Pathophysiology of superficial femoral artery in-stent restenosis

Peripheral artery disease (PAD) is an emerging problem especially with aging population and increase in the incidence of diabetes and metabolic syndrome. The disease is histologically characterized by the presence of moderate to severe calcification and fibrous plaques as compared to coronary and carotid atherosclerotic disease, which are richer in necrotic core. Endovascular therapy for the superficial femoral artery (SFA), at least in the United States, has been largely limited to balloon angioplasty and stenting and these are considered safe and relatively effective therapies. However, the patency rates remain low even at one year and restenosis is a growing and challenging problem. Recently the development of newer devices, i.e., drug-eluting stent, and drug coated balloon are showing greater efficacy and are being adopted into daily practice. In this review, we will present the morphologic characteristics of the underlying SFA atherosclerotic disease and discuss in-stent restenosis and the mechanisms that may be involved in the induction of excessive smooth muscle cell proliferation and deposition of proteoglycans and collagen, that lead to restenosis.

Unique demands of the femoral anatomy and pathology and the need for unique interventions

With the aging of the population the incidence of peripheral artery disease (PAD) is increasing, which is histologically characterized by fibrocalcific intimal plaques as well as underlying Mönckeberg's medial calcinosis as compared to coronary and carotid artery disease. Superficial femoral artery (SFA) is one of the longest and most dynamically active vessels in the body undergoing torsion, compression, flexion, and extension from leg motion, and is known to be more susceptible to atherosclerosis because of low shear stress or spiral flow, best appreciated in the long segment in its lesser curvature. Endovascular interventions are now considered the first-line strategy for the treatment of PAD patients presenting with claudication or critical limb ischemia, where physiologic stresses on the arterial wall, anatomic considerations, and lesion characteristics impact on their success. Stent fracture and malapposition, are a common phenomenon in PAD which are attributed to severe calcification and fibrosis along with greater motion of the lower extremity, that result in the dampening of the efficacy of stenting and balloon angioplasty. Better designs of self-expanding stents have resulted in either reduction in stent fracture rates or its elimination at least in the short-term follow-up studies, to date. Although drug-eluting stents (DES) have reduced restenosis rates in the coronary circulation, this benefit has not been consistently observed in PAD. However, recent clinical studies utilizing novel Zilver-PTX self-expanding stent (DES) have demonstrated favorable patency rate. Also, in patients with critical limb ischemia, better outcomes have been reported for below-the-knee utilization of DES. Nevertheless, drawbacks of stent technology remain and interests in the greater use of drug-coated balloons (DCB) for PAD have emerged. Randomized controlled trials have consistently shown superiority of DCB over uncoated balloons in reducing neointimal formation in patients with SFA disease. Moreover, there is a growing interest in atherectomy as an alternative treatment strategy for PAD, thus decreasing plaque burden with possibly avoidance of barotrauma. The results from registries support the effectiveness of the atherectomy devices; however, prospective randomized controlled trials are needed to confirm their benefit.

Glucosylceramide accumulates preferentially in lamellar bodies in differentiated keratinocytes

BACKGROUND

Sphingolipids, e.g. ceramide (Cer), glucosylceramide (GlcCer) and sphingomyelin (SM), are important bulk constituents of plasma membranes in mammalian cells. In addition, these lipids are also enriched in certain intracellular organelles, as well as in the epidermal lamellar bodies (LBs) of differentiating keratinocytes (KCs). Epidermal Cer, which comprises a heterogeneous family of at least 10 members, is a key component of the stratum corneum (SC) lipids, and regulates permeability barrier function. Levels of GlcCer, but not SM, significantly increase during epidermal differentiation, and then both GlcCer and SM are enzymatically hydrolysed to Cer at and just above the transition from the stratum granulosum to the SC.

OBJECTIVES

To determine: (i) whether the GlcCer contained in different pools, i.e. the membrane fraction or the LB fraction, has different metabolic fates; and (ii) whether specific molecular species of GlcCer localize to distinct subcellular pools.

METHODS

To study the metabolic fate of specific molecular fractions of GlcCer and Cer, we first ascertained the full spectrum of molecular species present in cultured normal human KCs (CHK) in a differentiated condition as shown in vivo in epidermis. Cer species were analysed in CHK using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Next, the metabolic fate of the GlcCer was studied by pulse-labelling of CHK with L-[14C]-serine.

RESULTS

The GlcCer of undifferentiated KCs comprised GlcCer B and Cer NS (or Cer 2), which contain nonhydroxy fatty acid (FA) as the amide-linked FA, while differentiated KCs displayed further heterogeneity of both GlcCer and Cer, including the presence of acylGlcCer and acylCer. The metabolic fates of these sphingolipids were determined. The GlcCer B level decreased over 2 days and then plateaued between days 3 and 5 following pulse-labelling of sphingolipids for 24 h. As GlcCer B declined, Cer NS (Cer 2) increased in a similar time-dependent manner. In contrast, both acylGlcCer and acylCer increased continuously in parallel over this experimental period.

CONCLUSIONS

Distinct GlcCer pools segregated to those that were either hydrolysable or nonhydrolysable in differentiated KCs. We assume that the latter pool appears to be LB enriched, and also sequestrates acylGlcCer from other cellular membrane fractions.

Effect of cabergoline treatment on Cushing's disease caused by aberrant adrenocorticotropin-secreting macroadenoma

The present case involves a 47-yr-old woman with Cushing's disease due to pituitary macroadenoma. The patient had suffered from hypertension and obesity for two yr. Her serum cortisol levels were moderately elevated throughout the observation period, and dexamethasone failed to suppress the cortisol secretion. Plasma ACTH levels were markedly high (>100 pg/ml) and did not respond to CRH provocation. Gel filtration analysis of the patient's plasma detected the existence of big ACTH molecules, which eluted with a peak of authentic 1-39 ACTH. Cranial magnetic resonance imaging (MRI) revealed a 3 cm pituitary tumor occupying the sellar region and right cavernous sinus with diffuse enhancement by gadolinium. The pituitary mass was removed by transsphenoidal surgery, and was pathologically identified as compatible to ACTH-producing pituitary adenoma by immunohistochemistry. RT-PCR analysis of total cellular RNA extracted from the resected adenoma revealed a relatively high expression level of dopamine D2 receptor (D2R) mRNA. Therefore, a long-acting D2R agonist, cabergoline (0.25 to 0.5 mg/week), was administered for the remnant adenoma, which gradually reduced ACTH levels in 90 days. In addition, cranial MRI exhibited shrinkage of the remnant pituitary mass after a 6-month treatment with cabergoline. This case demonstrates the efficacy of cabergoline to treat Cushing's disease caused by pituitary macroadenoma secreting aberrant ACTH molecules.