneurysm

Ann Vasc Surg 2011

Our Experience

RISK OF RUPTURE

Vascular surgery – Abdominal Aortic Aneurysm

Our ExperienceRISK OF RUPTURE

Vascular surgery – Abdominal Aortic Aneurysm

Ann Vasc Surg 2011

Research topics

- risk of rupture;

- AAA screening.

Clinical research3

SCREENING

Vascular surgery – Abdominal Aortic Aneurysm

Our Experience

SCREENING

Vascular surgery – Abdominal Aortic Aneurysm

J Vasc Surg 2011

Our Experience

SCREENING

Vascular surgery – Abdominal Aortic Aneurysm

S.A.Ge

S.A.GeScreening Aneurisma Aorta Addominale Genova

Aortic Abdominal Aneurysm Screening: male patients between 65 and 75 years in Genova: about 26000 examinations

U.O CHIRURGIA VASCOLARE ED ENDOVASCOLARE

SCREENING

Vascular surgery – Abdominal Aortic Aneurysm

SCREENING

Vascular surgery – Abdominal Aortic Aneurysm

Bonaventura A. et al »Intraplaque Expression of C-Reactive Protein PredictsCardiovascular Events in Patients with Severe Atherosclerotic Carotid ArteryStenosis». Mediators Inflamm. Epub 2016 Sep.

Carbone F. et al«Vitamin D receptor is expressed within human carotid plaques and correlates with pro-inflammatory M1 macrophages». Vascul Pharmacol.Epub 2016 Aug 20.

Pagano S. et al. «Anti-apolipoprotein A-1 auto-antibodies as active modulators ofAtherothrombosis». Thromb Haemost. 2016 Aug.

Lenglet S. et al «Statin treatment is associated with reduction in serum levels of receptoractivator of NF-κB ligand and neutrophil activation inpatients with severe carotid stenosis». Mediators Inflamm. Epub 2014 Feb.

Fraga-Silva RA. Et al «Treatment with Angiotensin-(1-7) reduces inflammation in carotidatherosclerotic plaques». Thromb Haemost. 2014 Apr.

Vuilleumier N. et al «Serum levels of anti-apolipoprotein A-1 auto-antibodies and myeloperoxidase as predictors of major adverse cardiovascular events after carotidendarterectomy». Thromb Haemost. 2013 Apr.

Montecucco F. et al «The activation of the cannabinoid receptor type 2 reducesneutrophilic protease-mediated vulnerability in atheroscleroticPlaques». Eur Heart J. 2012 Apr.

Montecucco F. et al «Anti-Apolipoprotein A-1 auto-antibodies are active mediators of atherosclerotic plaque vulnerability.» Eur Heart J. 2011Feb.

Montecucco F. «Systemic and intraplaque mediators of inflammation areincreased in patients symptomatic for ischemic stroke». Stroke. 2010 Jul.

Other studies and projects

Conclusion

- Interdisciplinary experience has allowed to open new fields of inquiry.

- The engineers contribution to the team allows new therapeutic approaches.

- The goal for the future is a new professional figure able to blend the surgical skills and

the ability to conduct scientific projects for development of new therapeutic strategies:

the Vascular Specialist.

Able to take care of the vascular disease

as a whole

In other words…

Research Team

UNIVERSITY OF GENOVA - IRCCS SAN MARTINO HOSPITAL

COMPMECH GROUP UNIVERSITY OF PAVIA

Contact: domenico.palombo@unige.it

Surgical and Integrated Diagnostic Sciences