The study of the microscopic structure of tissues is called histology. In histology, advanced imaging techniques, such as electron microscopy or light microscopy, are used to analyze and identify the tissue and the structures present. In histology, samples can be specially processed and prepared for visualization of the structure and the disease. In, Figure 1.7 histology of the arterial vessel wall shows the intima, the media and the adventitia along with IEL and smooth muscle cells. Generally, there are different techniques in the processing of the tissue for histology. The tissue processing methods include plastic and paraffin histology along with different staining techniques such as hematoxylin and eosin , Movat’s Pentachrome and Elastin Trichrome staining to analyze and visualize the tissue structure. In each process, the tissue is fixed using dehydrated techniques using alcohol. Then the tissue is embedded in either plastic or paraffin resin. Each sample then is sectioned using a grinding method or cutting method using a sharp blade. In plastic histology processing each section can be cut in 19 to 90 microns vs. in paraffin histology the tissue embedded in paraffin, which is similar in density to tissue can be sectioned at anywhere from 3 to 10 microns. Analysis can be performed after staining methods under a microscope. Usually H&E staining can be used to examine cellular type and quantity and fibrin deposition, while Trichrome Elastin staining can be used for observing any type of injury in the lumen of a vessel, garden pots square the media, or EIL, EEL and other structures. At the beginning of this chapter the limitation in the current stents for use in rapid growing children was discussed, and a great interest among pediatric community in stents that can grow with an artery or be resorbed.
Coarctation of the aorta is a congenital disease in children that can potentially benefit from self-growing stents. Stenting as a superior solution compared to balloon angioplasty and surgery for fixation of CoA was discussed. The properties of Nitinol, an alloy that can be used for self-expanding stents due to some of its unique characteristic properties such as super elasticity, and biased stiffness was discussed. Also, the vascular injury and its remodeling process after the injury, such as negative and positive remodeling was reviewed. In addition, histology and several types of processing and staining that are utilized in the science of histology for microscopic evaluation of the tissue structure was mentioned. Currently, there is little information available on the effect of stent radial force on the rapid growing arteries in pediatric patients. However, there are a good number of studies focusing on the adult abdominal stent grafts, coronary and peripheral artery stents, exhibiting the effect of stent and stent grafts, and their radial forces on the vascular biology. Nevertheless, none of the investigators looked extensively at the large growth of small crimp profile bare metal stents and, particularly, did not design a stent that can grow with the small rapid growing arteries for use in the pediatric endovascular applications. An extensive literature search was performed and the findings from a few key sources are summarized in two categories below. Siegenthaler et al., evaluated the growth and the effect of the stent grafts covered with polyester on the thoracic aorta in young piglets. The authors concluded that the stent graft may inhibit growth of the nonatherosclerotic normal aorta and lead to intimal hyperplasia and focal fibrosis in the inner media adjacent to the stent. Siegenthaler et al., proposed several reasons for their finding, including vascular hemodynamics and the change in pressure profile on the arterial wall due to the polyester covers on the stent.
Polyester covers can absorb the most mechanical forces on the arterial lumen, leading the change in the wall stress and less pressure contact and reduce the pulstality exposure of the aortic wall. Another problem with the stent graft is the potential to cover the side branch vessels during deployment, usually the subclavian artery ostium in CoA. In conclusion, the authors suggested that more study should be conducted to evaluate stent and stents grafts in growing aorta. Cheung et al., reported on the early and the intermediate-term follow-up results of Wallstent a self-expandable stent implanted in children with congenital heart disease. The Wallstent has been widely used by interventionalist in Europe for adult patients with the iliac and femoral arterial stenosis. In two different centers, from 1993 to 1997, Cheung et al., implanted Wallstents in 20 children with average age of 10 years old and an average weight of 30.5 kg. The results showed immediate expansion of the stents and reduction of the pressure gradient in the patients. However, the authors observed migration in two of the optimally positioned stents within 24 hours of implantation, along with significant neointimal in growth in 28% of the patient at the mean follow-up duration of 8.1 months, which contrasts with the experience of patients with Palmaz stents where the significant restenosis is at 3%. Cheung et al., suggested the thrombogenicity of the stent could be due to the design of the stent, woven mesh with expanding radial force, versus Palmaz’s rigid slotted tubes with smooth and even surface. The authors also reported the stent did not pace with the growth of the vessel, therefore limits it use in young children. Hong et al., performed an experimental study with CardioCoil , a self-expanding stent in the coronary artery of pigs, for a duration of six months. The authors performed angiographic and histologic analyses to evaluate the deployment characteristics, patency rates, and neointimal response. The neointimal responses in this study were not significant and the stents were patent through the survival period up to 6 months.
The stents expanded over time; the diameter of the stents at the time of implant was 2.85 ± 0.78 and at the follow-up showed to be 3.24 ± 097mm. Hong et al., observed penetration of most of the stent’s struts into the adventitia. The authors concluded that the self-expanding stent is related with favorable deployment characteristics and potency rates, although appropriate sizing is more crucial than with balloon-expandable stents. More importantly, Hong et al., concluded that, unlike balloon-expandable stents, there is a dissociation between major vessel injury by the chronic strut expansion process and the neointimal reaction. Freeman et al., explored the effect of the stent forces in vascular stenosis and remodeling by placing stainless steel stents with three chronic outward forces —3.4N, 16.4N and 19.4N—in the iliac arteries of juvenile porcine models for a duration of 30 days to explore and develop an equation for identifying the optimal stent force. The results of the authors’ investigation revealed a significant increase in the total thickness and neointimal hyperplasia in the stents with higher COF than the lower ones, which corresponds with several other similar findings. Freeman et al., concluded that the geometry, structure, and mechanics of the target vessel need to be considered when a stent is designed and, in order to achieve maximum dilation, stents should not produce stress in the vessel wall greater than the end of the transitional domain of the vessel’s stress-strain curve. The authors suggested that their findings could be extremely useful in the vascular stent developments. In a 180-day study, Zhao et al., explored late stent expansion and neointimal proliferation of over-expanded Nitinol stents in the peripheral arteries. The authors used Nitinol selfexpanding stents with a maximum diameter of 8 mm and length of 28mm. Zhao et al., implanted the stents into the iliofemoral arteries of Yucatan swine. Due to variations in target artery size, the stent-to-artery ration ranged from 1.2:1 to 1.9:1 and the effect of stretching investigated. the authors observed high stent diameter-to-artery ratio, which resulted in overstretching of the arterial wall. Finally, Zhao et al., reported that the overstretching of an artery can lead to medial injury, square pots and medial injury will cause a profound long-term histological response, including significant neointimal proliferation. Saguner et al., found that stents constrained by their target artery at implantation expanded over time to near their nominal diameter within five months. Like the previous study, severe oversizing determined as an oversizing ratio resulted in significant neointimal proliferation and in-stent restenosis. Barth et al., performed a side-by side comparison of three current stents in the market that are substantially different in their physical characteristics: Palmaz stent, Strecker stent and Wallstents. Palmaz is the most rigid stent and has a very high resistive outward force in vitro in comparison to the Wallstent. The Strecker is made of tantalum, has the lowest resistive force of the three, and is very flexible and maneuverable. Among the three, the Palmaz stent is the nonelastic one with a lower profile, the Wallstent is fully elastic with a higher profile, and the Strecker stent is elastic to a lesser degree with a higher profile. All stents were implanted into canine external iliac and the flexing portion of the proximal femoral artery of dogs. Angiographic images of mid-stent luminal diameters instantly after placement of the stent and at follow-up, as well as mid-stent cross-sectional areas of neointima were compared by the investigators for significant differences. Barth et al., concluded that the Strecker stent with a high profile and low resistive force is affected by the vascular wall recoil and caused the formation of a greater amount of neointima in comparison to the lower profile high resistive force Palmaz stent and Wallstent. Medial atrophy is pronounced outside the latter two stents. The authors found that in the flexing arteries, the rigid stent can penetrate through the vascular wall. Sakakoa et al., studied the vascular response of bare Nitinol stent in porcine femoral and femoropopliteal arteries. The authors performed quantitative angiography and histopathology at one and three months to evaluate and assess the biological response to the two devices. Sakakoa et al., observed an increase in the neointimal area in FPA in comparison to FA and late lumen loss in FPA than in FA. The authors concluded that repetitive interaction between the stent and the vessel wall during dynamic vessel motion could affect vascular responses. Several clinical studies reported the use of different types of stents for fixation of the CoA. We reviewed a few of them and some of them are summarized here.
Haji-Zeinali et al., used currently in the market self-expandable Nitinol aortic stents in eight hypertensive patients with coarctation of the aorta.48 The authors showed that after implantation of the stents, the mean systolic gradient decreased significantly. Haji-Zeinali et al., also reported that Nitinol stents were easier to deploy and conformed better to the aortic anatomy compared to balloon expandable stents. Finally, the authors found that Nitinol stents could be used to treat the coarctation of the aorta safely and effectively; these types of stents had similar efficacy in reducing coarctation of the aorta as surgical repair. Although Haji-Zeinali used these stents in adult patients, we believe the application of Nitinol self-expanding stents can be extended to the pediatric applications and especially neonatal applications for the reduction of CoA. Bugeja et al., used a stent in neonatal for fixation of the coarctation of the aorta. They reported a case of a severely-ill newborn with complex coarctation, multiorgan failure, disseminated intravascular coagulation and oedema, who had to go through an emergency stenting procedure on the tenth day of her life. Since there are no designed stents for neonates, the authors used an off-label used bare metal adult coronary stent . With a fast pace of growth in the neonates, Bugeja et al., placed the stent temporarily and planned a surgical procedure to remove the stent and fix the coarctation surgically. This study clearly demonstrated the need for a stent that can be placed in patients and grow with them to eliminate or reduce the future interventions. Prior to designing the stent for this investigation, the most used stents in the congenital heart disease field was reviewed. Stents can be categorized based on their delivery method: balloon-expandable or self-expandable stents.2 Balloon expandable stents are inflated with a balloon and their size is determined by the diameter of the balloon that they are inflated with. These stents are mostly rigid with high external outward force.