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Faridi MH, Maiguel D, Brown BT, Suyama E, Barth CJ, Hedrick M, Vasile S, Sergienko E, Schürer S, Gupta V. High-throughput screening based identification of small molecule antagonists of integrin CD11b/CD18 ligand binding. Biochem Biophys Res Commun 2010; 394:194-9. [PMID: 20188705 DOI: 10.1016/j.bbrc.2010.02.151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 02/23/2010] [Indexed: 01/05/2023]
Abstract
Binding of leukocyte specific integrin CD11b/CD18 to its physiologic ligands is important for the development of normal immune response in vivo. Integrin CD11b/CD18 is also a key cellular effector of various inflammatory and autoimmune diseases. However, small molecules selectively inhibiting the function of integrin CD11b/CD18 are currently lacking. We used a newly described cell-based high-throughput screening assay to identify a number of highly potent antagonists of integrin CD11b/CD18 from chemical libraries containing >100,000 unique compounds. Computational analyses suggest that the identified compounds cluster into several different chemical classes. A number of the newly identified compounds blocked adhesion of wild-type mouse neutrophils to CD11b/CD18 ligand fibrinogen. Mapping the most active compounds against chemical fingerprints of known antagonists of related integrin CD11a/CD18 shows little structural similarity, suggesting that the newly identified compounds are novel and unique.
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Affiliation(s)
- Mohd Hafeez Faridi
- Division of Nephrology and Hypertension, Department of Medicine, University of Miami, Peggy and Harold Katz Family Drug Discovery Center, Miami, FL 33136, USA
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52
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Afergan E, Ben David M, Epstein H, Koroukhov N, Gilhar D, Rohekar K, Danenberg HD, Golomb G. Liposomal simvastatin attenuates neointimal hyperplasia in rats. AAPS JOURNAL 2010; 12:181-7. [PMID: 20143196 DOI: 10.1208/s12248-010-9173-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 01/04/2010] [Indexed: 01/12/2023]
Abstract
Monocytes, macrophages, and inflammation play a key role in the process of neointimal proliferation and restenosis. The present study evaluated whether systemic and transient depletion of monocytes could be obtained by a single intravenous (IV) injection of simvastatin liposomes, for the inhibition of neointima formation. Balloon-injured carotid artery rats (n = 30) were randomly assigned to treatment groups of free simvastatin, simvastatin in liposomes (3 mg/kg), and saline (control). Stenosis and neointima to media ratio (N/M) were determined 14 days following single IV injection at the time of injury by morphometric analysis. Depletion of circulating monocytes was determined by flow cytometry analyzes of blood specimens. Inhibition of RAW264.7, J774, and THP-1 proliferation by simvastatin-loaded liposomes and free simvastatin was determined by the 3-(4, 5-dimethylthiazolyl-2)-2, 5- diphenyltetrazolium bromide assay. Simvastatin liposomes were successfully formulated and were found to be 1.5-2 times more potent than the free drug in suppressing the proliferation of monocytes/macrophages in cell cultures of RAW 264.7, J774, and THP-1. IV injection of liposomal simvastatin to carotid-injured rats (3 mg/kg, n = 4) resulted in a transient depletion of circulating monocytes, significantly more prolonged than that observed following treatment with free simvastatin. Administration to balloon-injured rats suppressed neointimal growth. N/M at 14 days was 1.56 +/- 0.16 and 0.90 +/- 0.12, control and simvastatin liposomes, respectively. One single systemic administration of liposomal simvastatin at the time of injury significantly suppresses neointimal formation in the rat model of restenosis, mediated via a partial and transient depletion of circulating monocytes.
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Affiliation(s)
- Eyal Afergan
- Department of Pharmaceutics, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem 91120, Israel
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Kovacic JC, Gupta R, Lee AC, Ma M, Fang F, Tolbert CN, Walts AD, Beltran LE, San H, Chen G, St Hilaire C, Boehm M. Stat3-dependent acute Rantes production in vascular smooth muscle cells modulates inflammation following arterial injury in mice. J Clin Invest 2009; 120:303-14. [PMID: 20038813 DOI: 10.1172/jci40364] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 10/07/2009] [Indexed: 11/17/2022] Open
Abstract
Inflammation is a key component of arterial injury, with VSMC proliferation and neointimal formation serving as the final outcomes of this process. However, the acute events transpiring immediately after arterial injury that establish the blueprint for this inflammatory program are largely unknown. We therefore studied these events in mice and found that immediately following arterial injury, medial VSMCs upregulated Rantes in an acute manner dependent on Stat3 and NF-kappaB (p65 subunit). This led to early T cell and macrophage recruitment, processes also under the regulation of the cyclin-dependent kinase inhibitor p21Cip1. Unique to VSMCs, Rantes production was initiated by Tnf-alpha, but not by Il-6/gp130. This Rantes production was dependent on the binding of a p65/Stat3 complex to NF-kappaB-binding sites within the Rantes promoter, with shRNA knockdown of either Stat3 or p65 markedly attenuating Rantes production. In vivo, acute NF-kappaB and Stat3 activation in medial VSMCs was identified, with acute Rantes production after injury substantially reduced in Tnfa-/- mice compared with controls. Finally, we generated mice with SMC-specific conditional Stat3 deficiency and confirmed the Stat3 dependence of acute Rantes production by VSMCs. Together, these observations unify inflammatory events after vascular injury, demonstrating that VSMCs orchestrate the arterial inflammatory response program via acute Rantes production and subsequent inflammatory cell recruitment.
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Affiliation(s)
- Jason C Kovacic
- Translational Medicine Branch, National Heart, Lung, and Blood Institute/NIH, Bethesda, MD 20892, USA
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Tieu BC, Lee C, Sun H, Lejeune W, Recinos A, Ju X, Spratt H, Guo DC, Milewicz D, Tilton RG, Brasier AR. An adventitial IL-6/MCP1 amplification loop accelerates macrophage-mediated vascular inflammation leading to aortic dissection in mice. J Clin Invest 2009; 119:3637-51. [PMID: 19920349 DOI: 10.1172/jci38308] [Citation(s) in RCA: 337] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 09/23/2009] [Indexed: 12/14/2022] Open
Abstract
Vascular inflammation contributes to cardiovascular diseases such as aortic aneurysm and dissection. However, the precise inflammatory pathways involved have not been clearly defined. We have shown here that subcutaneous infusion of Ang II, a vasopressor known to promote vascular inflammation, into older C57BL/6J mice induced aortic production of the proinflammatory cytokine IL-6 and the monocyte chemoattractant MCP-1. Production of these factors occurred predominantly in the tunica adventitia, along with macrophage recruitment, adventitial expansion, and development of thoracic and suprarenal aortic dissections. In contrast, a reduced incidence of dissections was observed after Ang II infusion into mice lacking either IL-6 or the MCP-1 receptor CCR2. Further analysis revealed that Ang II induced CCR2+CD14hiCD11bhiF4/80- macrophage accumulation selectively in aortic dissections and not in aortas from Il6-/- mice. Adoptive transfer of Ccr2+/+ monocytes into Ccr2-/- mice resulted in selective monocyte uptake into the ascending and suprarenal aorta in regions of enhanced ROS stress, with restoration of IL-6 secretion and increased incidence of dissection. In vitro, coculture of monocytes and aortic adventitial fibroblasts produced MCP-1- and IL-6-enriched conditioned medium that promoted differentiation of monocytes into macrophages, induced CD14 and CD11b upregulation, and induced MCP-1 and MMP-9 expression. These results suggest that leukocyte-fibroblast interactions in the aortic adventitia potentiate IL-6 production, inducing local monocyte recruitment and activation, thereby promoting MCP-1 secretion, vascular inflammation, ECM remodeling, and aortic destabilization.
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Affiliation(s)
- Brian C Tieu
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, Texas, USA
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Abstract
Although critical for cell adhesion and migration during normal immune-mediated reactions, leukocyte integrins are also involved in the pathogenesis of diverse clinical conditions including autoimmune diseases and chronic inflammation. Leukocyte integrins therefore have been targets for anti-adhesive therapies to treat the inflammatory disorders. Recently, the therapeutic potential of integrin antagonists has been demonstrated in psoriasis and multiple sclerosis. However, current therapeutics broadly affect integrin functions and, thus, yield unfavorable side effects. This review discusses the major leukocyte integrins and the anti-adhesion strategies for treating immune diseases.
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Affiliation(s)
- Teruo Inoue
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine
| | - Koichi Node
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine
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Shi C, Sakuma M, Mooroka T, Liscoe A, Gao H, Croce KJ, Sharma A, Kaplan D, Greaves DR, Wang Y, Simon DI. Down-regulation of the forkhead transcription factor Foxp1 is required for monocyte differentiation and macrophage function. Blood 2008; 112:4699-711. [PMID: 18799727 PMCID: PMC2597137 DOI: 10.1182/blood-2008-01-137018] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 08/22/2008] [Indexed: 11/20/2022] Open
Abstract
Down-regulation of the forkhead transcription factor Foxp1 by integrin engagement controls monocyte differentiation in vitro. To determine whether Foxp1 plays a critical role in monocyte differentiation and macrophage functions in vivo, we generated transgenic mice (macFoxp1tg) overexpressing human FOXP1 in monocyte/macrophage lineage cells using the CD68 promoter. Circulating blood monocytes from macFoxp1tg mice have reduced expression of the receptor for macrophage colony-stimulating factor (c-Fms/M-CSFR), impaired migratory capacity, and diminished accumulation as splenic macrophages. Macrophage functions, including cytokine production, phagocytosis, and respiratory burst were globally impaired in macFoxp1tg compared with wild-type cells. Osteoclastogenesis and bone resorption activity were also attenuated in macFoxp1tg mice. In models of chemical and bacterial peritonitis, macFoxp1tg mice exhibited reduced macrophage accumulation, bacterial clearance, and survival. Enforced overexpression of c-Fms/M-CSFR reversed the cytokine production and phagocytosis defects in macFoxp1tg macrophages, indicating that repression of c-fms/M-CSFR is likely the dominant mechanism responsible for Foxp1 action in monocyte differentiation and macrophage function. Taken together, these observations identify down-regulation of Foxp1 as critical for monocyte differentiation and macrophage functions in vivo.
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Affiliation(s)
- Can Shi
- Department ofMedicine, Case Cardiovascular Center, Case Western Reserve University School of Medicine, Cleveland, OH 44022, USA
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Expression, activation, and function of integrin alphaMbeta2 (Mac-1) on neutrophil-derived microparticles. Blood 2008; 112:2327-35. [PMID: 18509085 DOI: 10.1182/blood-2007-12-127183] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Leukocyte-derived microparticles (MPs) are markers of cardiovascular diseases and contribute to pathogenesis by their interaction with various cell types. The presence and activation state of a multifunctional leukocyte receptor, integrin alpha(M)beta(2) (CD11b/18), on MPs derived from human neutrophils (PMNs) were examined. alpha(M)beta(2) expression was significantly enhanced on MPs derived from stimulated compared with resting PMNs. Furthermore, alpha(M)beta(2) on MPs from stimulated but not resting PMNs was in an activated conformation because it was capable of binding activation-specific monoclonal antibodies (CBRM1/5 and mAb24) and soluble fibrinogen. MPs expressing active alpha(M)beta(2) interacted with and were potent activators of resting platelets as assessed by induction of P-selectin expression and activation of alpha(IIb)beta(3). With the use of function-blocking antibodies and MPs obtained from alpha(M)(-/-)-deficient mice, we found that engagement of GPIbalpha on platelets by alpha(M)beta(2) on MPs plays a pivotal role in MP binding. Platelet activation by MPs occurs by a pathway dependent on Akt phosphorylation. PSGL-1/P-selectin interaction also is involved in the conjugation of MPs to platelets, and the combination of blocking reagents to both alpha(M)beta(2)/GPIbalpha and to PSGL-1/P-selectin completely abrogates MP-induced platelet activation. Thus, cooperation of these 2 receptor/counterreceptor systems regulates the prothrombotic properties of PMN-derived MPs.
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Atta HM, El-Rehany MA, Abdel Raheim SR, Fouad R, Galal AMF. Colchicine Inhibits Intimal Hyperplasia and Leukocyte VEGF Expression in Dogs. J Surg Res 2008; 146:184-9. [PMID: 17597159 DOI: 10.1016/j.jss.2007.04.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 04/16/2007] [Accepted: 04/18/2007] [Indexed: 01/28/2023]
Abstract
BACKGROUND Restenosis due to intimal hyperplasia following percutaneous transluminal angioplasty limits its long-term efficacy. We evaluated the effect of colchicine on the development of intimal hyperplasia following balloon angioplasty and on the vascular endothelial growth factor (VEGF) expression in leukocytes. MATERIAL AND METHODS Adult dogs underwent balloon angioplasty of the right iliofemoral artery. Group 1 served as control, while groups 2 and 3 (six animals per group) received 0.1 and 0.5 mg/kg/d of colchicine p.o., respectively, starting 2 d before angioplasty and continued for 14 d. Before angioplasty and at day 14, blood samples were collected for drug toxicity analysis and the determination of leukocyte expression of VEGF. Animals were euthanized and iliofemoral arteries were perfusion fixed in situ and processed for histological and morphometric analysis. RESULTS Balloon angioplasty without colchicine resulted in 446% (P < 0.001), 111% (P = 0.7), and 267% (P < 0.001) increase in intimal and medial thickness and intima/media ratio compared with contralateral uninjured iliofemoral arteries. Low-dose and high-dose colchicine resulted in 32% and 58% reduction in intima/media ratio, respectively (both P < 0.001). VEGF expression in leukocytes of control group was up-regulated (40%), but was down-regulated by 12% and 55%, respectively, in low-dose and high-dose colchicine groups at 2 wk after angioplasty compared with preangioplasty expression. The results of complete blood count and serum transaminases and creatinine were within normal range. CONCLUSION This study demonstrates that oral colchicine for 2 wk significantly reduces intimal hyperplasia following balloon angioplasty in dogs through down-regulation of leukocyte VEGF expression and without apparent toxicity.
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Affiliation(s)
- Hussein M Atta
- Department of Surgery, Faculty of Medicine, Minia University, El-Minia, Egypt.
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Narita H, Chen S, Komori K, Kadomatsu K. Midkine is expressed by infiltrating macrophages in in-stent restenosis in hypercholesterolemic rabbits. J Vasc Surg 2008; 47:1322-9. [PMID: 18353604 DOI: 10.1016/j.jvs.2007.12.037] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 12/04/2007] [Accepted: 12/16/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Neointimal hyperplasia is strikingly suppressed in an endothelium injury model in mice deficient in the growth factor midkine. Knockdown of midkine expression by means of antisense oligonucleotide or small interfering RNA has been shown to lead to suppression of neointimal hyperplasia in a balloon injury model and a rabbit vein graft model; therefore, midkine is an essential factor for neointimal hyperplasia. These findings, however, do not necessarily apply to the function of midkine in vascular stenoses such as in-stent restenosis, because human vascular stenosis is often accompanied by atherosclerosis. METHODS We investigated midkine expression in the neointima induced by implantation of a bare metal stent in the atheromatous lesions of hypercholesterolemic rabbits. We analyzed midkine expression during a THP-1 cell differentiation and in peritoneal macrophages exposed to low-density lipoprotein or oxidized low-density lipoprotein. RESULTS Midkine expression reached the maximum level within 7 days after stenting and was detected in infiltrating macrophages. Differentiation of THP-1 cells to macrophage-like cells did not trigger midkine expression. Neither low-density lipoprotein nor oxidized low-density lipoprotein enhanced midkine expression in peritoneal macrophages that had been activated by thioglycollate, although these cells expressed a significant amount of midkine. CONCLUSION The results indicate that macrophages are the major source of midkine in the atherosclerotic neointima. The amount of midkine expressed in macrophages may be sufficient (ie, further enhancement of the expression is not necessary) for the pathogenesis, because oxidized low-density lipoprotein stimulation did not induce the midkine expression. CLINICAL RELEVANCE The growth factor midkine is induced during vascular stenosis in mouse and rat models with normal diet. Knockdown of midkine expression suppresses neointimal hyperplasia. The vascular response after stenting differs from that after balloon injury in that the inflammation is more prolonged and the accumulation of macrophages is more abundant in stent-injured vessel. We found here that macrophages are the major source of midkine in the atherosclerotic neointima of in-stent restenosis in hypercholesterolemic rabbits. Our data suggest that midkine has an important role in in-stent restenosis of atherosclerotic vessels and is a candidate molecular target to prevent in-stent restenosis.
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Affiliation(s)
- Hiroshi Narita
- Department of Biochemistry, Nagoya University Graduate School of Medicine, Nagoya, Japan
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61
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Abstract
The most commonly used procedures to induce arterial injury in mice are carotid artery ligation with cessation of blood flow and mechanically-induced denudation of endothelium in the carotid or the femoral arteries. Both procedures result in neointimal hyperplasia after two to three weeks. A survey of various inbred strains of mice shows that strain-specific differences in susceptibility to injury-induced neointimal hyperplasia are different than those for susceptibility to diet-induced atherosclerosis, with strains identified as susceptible to both neointimal hyperplasia and atherosclerosis, resistant to both, susceptible to atherosclerosis but resistant to neointimal hyperplasia, or resistant to atherosclerosis but susceptible to neointimal hyperplasia. Inflammatory cells such as T and B lymphocytes, which are contributory to atherosclerosis, are protective against injury-induced neointimal hyperplasia. In contrast, the infiltration of monocytes into the site of injury and their differentiation to macrophages favor neointimal hyperplasia similar to their pathogenic role in atherosclerosis. The regulatory role of lymphocytes and macrophages in neointimal hyperplasia is related to the production of cytokines such as interferon-gamma and tumor necrosis factor-alpha, respectively. Interestingly, inducible nitric oxide synthase (iNOS) activity appears to inhibit neointimal hyperplasia in the endothelial denudation model but contributes to neointimal hyperplasia when arterial injury is induced by periadventitial cuff placement. The difference appears to be due to the time required for endothelial recovery and the participation of inflammatory cells. Thus, although arterial injury-induced neointimal hyperplasia results in similar vascular occlusion as progressive atherosclerosis, the pathology and mechanism of the two disease processes are quite different.
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Affiliation(s)
- David Y Hui
- Department of Pathology and Laboratory Medicine, Genome Research Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio 45237, USA.
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Epstein H, Grad E, Golomb M, Koroukhov N, Edelman ER, Golomb G, Danenberg HD. Innate immunity has a dual effect on vascular healing: suppression and aggravation of neointimal formation and remodeling post-endotoxin challenge. Atherosclerosis 2007; 199:41-6. [PMID: 18067897 DOI: 10.1016/j.atherosclerosis.2007.10.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Revised: 09/05/2007] [Accepted: 10/15/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Inflammation is important to vascular repair following injury, modulating neointimal proliferation and remodeling. Previously, we have shown that a low-intensity inflammatory response aggravates neointimal formation following balloon and stent injury. The present study examined whether modulation of the extent and timing of nonspecific inflammation mediates the local vascular response in an additive unidirectional or rather a bidirectional fashion. METHODS AND RESULTS Rabbits subjected to denudation and balloon injury of the iliac artery were treated with low (1 microg/kg) or high (100 microg/kg) doses of bacterial endotoxin (LPS) immediately after injury, or with early high-dose LPS administered 3 days prior to injury (preconditioning). Neointimal formation at 28 days was significantly increased in the low-dose group (0.537+/-0.059 mm(2)) as compared with controls (0.3+/-0.03 mm(2)). High-dose LPS did not significantly affect neointimal formation while early high dose significantly reduced neointima (0.296+/-0.033 and 0.194+/-0.025 mm(2), respectively, n=12-14/group). Arterial wall and systemically circulating interleukin-1 beta levels, and monocyte CD14 activation correlated with neointimal formation. Vascular remodeling was accelerated in animals treated with low- or high-dose LPS while not affected in the preconditioned group. Remodeling index inversely correlated with arterial matrix metalloproteinase-2 levels 6 days after injury. CONCLUSIONS The extent and timing of nonspecific inflammation that is concurrent with vascular injury can determine different and opposite vascular repair patterns.
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Affiliation(s)
- H Epstein
- School of Pharmacy, Hebrew University of Jerusalem, Israel
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63
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Waksman R, Pakala R, Baffour R, Hellinga D, Seabron R, Tio FO, Wittchow E, Tittelbach M, Diener T, Harder C, Virmani R, Jones R. Efficacy and safety of pimecrolimus-eluting stents in porcine coronary arteries. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:259-74. [DOI: 10.1016/j.carrev.2007.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 09/19/2007] [Indexed: 11/24/2022]
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Charron T, Nili N, Strauss BH. The cell cycle: a critical therapeutic target to prevent vascular proliferative disease. Can J Cardiol 2007; 22 Suppl B:41B-55B. [PMID: 16498512 PMCID: PMC2780832 DOI: 10.1016/s0828-282x(06)70986-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Percutaneous coronary intervention is the preferred revascularization approach for most patients with coronary artery disease. However, this strategy is limited by renarrowing of the vessel by neointimal hyperplasia within the stent lumen (in-stent restenosis). Vascular smooth muscle cell proliferation is a major component in this healing process. This process is mediated by multiple cytokines and growth factors, which share a common pathway in inducing cell proliferation: the cell cycle. The cell cycle is highly regulated by numerous mechanisms ensuring orderly and coordinated cell division. The present review discusses current concepts related to regulation of the cell cycle and new therapeutic options that target aspects of the cell cycle.
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Affiliation(s)
| | | | - Bradley H Strauss
- Correspondence: Dr Bradley H Strauss, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B IW8. Telephone 416-864-5913, fax 416-864-5978, e-mail
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Kotooka N, Inoue T, Fujimatsu D, Morooka T, Hashimoto S, Hikichi Y, Uchida T, Sugiyama A, Node K. Pentraxin3 is a novel marker for stent-induced inflammation and neointimal thickening. Atherosclerosis 2007; 197:368-74. [PMID: 17640648 DOI: 10.1016/j.atherosclerosis.2007.05.031] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Revised: 05/08/2007] [Accepted: 05/30/2007] [Indexed: 11/17/2022]
Abstract
Inflammation in the injured vessel wall plays an essential role in the mechanism of restenosis. Pentraxin3 (PTX3) is synthesized at the inflammatory site in response to primary inflammatory stimuli. To establish the clinical significance of plasma PTX3 levels in the pathophysiology of inflammation in the injured vessels, we serially measured the levels in 20 patients undergoing elective coronary stenting. Plasma PTX3 levels increased 15 min after coronary stenting, and reached a maximum at 24h in the coronary sinus (P<0.001 versus baseline) and peripheral blood (P<0.001 versus baseline). The transcardiac gradient of PTX3 at 15 min after PCI was higher in patients with than those without restenosis (0.40+/-0.64 versus -0.19+/-0.33 ng/ml, P=0.02). Furthermore, the increase in PTX3 at 24h was positively correlated with the increase in activated Mac-1 on the surface of neutrophils at 48 h (r=0.48, p<0.05) in the coronary sinus. Stepwise multiple regression analysis demonstrated that the relative increase in PTX3 at 24h was the most powerful predictor of late lumen loss (r=0.547, P=0.007). Coronary stenting enhanced circulating PTX3 levels in association with an inflammatory response. PTX3 may be a useful marker for evaluation of inflammatory reaction and neointimal thickening after vascular injury.
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Affiliation(s)
- Norihiko Kotooka
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, Saga, Japan
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66
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Caixeta AM, Brito FS, Costa MA, Serrano CV, Petriz JL, Da Luz PL. Enhanced inflammatory response to coronary stenting marks the development of clinically relevant restenosis. Catheter Cardiovasc Interv 2007; 69:500-7. [PMID: 17285569 DOI: 10.1002/ccd.21007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aims of this study were to investigate the effect of coronary stenting on the release of cytokines and cell-mediated immunity factors and to evaluate the association between inflammation and clinical outcomes at 6 months. BACKGROUND Circulating levels of inflammatory markers and cytokines are elevated in patients with acute coronary syndromes and are related to an unfavorable outcome. The aims of this study were to investigate the effect of coronary stenting on the release of cytokines and cell-mediated immunity factors and to evaluate the association between inflammation and clinical outcomes at 6 months. METHODS Forty patients with single native coronary artery disease treated with stenting were enrolled. Peripheral venous blood samples were collected before and 6 h, 48 h, and 12 weeks after stenting. Serum concentrations of high-sensitivity C-reactive protein, interleukin-6, interleukin-8, tumor necrosis factor-alpha (markers of inflammation) and serum-soluble interleukin-2 receptor for T-lymphocyte activation (sIL2-R, marker of cell-mediated immunity) were measured. Patients also were evaluated clinically one, 3, and 6 months post-stenting or when they presented with cardiovascular symptoms to identify major adverse cardiac events (cardiac death, MI, revascularization). RESULTS Concentrations of interleukins 6 and 8 and tumor necrosis factor-alpha peaked at 6 h (11.0, 12.6, and 5.3 pg/ml, respectively). The peak level of high-sensitivity C-reactive protein (2.77 mg/dL) occurred 48 h post stenting, while sIL2-R peaked (495 U/ml) at 12 weeks. Patients who experienced restenosis had higher levels of C-reactive protein at 48 h (4.94 vs. 1.84 mg/dl; P = 0.043) and of IL-8 at 6 h (26.75 vs. 13.55 pg/mL; P = 0.048) than those without restenosis. CONCLUSIONS Proinflammatory cytokines and inflammatory markers are released into the peripheral circulation early after coronary stenting, and increased levels of some are associated with clinically relevant restenosis.
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Affiliation(s)
- Adriano M Caixeta
- Division of Interventional Cardiology, Brasília Heart Institute (InCor-DF), Zerbini Foundation, Estrada Parque Contorno do Bosque, s/n Parte, CEP:70658-900 Brasília, DF, Brazil.
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Thanyasiri P, Kathir K, Celermajer DS, Adams MR. Endothelial dysfunction and restenosis following percutaneous coronary intervention. Int J Cardiol 2007; 119:362-7. [PMID: 17092587 DOI: 10.1016/j.ijcard.2006.08.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 07/31/2006] [Accepted: 08/02/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Restenosis remains an important limitation of PCI. Although local factors such as small vessel diameter and systemic factors such as diabetes explain some of its incidence, it nevertheless also occurs in low-risk patients. We hypothesize that endothelial dysfunction may be an independent risk factor in some of these cases. METHODS 20 patients who had previously undergone PCI were studied at cardiac catheterization (10 with restenotic lesions were matched to 10 without restenosis). Infusion of multiple concentrations of acetylcholine (ACh) and nitroglycerine (GTN) were made via a 3F infusion catheter into the target artery. Following infusion, changes in diameter of segments proximal and distal to the PCI site were measured. RESULTS There was a significant impairment in endothelium-dependent dilatation at the maximal dose of acetylcholine in those with restenosis compared to those without restenosis, both proximal and distal to the stented area (proximal; 11.5+/-7.0% versus -20.9+/-9.0% p<0.001, distal; 12.0+/-3.1% versus -17.8+/-8.1% p<0.001), but there was no difference in the response to GTN. There was a significant correlation between the endothelium-dependent dilatation response and the percent restenosis (r=-0.65, p=0.003). CONCLUSIONS Coronary endothelium-dependent dilatation is reduced in subjects with restenosis in arterial segments separate from the stented lesion. This supports a hypothesis that endothelial dysfunction contributes to the development of restenosis, following percutaneous coronary intervention.
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Affiliation(s)
- Panuratn Thanyasiri
- Department of Cardiology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown 2050, Sydney, Australia
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68
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Park JY, Arnaout MA, Gupta V. A simple, no-wash cell adhesion-based high-throughput assay for the discovery of small-molecule regulators of the integrin CD11b/CD18. JOURNAL OF BIOMOLECULAR SCREENING 2007; 12:406-17. [PMID: 17438069 PMCID: PMC3075871 DOI: 10.1177/1087057106299162] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The leukocyte-specific integrin CD11b/CD18 plays a key role in the biological function of these cells and represents a validated therapeutic target for inflammatory diseases. Currently, the low affinity interaction between CD11b/CD18 integrin and its respective ligand poses a challenge in the development of cell-based adhesion assays for the high-throughput screening (HTS) environment. Here the authors describe a simple cell-based adhesion assay that can be readily used for HTS for the discovery of functional regulators of CD11b/CD18. The assay consistently produces acceptable Z' values (> 0.5) for HTS. After testing the assay using 2 established blocking antibodies as reference biologicals, the authors performed a proof-of-concept primary screen using a library of 6612 compounds and identified both agonist and antagonist hits.
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Affiliation(s)
- Jun Y Park
- Nephrology Division, Leukocyte Biology and Inflammation Program, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
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69
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Zirlik A, Maier C, Gerdes N, MacFarlane L, Soosairajah J, Bavendiek U, Ahrens I, Ernst S, Bassler N, Missiou A, Patko Z, Aikawa M, Schönbeck U, Bode C, Libby P, Peter K. CD40 ligand mediates inflammation independently of CD40 by interaction with Mac-1. Circulation 2007; 115:1571-80. [PMID: 17372166 DOI: 10.1161/circulationaha.106.683201] [Citation(s) in RCA: 234] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Strong evidence supports a role for CD40 ligand (CD40L) as marker and mediator of inflammatory diseases such as atherosclerosis. Despite extensive characterization of CD40, the classic receptor of CD40L, its role in immune defense against inflammatory diseases remains uncertain. The present study aimed to characterize the contribution of CD40 signaling to atherogenesis. METHODS AND RESULTS Surprisingly, mice deficient in both CD40 and the low-density lipoprotein receptor did not develop smaller lesions in the aortic arch, root, and thoracoabdominal aorta compared with mice deficient only in the low-density lipoprotein receptor that consumed an atherogenic diet for 8 and 16 weeks. By flow cytometry, radioactive binding assays, and immunoprecipitation, we demonstrate that CD40L interacts with the integrin Mac-1, which results in Mac-1-dependent adhesion and migration of inflammatory cells as well as myeloperoxidase release in vitro. Furthermore, mice deficient in CD40L show significantly reduced thioglycolate-elicited invasion of inflammatory cells into the peritoneal cavity compared with mice deficient in CD40 and wild-type controls. Inhibition of Mac-1 in low-density lipoprotein receptor-deficient mice attenuates lesion development and reduces lesional macrophage accumulation. CONCLUSIONS These observations identify the interaction of CD40L and Mac-1 as an alternative pathway for CD40L-mediated inflammation. This novel mechanism expands understanding of inflammatory signaling during atherogenesis.
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MESH Headings
- Animals
- Aorta, Thoracic/chemistry
- Aorta, Thoracic/pathology
- Aortic Diseases/etiology
- Aortic Diseases/pathology
- Atherosclerosis/etiology
- Atherosclerosis/genetics
- Atherosclerosis/physiopathology
- Atherosclerosis/prevention & control
- CD40 Ligand/deficiency
- CD40 Ligand/physiology
- CHO Cells
- Chemotaxis, Leukocyte/physiology
- Cholesterol, Dietary/toxicity
- Cricetinae
- Cricetulus
- Crosses, Genetic
- Diet, Atherogenic
- Foam Cells/pathology
- Genetic Predisposition to Disease
- Humans
- Inflammation/etiology
- Inflammation/genetics
- Inflammation/physiopathology
- Lipids/analysis
- Macrophage-1 Antigen/physiology
- Macrophages/pathology
- Mice
- Mice, Inbred C57BL
- Mice, Knockout
- Models, Biological
- Monocytes/drug effects
- Monocytes/enzymology
- Peritonitis/chemically induced
- Peritonitis/metabolism
- Peritonitis/pathology
- Peroxidase/metabolism
- Receptors, LDL/deficiency
- Receptors, LDL/genetics
- Rheology
- Tetradecanoylphorbol Acetate/pharmacology
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Affiliation(s)
- Andreas Zirlik
- Donald W. Reynolds Center, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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70
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Kollum M, Hoefer I, Schreiber R, Bode C, Hehrlein C. Systemic application of anti-ICAM-1 monoclonal antibodies to prevent restenosis in rabbits: an anti-inflammatory strategy. Coron Artery Dis 2007; 18:117-23. [PMID: 17301603 DOI: 10.1097/mca.0b013e328011c084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES After vascular intervention, cell adhesion molecules such as ICAM-1 and VCAM are fundamental in inflammatory processes. In particular, ICAM-1 expression is strongly associated with macrophage-rich areas in restenotic lesions. Therefore, we hypothesized an anti-restenotic effect by systemic application of anti-ICAM-1 monoclonal antibodies (mAb). METHODS Thirty two rabbits underwent balloon angioplasty and stent implantation either in the right or left iliac artery, Animals received either anti-ICAM mAb or saline solution as a control. Animals were sacrificed 7 (n=8) and 14 (n=8) days and tissue was analyzed for basic fibroblast growth factor (bFGF) and transforming growth factor beta (TGF-beta) expression. Sixteen animals were sacrificed 6 months following treatment and tissue was harvested for histomorphometric analysis. RESULTS After balloon injury, bFGF significantly increased from 7 to 14 days only in the control group and was significantly higher compared to the anti-ICAM group. At 14 days after stent implantation, controls showed a significant increase of both bFGF and TGF-beta, whereas the anti-ICAM group only showed a significant increase of TGF-beta. Histomorphometric analysis for neointimal growth did not show any differences between control and anti-ICAM groups either after balloon injury or after stent implantation at 6 months. CONCLUSION Administration of anti-ICAM-1 mAb following either balloon angioplasty or stent implantation results in a suppression of bFGF in the early phase of restenosis, whereas TGF-beta significantly increases from 7 to 14 days after stent implantation independent of anti-ICAM-1 mAb application. Therefore we conclude that anti-inflammatory strategies are able to interfere with growth factor expression after vascular injury.
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Affiliation(s)
- Marc Kollum
- Department of Cardiology and Angiology, University Clinic of Freiburg, Freiburg i. Br., Germany.
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71
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Inoue T, Sata M, Hikichi Y, Sohma R, Fukuda D, Uchida T, Shimizu M, Komoda H, Node K. Mobilization of CD34-positive bone marrow-derived cells after coronary stent implantation: impact on restenosis. Circulation 2007; 115:553-61. [PMID: 17261663 DOI: 10.1161/circulationaha.106.621714] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recently, accumulating evidence has indicated that bone marrow-derived stem cells are capable of differentiating into vascular cells. It has been hypothesized that the inflammatory response after vascular injury triggers the mobilization of endothelial and smooth muscle progenitor cells from bone marrow. METHODS AND RESULTS We measured circulating CD34-positive mononuclear cells, activation of integrin Mac-1 on the surface of neutrophils, and plasma granulocyte-colony stimulating factor levels in 40 patients undergoing coronary stenting. After bare-metal stenting, CD34-positive cells increased, reaching a maximum on day 7 after stenting. The maximum change compared with baseline before stenting was more striking in patients with restenosis than without restenosis (332+/-108% versus 148+/-49%; P<0.05). In contrast, CD34-positive cells decreased after sirolimus-eluting stenting (72+/-21% on day 7). The change in CD34-positive cells on day 7 relative to baseline was closely correlated with that in activated Mac-1 at 48 hours (R=0.52, P<0.01) and that in granulocyte-colony stimulating factor levels at 24 hours (R=0.42, P<0.05). Cell culture assay on day 7 showed that mononuclear cells differentiated into CD31-positive endothelium-like cells after bare-metal stenting. In patients with restenosis, mononuclear cells differentiating into alpha-smooth muscle actin-positive smooth muscle-like cells also were observed. Implantation of sirolimus-eluting stents suppressed both types of differentiation. CONCLUSIONS Stent implantation may induce differentiation of bone marrow cells into endothelial or smooth muscle cells. Endothelial cells may participate in reendothelialization, a protective reaction against vascular injury, whereas smooth muscle cells may participate in neointimal thickening and restenosis. Sirolimus-eluting stents appear to inhibit the mobilization and differentiation of bone marrow cells.
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Affiliation(s)
- Teruo Inoue
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan.
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72
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Inoue T, Komoda H, Kotooka N, Morooka T, Fujimatsu D, Hikichi Y, Soma R, Uchida T, Node K. Increased circulating platelet-derived microparticles are associated with stent-induced vascular inflammation. Atherosclerosis 2007; 196:469-476. [PMID: 17234194 DOI: 10.1016/j.atherosclerosis.2006.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2006] [Revised: 10/30/2006] [Accepted: 12/02/2006] [Indexed: 11/30/2022]
Abstract
Inflammation as well as platelet activation at the site of local vessel-wall injury plays an essential role in the mechanism of restenosis after Percutaneous coronary intervention (PCI). Platelet-derived microparticles (PDMPs) released from activated platelets are thought to play a role in the inflammatory process, possibly interacting with leukocyte integrin Mac-1. We serially measured circulating PDMPs, high-sensitive C-reactive protein (hs-CRP) and activated Mac-1 on the surface of neutrophils in 61 patients undergoing coronary stenting. PDMPs, hs-CRP and Mac-1 increased after coronary stenting in a time-dependent manner with the maximum response at 48 h in coronary sinus blood (PDMPs: 10.3+/-8.9-32.8+/-13.8 U/ml; P<0.001, hs-CRP: 0.27+/-0.23-1.46+/-0.99 mg/dl; P<0.001, activated Mac-1, 134+/-19% relative increase, P<0.001). PDMPs were correlated with hs-CRP (R=0.58, P<0.001) and the relative increase in Mac-1 (R=0.69, P<0.001) 48 h after coronary stenting. Multiple regression analysis showed that each of PDMPs (R=0.40, P<0.05), hs-CRP (R=0.33, P<0.05) and Mac-1 (R=0.48, P<0.01) was an independent predictor of the late lumen loss. Coronary stenting enhanced circulating PDMPs in association with an inflammatory response in the injured vessel wall. PDMPs may be a useful marker for evaluation of stent-induced inflammatory status and a powerful predictor of restenosis equivalent to activated Mac-1.
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Affiliation(s)
- Teruo Inoue
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan.
| | - Hiroshi Komoda
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Norihiko Kotooka
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Toshifumi Morooka
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Daisuke Fujimatsu
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Yutaka Hikichi
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Ryoichi Soma
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Toshihiko Uchida
- Department of Cardiology, Koshigaya Hospital, Dokkyo Medical University, Koshigaya, Japan
| | - Koichi Node
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, 5-1-1 Nabeshima, Saga 849-8501, Japan
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73
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Tanous D, Bräsen JH, Choy K, Wu BJ, Kathir K, Lau A, Celermajer DS, Stocker R. Probucol inhibits in-stent thrombosis and neointimal hyperplasia by promoting re-endothelialization. Atherosclerosis 2006; 189:342-9. [PMID: 16529750 DOI: 10.1016/j.atherosclerosis.2006.01.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 01/27/2006] [Accepted: 01/30/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Evidence suggests that delayed re-endothelialization is responsible for in-stent thrombosis. Probucol inhibits neointimal thickening in animals via enhanced re-endothelialization and is the only oral drug that consistently inhibits restenosis after coronary angioplasty in humans. Here, we examined the effects of probucol on re-endothelialization and neointimal formation in a stent model. METHODS AND RESULTS New Zealand White rabbits were fed a hypercholesterolemic diet with probucol (1%) or without (control) (n=11 each) for 6 weeks. At 2 weeks, endothelial denudation and stenting of the iliac artery was performed. Iliac arteries were harvested at week 6, and stented segments sectioned and analyzed. Compared with control, probucol increased in-stent re-endothelialization (74+/-6% in controls versus 93+/-3% in probucol-treated; P=0.008), and decreased average luminal stenosis (58+/-27 versus 31+/-16%; P=0.01) and stent depth (619+/-310 versus 314+/-158 microm; P=0.009). Compared with control, probucol also decreased accumulation of macrophages in the neointima. Furthermore, none of the probucol-treated rabbits had in-stent thrombosis, whereas four of eleven control rabbits showed thrombosis (P=0.04). CONCLUSIONS Probucol demonstrates anti-restenotic and appears to have anti-thrombotic properties that are likely related to its ability to promote in-stent re-endothelialization.
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Affiliation(s)
- David Tanous
- Centre for Vascular Research, School of Medical Sciences, University of New South Wales and Department of Haematology, Prince of Wales Hospital, Sydney, Australia
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74
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Abstract
Cellular adhesion molecules (CAMs), by mediating the recruitment of circulating leukocytes to the blood vessel wall and their subsequent migration into the subendothelial spaces, play a crucial role in all stages of atherosclerosis. Soluble forms of CAMs, probably derived from proteolytic shedding, are present in the circulation and their blood levels parallel the amount expressed on the cell surface. In patients with peripheral arterial disease (PAD), increased levels of soluble CAMs have been found during exercise-induced claudication, are associated with the presence, the severity and the extent of atherosclerosis in the arteries of the lower limbs, and portend a worse outcome. These findings have provided new insights into the pathophysiology of PAD and its consequences. However, further large population studies are needed to firmly establish whether increased levels of circulating CAMs give additive information to current risk assessment approaches, and to verify whether PAD patients with elevated levels of circulating CAMs would benefit from any specific therapy.
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Affiliation(s)
- Gregorio Brevetti
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Napoli, Italy.
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75
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Jabs A, Okamoto EI, Vinten-Johansen J, Bauriedel G, Wilcox JN. Sequential patterns of chemokine- and chemokine receptor-synthesis following vessel wall injury in porcine coronary arteries. Atherosclerosis 2006; 192:75-84. [PMID: 16926016 DOI: 10.1016/j.atherosclerosis.2006.05.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Revised: 05/02/2006] [Accepted: 05/04/2006] [Indexed: 10/24/2022]
Abstract
Inflammation plays a central role in vascular repair, and spreads into perivascular tissue (PVT) following angioplasty. Chemokines (CK) and chemokine receptors (CKR) are key determinants of inflammatory chemotaxis. We sought to assess the arterial and perivascular expression of the CK CCL2 and CXCL2, and the CKR CCR2, CCR5, and CXCR4 in balloon-injured porcine coronary arteries. Vascular cells that express specific CK and CKR mRNA during post-angioplasty time course were detected by in situ hybridization (ISH), and expression was quantified by real time RT-PCR in PVT. CCL2 was maximal in PVT from 2 to 24h post injury, coincident with local macrophage-activation. Expression was upregulated in media and adventitia from 24h to 3 days, and in neointima at 7 days. CXCL2 was detected in media at 2 and 4h, and also in some neointimal cells. CCR2 and CCR5 were maximal in PVT at 24h and 3 days, respectively. Expression shifted to media and adventitia at 2 and 3 days, and to neointima and adventitia at 7 days, and was low at 14 days. CXCR4 was low in PVT, but was upregulated in media and adventitia at 2 and 3 days, as well as in neointima and adventitia at 7 days. In conclusion, PVT is the primary source of inflammatory CK and CKR early post-angioplasty. Specific sequential patterns of CK- and CKR-synthesis are identified that may regulate phase-specific chemotaxis by spatio-temporally differential expression during coronary response to injury.
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Affiliation(s)
- Alexander Jabs
- Winship Cancer Institute Department of Hematology/Oncology, Emory University School of Medicine, Atlanta, GA, USA
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76
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Scott NA. Restenosis following implantation of bare metal coronary stents: pathophysiology and pathways involved in the vascular response to injury. Adv Drug Deliv Rev 2006; 58:358-76. [PMID: 16733073 DOI: 10.1016/j.addr.2006.01.015] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2005] [Accepted: 01/31/2006] [Indexed: 02/06/2023]
Abstract
This review summarizes the restenotic process that occurs after the implantation of bare metal coronary stents. The pathology of in-stent restenosis is distinct from that seen after balloon angioplasty and is characterized by neointimal proliferation and extracellular matrix deposition. The degree of neointimal proliferation is proportional to the amount of injury, the intensity of the inflammatory infiltrate and the association of stent struts with lipid-filled plaque. In-stent restenosis also appears to be associated with systemic markers of inflammation. Shear stress has an important influence on restenosis as does the presence and adhesiveness of vascular progenitor cells. Clinical predictors (e.g., artery size, stent length, diabetes, and gender) may affect the incidence of restenosis seen after stent placement. A number of catheter-based interventions have been used to treat in-stent restenosis. Although preliminary data suggest that the use of drug-eluting stents may be effective, only intracoronary radiation has shown consistent efficacy in randomized trials.
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Affiliation(s)
- Neal A Scott
- Camino Cardiovascular Associates, 525 South Drive, Suite 107, Mountain View, CA 94040, USA.
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77
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Schühlen H, Kastrati A, Mehilli J, Hausleiter J, Dirschinger J, Dotzer F, Bollwein H, Schömig A. Abciximab and angiographic restenosis after coronary stent placement. Analysis of the angiographic substudy of ISAR-REACT--a double-blind, placebo-controlled, randomized trial evaluating abciximab in patients undergoing elective percutaneous coronary interventions after pretreatment with a high loading dose of clopidogrel. Am Heart J 2006; 151:1248-54. [PMID: 16781230 DOI: 10.1016/j.ahj.2005.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Accepted: 08/04/2005] [Indexed: 02/02/2023]
Abstract
BACKGROUND ISAR-REACT was a trial designed to evaluate whether the glycoprotein IIb/IIIa inhibitor abciximab is beneficial in patients undergoing elective percutaneous coronary intervention (PCI) with stent placement after pretreatment with a 600 mg loading dose of clopidogrel. Objective for the angiographic substudy was to determine the impact of abciximab on angiographic restenosis after coronary stent placement. Previous analyses have suggested a reduction in the incidence of restenosis after the administration of abciximab. METHODS The angiographic substudy comprises 1885 of 2159 patients enrolled in ISAR-REACT: 994 patients were randomly assigned to abciximab and 941 patients to placebo. All patients were scheduled for a routine angiographic follow-up after 6 months (performed in 80% of eligible patients). End points for the angiographic substudy were the rates of angiographic restenosis (> or = 50% diameter stenosis) and target lesion revascularization. RESULTS The incidence of angiographic restenosis was 27% in the abciximab group and 29% in the placebo group (relative risk 0.92, 95% CI 0.79-1.06, P = .27). Late angiographic lumen loss was 0.95 +/- 0.68 and 0.99 +/- 0.70 mm, respectively (P = .25). Similar results were obtained in a subgroup analysis focusing on high-risk subsets. The rate of target lesion revascularization procedures was 22% in the abciximab group and 23% in the placebo group (relative risk 0.94, 95% CI 0.79-1.12, P = .52). CONCLUSIONS In low- to intermediate-risk patients who undergo elective PCI after pretreatment with a high loading dose of clopidogrel >2 hours before PCI, the additional administration of the glycoprotein IIb/IIIa inhibitor abciximab is not associated with a significant reduction in angiographic restenosis.
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78
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Varcoe RL, Mikhail M, Guiffre AK, Pennings G, Vicaretti M, Hawthorne WJ, Fletcher JP, Medbury HJ. The role of the fibrocyte in intimal hyperplasia. J Thromb Haemost 2006; 4:1125-33. [PMID: 16689767 DOI: 10.1111/j.1538-7836.2006.01924.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Experimental animal studies have shown that the intimal hyperplasia (IH) responsible for occlusion after successful revascularization procedures may be partially caused by a bone marrow-derived cell that migrates to the site of vascular injury. Concurrent studies have demonstrated an extensive role in wound healing for the circulating fibrocyte. OBJECTIVES We aimed to trace the path of the circulating cell that contributes to IH and determine if it is the fibrocyte. METHODS AND RESULTS We established an in vitro model whereby purified monocytes from six healthy human volunteers were cultured into fibrocytes. These cells were morphometrically similar to the vascular smooth muscle cell (VSMC) found in IH and expressed alpha-smooth muscle actin (alpha-SMA) as well as CD34, CD45 and Collagen I (Col I), markers indicative of the fibrocyte. In an in vivo ovine carotid artery synthetic patch graft model, carboxyfluorescein diacetate, succinimidyl ester (CFSE) labeled circulating leukocytes were observed throughout the graft as well as in the neointima in 18 sheep. These cells were shown to produce collagen and alpha-SMA at 1, 2 and 4 weeks. These cells then underwent immunohistochemical analysis and were found to express a set of markers unique to the fibrocyte (CD34, CD45, Vimentin and alpha-SMA) and also to double stain for CD34 and alpha-SMA. CONCLUSIONS IH in an ovine carotid artery patch graft model is partially derived from a hematopoietic circulating progenitor cell that acquires mesenchymal features as it matures at the site of injury.
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Affiliation(s)
- R L Varcoe
- Department of Surgery, Vascular Biology Research Centre, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
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79
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Kawamoto R, Yamashita A, Nishihira K, Furukoji E, Hatakeyama K, Ishikawa T, Imamura T, Itabe H, Eto T, Asada Y. Different inflammatory response and oxidative stress in neointimal hyperplasia after balloon angioplasty and stent implantation in cholesterol-fed rabbits. Pathol Res Pract 2006; 202:447-56. [PMID: 16635553 DOI: 10.1016/j.prp.2005.12.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Accepted: 12/23/2005] [Indexed: 11/19/2022]
Abstract
Inflammatory responses appear to play an important role in the occurrence of restenosis following coronary intervention. However, the contribution of C-reactive protein (CRP) and oxidative stress to restenosis after balloon angioplasty and stent implantation remains unclear. The aim of this study was to examine this issue using hyperlipidemic rabbits. Rabbits were divided into two groups; they were fed with a 0.5% cholesterol diet and with a mixed 0.5% cholesterol and 0.5% probucol diet. Each group of rabbits underwent balloon injury and stent implantation in right and left iliac arteries, respectively. Eight weeks after the intervention, we examined luminal stenosis, neointimal hyperplasia, immunoreactivity for macrophage, CRP and oxidized phosphatidylcholine (oxPC), and also the expression of CRP mRNA. The degrees of neointimal hyperplasia and immunopositive areas (%) for macrophage, CRP, and oxPC in the neointima were significantly higher after stent implantation than after balloon injury, but CRP mRNA was undetectable in either artery. Anti-oxidant probucol reduced angiographic stenosis, neointimal hyperplasia, and macrophage- and oxPC-positive areas much more significantly after stenting. The results demonstrate that the inflammatory response to the development of neointimal hyperplasia differs after balloon injury and stent implantation and that CRP deposition and oxidative stress might be involved more significantly in neointimal development after stent implantation.
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Affiliation(s)
- Riichirou Kawamoto
- First Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692 Japan
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80
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Collin B, Busseuil D, Korandji C, Zeller M, Cottin Y, Duvillard L, Rioufol G, Pitois-Merli I, Rochette L. Short-term atorvastatin treatment does not modify neointimal morphology but reduces MMP-2 expression in normocholesterolemic rabbit stented arteries. J Cardiovasc Pharmacol 2006; 47:428-36. [PMID: 16633086 DOI: 10.1097/01.fjc.0000211706.64993.cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of our study was to explore some potential pleïotropic effects of atorvastatin, after stenting in the iliac arteries of normocholesterolemic rabbits. On day 0, 27 rabbits underwent stent implantation and were randomized into either the control group (standard chow, CTRL, n = 15) or the atorvastatin group (10 mg/kg/d per os, Ator, n = 12). On day 30, the stented arteries were harvested for histomorphometry and neointimal analysis [macrophages, matrix metalloproteinases (MMP-2), tissue inhibitor of metalloproteinase-2, vascular smooth muscle cells, and collagen]. Atorvastatin did not induce significant histomorphometric and inflammatory modifications but reduced neointimal expression of MMP-2 with no modification of tissue inhibitor of metalloproteinase-2, and also induced higher neointimal collagen content (Ator vs. CTRL: MMP-2: 0.05 +/- 0.03 vs. 0.70 +/- 0.20, P < 0.01; collagen: 17.0+/-0.7%/mm vs. 12.0 +/- 1.2%/mm(2) P < 0.01). Atorvastatin treatment also induced a significant decrease in neointimal vascular smooth muscle cells and cellular density (respectively: 2.0 +/- 0.2 vs. 1.4 +/- 0.2, P < 0.05; 5406 +/- 241 nuclei/mm(2) vs. 4402 +/- 163 nuclei/mm(2), P < 0.001). Our study provides new insights into the field of MMP response to stenting and the effects of statin therapy, which could have important implications in the field of in-stent restenosis.
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Affiliation(s)
- Bertrand Collin
- Laboratory of Cardiovascular and Experimental Physiopathology and Pharmacology, Faculty of Medicine, University of Burgundy, 7 Bd Jeanne d'Arc, France.
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81
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Hong YJ, Jeong MH, Lim SY, Lee SR, Kim KH, Sohn IS, Wookpark H, Kim JH, Kim W, Ahn Y, Cho JG, Park JC, Kang JC. Preinterventional peak monocyte count and in-stent intimal hyperplasia after coronary stent implantation in human coronary arteries. Clin Cardiol 2006; 28:512-8. [PMID: 16450794 PMCID: PMC6653908 DOI: 10.1002/clc.4960281105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The mechanism of restenosis after stent implantation principally is neointimal hyperplasia. There is evidence that monocytes play a important role in in-stent restenosis (ISR) after stent implantation. HYPOTHESIS This study assessed the relationship between preinterventional peak monocyte count and neointimal growth after successful stent implantation. METHODS We performed coronary stent implantation in 85 patients (85 de novo lesions). Peripheral blood sample was obtained in all patients every 12 h before coronary angiography for measurement of peripheral monocytes. All patients received angiographic and intravascular ultrasound (IVUS) follow-up at 6 months after stenting. RESULTS The preinterventional circulating monocyte count was significantly higher in the ISR group than that in the group without ISR (654 +/- 62/vs. 461 +/- 222/mm3, p < 0.001) and was significantly higher in the reintervention group than that in the no-reintervention group (660 +/- 72/ vs. 470 +/- 216/mm3, p< 0.001). The incidence of ISR and repeat intervention associated with preinterventional monocyte count was highest among the patients in the highest tertile, who were at a 2.64-fold increased risk of ISR and 3.22-fold increased risk of repeat intervention compared with the patients in the lowest tertile. A significant positive correlation was found between preinterventional peak monocyte count and preinterventional plaque and media cross-sectional area and follow-up neointima area (r = 0.311, p = 0.007, r = 0.465, p < 0.001, respectively). The neointima area associated with preinterventional monocyte count was largest among the patients in the highest tertile, that is, 2-fold larger than that of the patients in the lowest tertile (p < 0.001) and 1.44-fold larger than that of the patients in the middle tertile (p = 0.001). CONCLUSION Our results suggest that circulating preinterventional monocytes play a principal role in the process of in-stent neointimal growth after successful stent implantation.
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Affiliation(s)
- Young Joon Hong
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Myung Ho Jeong
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Sang Yup Lim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Sang Rok Lee
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Kye Hun Kim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Il Suk Sohn
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Hyung Wookpark
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Ju Han Kim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Weon Kim
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Youngkeun Ahn
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Jeong Gwan Cho
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Jong Chun Park
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
| | - Jung Chaee Kang
- The Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Science, Gwangju, Korea
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82
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Affiliation(s)
- Marco A Costa
- Division of Cardiology & Cardiovascular Imaging Core Laboratories, University of Florida, Shands-Jacksonville, Jacksonville, Fla, USA
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83
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Ge J, Shen C, Liang C, Chen L, Qian J, Chen H. Elevated matrix metalloproteinase expression after stent implantation is associated with restenosis. Int J Cardiol 2005; 112:85-90. [PMID: 16316696 DOI: 10.1016/j.ijcard.2005.10.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Revised: 10/14/2005] [Accepted: 10/28/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Matrix metalloproteinases (MMPs) play a key role in intimal growth and is responsible for ventricular remodeling after stent implantation. However, little is known about the relationship between early MMPs expression post-stent implantation and follow-up restenosis. METHODS We investigated the serial changes of serum MMP-9, MMP-2 and tissue inhibitor of metalloproteinase-1 (TIMP-1) in 16 control subjects with normal coronary angiography (control) and 40 patients before and on the 1st, 3rd and 7th day after uncomplicated stent implantation. Follow-up angiography was performed at 6 months after stent implantation. RESULTS Serum MMP-2 level was higher in patients with restenosis on the 1st day post-stent implantation and returned to pre-operation level thereafter. Serum MMP-9 levels consistently increased in patients with restenosis up to 7th day post-stent implantation; MMP-9 levels in the 1st, 3rd and 7th day after stent implantation were positively correlated to the late loss index 6 months after stent implantation. CONCLUSIONS Increased serum MMP-9 level is associated with increased risk of restenosis post-stent implantation.
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Affiliation(s)
- Junbo Ge
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Fenglin Road 180, Shanghai 200032, People's Republic of China.
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84
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Wang Y, Sakuma M, Chen Z, Ustinov V, Shi C, Croce K, Zago AC, Lopez J, Andre P, Plow E, Simon DI. Leukocyte engagement of platelet glycoprotein Ibalpha via the integrin Mac-1 is critical for the biological response to vascular injury. Circulation 2005; 112:2993-3000. [PMID: 16260637 DOI: 10.1161/circulationaha.105.571315] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Leukocyte-platelet interactions are critical in the initiation and progression of atherosclerosis as well as restenosis. Although the leukocyte integrin Mac-1 (alphaMbeta2, CD11b/CD18) has been implicated in the firm adhesion and transmigration of leukocytes at sites of platelet deposition, the precise alphaMbeta2 counterligand responsible for mediating adhesion-strengthening interactions between neutrophils and platelets in vivo has not previously been identified. METHODS AND RESULTS Our previous studies have established the P201-K217 sequence in the alphaMI domain as the binding site for platelet glycoprotein (GP) Ibalpha. Here we report that antibody targeting of alphaM(P201-K217) reduced alphaMbeta2-dependent adhesion to GP Ibalpha but not other alphaMbeta2 ligands, including fibrinogen, intercellular adhesion molecule-1, and junctional adhesion molecule-3. Anti-alphaM(P201-K217) inhibited the firm adhesion of both human and murine leukocytes to adherent platelets under laminar flow conditions. In a mouse femoral artery wire injury model, antibody targeting of alphaM(P201-K217) reduced leukocyte accumulation after injury that was accompanied by inhibition of cellular proliferation and neointimal thickening. CONCLUSIONS This study demonstrates that GP Ibalpha is a physiologically relevant ligand for alphaMbeta2 and that integrin engagement of GP Ibalpha is critical to leukocyte function and the biological response to vascular injury. These observations establish a molecular target for selectively disrupting leukocyte-platelet complexes that promote inflammation in thrombosis and restenosis.
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Affiliation(s)
- Yunmei Wang
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115, USA
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85
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LaDisa JF, Meier HT, Olson LE, Kersten JR, Warltier DC, Pagel PS. Antegrade iliac artery stent implantation for the temporal and spatial examination of stent-induced neointimal hyperplasia and alterations in regional fluid dynamics. J Pharmacol Toxicol Methods 2005; 51:115-21. [PMID: 15767204 DOI: 10.1016/j.vascn.2004.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2004] [Accepted: 08/05/2004] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Neointimal hyperplasia remains an important problem after stent implantation. Previous investigations examining vascular responses to stent implantation and effects of drugs have used a retrograde deployment approach that may inadvertently alter the local fluid dynamics surrounding the stent. We present a model of antegrade iliac artery stent implantation that facilitates the analysis of stent-induced alterations in neointimal hyperplasia and wall shear stress in vivo. METHODS Stent delivery catheters were inserted through the left carotid artery in anesthetized rabbits (n=37). Catheters were advanced under fluoroscopic guidance to the distal iliac arteries, where the stent was deployed. Hemotoxylin and eosin (H&E) staining of unstented and stented vascular sections was performed 21 days after implantation. RESULTS Selective unilateral stent implantation was successful in 32 of 37 rabbits. No histological abnormalities were observed in the aorta, contralateral unstented iliac, or distal femoral arteries. Neointimal hyperplasia was localized to the stented region. DISCUSSION The model of stent implantation was relatively easy to perform and produced selective neointimal hyperplasia within the stented region without evidence of damage, cellular proliferation, or flow disruption in the surrounding normal arterial vessels. The model will allow detailed examination of the influence of stent implantation on indices of wall shear stress, neointimal hyperplasia, the mechanisms of cellular proliferation in vivo, and their modification by drugs.
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Affiliation(s)
- John F LaDisa
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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86
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Inoue T, Kato T, Uchida T, Sakuma M, Nakajima A, Shibazaki M, Imoto Y, Saito M, Hashimoto S, Hikichi Y, Node K. Local Release of C-Reactive Protein From Vulnerable Plaque or Coronary Arterial Wall Injured by Stenting. J Am Coll Cardiol 2005; 46:239-45. [PMID: 16022949 DOI: 10.1016/j.jacc.2005.04.029] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2004] [Revised: 03/24/2005] [Accepted: 04/14/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to assess local release of C-reactive protein (CRP) from atherosclerotic plaques or the vessel wall injured by stenting. BACKGROUND Recent research has focused on the local production of CRP, especially in inflammatory atherosclerotic plaques. METHODS The study consisted of two separate protocols. In protocol 1, we measured serum high-sensitivity-CRP (hs-CRP) levels in coronary arterial blood sampled just distal and proximal to the culprit lesions in 36 patients with stable angina and 13 patients with unstable angina. In protocol 2, we measured serial serum hs-CRP levels and activated Mac-1 on the surface of neutrophils in both coronary sinus and peripheral blood in 20 patients undergoing coronary stenting. RESULTS In protocol 1, CRP was higher in distal blood than proximal blood in both stable (p < 0.05) and unstable angina (p < 0.01). The translesional CRP gradient (distal CRP minus proximal CRP, p < 0.05) as well as the proximal CRP (p < 0.05) and distal CRP (p < 0.05) was higher in unstable angina than in stable angina. In protocol 2, the transcardiac CRP gradient (coronary sinus minus peripheral blood) and activated Mac-1 increased gradually after stenting, reaching a maximum at 48 h (p < 0.001 vs. baseline for both). There was a positive correlation between the transcardiac CRP gradient and activated Mac-1 at 48 h (r = 0.45, p < 0.01). CONCLUSIONS C-reactive protein is an excellent marker for plaque instability or poststent inflammatory status, and its source might be the inflammation site of the plaque or the coronary arterial wall injured by stenting.
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Affiliation(s)
- Teruo Inoue
- Department of Cardiovascular and Renal Medicine, Saga University Faculty of Medicine, Saga, Japan.
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87
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Wang YX. Cardiovascular functional phenotypes and pharmacological responses in apolipoprotein E deficient mice. Neurobiol Aging 2005; 26:309-16. [PMID: 15639308 DOI: 10.1016/j.neurobiolaging.2004.06.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2003] [Revised: 06/08/2004] [Accepted: 06/30/2004] [Indexed: 11/16/2022]
Abstract
This is an overview of recent findings, mainly from our laboratory, describing the cardiovascular functional phenotypes and pharmacological responses in mice genetically deficient in apolipoprotein E (apoE-KO). ApoE-KO mice are hyperlipidemic and spontaneously develop atherosclerosis. We have detected several new cardiovascular functional phenotypes in apoE-KO mice: hyperglycemia, age-dependent aortic stiffening, cardiac hypertrophy and increased cardiac output. Angiotensin II (Ang II) promoted vascular inflammation and atherosclerosis, increased vascular stiffness, and induced abdominal aortic aneurysm (AAA) in apoE-KO mice, in which activation of NF-kappaB mediated pro-inflammatory genes plays an important role. Inhibition of nitric oxide (NO) synthesis with N(omega)-nitro-L-arginine methyl ester (L-NAME) significantly inhibited NO-mediated vascular responses and accelerated atherosclerosis in apoE-KO mice, supporting a protective role of NO against atherosclerosis. Estrogen attenuated atherosclerosis in apoE-KO mice, even in those with atherosclerosis being accelerated by Ang II, hyperglycemia, or L-NAME, demonstrating an anti-atherosclerotic effect of estrogen. Simvastatin paradoxically increased lipid and atherosclerosis in apoE-KO mice, but it decreased lipid and atherosclerosis in LDLR-KO mice, indicating that anti-atherosclerotic effect of simvastatin requires the presence of an intact apoE.
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Affiliation(s)
- Yi-Xin Wang
- Department of Pharmacology, Berlex Biosciences, P.O. Box 4099, 2600 Hilltop Drive, Richmond, CA 94804-0099, USA.
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89
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90
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Linde J, Strauss BH. Pharmacological treatment for prevention of restenosis. Expert Opin Emerg Drugs 2005; 6:281-302. [PMID: 15989527 DOI: 10.1517/14728214.6.2.281] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coronary artery disease (CAD) is the leading cause of mortality and morbidity among adults in the Western world. Coronary artery bypass grafting and percutaneous coronary interventions (PCI) have gained widespread acceptance for the treatment of symptomatic CAD. There has been an explosive growth worldwide in the utilisation of PCI, such as balloon angioplasty and stenting, which now accounts for over 50% of coronary revascularisation. Despite the popularity of PCI, the problem of recurrent narrowing of the dilated artery (restenosis) continues to vex investigators. In recent years, significant advances have occurred in the understanding of restenosis. Two processes seem to contribute to restenosis: remodelling (vessel size changes) and intimal hyperplasia (vascular smooth muscle cell [VSMC] proliferation and extracellular matrix [ECM] deposition). Despite considerable efforts, pharmacological approaches to decrease restenosis have been largely unsuccessful and the only currently applied modality to reduce the restenosis rate is stenting. However, stenting only prevents remodelling and does not inhibit intimal hyperplasia. Several potential targets for inhibiting restenosis are currently under investigation including platelet activation, the coagulation cascade, VSMC proliferation and migration, and ECM synthesis. In addition, new approaches for local drug therapy, such as drug eluting stents, are currently being evaluated in preclinical and clinical studies. In this article, we critically review the current status of drugs that are being evaluated for restenosis at various stages of development (in vitro, preclinical animal models and human trials).
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Affiliation(s)
- J Linde
- The Roy and Ann Foss Interventional Cardiology Research Program, Terrence Donnelly Heart Center, 30 Bond Street, St. Michael's Hospital, Toronto, Ontario, M5B 1W8, Canada
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91
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LaDisa JF, Olson LE, Molthen RC, Hettrick DA, Pratt PF, Hardel MD, Kersten JR, Warltier DC, Pagel PS. Alterations in wall shear stress predict sites of neointimal hyperplasia after stent implantation in rabbit iliac arteries. Am J Physiol Heart Circ Physiol 2005; 288:H2465-75. [PMID: 15653759 DOI: 10.1152/ajpheart.01107.2004] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Restenosis resulting from neointimal hyperplasia (NH) limits the effectiveness of intravascular stents. Rates of restenosis vary with stent geometry, but whether stents affect spatial and temporal distributions of wall shear stress (WSS) in vivo is unknown. We tested the hypothesis that alterations in spatial WSS after stent implantation predict sites of NH in rabbit iliac arteries. Antegrade iliac artery stent implantation was performed under angiography, and blood flow was measured before casting 14 or 21 days after implantation. Iliac artery blood flow domains were obtained from three-dimensional microfocal X-ray computed tomography imaging and reconstruction of the arterial casts. Indexes of WSS were determined using three-dimensional computational fluid dynamics. Vascular histology was unchanged proximal and distal to the stent. Time-dependent NH was localized within the stented region and was greatest in regions exposed to low WSS and acute elevations in spatial WSS gradients. The lowest values of WSS spatially localized to the stented area of a theoretical artery progressively increased after 14 and 21 days as NH occurred within these regions. This NH abolished spatial disparity in distributions of WSS. The results suggest that stents may introduce spatial alterations in WSS that modulate NH in vivo.
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Affiliation(s)
- John F LaDisa
- Department of Pediatric Cardiology, Stanford University, Stanford, California, USA
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92
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Drachman DE, Simon DI. Inflammation as a mechanism and therapeutic target for in-stent restenosis. Curr Atheroscler Rep 2005; 7:44-9. [PMID: 15683602 DOI: 10.1007/s11883-005-0074-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Restenosis following coronary stenting has long been attributed to neointimal proliferation, thrombosis, and negative remodeling. More recently, the important role of inflammation in vascular healing has also been increasingly well understood. From animal models and from clinical experience, we know that endothelial injury, platelet and leukocyte interactions, and subcellular chemoattractant and inflammatory mediators are pivotal in the development of the inflammatory response following stent implantation. By examining the specific mechanisms governing the inflammatory response to percutaneous coronary intervention, we may gain insight into potential therapeutic targets and strategies to prevent restenosis in clinical practice.
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Affiliation(s)
- Douglas E Drachman
- Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA.
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93
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Mehilli J, Kastrati A, Schühlen H, Dibra A, Dotzer F, von Beckerath N, Bollwein H, Pache J, Dirschinger J, Berger PP, Schömig A. Randomized Clinical Trial of Abciximab in Diabetic Patients Undergoing Elective Percutaneous Coronary Interventions After Treatment With a High Loading Dose of Clopidogrel. Circulation 2004; 110:3627-35. [PMID: 15531766 DOI: 10.1161/01.cir.0000148956.93631.4d] [Citation(s) in RCA: 239] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diabetic patients are at increased risk of adverse outcomes after percutaneous coronary interventions. Although subset analyses suggest particular benefit from the administration of abciximab in diabetic patients, no dedicated large randomized trials have been performed in diabetic patients undergoing percutaneous coronary intervention, and certainly not after pretreatment with a high loading dose of clopidogrel. METHODS AND RESULTS This study (Intracoronary Stenting and Antithrombotic Regimen: Is Abciximab a Superior Way to Eliminate Elevated Thrombotic Risk in Diabetics [ISAR-SWEET] Study) enrolled 701 diabetic patients with coronary artery disease who underwent an elective percutaneous coronary intervention after pretreatment with a 600-mg dose of clopidogrel >2 hours before the procedure: 351 patients were randomly assigned to abciximab and 350 patients to placebo. The primary end point of the trial was the composite incidence of death and myocardial infarction at 1 year. The frequency of angiographic restenosis (diameter stenosis > or =50%) was the secondary end point. The incidence of death or myocardial infarction was 8.3% in the abciximab group and 8.6% in the placebo group (P=0.91), with a relative risk of 0.97 (95% CI, 0.58 to 1.62). The incidence of angiographic restenosis was 28.9% in the abciximab group and 37.8% in the placebo group (P=0.01), with a relative risk of 0.76 (95% CI, 0.62 to 0.94). The incidence of target lesion revascularization was 23.2% in the abciximab group and 30.4% in the placebo group (P=0.03). CONCLUSIONS The findings of this study do not support a significant impact of abciximab on the risk of death and myocardial infarction in diabetic patients undergoing percutaneous coronary interventions after pretreatment with a 600-mg loading dose of clopidogrel at least 2 hours before the procedure. The present findings suggest, however, that abciximab reduces the risk of restenosis in diabetic patients receiving coronary bare metal stents.
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Affiliation(s)
- Julinda Mehilli
- Deutsches Herzzentrum, Lazarettstrasse 36, 80636 Munich, Germany
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94
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Nührenberg TG, Voisard R, Fahlisch F, Rudelius M, Braun J, Gschwend J, Kountides M, Herter T, Baur R, Hombach V, Baeuerle PA, Zohlnhöfer D. Rapamycin attenuates vascular wall inflammation and progenitor cell promoters after angioplasty. FASEB J 2004; 19:246-8. [PMID: 15546959 DOI: 10.1096/fj.04-2431fje] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Rapamycin combines antiproliferative and antiinflammatory properties and reduces neointima formation after angioplasty in patients. Its effect on transcriptional programs governing neointima formation has not yet been investigated. Here, we systematically analyzed the effect of rapamycin on gene expression during neointima formation in a human organ culture model. After angioplasty, renal artery segments were cultured for 21 or 56 days in absence or presence of 100 ng/ml rapamycin. Gene expression analysis of 2312 genes revealed 264 regulated genes with a peak alteration after 21 days. Many of those were associated with recruitment of blood cells and inflammatory reactions of the vessel wall. Likewise, chemokines and cytokines such as M-CSF, IL-1beta, IL-8, beta-thromboglobulin, and EMAP-II were found up-regulated in response to vessel injury. Markers indicative for a facilitated recruitment and stimulation of hematopoetic progenitor cells (HPC), including BST-1 and SDF-1, were also induced. In this setting, rapamycin suppressed the coordinated proadhesive and proinflammatory gene expression pattern next to down-regulation of genes related to metabolism, proliferation, and apoptosis. Our study shows that mechanical injury leads to induction of a proinflammatory, proadhesive gene expression pattern in the vessel wall even in absence of leukocytes. These molecular events could provide a basis for the recruitment of leukocytes and HPC. By inhibiting the expression of such genes, rapamycin may lead to a reduced recruitment of leukocytes and HPC after vascular injury, an effect that may play a decisive role for its effectiveness in reducing restenosis.
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MESH Headings
- Aged
- Angioplasty, Balloon/adverse effects
- Apoptosis/genetics
- Cell Proliferation/drug effects
- Cluster Analysis
- Down-Regulation/drug effects
- Endothelium, Vascular/chemistry
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/metabolism
- Endothelium, Vascular/pathology
- Extracellular Matrix/genetics
- Female
- Gene Expression Profiling/methods
- Gene Expression Profiling/statistics & numerical data
- Gene Expression Regulation/drug effects
- Gene Expression Regulation/genetics
- Graft Occlusion, Vascular/genetics
- Graft Occlusion, Vascular/pathology
- Graft Occlusion, Vascular/prevention & control
- Humans
- Immunohistochemistry/methods
- Inflammation/genetics
- Inflammation/prevention & control
- Male
- Neovascularization, Pathologic/drug therapy
- Neovascularization, Pathologic/genetics
- Oligonucleotide Array Sequence Analysis/methods
- Oligonucleotide Array Sequence Analysis/statistics & numerical data
- Organ Culture Techniques/methods
- Renal Artery/chemistry
- Renal Artery/drug effects
- Renal Artery/metabolism
- Renal Artery/pathology
- Sirolimus/pharmacology
- Sirolimus/therapeutic use
- Stem Cells
- Stents
- Time
- Tissue Adhesions/genetics
- Transcription, Genetic/drug effects
- Transcription, Genetic/genetics
- Tunica Intima/metabolism
- beta-Thromboglobulin/biosynthesis
- beta-Thromboglobulin/immunology
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95
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Liu X, De Scheerder I, Desmet W. Dexamethasone-eluting stent: an anti-inflammatory approach to inhibit coronary restenosis. Expert Rev Cardiovasc Ther 2004; 2:653-60. [PMID: 15350167 DOI: 10.1586/14779072.2.5.653] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The long-term efficacy of percutaneous coronary interventions is still hampered by restenosis. Restenosis is the result of a complex pathophysiological process, which is thought to be caused by an exaggerated healing response induced by the vascular injury caused by the percutaneous coronary interventions and the implantation of a foreign body (the stent). There is increasing evidence that inflammation plays an important role in the initiation and development of neointimal hyperplasia and subsequent restenosis. Dexamethasone (Decadron, Merck Sharpe and Dohme Ltd) is a glucocorticoid with well-known potent anti-inflammatory and antiproliferative properties. Early studies using either systemic or local delivery of dexamethasone have shown limited beneficial effects on restenosis. The dexamethasone-eluting stent (Dexamet, Abbott Vascular Devices Ltd) is one of the first generation of drug-eluting stents for local drug delivery to prevent restenosis. Preclinical studies demonstrated that implantation of dexamethasone-loaded coronary stents was safe and had a beneficial effect on stent implantation-related inflammation. A pilot trial suggested a beneficial effect on restenosis. Large randomized trials are underway to confirm these findings. This article reviews the potential role of inflammation in the pathogenesis of restenosis and the efficacy of dexamethasone in the prevention of restenosis.
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Affiliation(s)
- Xiaoshun Liu
- Cardiac Catheterization Laboratory, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
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96
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Preclinical restenosis models and drug-eluting stents: still important, still much to learn. J Am Coll Cardiol 2004; 44:1373-85. [PMID: 15464316 DOI: 10.1016/j.jacc.2004.04.060] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2004] [Revised: 03/28/2004] [Accepted: 04/06/2004] [Indexed: 11/30/2022]
Abstract
Percutaneous coronary intervention continues to revolutionize the treatment of coronary atherosclerosis. Restenosis remains a significant problem but may at last be yielding to technologic advances. The examination of neointimal hyperplasia in injured animal artery models has helped in our understanding of angioplasty and stenting mechanisms, and as drug-eluting stent (DES) technologies have arrived, they too have been advanced through the study of animal models. These models are useful for predicting adverse clinical outcomes in patients with DESs because suboptimal animal model studies typically lead to problematic human trials. Similarly, stent thrombosis in animal models suggests stent thrombogenicity in human patients. Equivocal animal model results at six or nine months occasionally have been mirrored by excellent clinical outcomes in patients. The causes of such disparities are unclear but may result from differing methods, including less injury severity than originally described in the models. Ongoing research into animal models will reconcile apparent differences with clinical trials and advance our understanding of how to apply animal models to clinical stenting in the era of DESs.
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97
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Cilostazol inhibits leukocyte integrin Mac-1, leading to a potential reduction in restenosis after coronary stent implantation. J Am Coll Cardiol 2004; 44:1408-14. [PMID: 15464320 DOI: 10.1016/j.jacc.2004.06.066] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Revised: 06/23/2004] [Accepted: 06/29/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The aim of this study was to confirm clinically a hypothesis that cilostazol inhibits leukocyte Mac-1, leading to prevention of post-stent restenosis. BACKGROUND The platelet phosphodiesterase III inhibitor called cilostazol also inhibits alpha-granule release of P-selectin in platelets. The P-selectin-mediated platelet-leukocyte interaction promotes activation and upregulation of leukocyte Mac-1 after coronary stenting, which plays a key role on the mechanism of restenosis. Thus, cilostazol's potential inhibition of this process may lead to prevention of restenosis. METHODS Using flow cytometric analysis of whole blood obtained from the coronary sinus, the expression of platelet membrane glycoproteins and neutrophil adhesion molecules was observed in 70 consecutive patients undergoing coronary stenting. The patients were randomly assigned to either a cilostazol or ticlopidine group before stent placement. RESULTS The restenosis rate was lower (15% vs. 31%, p < 0.05) in the cilostazol group (n = 34) than in the ticlopidine group (n = 32). A stent-induced increase in platelet P-selectin (CD62P) expression and an increase in neutrophil Mac-1 (CD11b) expression were suppressed in the cilostazol group compared with the ticlopidine group. Angiographic late lumen loss was correlated with the relative changes in platelet P-selectin and neutrophil Mac-1 at 48 h after coronary stenting. CONCLUSIONS Cilostazol may have effects on suppression of P-selectin-mediated platelet activation, platelet-leukocyte interaction, and subsequent Mac-1-mediated leukocyte activation, which might lead to a reduced restenosis rate after coronary stent implantation.
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98
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Lee MS, David EM, Makkar RR, Wilentz JR. Molecular and cellular basis of restenosis after percutaneous coronary intervention: the intertwining roles of platelets, leukocytes, and the coagulation-fibrinolysis system. J Pathol 2004; 203:861-70. [PMID: 15258987 DOI: 10.1002/path.1598] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The major limitation of percutaneous coronary intervention (PCI) is restenosis. Restenosis is considered to be an overreaction of the natural healing process after traumatic balloon dilatation. An elaborate web of cellular and molecular responses, including the interaction of platelets, leukocytes, and the coagulation-fibrinolysis system, as well as the secretion of various growth factors and pro-inflammatory cytokines, contributes to neointimal hyperplasia and the development of restenosis. Moreover, platelet and neutrophil activation after stenting appears to be different from that after balloon angioplasty alone. Pharmacotherapy targeting the cell-to-cell interaction between platelets and neutrophils may potentially offer an effective treatment strategy against restenosis after PCI.
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Affiliation(s)
- Michael S Lee
- Cedars-Sinai Medical Center, UCLA School of Medicine, Cardiovascular Intervention Center, Los Angeles, California, USA.
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99
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Ohtani K, Usui M, Nakano K, Kohjimoto Y, Kitajima S, Hirouchi Y, Li XH, Kitamoto S, Takeshita A, Egashira K. Antimonocyte chemoattractant protein-1 gene therapy reduces experimental in-stent restenosis in hypercholesterolemic rabbits and monkeys. Gene Ther 2004; 11:1273-82. [PMID: 15175640 DOI: 10.1038/sj.gt.3302288] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In-stent restenosis results exclusively from neointimal hyperplasia due to mechanical injury and a foreign body response to the prosthesis. Inflammation mediated by monocyte chemoattractant protein-1 (MCP-1) might therefore underlie in-stent restenosis. We recently devised a new strategy for anti-MCP-1 gene therapy by transfecting an N-terminal deletion mutant of the MCP-1 gene into skeletal muscles. We used this strategy to investigate the role of MCP-1 in experimental in-stent restenosis in hypercholesterolemic rabbits and monkeys. Transfection of the mutant MCP-1 gene suppressed monocyte infiltration/activation in the stented arterial wall and markedly reduced the development of neointimal hyperplasia. This strategy also suppressed local expression of MCP-1 and inflammatory cytokines. Therefore, inhibition of MCP-1-mediated inflammation is effective in reducing experimental in-stent restenosis. This strategy might be a useful form of gene therapy against human in-stent restenosis.
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Affiliation(s)
- K Ohtani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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100
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Mazighi M, Gouëffic Y, Scheuble A, Feldman LJ. [Prevention of in-stent restenosis: towards an in situ treatment?]. Med Sci (Paris) 2004; 20:98-104. [PMID: 14770371 DOI: 10.1051/medsci/200420198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The use of intracoronary stents represent a major breakthrough in the armamentarium of interventional cardiology. Stents reduce significantly the incidence of recurrent stenosis (in-stent restenosis) via an improved post-procedure luminal diameter and an abrogation of the constrictive remodeling of the arterial wall. However, stent-related arterial injury results in intense proliferative and inflammatory responses and severe intimal hyperplasia, which, in 20% to 40% of the patients, may end up with clinically significant in-stent restenosis. Efficient prevention of in-stent restenosis has yet to be found. Systemic treatments have failed because they don't take into account the specific physiopathology and, most importantly, the focal nature of in-stent intimal hyperplasia. Hence, local prevention appears to be a straightforward approach to the unsolved issue of in-stent restenosis. In situ beta- or gamma-irradiation (brachytherapy) has received much attention as a curative treatment of in-stent restenosis but is not indicated for prevention. In contrast, drug-releasing stents have been tested in experimental models and have already provided very promising results in randomized clinical trials. Most of clinical studies have been performed with the antiproliferative agents sirolimus and paclitaxel, but other agents are under scrutiny. In addition, important research is carried out, in which the efficacy of antiproliferative genes is investigated. Clearly, drug-releasing stents are on the verge of profoundly modifying our practice of interventional cardiology. However, several questions remain unanswered as regard to the long term efficacy/toxicity and the cost-effectiveness of this new approach.
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Affiliation(s)
- Mikaël Mazighi
- Service de Cardiologie et Inserm U.460, Hôpital Bichat, 46, rue Henri Huchard, 75018 Paris, France
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