Injury and repair of smaller muscular and elastic arteries. A light microscopical study on the different healing patterns of rabbit femoral and carotid arteries following dilatation injuries by a balloon catheter

FX MiniRAILtm Catheter Usage for Treatment of De Novo Complex Coronary Lesions: Results from the "OFFAR"

INTRODUCTION

Gradual prolonged balloon angioplasty may cause less arterial trauma, higher success rates, and fewer complications than conventional angioplasty (POBA). The OFFAR aimed to determine the safety and effectiveness of the FX MiniRAIL (FX) catheter, used with a slow, stepwise inflation protocol.

METHODS AND RESULTS

From June to December 2003, 181 consecutive patients (age 61.9 +/- 10.6 years) with de novo coronary artery lesions (n = 217) were treated by FX and stent implantation in 11 European centers. Fifty-one patients (28.2%) had diabetes, and 70 (38.7%) had prior MI; 73 patients (40.3%) presented with stable angina and 85 (47.0%) with unstable angina. Fifty-five lesions (25.3%) were in small vessels (<2.5 mm), 40 (18.6%) were highly calcific, and 133 (62%) were long lesions (>18 mm). Stenosis resolution pressure was 7.17 +/- 4.2 atm; inflation time was 116.5 +/- 54.6 seconds. FX technical success (residual stenosis <50% post-FX) was obtained in 191 lesions (88.0%), and FX optimal success (residual stenosis <20% post-FX) in 117 (54.9%). Dissection was observed in 34 lesions (15.9%), 27 (79.3%) of which were type A or B. No coronary ruptures occurred. Nine (5.0%) in-hospital events occurred, all non-Q-wave MI. During 6-month follow-up, major adverse clinical events occurred in 14.4% of cases (n = 26; 3 cardiac deaths, 1 Q-wave MI, 2 non-Q-wave MI, 3 CABG, and 17 re-PTCA).

CONCLUSION

The results of the OFFAR suggest that FX utilization for treatment of de novo complex coronary lesions is safe and effective.

Intermittent short-duration exposure to low wall shear stress induces intimal thickening in arteries exposed to chronic high shear stress

We sought to determine whether intermittent short-duration exposure to low wall shear stress could induce intimal thickening in arteries chronically exposed to high shear stress. An arteriovenous fistula (AVF) was created between the left common carotid artery and the corresponding external jugular vein in 20 Japanese white male rabbits. After 4 weeks, blood flow was increased 10-fold to 182 +/- 39 ml/min and shear stress was increased to 33.4 +/- 13 dyn/cm(2). The AVF was then occluded for 1 h by finger compression with an 85% reduction in carotid artery blood flow (27 +/- 7 ml/min) and a reduction in wall shear stress to 4.9 +/- 1.7 dyn/cm(2) (P < 0.0001). Release of finger compression restored flow to the AVF and high shear stress to the carotid artery. This procedure was repeated at weekly intervals with a cumulative total of 4 h of low shear stress exposure. Arteries exposed to intermittent low shear stress developed a layer of intimal thickening which consisted of 3-4 layers of smooth muscle cells lined with thin elastic fibers and medial hyperplasia. Control arteries exposed to 8 weeks of continuous high shear had no intimal thickening. Transient exposure to low shear stress upregulated TGF-beta1, MMP-2, -14, and TIMP-2 gene expression while MMP-9 expression was downregulated. We conclude that repeated, intermittent short-duration exposure to low shear stress in the setting of high flow and high shear stress can induce arterial intimal thickening. Short-duration alterations in hemodynamic forces can induce rapid vascular cell message expression, which may effect arterial remodeling. This experiment suggests that a threshold value of 5 dyn/cm(2) may be needed in order to initiate and sustain the intimal thickening response.

Antisense oligodeoxyribonucleotide as to the growth factor midkine suppresses neointima formation induced by balloon injury

Restenosis is the major clinical problem of angioplasty. We have previously shown that neointima formation is strikingly suppressed in midkine (MK)-deficient mice. Neointima formation is restored if MK protein is administrated to the deficient mice. MK is a heparin-binding growth factor and implicated in the migration of inflammatory cells and vascular smooth muscle cells. Consistently, the suppression of neointima formation in the deficient mice is accompanied by suppression of recruitment of inflammatory cells into the vascular wall. Here, we evaluated the potential of MK antisense oligodeoxyribonucleotide (ODN) for the prevention of restenosis. We cloned the cDNA of rabbit MK, which showed a strongly conserved sequence in mammals. The balloon injury induced MK expression, with the maximum level occurring 7-14 days after angioplasty, in the rabbit carotid artery. Two antisense ODNs suppressed the production of MK in a rabbit kidney cell line, RK13 cells, one of which was then transfected into the arterial wall by means of lipofection immediately after balloon treatment. The antisense ODN suppressed MK induction in vivo and consequently suppressed neointima formation to 60% of the control level. These results suggest that MK is a candidate molecular target for the therapy for vascular restenosis.

Prevention of intimal hyperplasia by irradiation. An experimental study in rabbits

PURPOSE

This experimental study was designed to investigate the effect of irradiation in prevention of intimal hyperplasia.

MATERIAL AND METHODS

Twenty rabbits were divided into 4 groups, which were irradiated with 2, 5, 10 and 20 Gy, respectively. The intima of both femoral arteries was injured by air-drying, and irradiation was performed on the unilateral side. The contralateral+ femoral artery served as a control. Angiograms as well as histologic specimens were obtained 1 month later.

RESULTS

Marked intimal hyperplasia was observed in all control sites. There were no significant differences in thickness of intimal hyperplasia between irradiated and control sites in groups irradiated with 2 and 5 Gy. However, in the 10-Gy- and 20-Gy-irradiated groups, intimal hyperplasia of the irradiated site was significantly suppressed. Medial thinning and dilation of the lumen were observed in the 20-Gy-irradiated group.

CONCLUSION

Radiation may prevent intimal hyperplasia. Further investigation of the optimal dose, timing of irradiation, and long-term patency of irradiated vessels may be needed.

Immunological studies in giant cell arteritis

The results of investigations on the humoral immunological mechanisms are conflicting in giant cell arteritis (GCA) and have not been able to explain the pathological findings in the inflamed arterial wall. Altogether, immunological studies suggest that a cell-mediated immune reaction, possibly against an autologous antigen, occurs locally in the arteritic lesions of GCA. The excellent effect of treatment with glucocorticosteroids on the inflammation in GCA can also be explained by this model. The glucocorticosteroids inhibit the synthesis of interleukin-1 (IL-1) by the macrophages and suppress the IL-2 production from the T cells (Palacios, 1982). The observed HLA-DR expression in the arterial wall can be accounted for by the sum of macrophages and activated T cells, the macrophages being the most probable antigen-presenting cells. The interdigitating reticulum cells observed in some of the GCA patients may also be involved in antigen presentation. What the antigen(s) may be is, however, still unknown, as are the factors initiating the inflammatory process. It has recently been possible to extract T lymphocytes from the inflamed tissue and to culture these cells in vitro. After culture, it is possible to study the gene for the T-cell receptor, and probably even the antigenic specificity of the T cells. I hope that this approach may lead to a better understanding of the pathogenic mechanisms in GCA.

Growth factors in pathogenesis of coronary arterial restenosis

Restenosis occurs in 25% to 55% of patients within 6 months of successful angioplasty. The major histologic component of the restenotic lesion is intimal hyperplasia, which is almost certainly driven by growth factors. After vascular injury, smooth muscle cells proliferate, reaching a maximum rate at day 2. Smooth muscle cell proliferation diminishes as the vessel surface is re-endothelialized at about day 7, and by week 4 the smooth muscle cell mitotic rate returns to baseline of less than 1% per day. The events of the histologic evolution of arterial injury can be used to create a hypothetical paradigm for the role of growth factors in restenosis. Restenosis might logically be prevented by an inhibitory intervention at any of the various steps in the healing process.

Early and late arterial healing response to catheter-induced laser, thermal, and mechanical wall damage in the rabbit

Pulsed lasers are being promoted for laser angioplasty because of their capacity to ablate obstructions without producing adjacent thermal tissue injury. The implicit assumption that thermal injury to the artery is to be avoided was tested. Thermal lesions were produced in the iliac arteries and aorta of normal rabbits by a) electrical spark erosion, b) the metal laser probe, and c) continuous wave neodymium-yttrium aluminum garnet (Nd-YAG) laser energy through the sapphire contact probe. High-energy doses were used to induce substantial damage without perforating the vessel wall. Thermal lesions (n = 77) were compared with mechanical lesions (n = 22) induced by oversized balloon dilation. Medial necrosis was induced by all four injury methods. Provided no extravascular contrast was observed after the injury, all damaged segments were patent after 1 to 56 days. The progression of healing with myointimal proliferation was remarkably similar for all injuries. At 56 days, the neointima measured up to 370 microns. In conclusion, provided no perforation with contrast extravasation occurred, the normal rabbit artery recovered well from transmural thermal injury. The wall healing response is largely nonspecific.

Restenosis after coronary angioplasty. Potential biologic determinants and role of intimal hyperplasia

Restenosis after successful PTCA remains a major problem limiting the efficacy of the procedure. The pathophysiologic mechanism of restenosis has been enigmatic so far, but accumulated evidence strongly suggests that intimal hyperplasia is the major mechanism. Based on current understanding of the process of intimal hyperplasia, one unifying concept may be that there are at least two major local biologic determinants influencing this process, lesion characteristics and regional flow dynamics. Lesion characteristics include the plaque structure and the quantity of smooth muscle. These may provide the anatomic substrate that determines the extent of injury and the degree of smooth muscle cell proliferation. The amount of smooth muscle cells in the stenotic lesion activated by injury to undergo proliferation may determine the eventual bulk of the restenotic lesion. In addition, low wall shear stress could promote intimal hyperplasia and cause structural change of vessels to decrease the lumen, whereas high wall shear stress exerts the opposite effects. Intimal hyperplasia after balloon injury is a complex process involving platelets, growth factors, endothelial cells, smooth muscle cells, mechanical injury, wall shear stress, and probably other unknown factors. Platelets not only contribute growth factors such as PDGF but also cause organized thrombus. Different growth factors may be involved in initiating smooth muscle cell proliferation and may come from many different sources, including smooth muscle cells, endothelial cells, and macrophages. Intact confluent endothelial cells may produce heparin sulfates and inhibit intimal proliferation; however, regenerating endothelial cells may have the opposite effect. Thus, the proliferative potential of smooth muscle cells, endothelial recovery, extent of injury, wall shear stress, and other unknown factors may all influence this process. Based on these concepts concerning the biology of restenosis, some research directions concerning potential forms of therapy are proposed.

Injury and repair of smaller muscular and elastic arteries. Immunohistochemical demonstration of fibronectin and fibrinogen/fibrin and their degradation products in rabbit femoral and common carotid arteries following a dilatation injury

Indirect immunoperoxidase staining for fibrinogen/fibrin and fibronectin was performed on normal and healing arterial tissue of muscular and smaller elastic arteries. Fibronectin was observed in the wall of the normal arteries, whereas fibrinogen/fibrin could not be demonstrated. Fibronectin was observed in the intima as well as the media deposited in a similar fashion in the femoral and carotid artery during repair. Apart from the early occurrence of fibrin/fibrinogen in the media of both arteries the distribution of fibrinogen/fibrin and degradation products differed. In the femoral artery a progressively weakening positive reaction for fibrinogen/fibrin and degradation products towards the lumen was observed in the intima and the media 7 and 14 days after the lesion. By 28 days the reaction in the media was negative. No thrombus formation was observed. In contrast, all the specimens examined from the common carotid arteries were obliterated by luminal thrombi 28 days after the lesion. The thrombus as well as the damaged intimal thickening and the compressed media were loaded with fibrinogen/fibrin and degradation products. The deposition of fibronectin, fibrinogen, and degradation products in the carotid artery was similar to that previously reported in experimental aortic arteriosclerosis in rabbits as well as in giant cell arteritis.

Pathogenesis of cardiovascular alterations in dogs treated with minoxidil

Minoxidil and other potent vasodilators cause coronary arterial injury, right atrial hemorrhagic lesions, and subendocardial necrosis in dogs. This paper discusses the pathogenesis of coronary arterial and right atrial lesions associated with minoxidil in the dog. Acute coronary vascular injury characterized by segmental medial hemorrhage and necrosis and perivascular inflammation occurred only during the first few days of treatment, after which tolerance to further acute injury developed. At 30 d or more of treatment, coronary vascular injury was characterized by perivascular fibrosis rarely attended by medial distortion or hyperplasia and subintimal thickening, changes consistent with responses to previous injury. Right atrial hemorrhagic lesions, unlike coronary vascular injury, often became progressively more extensive with continued treatment. At 3 d, atrial hemorrhage and inflammation were confined to the subepicardium of the right atrium, evidently around affected subepicardial branches of the right coronary artery. At 30 d, fibrovascular proliferative right atrial lesions (granulation tissue with evidence of continual hemorrhage) extended from the epicardium to the myocardium, with eventual replacement of the atrial wall by mature connective tissue at 1 yr of treatment. Minoxidil-induced cardiovascular lesions were not prevented by treatment with a beta-blocker (propranolol), or an alpha-blocker (dibenzylene), or by sympathetic neural activity suppression (surgical sympathectomy or constant carotid sinus nerve stimulation), suggesting that the sympathetic response to the pharmacologic activity of minoxidil was not responsible for the induction of the cardiovascular lesions. Minoxidil-related vascular lesions were confined to the most pharmacologically responsive segment of the arterial system, the coronary arteries, suggesting that medial injury may have been associated with tensile changes in the arterial wall.

Effect of monocytopenia on trauma-induced atherosclerotic lesions in the rabbit ear artery

In a trauma model of atherosclerosis (repeated mechanical injury of the rabbit ear artery), rabbits were pretreated either with etoposid (inducing a monocytopenia) or with prednisolone (inhibiting monocyte function) to investigate the role of monocytes in traumatically induced plaque formation. Three weeks after the last injury the arteries were carefully examined. While a profound monocytopenia during the period of injuries did not at all influence the size of the plaque formation, this was almost completely inhibited in the prednisolone-treated rabbits. Obviously, the effect of prednisolone must be attributed to other pharmacological properties. Monocytes appear to be of less importance in purely trauma atherosclerosis models.

Giant-cell arteritis. Histological, immunohistochemical and electronmicroscopic studies

Biopsies from the temporal artery of 32 patients suspected of giant-cell arteritis were evaluated retrospectively by light microscopy, histochemical, and immunohistochemical methods, as well as by transmission electron microscopy (TEM). At the clinical follow-up the 32 patients included four clinical groups: temporal arteritis (8 patients), polymyalgia rheumatica (10 patients), rheumatoid arthritis (4 patients), and a group of miscellaneous diseases unrelated to inflammatory rheumatic diseases (10 patients). There were a number of similarities between age-related alterations in the arteries and the changes in giant-cell arteritis. The most important differences were the inflammatory cellular infiltration of the media, the perifocal accumulation of fibronectin, and the occurrence of deposits of fibrin/fibrinogen and fibrin/fibrinogen degradation products. In addition, alpha-2 macroglobulin, lysozyme and factor VIII were also noted in giant-cell arteritis. The alterations in giant-cell arteritis show a number of similarities to the changes following experimental vascular injury of the rabbit aorta. The nature of the findings in human giant-cell arteritis, as well as the similarity to the experimental arteritis, indicate that giant-cell arteritis may reflect a non-specific reaction to injury, independent of the cause of the disease.