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We genetically manipulated the major platelet vesicle-associated membrane proteins (VAMP2, VAMP3, and VAMP8) to create mice with varying degrees of disrupted platelet secretion. As previously shown, loss of VAMP8 reduced granule secretion, and this defect was exacerbated by further deletion of VAMP2 and VAMP3. VAMP2Δ3Δ8-/- platelets also had reduced VAMP7. Loss of VAMP2 and VAMP3 (VAMP2Δ3Δ) had a minimal impact on secretion when VAMP7 and VAMP8 were present. Integrin αIIbβ3 activation and aggregation were not affected, although spreading was reduced in VAMP2Δ3Δ8-/- platelets. Using these mice as tools, we asked how much secretion is needed for proper thrombosis and hemostasis in vivo. VAMP2Δ3Δ mice showed no deficiency, whereas VAMP8-/- mice had attenuated formation of occlusive thrombi upon FeCl3-induced arterial injury but no excessive bleeding upon tail transection. VAMP2Δ3Δ8-/- mice bled profusely and failed to form occlusive thrombi. Plasma-coagulation factors were normal in all of the strains, but phosphatidylserine exposure was reduced in VAMP2Δ3Δ and VAMP2Δ3Δ8-/- platelets. From our data, an ∼40% to 50% reduction in platelet secretion in vitro (dense and α granule) correlated with reduced occlusive thrombosis but no compromise in hemostasis. At a >50% reduction, thrombosis and hemostasis were defective in vivo. Our studies are the first systematic manipulation of platelet exocytic machinery to demonstrate a quantitative linkage between in vitro platelet secretion and hemostasis and thrombosis in vivo. The animals described will be invaluable tools for future investigations into how platelet secretion affects other vascular processes.

Vascular damage presents in many forms and varying geometries. Nevertheless, the platelet response to endothelial damage to the blood vessel wall, be it through a prick or a full puncture wound, is thought to be staged by a qualitatively similar temporal variance in signaling agonists. For example, endothelial damage in the microvasculature is thought to be initially dominated by thrombin and later by platelet released ADP and thromboxane. The same temporal sequence in signaling has been proposed to exist in a profusely bleeding puncture wound 1. If so, platelet morphology, a gold standard of platelet activation state, could provide a strong readout of temporally distinct signaling effects. Platelet morphology has long been considered to be a reliable indicator of a strong agonist such as thrombin acting through PAR receptors that produces a rounded, pseudopod extending, degranulated, highly adhesive platelet versus weaker agonists such as ADP or thromboxane acting through P2Y 12 receptors to produce a less adhesive, somewhat rounded platelet. A testable prediction of existing hemostasis models is that temporal staging of signaling leads to temporal differences in platelet morphology within the forming/remodeling thrombus. Such hypothesized temporal differences in signaling are clinically significant as they form the basis for hypothesizing phenotypically distinct outcomes for direct acting anti-coagulants (DOACs) affecting thrombin versus anti-platelet drugs affecting P2Y 12, ADP receptors. Advances in imaging, e.g., wide area transmission electron microscopy (WA-TEM), make possible the local determination of platelet activation state with high precision 2. Taking a mouse jugular vein puncture wound model 1,2, we found that all morphologically recognized platelet activation states were present early, 1 min post puncture, with loosely bound discoid shaped platelets being the most peripherally located. For bleeding, early-stage puncture wound, these loosely adherent, low activation state platelets were located on both intravascular and extravascular thrombus aggregates. Once the puncture wound is closed, loosely adherent platelets were only found on the intravascular surfaces of the thrombus. We propose that this result is most consistent with a platelet conversion model in which new loosely adherent platelets rapidly convert to tightly packed platelets. As the thrombus remodels, 5 and 20 min post-puncture, the thrombus continued to accumulate platelets both intravascularly and extravascularly. Peripheral, discoid shaped platelets provided a source for intravascular thrombus growth. However, any subsequent extravascular thrombus growth must be due to platelet migration. Significantly, we found that cangrelor, a direct acting P2Y 12 inhibitor, stalled thrombus formation/remodeling at an early stage (Figure 1A,C,E see also ref 1,2). By WA-TEM, the accumulation of discoid-shaped, loosely adherent platelets appeared to be enhanced in a cangrelor treated 5 min thrombus (Figure 1E,F). We suggest that P2Y 12 receptors must act early in thrombus formation with the conversion of discoid to more activated platelets being most affected. In contrast, a 5-min post puncture dabigatran (DOAC) treated showed deformed architecture with inhibition of the accumulation of discoid shaped platelets/rounded loosely adherent platelets being most affected (Figure 1D,F, see also ref 2). Accumulation of degranulated platelets appeared to be lessened in both cangrelor and dabigatran treated thrombi. We propose that the simplest explanation of these results is that multiple signaling pathways act in parallel with select activation states being more dependent on one pathway than another. Clinically, our results suggest that P2Y 12 inhibitors can affect thrombus formation at early time points in addition to the late time points projected by current models. 1. Tomaiuolo M., Matzko C.N., Posentud-Fuentes I., Weisel J.W., Brass L.F. & Stalker T.J. Interrelationships between structure and function during the hemostatic response to injury. Proc Natl Acad Sci USA. 116. 2243-2252 (2019). 2. Rhee, Pokrovskaya I.D.,BallK., LingK., VedanapartiY., CohenJ., CruzD., ZhaoO.S., AronovaM.A., ZhangG., Kamykowski J.A., LeapmanR.D., & StorrieB. Venous puncture wound hemostasis results in a vaulted thrombus structured by locally nucleated platelet aggregates. Commun. Biol., accepted. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Introduction: Vascular damage comes in many forms with the puncture wound likely the longest known to humans. Experimentally, vascular damage has typically been visualized in mouse models in which there is little bleeding. Under these conditions, damage is limited mostly to the endothelial layer lining the vessel. Visualization has varied from light to scanning electron microscopy. Interpretation has been dominated by intravital microscopy outcomes in which an initial layer of p-selection-exposed, i.e., α-granule secretion-positive, platelets is deposited in association with the damaged vessel wall and extended by the accumulation of a less activated outer layer of platelets. These results have given rise to a Core and Shell model of platelet-rich thrombus formation [Tomaiuolo et al., 2017]. Recently, new mouse models have been presented in which the vessel is punctured to create a 300 to 600 micron wound hole [Tomoiuolo et al., 2019]. Bleeding is now profuse. The puncture wound results have been interpreted within a Core and Shell model. However, two important aspects of the experimental data [Tomoiuolo et al., 2019] suggest that the existing model may not explain the actual results. First, p-selectin expression as a marker for α-granule secretion and platelet activation was present in limited areas towards the periphery of the resulting thrombus, not as well-defined Core. Second, the hemostatic thrombus when viewed at early stages, ex vivo, showed a pebbly distribution of platelet aggregates suggestive of nucleated platelet accumulation rather than the smooth layers that would follow from a Core and Shell model. We hypothesize that nucleated accumulation of platelet aggregates within the puncture hole could provide pedestals upon which localized accumulation of platelets form the infrastructure of a vaulted thrombus whose extravascular capping leads to bleeding cessation. Methods: To test the proposed hypothesis, we visualized the interior and overall structure of the forming puncture wound thrombus in full 3D at sub-platelet level resolution. To achieve this end, we took our proven serial block face scanning electron microscopy (SBF-SEM) protocols for visualizing platelet organelles in 3D [Pokrovskaya et al., 2018] and adapted them to the visualization of forming thrombi over 1000s of image. To localize samples for electron microscopy, we used in vivo antibody labeling [Tomaiuolo et al., 2019]. This approach had the added advantage of enabling correlative light microscopy mapping overall p-selectin, a marker of platelet secretion, and fibrin distributions against 3D, platelet resolution, thrombus morphology. Results: We found that a 1 min thrombus, pre-bleeding cessation, was structured about the localized accumulation of pedestal-like platelet aggregates along the sides of the puncture hole, extended and spaced along the extravascular adventitia. Subsequent pedestal extension formed a "pontoon" bridge that "capped" extravascularly the puncture hole. At 5 min, full bleeding cessation, we found that forming platelet thrombus had a Swiss cheese-like interior of vaults that were continuous with the intravascular vessel lumen and framed by columns of platelets, presumed pedestal extensions. The thrombus was sealed on the extravascular side by a platelet "cap" (Figure). As expected after bleeding cessation, red blood cells accumulated on the intravascular side of the cap. Formation of a tightly sealed cap was dependent on α-granule secretion as indicated by the effect of knockout of VAMP-8, the primary SNARE protein involved in a-granule release. Based upon morphology, vaults within the forming thrombus were lined with apparent procoagulant platelets providing a potential protected surface for coagulation factor activation. Conclusions: We conclude that bleeding cessation in a true puncture wound occurs from the extravascular side of the thrombus rather than through the formation of a platelet plug that fills the hole. We propose an alternative model of bleeding cessation in which localized platelet aggregates are the starting pedestal upon which all subsequent steps in puncture thrombus formation build, i.e., "Cap and Build". The extent to which properties differ among systems remains an open question. Tomaiuolo et al. 2017. Intervent. Cardiol. Clin. 6: 1-12. Pokrovskaya et al. 2018. Blood Adv. 2: 2947-2958 Tomaiuolo et al. 2019. Proc. Natl. Acad. Sci. USA 116:2 243-2252 Figure Disclosures No relevant conflicts of interest to declare.

Introduction: Platelet recruitment to generate a thrombus is key to bleeding cessation. That recruitment is dependent on a series of platelet activation processes that include adhesion to the exposed vessel matrix, platelet-platelet adhesion and platelet granule release. How platelet activation is patterned to generate a thrombus has previously been studied by intravital light microscopy, two-photon microscopy and scanning electron microscopy at resolutions insufficient to infer platelet activation at the level of the individual platelet. Here, we present a collaborative effort to stratify spatially the extent of platelet activation at the cellular level in a mouse jugular vein puncture model. We used wide-area transmission electron microscopy (WA-TEM) and serial block face scanning electron microscopy (SBF-SEM) at a resolution of 3 to 100 nm across whole thrombi to determine activation state of individual platelets. Our results, indicate a pattern of platelet stratification within the puncture wound that varies in a time-dependent manner with distinct structural stages in the formation of the thrombus. Methods: Jugular vein thrombi from C57BL/6 mice were collected 1, 5, or 20 min after a 300 µm needle puncture and prepared for EM imaging. For WA-TEM, hundreds of overlapping 3 nm resolution images were acquired using a gondimeter stage. The images sets were aligned using NIH Fiji software to create a single high-res, thrombus-wide image. Individual platelets were stratified into morphologically defined activation states (1: no activation, 2: decreased granule number, 3: no visible granules left, 4: hollow inside). The spatial distribution of platelet stratification was analyzed using iVision software. For SBF-SEM, 100-nm XY-resolution SEM images were collected every 200 nm and 20 nm XY-resolution images every 20 µm. Semi-automated stratification of platelet activation state in individual slices of the thrombus were combined into a 3-D representation using Amira software. Volumetric distributions of platelets with respect to the puncture hole and the vascular wall were quantified. Results: Thrombus Formation Stage 1 (anchor and extend) -- One min post puncture, platelets were anchored in clumps along the exposed vessel wall. Near the damaged vessel wall was a peripheral layer of activated or degranulated platelets (states 3 and 4) covered by additional layers of less-activated platelets (state 1 and 2). Short cylindrical ingrowths extended into the 300 µm hole. Unexpectedly, large aggregates of platelets with a mixture of activation states (states 1 - 4) were found extending from these anchor points into the hole and vertically into the intravascular space. Aggregate surface layers were composed mostly of degranulated platelets (states 3 and 4). Less than 40% of neighboring platelets were of the same activation state as their neighbor. Surprisingly, Stage 2 (cap and erect) -- At 5 min after injury, the puncture hole was capped. ~70% of platelets neighboring degranulated platelets (3 and 4) formed visible aggregates within the thrombus. These aggregates were found along the exposed vessel wall and encasing vertical platelet aggregate towers containing a mixture of platelets in different states (1 - 4). Towers were typically separated by large cavities. SBF-SEM images, a machine-based, unbiased sampling of the underlying platelet distribution, revealed that ~10% of the platelet volume in the puncture hole of the thrombus and the intravascular towers contained largely degranulated platelets, similar to the data from WA-TEM. Stage 3 (infill and remodeling) - At 20 min post-puncture, the thrombus was filled with a mixture of platelets of varying activation states, which surrounded central, vertical aggregates (towers) of degranulated platelets seen at 5 min. Only minor cavity space was apparent. The intravascular surface of the thrombus was covered with an ~10 platelet-thick layer of loosely packed, variably activated platelets (states 1 - 4). Conclusions: Our results demonstrate dynamic spatial patterns of platelet activation within a forming puncture-wound thrombus. Such patterns yield insights into thrombus formation and suggest the need to reference platelets defects and anti-thrombotics drugs against new models. Figure Disclosures No relevant conflicts of interest to declare.

We interrogated in 3D-space the arrangement of alpha-granules and their proteins within 30 human platelets in order to address two central structure/function questions. First, are alpha-granules based on their size, shape and protein content a single population or not, and second, what implications could organelle frequency and organization within the resting platelet have for platelet biogenesis and membrane fusion events in activated platelets? We used serial block face scanning electron microscopy (SBF-SEM) to render in full platelet volume the ultrastructure of alpha-granules, dense granules, mitochondria, canalicular system (CS), and plasma membrane (PM) in 30 platelets, 10 each from 3 donors. Size and shape were measured for 1488 a-granules. Compositional data were assessed for multiple proteins over hundreds of granules by 3D-structured illumination microscopy (SIM) and serial section cryo-immunogold electron microscopy. Data analysis led to 3 conclusions: 1) Based on size, shape and protein composition, there was one major population of alpha-granules in resting human platelets, 2) Alpha-granules clustered tightly together while dense granules were more peripherally located and distal from one another suggesting a spatial arrangement that in the one case supports compound granule fusion and in the other case rapid fusion with the PM, and 3) Based on the weak relationship between platelet size and organelle number and volume, we inferred that platelet biogenesis is likely relatively imprecise with alpha-granule inclusion being more precisely metered than that of other organelles,. These results provide a strong, informative baseline for a-granule structural properties and suggest a spatial clustering of organelles within the resting platelet that may be functionally significant during platelet activation. Figure. Figure. Disclosures No relevant conflicts of interest to declare.