Progression Of Intimal Hyperplasia Research Articles

Urotensin II receptor deficiency ameliorates ligation-induced carotid intimal hyperplasia partially through the RhoA-YAP1 pathway

Intimal hyperplasia (IH) is a common pathological feature of vascular proliferative diseases, such as atherosclerosis and restenosis after angioplasty. Urotensin II (UII) and its receptor (UTR) are widely expressed in cardiovascular tissues. However, it remains unclear whether the UII/UTR system is involved in IH. Right unilateral common carotid artery ligation was performed and maintained for 21 days to induce IH in UTR knockout (UTR−/−) and wild-type (WT) mice. Histological analysis revealed that compared with WT mice, UTR-deficient mice exhibited a decreased neointimal area, angiostenosis and intima–media ratio. Immunostaining revealed fewer smooth muscle cells (SMCs), endothelial cells and macrophages in the lesions of UTR−/− mice than in those of WT mice. Protein interaction analysis suggested that the UTR may affect cell proliferation by regulating YAP and its downstream target genes. In vitro experiments revealed that UII can promote the proliferation and migration of SMCs, and western blotting also revealed that UII increased the protein expression of RhoA, CTGF, Cyclin D1 and PCNA and downregulated p-YAP protein expression, while these effects could be partly reversed by urantide. To evaluate the translational value of UTRs in IH management, WT mice were also treated with two doses of urantide, a UTR antagonist, to confirm the benefit of UTR blockade in IH progression. A high dose of urantide (600 μg/kg/day), rather than a low dose (60 μg/kg/day), successfully improved ligation-induced IH compared with that in mice receiving vehicle. The results of the present study suggested that the UII/UTR system may regulate IH partly through the RhoA-YAP signaling pathway.

Protein arginine methyltransferase 5-mediated arginine methylation stabilizes Kruppel-like factor 4 to accelerate neointimal formation.

Accumulating evidence supports the indispensable role of protein arginine methyltransferase 5 (PRMT5) in the pathological progression of several human cancers. As an important enzyme-regulating protein methylation, how PRMT5 participates in vascular remodelling remains unknown. The aim of this study was to investigate the role and underlying mechanism of PRMT5 in neointimal formation and to evaluate its potential as an effective therapeutic target for the condition. Aberrant PRMT5 overexpression was positively correlated with clinical carotid arterial stenosis. Vascular smooth muscle cell (SMC)-specific PRMT5 knockout inhibited intimal hyperplasia with an enhanced expression of contractile markers in mice. Conversely, PRMT5 overexpression inhibited SMC contractile markers and promoted intimal hyperplasia. Furthermore, we showed that PRMT5 promoted SMC phenotypic switching by stabilizing Kruppel-like factor 4 (KLF4). Mechanistically, PRMT5-mediated KLF4 methylation inhibited ubiquitin-dependent proteolysis of KLF4, leading to a disruption of myocardin (MYOCD)-serum response factor (SRF) interaction and MYOCD-SRF-mediated the transcription of SMC contractile markers. Our data demonstrated that PRMT5 critically mediated vascular remodelling by promoting KLF4-mediated SMC phenotypic conversion and consequently the progression of intimal hyperplasia. Therefore, PRMT5 may represent a potential therapeutic target for intimal hyperplasia-associated vascular diseases.

Deficiency of thrombospondin-2 alleviates intimal hyperplasia in mice by modulating vascular smooth muscle cell proliferation and migration.

Thrombospondin-2 (Tsp2), a glycoprotein in the extracellular matrix, plays a critical role in the maintenance of vascular homeostasis. However, its role in the pathogenesis of cardiovascular disorders such as intimal hyperplasia is not fully elucidated. This study, therefore, aims to explore the effect of Tsp2 on intimal hyperplasia and its associated underlying mechanisms. Intimal hyperplasia (IH) was established using a modified wire-mediated femoral artery injury model. Immunofluorescence and qPCR identified upregulated Tsp2 expression in the injured femoral artery compared with the uninjured femoral artery. Similarly, TSP2 expression was also increased in human samples from the atherosclerotic femoral artery and colocalized with vascular smooth muscle cells (VSMCs). Compared with the wild-type littermates, Tsp2 knockout mice displayed a mitigated IH in the injured femoral artery, as demonstrated by a decreased neointimal area and intimal/median ratio. Primary mouse VSMCs were cultured to explore the mechanism by which Tsp2 influenced IH in vitro. PDGF-stimulated VSMCs presented an elevated Tsp2 expression and enhanced migration and proliferation. However, Tsp2 knockdown by siRNA blocked the increased migration and proliferation of VSMCs. Further analysis identified an association between Notch3 and IH when the intracellular domain of Notch3 (Nicd3) was upregulated in PDGF-stimulated VSMCs and femoral arteries with IH in human tissues. Along with the overexpression and downregulation of Tsp2, the Nicd3 expression was also up and downregulated accordingly. Tsp2 was associated with IH and may serve as a therapeutic target for IH. Downregulation of Tsp2 could mitigate the progression of IH by modulating the proliferation and migration of VSMCs.

Atorvastatin-loaded spray-dried PLGA microparticles for local prevention of intimal hyperplasia: Drug release rate optimization and activity on synthetic vascular smooth muscle cells

Intimal hyperplasia (IH) occurs in vascular bypass grafts and is responsible for their failure. This study aimed to encapsulate high payload of atorvastatin (ATV) to efficiently prevent IH, and to evaluate its activity towards synthetic smooth muscle cells (SMC), implicated in IH progression. Poly (lactic-co-glycolic acid) microparticles (MPs) were formulated by spray-drying with three nominal drug loadings: 10, 20 and 30% w/w. We have measured the particle drug load and studied the release of ATV for 90 days with U-HPLC analysis. Scanning electron microscopy, as well as Energy Dispersive X-ray Spectroscopy were used to discuss the differences in the release profiles from the MPs with different drug loadings. The MPs were sterilized by γ-rays and were incubated with synthetic SMC, obtained from pig coronary arteries. We evaluated the impact of ATV release on cell migration, proliferation with flow cytometry, and performed real-time polymerase chain reaction to determine the effect on the dedifferentiation markers. The obtained particles had high drug loads with 76–85% encapsulation efficiencies. Sustained drug release for 90 days was achieved with 10 and 20% ATV-loaded MPs. The comparison of the MPs before and after γ-ray sterilization showed no major influence of the treatment on particle morphology, size or polymer molecular weight, indicating their potential for further use in vitro and in vivo. The ATV-loaded MPs could reverse the synthetic phenotype of SMCs and attenuated their migratory and proliferative capacities.

Bioadhesive Perivascular Microparticle-Gel Drug Delivery System for Intimal Hyperplasia Prevention: In Vitro Evaluation and Preliminary Biocompatibility Assessment.

Intimal hyperplasia (IH) is an undesirable pathology occurring after peripheral or coronary bypass surgery. It involves the proliferation and migration of vascular smooth muscle cells, leading to a reduction in the diameter of the vascular lumen, which can lead to stenosis and graft failure. Topically applied atorvastatin (ATV) has been shown to slow down this process. To be effective, the drug delivery system should remain at the perivascular site for 5-8 weeks, corresponding to the progression of IH, and be capable of releasing an initial dose of the drug followed by a sustained release. Ideally, bioadhesion would anchor the gel to the application site. To meet these needs, we encapsulated ATV in a 2-component system: a hyaluronic acid-dopamine bioadhesive gel for rapid release and biodegradable microparticles for sustained release. The system was characterized by scanning electron microscopy, rheology, bioadhesion on porcine arteries, and a release profile. The rheological properties were adequate for perivascular application, and we demonstrated superior bioadhesion and cohesion compared to the control HA formulations. The release profile showed a burst, generated by free ATV, followed by sustained release over 8 weeks. A preliminary evaluation of subcutaneous biocompatibility in rats showed good tolerance of the gel. These results offer new perspectives on the perivascular application towards an effective solution for the prevention of IH.

Simulation of blood flow past distal arteriovenous-graft anastomosis with intimal hyperplasia

Late-stage kidney disease patients have to rely on hemodialysis for the maintenance of their regular lives. Arteriovenous graft (AVG) is one of the commonly used devices for dialysis. However, this artificially created shunt may get clotted and eventually causes the dialysis to fail. The culprit behind the AVG clotting and failure is the intimal hyperplasia (IH), the gradual thickening of vein-wall in the vicinity of the blood vessel-graft conjunctions. The mechanism of IH is not well understood despite extensive studies. In this work, we investigate the effects of the IH development, including its location and severity on the flow and force fields in the distal AVG anastomosis using computational fluid dynamics. The stenosis due to IH is modeled in the shape of a Gaussian function with two free parameters. The blood is modeled as a viscous incompressible fluid, and the blood flow (pulsatile) is governed by the Navier–Stokes equations which are numerically solved by the lattice Boltzmann model (D3Q19). The fluid-structure interaction is modeled by the immersed boundary framework. Our computational results show that the IH severity has the most significant influences on the wall shear stress, wall-normal stress, and the axial oscillating index. The stenosis location and flow pulsatility do not have pronounced effects on flow and force fields. Our results indicate that the IH progression tends to exacerbate the disease and accelerate the closure of the vein lumen, and hence the dialysis failure.

Progression of vascular remodeling in pulmonary vein obstruction

ObjectivesPulmonary vein obstruction (PVO) frequently occurs after repair of total anomalous pulmonary vein connection with progression of intimal hyperplasia from the anastomotic site toward upstream pulmonary veins (PVs). However, the understanding of mechanism in PVO progression is constrained by lack of data derived from a physiological model of the disease, and no prophylaxis has been established. We developed a new PVO animal model, investigated the mechanisms of PVO progression, and examined a new prophylactic strategy. MethodsWe developed a chronic PVO model using infant domestic pigs by cutting and resuturing the left lower PV followed by weekly hemodynamic parameter measurement and angiographic assessment of the anastomosed PV. Subsequently, we tested a novel therapeutic strategy with external application of rapamycin-eluting film to the anastomotic site. ResultsWe found the pig PVO model mimicked human PVO hemodynamically and histopathologically. This model exhibited increased expression levels of Ki-67 and phospho-mammalian target of rapamycin in smooth muscle-like cells at the anastomotic neointima. In addition, contractile to synthetic phenotypic transition; that is, dedifferentiation of smooth muscle cells and mammalian target of rapamycin pathway activation in the neointima of upstream PVs were observed. Rapamycin-eluting films externally applied around the anastomotic site inhibited the activation of mammalian target of rapamycin in the smooth muscle-like cells of neointima, and delayed PV anastomotic stenosis. ConclusionsWe demonstrate the evidence on dedifferentiation of smooth muscle-like cells and mammalian target of rapamycin pathway activation in the pathogenesis of PVO progression. Delivery of rapamycin to the anastomotic site from the external side delayed PV anastomotic stenosis, implicating a new therapeutic strategy to prevent PVO progression.

Current understanding of intimal hyperplasia and effect of compliance in synthetic small diameter vascular grafts.

Despite much effort, synthetic small diameter vascular grafts still face limited success due to vascular wall thickening known as intimal hyperplasia (IH). Compliance mismatch between graft and native vessels has been proposed to be one of a key mechanical factors of synthetic vascular grafts that could contribute to the formation of IH. While many methods have been developed to determine compliance both in vivo and in vitro, the effects of compliance mismatch still remain uncertain. This review aims to explain the biomechanical factors that are responsible for the formation and development of IH and their relationship with compliance mismatch. Furthermore, this review will address the current methods used to measure compliance both in vitro and in vivo. Lastly, current limitations in understanding the connection between the compliance of vascular grafts and the role it plays in the development and progression of IH will be discussed.

Characteristic of apoptosis of coronary artery cells with atherosclerotic lesions

To study apoptosis of endothelial cells (EC), macrophages (MF) and smooth muscle cells (SMC) in the early atherosclerotic process (prior to plaque formation), elucidate mechanisms of its realization and evaluate effect on progression of atherosclerosis. Histopathological studies were performed on coronary arteries affected by atherosclerosis taken at autopsy of patients with coronary heart disease (n = 63). To detect apoptosis, the TUNEL method was used for calculating the apoptotic index (AI) in paraffin sections. Phenotyping the cells and test for expression of active caspase 3 (AC-3) and apoptosis-inducing factor (AIF) were performed using sections of coronary arteries stained by immunohistochemistry. The study of apoptosis showed a significant (p <0.0001) increase in AI of SMC, EC, MF coronary arteries affected by atherosclerosis compared with unaffected vessels. Progression of the atherosclerotic process led to a decrease of AI of SMC and EC. Statistical analysis revealed moderate feedback between AI of SMC and neointimal thickness in the development of atherosclerotic lesions (r = -0,44, p <0.0001). The amount of the AC-positive SMC and EC at the stage of lipoidosis significantly (p <0.0001) exceeded the number of AC -positive SMC at the liposclerosis stage. Expression of AIF was observed in the nuclei of EC in the newly formed vessels of hyperplastic intima. Early atherosclerotic lesions of the coronary arteries are accompanied by intense apoptosis of SMC, EC and MF. The intensity of apoptosis of SMC and EC decreases with the development of atherosclerosis. Progression of intimal hyperplasia at the early stages of atherosclerosis is associated with reduced apoptosis of smooth muscle cells and enhanced macrophage apoptosis. Apoptosis of SMC and MF is caspase-dependent. Apoptosis of endothelial cells can occur both with the participation of caspases and independently of them (with AIF).

Novel modular anastomotic valve device for hemodialysis vascular access: preliminary computational hemodynamic assessment.

Arteriovenous graft patency is limited by terminal occlusion caused by intimal hyperplasia (IH). Motivated by evidence that flow disturbances promote IH progression, a modular anastomotic valve device (MAVD) was designed to isolate the graft from the circulation between dialysis periods (closed position) and enable vascular access during dialysis (open position). The objective of this study was to perform a preliminary computational assessment of the device ability to normalize venous flow between dialysis periods and potentially limit IH development and thrombogenesis. Computational fluid dynamics simulations were performed to compare flow and wall shear stress (WSS) in a native vein and MAVD prototypes featuring anastomotic angles of 90° and 30°. Low WSS (LWSS) regions prone to IH development were characterized in terms of temporal shear magnitude (TSM), oscillatory shear index (OSI), and relative residence time (RRT). Thrombogenic potential was assessed by investigating the loading history of fluid particles traveling through the device. The closed MAVD exhibited the same flow characteristics as the native vein (0.3% difference in pressure drop, 3.5% difference in surface-averaged WSS). The open MAVD generated five LWSS regions (TSM <0.5 Pa) exhibiting different degrees of flow reversal (surface-averaged OSI: 0.03-0.36) and stagnation (max RRT: 2.50-37.16). Reduction in anastomotic angle resulted in the suppression of three LWSS regions and overall reductions in flow reversal (surface-averaged OSI <0.21) and stagnation (max RRT <18.05). This study suggests the ability of the MAVD to normalize venous flow between dialysis periods while generating the typical hemodynamics of end-to-side vein-graft anastomoses during dialysis.

INTIMAL HYPERPLASIA AND WALL SHEAR IN ARTERIAL BYPASS Y-GRAFTING AND CONSEQUENCE GRAFTING: A NUMERICAL STUDY

The progression of intimal hyperplasia is considered to be the main cause of bypass failure and is directly related to the individual blood rheology, local arterial geometry and placement of the junctions, graft diameter and graft surface characteristics as well as the degree of compliance. In this paper we use commercial computational fluid dynamics (CFD) ANSYS to examine under the correct physiological flow conditions the hemodynamic forces of composite bypass with internal mammary artery in Y-grafting and consequence grafting which is known to achieve high patency rate and highly recommended by clinicians. Particular emphasis is given here on the parameters that could initiate the development of intimal hyperplasia within these bypass configurations. The hemodynamic flow patterns between the consequence grafting and the composite Y-grafting are observed here to be different. Moreover, on both end-to-side and side-to-side configurations, the circulating flows are detected in the vicinity of the junction area, while the Dean flow vortexes are only observed on the end-to-side configuration. Likewise, the hemodynamic flow on the end-to-side configuration on the LCX of both 45° and 90° Y-grafting is found to be smoother than that of the junction on the LCA, regardless of the changing of anastomosis angles. The high WSS gradients are observed at the vicinity of the toe and on the bed of the junction, while the low WSS are presented at the distal of the stenosis and at the stagnation point. The clinical relevance of the results are presented and discussed with particular focus on the factors and the flow patterns that trigger the development of intimal hyperplasia.

Comparison between experimentally measured flow patterns for straigth and helical type graft

The long-term success of arterial bypass surgery is often limited by the progression of intimal hyperplasia at the anastomosis between the graft and the native artery. The experimental models were manufactured from glass tubing with constant internal diameter of 8 mm, fashioned into a straight configuration and helical configuration. The aim of this study was to determine the three-dimensional flow structures that occur at the proximal anastomosis under pulsatile flow conditions, to investigate the changes that resulted from variations in the anastomosis angle and flow division, and to establishing the major differences between the straight and helical graft. In the anastomosis domain, a strong region of recirculation is observed near the occluded end of the artery, which forces the flow to move into the perfused host coronary artery. The proximal portion of the host tube shows weak counter-rotating vortices on the symmetry plane. The exact locations and strengths of the vortices in this region are only weakly dependent on Re. A detailed comparison of experimentally measured axial velocity patterns for straight and helical grafts confirm the very strong nature of the secondary flows in the helical geometry. The helical configuration promotes the mixing effect of vortex motion such that the flow particles are mixed into the blood stream disal to the anastomotic junction.

C-Ski inhibits the proliferation of vascular smooth muscle cells via suppressing Smad3 signaling but stimulating p38 pathway

Proliferation of vascular smooth muscle cells (VSMCs) plays key roles in the progression of intimal hyperplasia, but the molecular mechanisms that trigger VSMC proliferation after vascular injury remain unclear. c-Ski, a co-repressor of transforming growth factor β (TGF-β)/Smad signaling, was detected to express in VSMC of rat artery. During the course of arterial VSMC proliferation induced by balloon injury in rat, the endogenous protein expressions of c-Ski decreased markedly in a time-dependent manner. In vivo c-Ski gene delivery was found to significantly suppress balloon injury-induced VSMC proliferation and neointima formation. Further investigation in A10 rat aortic smooth muscle cells demonstrated that overexpression of c-Ski gene inhibited TGF-β1 (1ng/ml)-induced A10 cell proliferation while knockdown of c-Ski by RNAi enhanced the stimulatory effect of TGF-β1 on A10 cell growth. Western blot for signaling detection showed that suppression of Smad3 phosphorylation while stimulating p38 signaling associated with upregulation of cyclin-dependent kinase inhibitors p21 and p27 was responsible for the inhibitory effect of c-Ski on TGF-β1-induced VSMC proliferation. These data suggest that the decrease of endogenous c-Ski expression is implicated in the progression of VSMC proliferation after arterial injury and c-Ski administration represents a promising role for treating intimal hyperplasia via inhibiting the proliferation of VSMC.

Nitric oxide treatment reduces neo-intimal formation and modulates osteopontin expression in an ex-vivo human model of intimal hyperplasia

In this study the effects of nitric oxide (NO) on intimal hyperplasia (IH) were evaluated in an ex-vivo model of human saphenous vein (SV). SV segments were cultured in conditions able to reproduce IH (FCS), or in medium alone (RPMI), or in presence of a NO donor (NO). Osteopontin (OPN) and Interleukin (IL)-6 were determined in the medium at different culture times and in the tissue, at the end of experiment. OPN and IL-6 release in medium was increased in FCS with respect to RPMI (OPN: 13.9 ± 2.9 vs. 2.3 ± 0.8 μg/ml, p = 0.0011; IL-6: 304.2 ± 64.7 vs. 42.0 ± 10.1 ng/ml, p < 0.0006) as well as intima thickness, that positively correlated with OPN production ( r = 0.81). In tissue OPN was higher in FCS (82.0 ± 30.3 ng/mg protein) than in RPMI (13.8 ± 4.2, p = 0.0051) and at baseline (3.7 ± 0.7, p = 0.018). NO reduces IH progression (25%) and both OPN and IL-6 expression (OPN/GAPDH: undetectable baseline; 0.27 ± 0.06 RPMI; 0.89 ± 0.28 FCS; 0.09 ± 0.05 NO; p = 0.026 FCS vs. baseline, p = 0.018 vs. RPMI, p = 0.005 vs. NO). The beneficial NO effect on IH reduction appears to be mediated by the indirect inhibition of OPN production. NO could modulates the initial inflammatory signals that induces the OPN over-production with the related cascade of events leading to IH.

Function and role of voltage-gated sodium channel NaV1.7 expressed in aortic smooth muscle cells

Voltage-gated Na(+) channel currents (I(Na)) are expressed in several types of smooth muscle cells. The purpose of this study was to evaluate the expression of I(Na), its functional role, pathophysiology in cultured human (hASMCs) and rabbit aortic smooth muscle cells (rASMCs), and its association with vascular intimal hyperplasia. In whole cell voltage clamp, I(Na) was observed at potential positive to -40 mV, was blocked by tetrodotoxin (TTX), and replacing extracellular Na(+) with N-methyl-d-glucamine in cultured hASMCs. In contrast to native aorta, cultured hASMCs strongly expressed SCN9A encoding Na(V)1.7, as determined by quantitative RT-PCR. I(Na) was abolished by the treatment with SCN9A small-interfering (si)RNA (P < 0.01). TTX and SCN9A siRNA significantly inhibited cell migration (P < 0.01, respectively) and horseradish peroxidase uptake (P < 0.01, respectively). TTX also significantly reduced the secretion of matrix metalloproteinase-2 6 and 12 h after the treatment (P < 0.01 and P < 0.05, respectively). However, neither TTX nor siRNA had any effect on cell proliferation. L-type Ca(2+) channel current was recorded, and I(Na) was not observed in freshly isolated rASMCs, whereas TTX-sensitive I(Na) was recorded in cultured rASMCs. Quantitative RT-PCR and immunostaining for Na(V)1.7 revealed the prominent expression of SCN9A in cultured rASMCs and aorta 48 h after balloon injury but not in native aorta. In conclusion, these studies show that I(Na) is expressed in cultured and diseased conditions but not in normal aorta. The Na(V)1.7 plays an important role in cell migration, endocytosis, and secretion. Na(V)1.7 is also expressed in aorta after balloon injury, suggesting a potential role for Na(V)1.7 in the progression of intimal hyperplasia.

The Effects of Toradol on Postoperative Intimal Hyperplasia in a Rat Carotid Endarterectomy Model: Laboratory Research

Carotid endarterectomy (CEA) and more recently carotid artery stenting are the treatments of choice for atherosclerotic disease of the extracranial carotid arteries; however, early restenosis caused by neointimal hyperplasia confounds surgical therapy. Oxidative stress has been implicated in the progression of intimal hyperplasia. The authors hypothesized that ketorolac tromethamine (Toradol), a nonsteroidal antiinflammatory drug that is a potent cyclooxygenase inhibitor, would decrease oxidative stress and thereby reduce intimal hyperplasia in a rat CEA model. Twenty-nine male Sprague-Dawley rats underwent CEA and were divided into 3 treatment groups as follows: (1) control (placebo), (2) 7.5 mg/kg Toradol, and (3) 10 mg/kg Toradol. Toradol treatment began 2 days before CEA and continued for 2 weeks. Two weeks after endarterectomy, carotid arteries were fixed, harvested, and examined for platelet activity (platelet reactive units), oxidative stress (malondialdehyde and glutathione), and intimal hyperplasia (measured as percentage of luminal stenosis). Platelet activity, malondialdehyde and glutathione, and intimal hyperplasia were all significantly lowered in both 7.5- and 10-mg/kg doses of Toradol versus control. Toradol given daily beginning 2 days before CEA and ending 2 weeks after the procedure was effective at significantly reducing platelet activity, oxidative stress, and intimal hyperplasia development in the rat without any increase in bleeding. Although the mechanism of action of this reduction is not completely understood, one possible explanation may be through the inhibition of reactive oxygen species production.

Vascular Remodeling 1 Year After Cardiac Transplantation

The belief that vascular remodeling and intimal hyperplasia are causes of luminal narrowing in cardiac allograft vasculopathy (CAV) is controversial. This study evaluated the relationship of vascular remodeling and intimal hyperplasia to luminal narrowing 1 year after orthotopic heart transplantation. Intravascular ultrasound imaging was performed on 190 cardiac transplant recipients at baseline and again 1 year after transplantation as part of a randomized trial of mycophenolate mofetil (MMF) and azathioprine (Aza). Studies 1 year apart were matched at 625 sites. All sites were classified into positive, non-significant and negative remodeling patterns, depending on a change of +/-10% in external elastic membrane area. Of the 190 patients, 99 were randomized to receive MMF, and 91 to receive Aza. A total of 625 sites were observed. Of these, 52% had no remodeling, 25% exhibited vessel dilation, and 23% had vessel shrinkage in the presence of variable intimal growth (Delta intimal area: 0.73 +/- 1.70 mm2, p < 0.0001; 1.23 +/- 2.02 mm2, p < 0.0001; and 0.20 +/- 1.40 mm2, p = 0.09, respectively). Sixty percent of the lumen loss was due to a decrease in external elastic membrane area and 40% to an increase in intimal area (p = 0.005). Compared with Aza-treated patients, the MMF-treated patients had a lower incidence of vessel shrinkage (17% vs 28%, p = 0.001), and a trend for smaller maximum intimal thickness (0.21 +/- 0.25 mm vs 0.29 +/- 0.31 mm, p = 0.052). Positive remodeling is associated with intimal growth, but negative remodeling does not correlate with any specific change in intimal hyperplasia. Constrictive remodeling is more responsible than intimal hyperplasia for the luminal narrowing that occurs. MMF is more efficacious than azathioprine in preventing the development of CAV at 1 year, by reducing the degree and incidence of vessel shrinkage and the progression of intimal hyperplasia.

Mycophenolate mofetil for secondary prevention of cardiac allograft vasculopathy: influence on inflammation and progression of intimal hyperplasia

Background: Cardiac allograft vasculopathy (CAV) remains the single most important complication impairing long-term survival after heart transplantation (HTx). Intimal hyperplasia as a response to immunologic and non-immunologic injury is involved in the pathogenesis. Because improved immunosuppressive properties with mycophenolate mofetil (MMF) have been shown within the first year, beneficial effects on intimal hyperplasia and systemic inflammation might be found late after HTx as well. Methods: After a baseline examination with intravascular ultrasound (IVUS, volumetric assessment) 30 patients (2.0 ± 1.1 years post-HTx) were prospectively randomized to receive either MMF (2 g/day) or to continue with azathioprine (AZA) as part of a triple immunosuppression protocol with cyclosporine and prednisolone. Markers of systemic inflammation and changes in vascular geometry were evaluated by IVUS after 1 year of follow-up. Results: With regard to inflammation, significantly lower values were found for high-sensitive C-reactive protein (CRP) in the MMF group (AZA 1.8 ± 1.2 mg/liter. vs MMF 1.0 ± 4.1 mg/liter, p = 0.02). Tumor necrosis factor (TNF)-α, interleukin (IL)-10, IL-6 and transforming growth factor (TGF)-β did not differ between the groups. IVUS revealed no significant differences between groups. There was a weak trend toward a larger increase in plaque volume (AZA 13 ± 43 mm 3 vs MMF 27 ± 41 mm 3, p = 0.33), whereas MMF-treated patients tended to show a small increase in vessel dimensions (AZA +10 ± 63 mm 3 vs MMF +50 ± 87 mm 3, p = 0.17). Conclusions: Changing immunosuppression from a standard AZA-based regimen to MMF resulted in a decrease in systemic inflammatory activity as indicated by levels of high-sensitive CRP. However, progression of intimal hyperplasia did not differ significantly, and the weak trend toward vascular enlargement could indicate some influence on vascular geometry.

Invited commentary

Well-conducted studies addressing the issue of vein graft patency are of major importance. Data provided will determine the future use of vein grafts and reinforce the argument for or against total arterial revascularization. The study by Chello and colleagues provides comprehensive evidence that distension of vein grafts after harvesting, promotes endothelial injury and neutrophil-endothelial interaction in vitro. Important issues raised by this study concern the effects of graft handling on endothelial activation, early and late graft patency, and of course clinical outcome. I was slightly puzzled by the fact that ICAM-1 and VCAM-1 upregulation appeared to have taken place only one to two hours after vein distension. While basal expression of these adhesion molecules is low, surface expression reaches peak levels at four to six hours, subject to DNA transcription [1Pober J.S. Gimbrone Jr, M.A. Lapierre L.A. Mendrick D.L. Fiers W. Rothlein R. Springer T.A. Overlapping patterns of activation of human endothelial cells by interleukin 1, tumor necrosis factor, and immune intereferone.J Immunol. 1986; 137: 1893-1896PubMed Google Scholar, 2Asimakopoulos G. Thompson R.D. Nourshargh S. Lidington E. Mason J.C. Haskard D.O. Ratnatunga R.C. Taylor K.M. Landis R.G. An anti-inflammatory property of aprotinin detected at the level of leukocyte extravasation.J Thorac Cardiovasc Surg. 2000; 120: 361-369Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar]. Longer incubation times, between mechanical stimulation and immunostaining, might have increased the potential of the study. With regard to early graft occlusion, endothelial damage is a major event. The platelet, rather than the neutrophil, is likely to be the main cellular component. Exposure of subendothelial matrix and secretion of von Willebrand factor by endothelial cells promote primary haemostatic phenomena with platelet aggregation and thrombus formation. Expression of P-selectin, ICAM-1 and VCAM-1 with subsequent leucocyte sequestration is of lesser importance. Chello and colleagues could, however, address this issue in the future using assays of platelet aggregation with their model. Finally, long term vein graft patency depends on the rate of intimal hyperplasia, possibly exacerbated by atheroclerotic obstruction. Neutrophil adhesion and migration into subendothelial tissues is certainly of major importance. The leucocyte integrin CD11b/CD18 is capable of binding both to subendothelial fibrinogen and endothelial ICAM-1. Evidence from animal models of vascular injury suggest that ICAM-1-mediated leucocyte adhesion plays a role in the progression of intimal hyperplasia [3Yasukawa H. Imaizumi T. Matsuoka H. Nakashima A. Morimatsu M. Inhibition of intimal hyperplasia after balloon injury by antibodies to intercellular adhesion molecule-1 and lymphocyte function-associated antigen-1.Circulation. 1997; 95: 1515-1522Crossref PubMed Scopus (100) Google Scholar, 4Rogers C. Edelman E.R. Simon D.I. A mAb to the b2-leukocyte integrin Mac-1 (CD11b/CD18) reduces intimal thickening after angioplasty or stent implantation in rabbits.Proc Natl Acad Sci USA. 1998; 95: 10134-10139Crossref PubMed Scopus (224) Google Scholar]. Although, by design, the study by Chello and colleagues does not answer the question: ‘Does distension of a vein graft after harvesting make it more likely to occlude?,’ it provides very interesting insight into the degree of endothelial damage 300 mm Hg of pressure causes. I predict that most surgeons who have read this article will now think twice before pressing the syringe.

Distribution and localization of cells and collagens in the proliferated intima of arterially implanted autovein grafts

We examined the microscopic features and distribution of collagens in the hyperplastic intima of arterially implanted autovein bypass grafts under conditions of a reduced blood flow with a poor distal outflow. Vascular anastomosis was made using 7-0 nonabsorbable polypropylene sutures (PP group), or absorbable polydioxanone sutures (PDS group). On the contralateral limb, an autovein bypass graft was performed under normal flow conditions (NF group). The thickness of the intima in the NF group was approximately 50 microm throughout the duration of the study, while in the PP and PDS groups, intimal hyperplasia progressed to 290+/-112 microm and 267+/-123 microm, respectively, at 13 months after grafting. Collagen accumulated significantly in both the PP and PDS groups; types IV and V collagen in particular increased considerably in the deep layer. Regardless of the suture materials, the progression of intimal hyperplasia was considered to be closely related to the poor distal outflow to be and caused by the proliferation of myofibroblasts and active production of collagen. The increase in types IV and V collagen, particularly in the deep layer of the hyperplastic intima, was due to development of numerous vasa vasora in this region.