Name: a novel murine model of arteriovenous fistula failure: the surgical procedure in detail
Uploaded: 2016-02-03T13:00:00
Description: Watch this Scientific Journal Video about A Novel Murine Model of Arteriovenous Fistula Failure: The Surgical Procedure in Detail at JoVE.com

This study was supported by a grant from the Dutch Kidney Foundation (KJPB 08.0003). 
Carolien Rothuizen is acknowledged for her contribution to the study. Hoang Pham is acknowledged for his assistance with the pathology work-up.

All experiments were approved by the committee on animal welfare of the Leiden University Medical Center.
1. Animal Preparation and Anaesthesia
<ol>
	<li>Anesthetize the mouse (1-3 months old) in a continuous anaesthetic induction chamber filled with 3-4% isoflurane.</li>
	<li>Shave the ventral side of the neck and the inside part of the left upper leg using an electrical razor and use a piece of tape to remove the hair.</li>
	<li>Apply ocular ointment on both eyes.</li>
	<li>Position the an...

<ol>
	<li>Rotmans, J. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Animal+Models+for+Studying+Pathophysiology+of+Hemodialysis+Access.">Animal Models for Studying Pathophysiology of Hemodialysis Access.</a> The Open Urology &amp; Nephrology Journal. 7, 14-21 (2014).</li><li>Kwei, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+adaptive+responses+of+the+vascular+wall+during+venous+arterialization+in+mice.">Early adaptive responses of the vascular wall during venous arterialization in mice.</a> Am.J.Pathol. 164 (1), 81-89 (2004).</li><li>Castier, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Characterization+of+neointima+lesions+associated+with+arteriovenous+fistulas+in+a+mouse+model.">Characterization of neointima lesions associated with arteriovenous fistulas in a mouse model.</a> Kidney Int. 70 (2), 315-320 (2006).</li><li>Krishnamoorthy, M. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemodynamic+wall+shear+stress+profiles+influence+the+magnitude+and+pattern+of+stenosis+in+a+pig+AV+fistula.">Hemodynamic wall shear stress profiles influence the magnitude and pattern of stenosis in a pig AV fistula.</a> Kidney Int. 74 (11), 1410-1419 (2008).</li><li>Ene-Iordache, B., Cattaneo, L., Dubini, G., Remuzzi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+anastomosis+angle+on+the+localization+of+disturbed+flow+in+'side-to-end'+fistulae+for+haemodialysis+access.">Effect of anastomosis angle on the localization of disturbed flow in 'side-to-end' fistulae for haemodialysis access.</a> Nephrol. Dial. Transplant. 28 (4), 997-1005 (2013).</li><li>Wong, C. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vascular+remodeling+and+intimal+hyperplasia+in+a+novel+murine+model+of+arteriovenous+fistula+failure.">Vascular remodeling and intimal hyperplasia in a novel murine model of arteriovenous fistula failure.</a> J.Vasc.Surg. 59 (1), 192-201 (2014).</li><li>Rekhter, M., Nicholls, S., Ferguson, M., Gordon, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cell+proliferation+in+human+arteriovenous+fistulas+used+for+hemodialysis.">Cell proliferation in human arteriovenous fistulas used for hemodialysis.</a> Arterioscler. Thromb. 13 (4), 609-617 (1993).</li><li>Falk, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Maintenance+and+salvage+of+arteriovenous+fistulas.">Maintenance and salvage of arteriovenous fistulas.</a> J. Vasc. Interv. Radiol. 17 (5), 807-813 (2006).</li><li>Tordoir, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+evaluation+of+failure+modes+in+autogenous+radiocephalic+wrist+access+for+haemodialysis.">Prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis.</a> Nephrol. Dial. Transplant. 18 (2), 378-383 (2003).</li><li>Dixon, B. 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The AVF is considered to be the Achilles&#39; heel in hemodialysis treatment. Unfortunately, the AVF still suffers from a high number of failure8-10. Despite extensive research on the underlying mechanisms, the exact pathophysiology remains unknown. Numerous murine models for AVF failure have already been described in literature2,3,11,12. However, none of these models incorporate a venous end to arterial side anastomosis configuration that is most used in the clinical situation. This is very relevan...

A functional vascular access conduit is of vital importance for patients with renal failure that depend on chronic hemodialysis to stay alive. The construction of an arteriovenous fistula (AVF) is currently the preferred choice for vascular access. However, AVF related complications constitute a major cause of morbidity for patients on chronic hemodialysis. Despite extensive scientific efforts, none of the novel approaches to reduce AVF access-related complications did result in substantial improvement of AVF durability. Part of this disappointing progress relates to incomplete understanding of the underlying pathophysiology of hemodialysis access failure.
To unravel the pathophysiology of AV access failure, animal models that closely mimic human pathology are of utmost importance. In this respect, not only the animal species but also the anastomotic site, the required anti-coagulatory therapy and the duration of follow up after surgery should be taken into account1. While large animals are the most suitable for intervention studies aimed to develop new therapeutic strategies, murine models have the greatest potential to gain more insight in the molecular mechanisms underlying AV access failure due to the availability of transgenic mice. In addition, a large number of mice can be used for this purpose at lower costs compared to larger animal use.
The first murine model of AVF failure was described in 2004 by Kwei and et al.2 In this model, AVFs were constructed using the carotid artery and the jugular vein in an end-to-end manner using an intravascular catheter. This model could be useful to study early venous adaptation in AVFs although the end-to-end configuration and the presence of an intravascular catheter limit the validity of this model for human AVFs. An improved AVF model was introduced by Castier and et al.3 in which the end of the carotid artery is connected to the side of the jugular vein. However, AVFs in hemodialysis patients are usually constructed by anatomizing the end of a vein to the side of an artery. The exact configuration of the AVF is a crucial characteristic of an AV access model since it determines the hemodynamic profile within the conduit4. The latter is an important contributor to endothelial dysfunction and subsequent development of intimal hyperplasia (IH)5.
A novel murine model was recently developed with an identical anatomical configuration as is utilized in humans6. In this model, AVF are created in C57BL/6 mice by anastomosing the end of a branch of the external jugular vein to the side of the common carotid artery with interrupted sutures. In the present paper, we focus on the microsurgical procedure of this model in order to facilitate the widespread use of this murine model, aimed to unravel the complex pathophysiology of hemodialysis access failure.

<table border="0" cellpadding="0" cellspacing="0" width="697">
	<tbody>
		<tr height="17">
			<td height="17" style="height:17px;width:247px;">Dissecting microsocpe</td>
			<td style="width:219px;">Leica</td>
			<td style="width:117px;">M80</td>
			<td style="width:115px;"></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Forceps</td>
			<td>Medicon</td>
			<td>07.61.25</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Vascular forceps</td>
			<td>S&#38;T</td>
			<td>JFL-3D.2</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Vascular forceps</td>
			<td>S&#38;T</td>
			<td>D-5a.2</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Forceps</td>
			<td>Roboz</td>
			<td>SS/45</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Micro scissor 5 mm blade</td>
			<td>Fine science tools</td>
			<td>15000-08</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Micro scissor 2 mm blade</td>
			<td>Fine science tools</td>
			<td>15000-03</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Scissor</td>
			<td>Medicon</td>
			<td>05.12.21</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Clip applier 1</td>
			<td>S&#38;T</td>
			<td>CAF-4</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Vascular clamp 1</td>
			<td>S&#38;T</td>
			<td>B-1V</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Clip applier 2</td>
			<td>BBraun</td>
			<td>FE572K</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Vascular clamp 2</td>
			<td>BBraun</td>
			<td>FE740K</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Hemostatic forceps</td>
			<td>BBraun</td>
			<td>BH110</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">10.0 sutures</td>
			<td>BBraun</td>
			<td>G1117041</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">6.0 sutures</td>
			<td>BBraun</td>
			<td>768464</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Cauterizer</td>
			<td>Fine science tools</td>
			<td>18010-00</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Needle holder</td>
			<td>Medicon</td>
			<td>11.82.18</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Ocular ointment</td>
			<td>Pharmachemie</td>
			<td>41821101</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Chlorhexidine tincture 0,5%</td>
			<td>Leiden University Medical Center</td>
			<td>NA</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Heparin</td>
			<td>Leo Pharma</td>
			<td>012866-08</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Buprenorphin</td>
			<td>RB Pharmaceuticals&#160;</td>
			<td>283732</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Isoflurane</td>
			<td>Pharmachemie</td>
			<td>45,112,110</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Anesthesia mask</td>
			<td>Maastricht university</td>
			<td>custom made</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Midazolam</td>
			<td>Actavis</td>
			<td>AAAC6877</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Dexmedetomidine</td>
			<td>Orion</td>
			<td>141-267</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Fentanyl</td>
			<td>Bipharma</td>
			<td>15923002</td>
			<td></td>
		</tr>
		<tr height="17">
			<td height="17" style="height:17px;">Continuous anaesthetic induction chamber</td>
			<td>Vet-tech solutions</td>
			<td>AN010R</td>
			<td></td>
		</tr>
	</tbody>
</table>

a novel murine model of arteriovenous fistula failure: the surgical procedure in detail

The arteriovenous fistula (AVF) still suffers from a high number of failures caused by insufficient remodeling and intimal hyperplasia from which the exact pathophysiology remains unknown. In order to unravel the pathophysiology a murine model of AVF-failure was developed in which the configuration of the anastomosis resembles the preferred situation in the clinical setting. A model was described in which an AVF is created by connecting the venous end of the branch of the external jugular vein to the side of the common carotid artery using interrupted sutures. At a histological level, we observed progressive stenotic intimal lesions in the venous outflow tract that is also seen in failed human AVFs. Although this procedure can be technically challenging due to the small dimensions of the animal, we were able to achieve a surgical success rate of 97% after sufficient training. The key advantage of a murine model is the availability of transgenic animals. In view of the different proposed mechanisms that are responsible for AVF failure, disabling genes that might play a role in vascular remodeling can help us to unravel the complex pathophysiology of AVF failure.

After the creation of the anastomosis (Figure 1), the patency should be assessed by shortly occluding the venous outflow tract with a vascular forceps. When the anastomosis is patent, the vascular tract proximal to the occlusion should clearly expand in a pulsatile manner. In addition, the patency is confirmed by using near infrared fluoroscopy (NIRF) that effectively functions as an angiography (Figure 2). A failure in the surgical procedure can lead to an occlusion of the anastomosis a...

Watch this Scientific Journal Video about A Novel Murine Model of Arteriovenous Fistula Failure: The Surgical Procedure in Detail at JoVE.com

A Novel Murine Model of Arteriovenous Fistula Failure: The Surgical Procedure in Detail

Here we present a murine model of arteriovenous fistula (AVF) failure in which a clinically relevant anastomotic configuration is incorporated. This model can be used to study the pathophysiology and to test possible therapeutic interventions.

The arteriovenous fistula (AVF) still suffers from a high number of failures caused by insufficient remodeling and intimal hyperplasia from which the ...

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