No delayed restenosis at 18 months after implantation of sirolimus-eluting stent

Influence of sirolimus-loaded nanoparticles on physiological functions of native human polymorphonuclear neutrophils

Sirolimus (SRL) is an immunosuppressive agent of high clinical relevance that has been associated with serious side effects. Biodegradable, SRL-loaded poly(d,l-lactide) nanoparticles (SRL-PLA-NPs) are being investigated as a drug delivery system to improve drug targeting. Polymorphonuclear neutrophils (PMNs) are phagocytes for particulate xenobiotics and also important trigger cells of the primary immune response. Therefore, the effects of SRL, SRL-PLA-NPs, and plain PLA-NPs on the viability of human PMNs, their essential functions, and the secretion of relevant cytokines were determined and evaluated with respect to the intracellular concentrations assessed by liquid chromatography-mass spectrometry ultra-trace analysis. For the first time to our knowledge, incorporation of NPs into PMNs was monitored by flow cytometry using fluorescence-labeled NPs. SRL accumulated intracellularly, exceeding therapeutic blood levels by a factor of two to four. Phagocytic activity was promptly reduced but recovered within 3 hours. No other parameters of the PMNs were affected. Hence, PLA-NPs appear suitable as drug carriers for SRL, allowing for better control of drug release.

FROM THE CLINICAL EDITOR

This team of authors describe the incorporation of sirolimus loaded florescent NPs into polymorphonuclear neutrophils, a process that has been monitored by flow cytometry utilizing the fluorescent properties of the polymeric NPs. SRL accumulated intracellularly, exceeding therapeutic blood levels by a factor of two to four, resulting in reduced phagocytic activity that recovered within 3 hours.

Inhibition of peptidyl-prolyl cis/trans isomerase Pin1 induces cell cycle arrest and apoptosis in vascular smooth muscle cells

This study was undertaken to determine the in vitro effect of lentivirus-mediated siPin1 on cell cycle and apoptosis of vascular smooth muscle cells (VSMCs). Further we sought to provide insight into the mechanisms behind these processes. Human umbilical artery smooth muscle cells (HUASMCs) were transfected with lentiviral siPin1. Real-time RT-PCR and Western blotting were used to examine Pin1 mRNA and protein expression. MTT and [(3)H]thymidine incorporation assays were employed to observe cell proliferation status. The apoptotic rate and cell cycle were analyzed by Hoechst33258 staining and flow cytometry. Finally we measured the expression of cyclin D1, beta-catenin, CDK4, cytochrome c, procaspase-3, cleaved caspase-3, procaspase-9, cleaved caspase-9, Bcl-2, Bax, STAT3, phosphorylated STAT3 and VEGF in lentiviral siPin1 infected VSMCs. Lentivirus-mediated siPin1 effectively diminished endogenous Pin1 expression in VSMCs resulting in cell cycle arrest and enhancement of apoptosis. This was accompanied by downregulation of cyclin D1, beta-catenin, CDK4, increase of Bax/Bcl-2 ratio, release of cytochrome c, and activation of caspase-3 and -9. We concluded that this effect was mediated, at least in part, via the beta-catenin/cyclin D1/CDK4 cascade, and that the mitochondrial pathway was responsible for VSMC apoptosis in the absence of Pin1. Our observations raised the possibility that Pin1 might be a potential therapeutic target to prevent stenosis.

Update on drug-eluting stents for prevention of restenosis

Despite the success of coronary stent implantations in the last decade, in-stent restenosis due to neointimal hyperplasia remains a problem to overcome. Neointimal hyperplasia is a vascular response to stent injury and mainly consists of proliferation of smooth muscle cells and deposition of extracellular matrix. Recently, local drug delivery has been advocated as a potential strategy to prevent in-stent restenosis. Unprecedented results have been obtained in early clinical studies on sirolimus-eluting and paclitaxel-eluting stents. Trials using various pharmaceutical coatings on different coronary stents are ongoing. More types of drug-eluting stents are expected on the market in the near future. Meanwhile, the evaluation of drug-eluting stents is entering the second phase in which the safety and efficacy in more complex lesion subsets and different clinical presentations are being investigated. Results including cost-benefit analyses are expected to have a tremendous impact on the practice of interventional cardiology in the next decade.

Estrogen-eluting stent implantation inhibits neointimal formation and extracellular signal-regulated kinase activation

OBJECTIVES

The goal of this study was to evaluate the efficacy and the mechanism of 17beta-estradiol-eluting stents on inhibiting neointimal formation of abdominal aortas in rabbits fed with high fat diet.

BACKGROUND

Animal experiments have shown that local delivery of estrogen reduced neointimal formation after coronary angioplasty. Preliminary trial of estrogen-eluting stent implantation in patients with coronary disease also suggests a reduction in restenosis.

METHODS

We implanted 17beta-estradiol-eluting stents, or control phosphorylcholine- coated stents, or bare metal stents of abdominal aortas in rabbits fed with high fat diet. Histology, immunohistochemistry, and Western blot analysis were used to assess the efficacy and mechanism of inhibiting neointimal formation of 17beta-estradiol-eluting stents.

RESULTS

Western blot analysis revealed marked increase in ERK phosphorylation in 30 min after deployment of phosphorylcholine-coated or bare metal stents, indicating activation of MAP kinase pathway. Immunohistochemistry showed intense staining of phospho-ERK in the medial smooth muscle cells in stent-implanted region. Extensive neointimal hyperplasia developed 12 weeks after stenting. In contrast, we observed significant inhibition of ERK phosphorylation and neointimal thickening in estrogen-eluting stent-implanted animals. Immunohistochemistry of factor VIII-related antigen demonstrated an accelerated reendothelialization as compared with the bare metal stent or phosphorylcholine-coated stent-implanted controls.

CONCLUSIONS

Current study suggests that estrogen-eluting stents reduce neointimal formation and hence prevent restenosis after angioplasty possibly by inhibiting ERK activation in smooth muscle cells and promoting reendothelialization.

Release of anti-restenosis drugs from poly(ethylene oxide)-poly(DL-lactic-co-glycolic acid) nanoparticles

Dexamethasone- or rapamycin-loaded nanoparticles based on poly(ethylene oxide) and poly(dl-lactic-co-glycolic acid) block copolymers (PEO-PLGA) were prepared without additional stabilizer using the salting-out method. A fast release of drug in PBS (pH 7.4) at 37 degrees C resulting in 100% release within 5 h was observed for both drugs. The rate of drug release was substantially reduced by treating the particles with gelatin or albumin after drug loading, resulting in a linear drug release in time. It was shown that the rate of drug release is related to the amount of protein associated with the nanoparticles. After gelatin treatment of drug-loaded nanoparticles, sustained release of dexamethasone for 17 days and of rapamycin for 50 days could be achieved.

Adenovirus-Mediated Intraarterial Delivery of PTEN Inhibits Neointimal Hyperplasia

Objective— Phosphoinositide (PI) 3-kinase promotes vascular smooth muscle cell (VSMC) responses necessary for neointimal hyperplasia. We recently demonstrated that the inositol 3-phosphatase PTEN is expressed in VSMCs and that its overexpression inhibits these cellular responses. The purpose of this study was to determine the effects of adenovirus-mediated overexpression of PTEN on neointimal hyperplasia in vivo in the rat carotid injury model.

Methods and Results— Rat carotid arteries were balloon-injured and treated with a recombinant control adenovirus (AdEV) (n=6), an adenovirus encoding wild-type PTEN (AdPTEN) (n=8), or phosphate-buffered saline (sham) (n=5). Injured vessels demonstrated PTEN overexpression by Western blotting and immunohistochemistry after AdPTEN treatment. Neointimal hyperplasia was assessed 2 weeks after balloon injury and adenovirus administration. Compared with controls, AdPTEN treatment significantly decreased neointimal area and percent stenosis. To investigate the mechanisms of action of AdPTEN, vessels were harvested 3 days after balloon injury and virus infection. AdPTEN significantly increased medial cell apoptosis while decreasing proliferation of the remaining viable cells.

Conclusions— PTEN overexpression potently inhibits neointimal hyperplasia through induction of apoptosis and inhibition of medial cell proliferation. These findings suggest that modulation of PTEN expression or activity may be a viable approach to treat neointimal hyperplasia.

Impact trial: Angiographic and intravascular ultrasound observations of the first human experience with mycophenolic acid-eluting polymer stent system

The purpose of the study was to examine the safety and efficacy of two different formulations of mycophenolic acid (MPA)-eluting Duraflex stents on coronary de novo lesions. Recent data indicate that local delivery of MPA in the porcine overstretch coronary model significantly reduces neointimal hyperplasia (NIH). Patients were divided into three consecutive groups. The first (n=50) and second (n=55) groups received moderate- and slow-release MPA-eluting Duraflex stent, respectively. The last group (n=50) received the bare metal Duraflex stent. Clinical, angiographic, and intravascular ultrasound analysis were performed at 6-month follow-up. All stents were successfully deployed and patients were discharged home without clinical events. Compared to controls, 6-month in-lesion and in-stent minimum luminal diameter as well as late lumen loss were not significantly different in the moderate- and slow-release treatment groups. At follow-up, percentage obstruction and NIH volume were also similar between the three groups. At 30 days and 6 and 12 months, there were no differences noted between the three groups with respect to major adverse cardiac events as well as the individual rates of mortality, myocardial infarction, or repeat revascularization. There were no cases of subacute or late thrombosis. In this feasibility trial, the MPA-eluting Duraflex stents in either slow- or moderate-release formulations were well tolerated, but showed no benefit for treatment of coronary lesions when compared to controls. Further testing with different drug dosing or delivery rate might improve these results.

First human experience with the 17-beta-estradiol–eluting stent

OBJECTIVES

The purpose of the study was to examine the safety and efficacy of 17-beta-estradiol-eluting stent implantation on coronary de novo lesions.

BACKGROUND

Recent animal data indicate that local delivery of 17-beta-estradiol promotes re-endothelialization, inhibits cell migration and proliferation, and prevents restenosis.

METHODS

A total of 30 consecutive patients underwent 17-beta-estradiol-eluting BiodVysio (Biocompatibles Ltd., London, United Kingdom) stent implantation for the treatment of coronary de novo lesions. Clinical, angiographic, and intravascular ultrasound (IVUS) analysis was performed at six-month follow-up.

RESULTS

All stents were successfully deployed and patients were discharged home without clinical events. A total of two patients exceeded 50% intra-stent narrowing by angiography, whereas no patients experienced edge restenosis. One patient had focal intra-stent restenosis (60% diameter stenosis) with no symptoms and negative stress test, whereas the other patient had diffuse restenosis, requiring target vessel revascularization. No other patient experienced any major adverse cardiac event. Follow-up IVUS revealed a neointimal hyperplasia volume of 32.3 +/- 16.4 mm(3), whereas the stent volume was 143.7 +/- 43.7 mm(3), resulting in a neointimal volume obstruction of 23.5 +/- 12.5%. None of the patients had > or =50% volume obstruction by IVUS.

CONCLUSIONS

Implantation of 17-beta-estradiol-eluted BiodVysio stents appears feasible and safe, showing low rates of binary restenosis and revascularization. These results warrant further confirmation with a large, randomized multicenter trial.