Introductionvon Willebrand factor (VWF) strings correspond to ultra-large (UL) VWF multimers that, after secretion from the endothelium, remain anchored to the cell surface. As a result of this tethering and the rheologic forces of flow, these VWF multimers unravel, can bind platelets, and wave in the direction of the blood flow 1 (Figure 1). Since their discovery, platelet-decorated VWF strings have proved fascinating, and yet puzzling entities, with interesting and rather unique characteristics. VWF strings can be extraordinarily long, can be anchored to endothelial cells through a discrete number of attachment sites, contain active platelet binding sites, and are susceptible to specific proteolysis by its regulating protease, ADAMTS13 (a disintegrin-like and metalloprotease domain with thrombospondin type-1 motif, number 13). VWF strings are considered prothrombotic and might therefore contribute to the pathophysiology of thrombotic disorders, such as thrombotic thrombocytopenic purpura (TTP) and arterial thrombosis. In addition, platelet-decorated VWF strings can also provide a reactive surface for leukocytes and parasite-infected red blood cells, which has suggested possible roles in both inflammation and malaria.In this review, we discuss the typical features of these intriguing VWF strings and highlight questions that remain to be resolved and that would provide a better understanding of VWF string biochemistry. VWF strings were first discovered and studied in the absence of ADAMTS13, a situation that does not mimic normal physiologic conditions. In the majority of pathophysiologic conditions, plasma ADAMTS13 activity levels are at most decreased, but very rarely absent. To this end, a discussion on the possible involvement of VWF strings in disease pathology might serve to put VWF string research into perspective.
VWF, UL-VWF multimers, and ADAMTS13VWF is the largest biopolymer present in plasma, and consists of multimers ranging in size from 500 to 10 000 kDa, with the largest multimers being the most hemostatically active. 2,3 The building block of these multimers is a mature VWF subunit consisting of D, A, B, C, and CK domains, 4,5 although the domain organization of VWF has recently been reannotated. 6 In circulation, VWF multimers adopt a folded, globular conformation that shields the platelet glycoprotein Ib (GPIb) binding sites in the VWF A1 domain. 7,8 This folding serves to prevent spontaneous binding of platelets to VWF in circulation. However, immobilization of VWF at sites of vascular injury (via the VWF A3-collagen interaction) leads to VWF unfolding in response to the shear forces exerted by the flowing blood. This exposes VWF A1 domains that, in turn, reveal the binding sites for the platelet GPIb receptor. The VWF-GPIb interaction is characterized by a fast association/dissociation rate, which enables platelets to "roll" over the VWF surface and provide the opportunity to establish firm platelet adhesion through the collagen receptors. [9][10][11][12] This adhesion step, which is partic...