Incorporation of Fibrin, Platelets, and Red Blood Cells into a Coronary Thrombus in Time and Space

Abstract

We describe the internal structure, spatial organization and dynamic formation of coronary artery thrombi from ST-segment elevation myocardial infarction patients. Scanning electron microscopy (SEM) revealed significant differences among four groups of patients (<2 hours; 2–6 hours; 6–12 hours, and >12 hours) related to the time of ischemia. Coronary artery thrombi from patients presenting less than 2 hours after the infarction were almost entirely composed of platelets, with small amounts of fibrin and red blood cells. In contrast, thrombi from late presenters (>12 hours) consisted of mainly platelets at the distal end, where clotting was initiated, with almost no platelets at the proximal end, while the red blood cell content went from low at the initiating end to more than 90% at the proximal end. Furthermore, fibrin was present mainly on the outside of the thrombi and older thrombi contained thicker fibers. The red blood cells in late thrombi were compressed to a close-packed, tessellated array of polyhedral structures, called polyhedrocytes. Moreover, there was redistribution from the originally homogeneous composition to fibrin and platelets to the outside, with polyhedrocytes on the interior. The presence of polyhedrocytes and the redistribution of components are signs of in vivo clot contraction (or retraction). These results suggest why later thrombi are resistant to fibrinolytic agents and other treatment modalities, since the close-packed polyhedrocytes form a nearly impermeable seal. Furthermore, it is of particular clinical significance that these findings suggest specific disparate therapies that will be most effective at different stages of thrombus development.

Keywords

coronary - aspiration thrombectomy - scanning electron microscopy - ST-segment elevation myocardial infarction

^† Demised.

Author Contributions

M. Maly designed the study, participated in the collection of samples and writing of the article; T. Riedel, J. Suttnar, R. Kotlin, and J. Kaufmanova participated in the analysis and interpretation of data; J. Stikarova participated in the analysis and interpretation of data and writing of the article; P. Tousek and O. Kucerka participated in the design of the study and collection of samples; J. W. Weisel participated in the concept and design of the study and writing of the article; Jan E. Dyr participated in the concept and design of the study, interpretation of data, and writing of the article.

Publication History

Received: 19 May 2021

Accepted: 26 September 2021

Article published online:
15 November 2021

• References

• 1 Silvain J, Collet J-P, Nagaswami C. et al. Composition of coronary thrombus in acute myocardial infarction. J Am Coll Cardiol 2011; 57 (12) 1359-1367
• 2 Quadros AS, Cambruzzi E, Sebben J. et al. Red versus white thrombi in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: clinical and angiographic outcomes. Am Heart J 2012; 164 (04) 553-560
• 3 Chernysh IN, Nagaswami C, Kosolapova S. et al. The distinctive structure and composition of arterial and venous thrombi and pulmonary emboli. Sci Rep 2020; 10 (01) 5112
• 4 Tutwiler V, Mukhitov AR, Peshkova AD. et al. Shape changes of erythrocytes during blood clot contraction and the structure of polyhedrocytes. Sci Rep 2018; 8 (01) 17907
• 5 Cines DB, Lebedeva T, Nagaswami C. et al. Clot contraction: compression of erythrocytes into tightly packed polyhedra and redistribution of platelets and fibrin. Blood 2014; 123 (10) 1596-1603
• 6 Zalewski J, Lewicki L, Krawczyk K. et al. Polyhedral erythrocytes in intracoronary thrombus and their association with reperfusion in myocardial infarction. Clin Res Cardiol 2019; 108 (08) 950-962
• 7 Nechipurenko DY, Receveur N, Yakimenko AO. et al. Clot contraction drives the translocation of procoagulant platelets to thrombus surface. Arterioscler Thromb Vasc Biol 2019; 39 (01) 37-47
• 8 Kovalenko TA, Giraud M-N, Eckly A. et al. Asymmetrical forces dictate the distribution and morphology of platelets in blood clots. Cells 2021; 10 (03) 584
• 9 Macrae FL, Duval C, Papareddy P. et al. A fibrin biofilm covers blood clots and protects from microbial invasion. J Clin Invest 2018; 128 (08) 3356-3368
• 10 Di Meglio L, Desilles J-P, Ollivier V. et al. Acute ischemic stroke thrombi have an outer shell that impairs fibrinolysis. Neurology 2019; 93 (18) e1686-e1698
• 11 Tutwiler V, Peshkova AD, Le Minh G. et al. Blood clot contraction differentially modulates internal and external fibrinolysis. J Thromb Haemost 2019; 17 (02) 361-370
• 12 Shin JW, Jeong HS, Kwon HJ, Song KS, Kim J. High red blood cell composition in clots is associated with successful recanalization during intra-arterial thrombectomy. PLoS One 2018; 13 (05) e0197492
• 13 Yunoki K, Naruko T, Sugioka K. et al. Erythrocyte-rich thrombus aspirated from patients with ST-elevation myocardial infarction: association with oxidative stress and its impact on myocardial reperfusion. Eur Heart J 2012; 33 (12) 1480-1490
• 14 Weisel JW, Litvinov RI. Red blood cells: the forgotten player in hemostasis and thrombosis. J Thromb Haemost 2019; 17 (02) 271-282
• 15 Ariens RAS. Contribution of red blood cells and clot structure to thrombosis. Blood 2015; 126 (23) SCI-15-SCI-15
• 16 Cambruzzi E, Sebben JC, David RB. et al. Histopathological evaluation of coronary thrombi in patients with ST-segment elevation myocardial infarction. Rev Bras Cardiol Invasiva (English Ed.) 2012; 20 (03) 267-273
• 17 Sebben JC, Cambruzzi E, Avena LM, Gazeta CdoA, Gottschall CA, Quadros AS. Clinical significance of histological features of thrombi in patients with myocardial infarction. Arq Bras Cardiol 2013; 101 (06) 502-510
• 18 R Core Team. R: A language and environment for statistical computing. Published online 2020. Accessed October 8, 2021 at: https://www.r-project.org/
• 19 Hess MW, Siljander P. Procoagulant platelet balloons: evidence from cryopreparation and electron microscopy. Histochem Cell Biol 2001; 115 (05) 439-443
• 20 El Dib R, Spencer FA, Suzumura EA. et al. Aspiration thrombectomy prior to percutaneous coronary intervention in ST-elevation myocardial infarction: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016; 16: 121
• 21 Perera D, Rathod KS, Guttmann O. et al. Routine aspiration thrombectomy is associated with increased stroke rates during primary percutaneous coronary intervention for myocardial infarction. Am J Cardiovasc Dis 2020; 10 (05) 548-556
• 22 Tessarolo F, Bonomi E, Piccoli F. et al. Assessing composition of coronary thrombus in STEMI patients - a multiscale approach to charaterize samples obtained by catheter aspiration. Paper presented at: Proceedings of the 2nd International Congress on Cardiovascular Technologies (CARDIOTECHNIX-2014; Rome, Italy; October 25–26, 2014:5–12
• 23 Novotny J, Chandraratne S, Weinberger T. et al. Histological comparison of arterial thrombi in mice and men and the influence of Cl-amidine on thrombus formation. PLoS One 2018; 13 (01) e0190728-e0190728
• 24 Ribeiro DRP, Cambruzzi E, Sebben JC. et al. Immunohistochemical characteristics of coronary thrombi in patients with ST-elevation myocardial infarction and diabetes mellitus: pilot studyy. Rev Bras Cardiol Invasiva (English Ed.) 2014; 22 (02) 131-136
• 25 Celi A, Merrill-Skoloff G, Gross P. et al. Thrombus formation: direct real-time observation and digital analysis of thrombus assembly in a living mouse by confocal and widefield intravital microscopy. J Thromb Haemost 2003; 1 (01) 60-68
• 26 Cooley BC. In vivo fluorescence imaging of large-vessel thrombosis in mice. Arterioscler Thromb Vasc Biol 2011; 31 (06) 1351-1356
• 27 Marchese P, Lombardi M, Mantione ME. et al. Confocal blood flow videomicroscopy of thrombus formation over human arteries and local targeting of P2 × 7. Int J Mol Sci 2021; 22 (08) 4066
• 28 Silvain J, Collet JP, Guedeney P. et al. Thrombus composition in sudden cardiac death from acute myocardial infarction. Resuscitation 2017; 113: 108-114
• 29 Zalewski J, Bogaert J, Sadowski M. et al. Plasma fibrin clot phenotype independently affects intracoronary thrombus ultrastructure in patients with acute myocardial infarction. Thromb Haemost 2015; 113 (06) 1258-1269
• 30 Sadowski M, Ząbczyk M, Undas A. Coronary thrombus composition: links with inflammation, platelet and endothelial markers. Atherosclerosis 2014; 237 (02) 555-561
• 31 Ouriel K, Donayre C, Shortell CK. et al. The hemodynamics of thrombus formation in arteries. J Vasc Surg 1991; 14 (06) 757-762
• 32 Mitrophanov AY, Govindarajan V, Zhu S. et al. Microfluidic and computational study of structural properties and resistance to flow of blood clots under arterial shear. Biomech Model Mechanobiol 2019; 18 (05) 1461-1474
• 33 Gersh KC, Edmondson KE, Weisel JW. Flow rate and fibrin fiber alignment. J Thromb Haemost 2010; 8 (12) 2826-2828
• 34 Undas A, Brummel-Ziedins K, Mann KG. Why does aspirin decrease the risk of venous thromboembolism? On old and novel antithrombotic effects of acetyl salicylic acid. J Thromb Haemost 2014; 12 (11) 1776-1787
• 35 Eikelboom JW, Connolly SJ, Bosch J. et al; COMPASS Investigators. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med 2017; 377 (14) 1319-1330
• 36 Xu R-G, Ariëns RAS. Insights into the composition of stroke thrombi: heterogeneity and distinct clot areas impact treatment. Haematologica 2020; 105 (02) 257-259
• 37 Staessens S, Denorme F, Francois O. et al. Structural analysis of ischemic stroke thrombi: histological indications for therapy resistance. Haematologica 2020; 105 (02) 498-507
• 38 Gersh KC, Nagaswami C, Weisel JW. Fibrin network structure and clot mechanical properties are altered by incorporation of erythrocytes. Thromb Haemost 2009; 102 (06) 1169-1175
• 39 Tutwiler V, Wang H, Litvinov RI, Weisel JW, Shenoy V. Active dynamic mechanics of blood clot contraction. Biophys J 2016; 110 (03) 305a-306a
• 40 Peshkova AD, Malyasyov DV, Bredikhin RA. et al. Reduced contraction of blood clots in venous thromboembolism is a potential thrombogenic and embologenic mechanism. TH Open 2018; 2 (01) e104-e115
• 41 Litvinov RI, Farrell DH, Weisel JW, Bennett JS. The platelet integrin αIIbβ3 differentially interacts with fibrin versus fibrinogen. J Biol Chem 2016; 291 (15) 7858-7867
• 42 Weitz JI. Insights into the role of thrombin in the pathogenesis of recurrent ischaemia after acute coronary syndrome. Thromb Haemost 2014; 112 (05) 924-931
• 43 Skeppholm M, Kallner A, Malmqvist K, Blombäck M, Wallén H. Is fibrin formation and thrombin generation increased during and after an acute coronary syndrome?. Thromb Res 2011; 128 (05) 483-489
• 44 Berny MA, Munnix ICA, Auger JM. et al. Spatial distribution of factor Xa, thrombin, and fibrin(ogen) on thrombi at venous shear. PLoS One 2010; 5 (04) e10415
• 45 Riedel T, Brynda E, Dyr JE, Houska M. Controlled preparation of thin fibrin films immobilized at solid surfaces. J Biomed Mater Res A 2009; 88 (02) 437-447
• 46 Dyr JE, Tichý I, Jiroušková M. et al. Molecular arrangement of adsorbed fibrinogen molecules characterized by specific monoclonal antibodies and a surface plasmon resonance sensor. Sens Actuators B Chem 1998; 51 (01) 268-272
• 47 Dyr JE, Ryšavá J, Suttnar J, Homola J, Tobiška P. Optical sensing of the initial stages in the growth and development of fibrin clot. Sens Actuators B Chem 2001; 74 (1–3): 69-73
• 48 Riedel T, Suttnar J, Brynda E, Houska M, Medved L, Dyr JE. Fibrinopeptides A and B release in the process of surface fibrin formation. Blood 2011; 117 (05) 1700-1706
• 49 Dyr JE, Blombäck B, Hessel B, Kornalík F. Conversion of fibrinogen to fibrin induced by preferential release of fibrinopeptide B. Biochim Biophys Acta 1989; 990 (01) 18-24
• 50 Weisel JW, Veklich Y, Gorkun O. The sequence of cleavage of fibrinopeptides from fibrinogen is important for protofibril formation and enhancement of lateral aggregation in fibrin clots. J Mol Biol 1993; 232 (01) 285-297