Proliferative heterogeneity of vascular smooth muscle cells and its alteration by injury

Arterial smooth muscle cell heterogeneity: implications for atherosclerosis and restenosis development

During atheromatous plaque formation or restenosis after angioplasty, smooth muscle cells (SMCs) migrate from the media toward the intima, where they proliferate and undergo phenotypic changes. The mechanisms that regulate these phenomena and, in particular, the phenotypic modulation of intimal SMCs have been the subject of numerous studies and much debate during recent years. One view is that any SMCs present in the media could undergo phenotypic modulation. Alternatively, the seminal observation of Benditt and Benditt that human atheromatous plaques have the features of a monoclonal or an oligoclonal lesion has led to the hypothesis that a predisposed, medial SMC subpopulation could play a crucial role in the production of intimal thickening. The presence of a distinct SMC population in the arterial wall implies that under normal conditions, SMCs are phenotypically heterogeneous. The concept of SMC heterogeneity is gaining wider acceptance, as shown by the increasing number of publications on this subject. In this review, we discuss the in vitro studies that demonstrate the presence of distinct SMC subpopulations in arteries of various species, including humans. Their specific features and their regulation will be highlighted. Finally, the relevance of an atheroma-prone phenotype to intimal thickening formation will be discussed.

The mechanisms of coronary restenosis: insights from experimental models

Since its introduction into clinical practice, more than 20 years ago, percutaneous transluminal coronary angioplasty (PTCA) has proven to be an effective, minimally invasive alternative to coronary artery bypass grafting (CABG). During this time there have been great improvements in the design of balloon catheters, operative procedures and adjuvant drug therapy, and this has resulted in low rates of primary failure and short-term complications. However, the potential benefits of angioplasty are diminished by the high rate of recurrent disease. Up to 40% of patients undergoing angioplasty develop clinically significant restenosis within a year of the procedure. Although the deployment of endovascular stents at the time of angioplasty improves the short-term outcome, 'in-stent' stenosis remains an enduring problem. In order to gain an insight into the mechanisms of restenosis, several experimental models of angioplasty have been developed. These have been used together with the tools provided by recent advances in molecular biology and catheter design to investigate restenosis in detail. It is now possible to deliver highly specific molecular antagonists, such as antisense gene sequences, to the site of injury. The knowledge provided by these studies may ultimately lead to novel forms of intervention. The present review is a synopsis of our current understanding of the pathological mechanisms of restenosis.

Differentiated properties and proliferation of arterial smooth muscle cells in culture

The smooth muscle cell is the sole cell type normally found in the media of mammalian arteries. In the adult, it is a terminally differentiated cell that expresses cytoskeletal marker proteins like smooth muscle alpha-actin and smooth muscle myosin heavy chains, and contracts in response to chemical and mechanical stimuli. However, it is able to revert to a proliferative and secretory active state equivalent to that seen during vasculogenesis in the fetus, and this is a prerequisite for the involvement of the smooth muscle cell in the formation of atherosclerotic and restenotic lesions. A similar transition from a contractile to a synthetic phenotype occurs when smooth muscle cells are established in culture. Accordingly, an in vitro system has been used extensively to study the regulation of differentiated properties and proliferation of these cells. During the first few days after seeding, the cells are reorganized structurally with a loss of myofilaments and formation of a widespread endoplasmic reticulum and a prominent Golgi complex. In parallel, they lose their contractility and instead become competent to divide in response to a large variety of mitogens, including platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF). After entering the cell cycle, they start to produce these and other mitogens on their own, and continue to replicate in the absence of exogenous stimuli for a restricted number of generations. Furthermore, they start to secrete extracellular matrix components such as collagen, elastin, and proteoglycans. The mechanisms that control this change in morphology and function of the smooth muscle cells are still poorly understood. Adhesive proteins such as fibronectin and laminin apparently have an important role in determining the basic phenotypic state of the cells and exert their effects via integrin receptors. The proliferative and secretory activities of the cells are influenced by a multitude of growth factors, cytokines, and other molecules. Although much work remains before an integrated view of this regulatory machinery can be achieved, there is no doubt that the cell culture technique has contributed substantially to our knowledge of smooth muscle differentiation and growth. At the same time, it has been crucial in exploring the role of these cells in vascular disease and developing new therapeutic strategies to cope with major causes of human death and disability.

Effects of a single administration of fibroblast growth factor on vascular wall reaction to injury

Expansion of the vascular wall through formation of neointimal fibromuscular lesions is the basic mechanism underlying stenosis of vascular grafts, restenosis of arteries treated by balloon angioplasty, and other major cardiovascular problems. This study examined the effect of a single, systemic, low dose of basic fibroblast growth factor (bFGF) on formation of neointimal fibromuscular lesions in response to injury. New Zealand white rabbits (n = 76) were subjected to balloon injury of the abdominal aorta. Forty-five rabbits were given a single intravenous dose of bFGF (0.5 microgram/kg) immediately after injury, and 31 rabbits were given only the vehicle solution as controls. After 2 (n = 15), 5 (n = 21), 14 (n = 29), or 28 (n = 11) days the rabbits were sacrificed. Those rabbits receiving the single administration of bFGF exhibited significantly greater intimal thickening (intima/media ratio) than the control group at 5 days (mean +/- standard error of the mean, 0.091 +/- 0.009 versus 0.058 +/- 0.006; p < 0.002), but not at 14 or 28 days. These results were achieved without any significant differences in mitotic indices, as determined by a mitostatic method, between the two groups at any postinjury interval examined. The findings suggest that a single systemic dose of exogenous bFGF has a relatively long term effect on enhancing the neointimal response to vascular injury. Therefore, local control of endogenous bFGF may be useful in limiting formation of vascular neointimal fibromuscular lesions, thus improving the long-term results of vascular grafts, balloon angioplasty, and other cardiovascular procedures.

Growth slow-down and growth arrest of human colon carcinoma cells HCT-8 in vitro after exposure to 5-fluoro-2'-deoxyuridine

Cellular heterogeneity in drug response denotes a mixed response among individual cells in a drug treated population. Individual cell responses may be more complex than 'cell kill' and 'no response'. In this study we employed a colony formation assay and high-resolution image analysis to detect the various responses such as immediate and delayed cessation of growth, growth delay and growth slow-down, at the level of the individual colony. The evaluation was carried out using a human ileocaecal adenocarcinoma cell line (HCT-8) and the anti-tumour agent 5-fluoro-2'-deoxyuridine (FdUrd). In the presence of a drug concentration which, in standard monolayer assays, inhibits the growth to about 50% (IC50) only about 20% of the colonies ceased to grow and the remaining colonies grew at a growth rate of about 70% of control. At an FdUrd concentration which, in standard monolayer assays, reduced growth by > 90% (> IC90), about 50% of the cells grew, with growth rates of about 30% of control. The slowing of growth, most prominent at lower drug concentrations, should be considered in determining mechanisms of drug action at the individual cell level. In clinical situations in which high drug doses are precluded by toxicity to normal tissues, growth slow-down may play a significant role in tumour response.

Biology of restenosis and therapeutic approach

Numerous attempts have been made to prevent restenosis after successful transluminal dilation of an atherosclerotic vessel using a variety of pharmacologic and mechanical approaches. This article reviews the pathobiology of the restenosis process, offers a hypothesis as to its cause, reviews attempts to modify the process, and outlines therapeutic approaches to future treatment.

Arterial response to mechanical injury: balloon catheter de-endothelialization

Coronary angioplasty has been used clinically for over a decade. Its initial promise as an alternative to coronary bypass surgery has only partially been fulfilled because of the high rate of post-operative restenosis. A number of animal models have been devised to study this phenomenon and although none is entirely satisfactory, they have, together with recent advances in molecular biology provided an insight into the cellular mechanisms that may contribute to this complication. This knowledge may ultimately lead to a means of therapeutic intervention. This review summarises our present understanding of the pathology of post-angioplasty re-stenosis as revealed by studies using the balloon catheter de-endothelialization model, and discusses some of the intervention strategies that have been attempted.

A standardised method of culturing aortic explants, suitable for the study of factors affecting the phenotypic modulation, migration and proliferation of aortic smooth muscle cells

The study of factors affecting phenotypic change and growth of aortic smooth muscle cells (SMC) typically involves either the isolation of SMC by enzymatic dissociation or observation of outgrowth of cells from primary explants of vascular tissue. Explants provide a system in which the growth of cells can be investigated without dissociating them totally from their normal environment and avoids some of the problems of variability associated with enzymatic digestion. We describe here a standardised method for the preparation of medial explants of arterial tissue using a McIlwain tissue chopper, which is both fast and reproducible. Measurement was made of the percentage of explants showing outgrowth and of the distance migrated by cells at various times after plating explants singly into wells of a 96-well plate. Using this method, by 12 days after explanting, more than 95% of explants from normal rabbit aorta had shown outgrowth, in contrast to only 50% of explants prepared using a scalpel blade. Explants from atherosclerotic rabbit aorta showed a shorter lag phase before outgrowth commenced than explants from normal rabbit aorta of a similar age, but the subsequent rate of growth was the same. In contrast, when explants of normal rabbit aorta were grown in hyperlipidic rabbit serum, the lag phase was the same as for normal serum, but the subsequent rate of growth was greater. Explants from normal rabbit aorta treated with heparin showed an increased lag phase but reduced rate of growth. Treatment with heparinase decreased the lag phase and increased the rate of growth as did elastase.

Smooth muscle cell growth factors

While the roles of the platelet-derived growth factors (PDGFs) in vascular smooth muscle cells (SMCs) continue to be elucidated, these cells, especially in their activated 'synthetic' state, have also been found to express, and proliferate in response to, many of the other families of polypeptide growth factors, such as the fibroblast growth factors. Other stimulators of DNA synthesis, and particularly of SMC hypertrophy, include the vasoconstrictor hormones such as angiotensin II, as well as physical forces, especially stretch or tension. For many of these ligands, multiple receptors have been identified and their means of signal transduction are being characterized rapidly. Regulatory regions of these genes are being identified as are transcription factors. Complex post-transcriptional regulation has also been shown by the findings that some growth factors are phosphorylated, or translocated to the nucleus or the extracellular matrix. Inhibitors have also been identified. These include some prostaglandins, calcium antagonists, agonists that activate guanylate and adenylate cyclases, inhibitors of angiotensin-converting enzyme, interferon gamma, and heparin. Future studies are likely to show that tyrosine phosphatases and recessive oncogenes also regulate growth. The existence of so many autocrine/paracrine mitogens--together with some experimental data--suggests some redundancy in the system as well as some additive effects. Redundancy may limit the efficacy of antibodies to a single growth factor to block cell proliferation. Their evolutionary conservation implies some unique roles for each growth factor but these have not been apparent from in vitro studies to date. Further insights are apt to come from the increasing recognition that growth factors have other effects--on cell attachment, migration, survival, production of extracellular matrix, thrombosis, vaso-constriction, regulation of cytokine synthesis, and inhibition of growth. Many of these effects may prove to be context-dependent, as with the case of growth inhibition by transforming growth factor-beta. Studies in monolayer cultures may not obtain the same results as studies using cocultures of endothelial and smooth muscle cells, or 3-dimensional matrix cultures, organ cultures, or in the intact animal. In vivo descriptive studies of growth factors expressed in vascular embryogenesis, hypertension, atherosclerosis, acute balloon injury and thrombosis are being supplemented by interventions such as infusions with growth factors, antibodies, and toxin conjugates. These studies, and studies using transgenic mice and homologous recombination, should yield information as to mechanisms and may also suggest new therapies.

Syndromes of accelerated atherosclerosis: role of vascular injury and smooth muscle cell proliferation

Vascular injury represents a critical initiating event in the pathogenesis of various vascular diseases, including atherosclerosis. This review discusses 1) the current understanding and a new pathologic classification of vascular injury; 2) the resultant cellular pathophysiologic responses, specifically, lipid accumulation, platelet aggregation, thrombus formation and smooth muscle cell proliferation; 3) the role of vascular injury in the pathogenesis of spontaneous and accelerated atherosclerosis; and 4) emerging therapeutic approaches in preventing these vascular diseases. The process of type I vascular injury (nondenuding functional injury) followed by lipid accumulation, monocyte and platelet adhesion, smooth muscle cell proliferation and resultant plaque formation represents the prevalent view of the early stages of spontaneous atherogenesis. The syndromes of accelerated atherosclerosis (namely, heart transplant atherosclerosis, coronary vein graft disease and restenosis after percutaneous transluminal coronary angioplasty) appear to share etiologic mechanisms with spontaneous atherosclerosis by means of the "response to injury" hypothesis. However, type II and type III vascular injury (denuding endothelial and intimal injury with or without medial damage) followed by thrombus and its organization by smooth muscle cell proliferation and subsequent fibrosis appear to be responsible for the vascular process. This accelerated and premature occlusive process accounts for significant morbidity and mortality in patients with these conditions. Better understanding of the nature of vascular injury and its pathophysiologic responses in these clinical situations may aid in developing therapeutic strategies for preventing these vascular diseases.

Changes in proteoglycans of cultured pig aortic smooth muscle cells during subculture

Smooth muscle cells were cultured from pig aorta. Changes in both the growth and the properties of sulfated proteoglycans were observed during passage. The population doubling time during log phase growth was 34 h from Passages 3 to 7-8 but 20 h at the Passage 11, and the cell density at the stationary phase, was 86,000 and 136,000 cells/cm2 at Passages 3 and 11, respectively. Structural characteristics of sulfated proteoglycans secreted into the medium were investigated after metabolic labeling with [35S]-sulfate. Significant differences were observed with age in vitro: a) [35S]proteoglycan complexes were in a greater amount at Passage 10 than at Passage 3; b) the hydrodynamic size of at least 45% of subunits and about 90% of monomers decreased with in vitro aging; c) this decrease in the size of proteoglycans was partly due to a decrease in the size of their glycanic chains; d) an increase of 15% in the proportion of dermatan sulfate was observed when cells were subjected to 10 passages.

The determination of growth rates of individual colonies in agarose using high-resolution automated image analysis

This paper describes the evaluation of a colony formation assay using automated image analysis, which permits the tracking of growth at the individual colony level, such that a growth rate can be estimated for each colony followed. In principle, this will permit quantitative characterization of cellular heterogeneity in growth rate and cellular heterogeneity in response to proliferation-modifying agents. In addition, we have demonstrated the possibility of using correlative microscopy to relate growth rate to other parameters, using metabolic viability as an example. This should be useful for determining cellular characteristics associated with proliferative behavior and response to proliferation-modifying agents.

Scoring of Cytotoxicity by Image Analysis using Animal Cell Cultures

The estimation and assessment of toxic effects can be made clearer by direct observation of the target object — the living cell. Following this approach we continuously assess the reactions of cell cultures (at a range of densities) by using image analysis equipment. The parameters evaluated are: growth rate, alteration of cell cycle time, cell progeny, and mortality rate. The use of multi-well culture plates during the observation period enables the effects of different agents at different concentrations to be examined simultaneously under the same experimental conditions. The automatic observation of the fate of many individual cells permits the accurate quantification and characterisation of cytotoxic effects for the exposed cells and their progeny. Using this method, we have examined ethyl methanesulfonate (EMS), cetyltrimethyl-ammonium chloride (CTAC), and Na-aciclovir (NaA), and we demonstrate the distinction between reversible and irreversible cell damage.

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.

T-2 toxin effect on rat aorta: cellular changes in vivo and growth of smooth muscle cells in vitro

Rats were injected intraperitoneally with T-2 toxin and their aortas were studied by light and electron microscopy. The growth of smooth muscle cell explants taken from the tunica media of aortas of similarly treated animals was observed. A single large dose (2 mg/kg) or four injections of 0.3 mg/kg T-2 toxin caused damage and occasional necrosis of endothelial cells, accumulation of basement membrane-like material in the intima, and swelling and activation of smooth muscle cells in the tunica media. Three or more weeks after the last injection of 0.3 mg/kg T-2 toxin the endothelial cells were normal but an excess of fragmented intimal basement membrane-like material persisted and smooth muscle cells were still activated. Outgrowths from explants of aortic tunica media taken within 1 week of the last dose of T-2 toxin showed marked inhibition of smooth muscle cell growth. Three or more weeks after the toxin, the explants showed significantly increased outgrowths. These findings suggest that T-2 toxin causes early endothelial and smooth muscle cell injury accompanied by inhibition of smooth muscle cell growth in culture. This is followed by stimulation of the proliferative capacity of smooth muscle cells in vitro. If a similar mechanism is operative in vivo, it could explain the chronic vascular changes observed after limited exposure to T-2 toxin.

Smooth muscle cell migration and proliferation: atherogenic mechanisms in hypertension

The proliferative and migratory behavior of explanted rat aortic smooth muscle cells (SMC) was investigated in cells obtained from either 24-week-old normotensive Wistar-Kyoto (WKY) or age-matched spontaneously hypertensive (SHR) rats. Time lapse video analysis of primary SMC growth in the presence of 10% serum revealed that interdivision times of cells from SHR were significantly shorter than those from WKY. Differences in the proliferative capacity of these cells were still present after two subcultivations, as analyzed by conventional growth curves. In contrast to the proliferative behavior, no differences in the migratory characteristics of SMC could be detected in a migration assay analyzing the SMC outgrowth of standardized aortic explants under low serum conditions (0.1% fetal bovine serum). It has been shown that another model of hypertension, the 4 week DOC/salt hypertensive rat results in a different reaction of SMC. Therefore, it can be considered that the extent of the potentially atherogenic alterations of SMC function in hypertension is dependent on the type, duration and the rate of increase of hypertension.

A possible role of catecholamines in atherogenesis and subsequent complications of atherosclerosis

Cultured smooth muscle cells (SMC) from rat aorta and endothelial cells (EC) from pig aorta were used to study the effect of the catecholamines epinephrine and norepinephrine on cell proliferation. Both stimulated growth of SMC and EC when added to the culture medium. Besides epinephrine and norepinephrine, dopamine and some of their metabolites also stimulated proliferation of cultured endothelial cells. Smooth muscle cells originating from rats being exposed to atherosclerotic risk factors, like diabetes, hypertension and balloon-injury, exhibited an increased susceptibility to these catecholamines compared to SMC from control animals. In comparison to normotensive control animals a 10-fold elevated plasma concentration of epinephrine was found in hypertensive rats. In man plasma epinephrine and norepinephrine concentration was determined in a healthy control group and in patients suffering from diabetes mellitus and coronary artery disease. Plasma epinephrine and norepinephrine levels were similar in patients suffering from diabetes mellitus compared to the control group. But in patients with coronary artery disease significantly higher plasma concentrations for epinephrine (p less than 0.001) and norepinephrine (p less than 0.01) were observed. These data support the hypothesis that catecholamines may play a role in the development and subsequent complications of atherosclerosis.

Proliferation kinetics of aortic smooth muscle cell populations: comparison of normotensive and spontaneously hypertensive rats

An in vitro autoradiographic study of the proliferation of smooth muscle cells (SMC) from the aorta of normotensive and spontaneously hypertensive rats has been made. It was found, in primary culture, that SMC of spontaneously hypertensive rats entered proliferation at 2-2.5 days later than those from normotensive animals. As revealed by their very intensive labelling, a subpopulation of SMC with a high turnover rate was found in primary culture. In freshly isolated SMC from normotensive rat aorta, a subpopulation in S phase was detected, but we failed to detect it in aortae from spontaneously hypertensive rats. A difference in proliferative behaviour was also observed in subcultures of SMC from rats of both strains.