Responses of cultured smooth muscle cells from human nonatherosclerotic arteries and primary stenosing lesions after photoradiation: implications for photodynamic therapy of vascular stenoses

Photodynamic Therapy and Cardiovascular Diseases

Cardiovascular diseases are the third most common cause of death in the world. The most common are heart attacks and stroke. Cardiovascular diseases are a global problem monitored by many centers, including the World Health Organization (WHO). Atherosclerosis is one aspect that significantly influences the development and management of cardiovascular diseases. Photodynamic therapy (PDT) is one of the therapeutic methods used for various types of inflammatory, cancerous and non-cancer diseases. Currently, it is not practiced very often in the field of cardiology. It is most often practiced and tested experimentally under in vitro experimental conditions. In clinical practice, the use of PDT is still rare. The aim of this review was to characterize the effectiveness of PDT in the treatment of cardiovascular diseases. Additionally, the most frequently used photosensitizers in cardiology are summarized.

Therapeutic strategies based on non-ionizing radiation to prevent venous neointimal hyperplasia: the relevance for stenosed arteriovenous fistula, and the role of vascular compliance

We have reviewed the development and current status of therapies based on exposure to non-ionizing radiation (with a photon energy less than 10 eV) aimed at suppressing the venous neointimal hyperplasia, and consequentially at avoiding stenosis in arteriovenous grafts. Due to the drawbacks associated with the medical use of ionizing radiation, prominently the radiation-induced cardiovascular disease, the availability of procedures using non-ionizing radiation is becoming a noteworthy objective for the current research. Further, the focus of the review was the use of such procedures for improving the vascular access function and assuring the clinical success of arteriovenous fistulae in hemodialysis patients. Following a brief discussion of the physical principles underlying radiotherapy, the current methods based on non-ionizing radiation, either in use or under development, were described in detail. There are currently five such techniques, including photodynamic therapy (PDT), far-infrared therapy, photochemical tissue passivation (PTP), Alucent vascular scaffolding, and adventitial photocrosslinking. The last three are contingent on the mechanical stiffening achievable by the exogenous photochemical crosslinking of tissular collagen, a process that leads to the decrease of venous compliance. As there are conflicting opinions on the role of compliance mismatch between arterial and venous conduits in a graft, this aspect was also considered in our review.

Recent Advances for Dynamic-Based Therapy of Atherosclerosis

Atherosclerosis (AS) is a chronic inflammatory disease, which may lead to high morbidity and mortality. Currently, the clinical treatment strategy for AS is administering drugs and performing surgery. However, advanced therapy strategies are urgently required because of the deficient therapeutic effects of current managements. Increased number of energy conversion-based organic or inorganic materials has been used in cancer and other major disease treatments, bringing hope to patients with the development of nanomedicine and materials. These treatment strategies employ specific nanomaterials with specific own physiochemical properties (external stimuli: light or ultrasound) to promote foam cell apoptosis and cholesterol efflux. Based on the pathological characteristics of vulnerable plaques, energy conversion-based nano-therapy has attracted increasing attention in the field of anti-atherosclerosis. Therefore, this review focuses on recent advances in energy conversion-based treatments. In addition to summarizing the therapeutic effects of various techniques, the regulated pathological processes are highlighted. Finally, the challenges and prospects for further development of dynamic treatment for AS are discussed.

The changing face of vascular interventional radiology: the future role of pharmacotherapies and molecular imaging

Interventional radiology has had to evolve constantly because there is the ever-present competition and threat from other specialties within medicine, surgery, and research. The development of new technologies, techniques, and therapies is vital to broaden the horizon of interventional radiology and to ensure its continued success in the future. In part, this change will be due to improved chronic disease prevention altering what we treat and in whom. The most important of these strategies are the therapeutic use of statins, Beta-blockers, angiotensin-converting enzyme inhibitors, and substances that interfere with mast cell degeneration. Molecular imaging and therapeutic strategies will move away from conventional techniques and nano and microparticle molecular technology, tissue factor imaging, gene therapy, endothelial progenitor cells, and photodynamic therapy will become an important part of interventional radiology of the future. This review looks at these new and exciting technologies.

Activation of the stress-activated JNK and p38 MAP kinases in human cells by Photofrin-mediated photodynamic therapy

We have examined the possible role of the stress-activated JNK and p38 protein kinases in cellular sensitivity following Photofrin-mediated photodynamic therapy (PDT). Previously we reported that immortalized Li-Fraumeni syndrome (LFS) cells are more resistant to Photofrin-mediated PDT compared to normal human fibroblasts (NHF) at equivalent cellular Photofrin levels. In the current work we report that Photofrin-mediated PDT increased the activity of JNK1 and p38 within 30 min in both cell types. However, the increased activity of JNK1 and p38 was transient in the sensitive NHF cells and returned back to near basal levels by 3 h after PDT. In contrast, the resistant LFS cells exhibited a more prolonged activation of JNK and p38, which lasted for at least 11 h and 7 h after PDT, respectively. Blocking of the p38 pathway in LFS cells by transient infection with a recombinant adenovirus expressing a dominant negative mutant of p38 or in HeLa cells by stable transfection with a dominant negative mutant of p38 had no effect on cell survival following PDT. These data suggest that although Photofrin-mediated PDT is able to induce JNK1 and p38 in human cells, the p38 pathway alone does not play a major role in the sensitivity of LFS cells to Photofrin-mediated PDT.

Photochemotherapy of vascular cells with 8-methoxypsoralen and visible light: differential effects on endothelial and smooth muscle cells

BACKGROUND

The long-term efficacy of percutaneous transluminal coronary angioplasty is limited by the restenosis which occurs in approximately 40% of patients, usually within 6 months of the procedure.

PURPOSE

The present study was designed to evaluate the effects of 8-methoxypsoralen (8-MOP) activated with visible light on the properties of bovine aortic smooth muscle cells (SMC) and endothelial cells (EC) in vitro.

METHODS

Cells were seeded in polystyrene wells, allowed to attach over a 24-h period, incubated with 1, 20, or 50 microg/ml 8-MOP and then exposed to 12 J/cm2 visible light (447 nm). Cell counts were performed for up 14 days (n = 4-6 wells per time point), and each experiment was performed in triplicate. Cellular migration, morphology, and size were also analyzed.

RESULTS

The lowest 8-MOP dose (1 microg/ml) had no significant effect on SMC proliferation, while the highest dose (50 microg/ml) induced cytostasis. An intermediate dose of 8-MOP (20 microg/ml) produced a transient and reversible inhibition of proliferation. There was no significant effect on proliferation of EC at lowest dose of 8-MOP (1 microg/ml). However, in contrast to the SMC experiments, a transient and reversible inhibition of EC proliferation was seen at both 20 and 50 microg/ml 8-MOP.

CONCLUSIONS

These experiments demonstrate that while 8-MOP photoactivated with 447 nm visible light can reversibly inhibit the proliferation of both SMC and EC in a dose-dependent fashion, SMC are more sensitive to the treatment than EC.

Photoangioplasty: An emerging clinical cardiovascular role for photodynamic therapy

Photodynamic therapy (PDT) has been studied and applied to various disease processes. The potential of PDT for selective destruction of target tissues is especially appealing in cardiovascular disease, in which other existing interventional tools are somewhat nonselective and carry substantial risk of damage to the normal arterial wall. Enthusiasm for photoangioplasty (PDT of vascular de novo atherosclerotic and, potentially, restenotic lesions) is fueled by more effective second-generation photosensitizers and technological advances in endovascular light delivery. This excitement revolves around at least 4 significant attributes of light-activated therapy: the putative selectivity and safety of photoangioplasty, the potential for atraumatic and effective debulking of atheromatous plaque through a biological mechanism, the postulated capability to reduce or inhibit restenosis, and the potential to treat long segments of abnormal vessel by simply using fibers with longer light-emitting regions. The available nonclinical data, coupled with the observations of a new phase I trial in human peripheral atherosclerosis, suggest a promising future for photoangioplasty in the treatment of primary atherosclerosis and prevention of restenosis.

In vivo intravascular laser photodynamic therapy in rabbit atherosclerotic lesions using a lateral direction fiber

BACKGROUND AND OBJECTIVE

This study was performed to evaluate the possibility of inducing regression of atherosclerotic foci by photodynamic therapy (PDT) using hematoporphyrin derivative (HpD).

STUDY DESIGN/MATERIALS AND METHODS

Atherosclerotic rabbits were divided into four groups: A (n = 6) and C (n = 6) were given 5 mg/kg of HpD intravenously; Groups B (n = 4) and D (n = 4) were not. Twenty-four hours after HpD administration, the aortae of groups A and B were exposed to 200 mw output argon dye laser beam at 630 nm for 10 minutes; groups C and D were exposed to 400 mw for 5 minutes. Three rabbits from groups A and C and two rabbits from groups B and D were sacrificed immediately after laser photoradiation, being named groups A 0, C 0 and groups B 0, D 0, respectively. Groups A 7, C 7, and Groups B 7, D 7 were sacrificed 7 days after the photoradiation.

RESULTS

In groups A 7 and C 7, most intimal cells and endothelial cells had become necrotic and disappeared, and a loss of intima was observed. No such changes were found in groups B 7, D 7.

CONCLUSION

The above data suggest that PDT caused effective regression of the atherosclerotic lesions.

Benzoporphyrin derivative monacid ring A (Verteporfin) alone has no inhibitory effect on intimal hyperplasia: in vitro and in vivo results

Benzoporphyrin derivative monoacid ring A (Verteporfin, BPD-MA), a photosensitizing drug, has been suggested as having inhibitory effects on smooth muscle cell (SMC) proliferation in rabbit aortic intimal injuries. The effect of BPD-MA on vascular SMCs in the absence of light stimulation in vitro and in vivo was studied using models of intimal hyperplasia. Human SMCs were incubated with BPD-MA for 4 h in darkness. A small (20%) but significant decrease in viability (n =42,p < .05) was noted for BPD-MA concentrations above 15 microg/mL. This was an all-or-none phenomenon with no further decrease in viability at higher concentrations. Treatment with BPD-MA was also carried out in vivo using a balloon injury model of intimal hyperplasia in rabbit aortas. Thirty-three rabbits were randomized into five groups and given intravenous BPD-MA (2 mg/kg) according to the following schedule: Group 1 (n = 8), BPD-MA 25 min prior to injury; Group 2 (n = 8), BPD-MA 25 min prior to injury plus a second dose 4 weeks later; Group 3 (n = 4), BPD-MA immediately postinjury; Group 4 (n = 7), BPD-MA immediately postinjury plus a second dose 4 weeks later; or Group 5 (n = 6), no drug (control group). No statistically significant difference was seen in the amount of intimal hyperplasia that developed in the five groups.

Pretreatment with continuous-wave ultraviolet irradiation to prevent the development of delayed vasospasm in the rabbit common carotid artery model

OBJECT

Ultraviolet (UV) light irradiation can lead to immunomodulation. The purpose of this study was to determine the preventive effect of UV light on cerebral vasospasm by using a rabbit common carotid artery (CCA) model.

METHODS

Rabbit CCAs were constricted for a long period by application of autologous blood within a silicon sheath. Before immersion in blood, the CCAs were adventitiously exposed to UV light emitted from a helium-cadmium laser (wavelength 325 nm) yielding an irradiation energy of 10 mJ/mm2. The occurrence of vasospasm was evaluated using angiography 48 hours after blood exposure in this model. The UV light treatment significantly reduced the degree of vasospasm. Compared with luminal diameters measured on Day 0, prior to treatment, the luminal diameters of UV light-treated arteries (six animals) decreased by only 6%, whereas that of the sham-treated arteries (eight animals) significantly decreased by 26% (p<0.001). Histological examination of UV light-treated CCAs revealed no endothelial damage and extended smooth-muscle cells, in which some fragmented nuclei were confirmed by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling. Twenty-eight days after blood exposure, examination of UV light-treated CCAs revealed only myointimal proliferation, similar to that of the sham-treated CCAs.

CONCLUSIONS

These results are the first to provide evidence of a prophylactic effect of UV light on vasospasm and are suggestive of involvement of apoptosis in the mechanism of this effect.

Photodynamic therapy for the prevention of intimal hyperplasia in balloon-injured rabbit arteries

This study was performed to demonstrate accumulation of the photosensitizer hematoporphyrin derivative (HPD) in atherosclerosis and to determine whether intimal hyperplasia, the main cause of restenosis after angioplasty, can be inhibited by photodynamic therapy (PDT). Forty Japanese White rabbits were subjected to balloon endothelial injury in the common iliac artery. Five groups of rabbits, ie, immediately after, or 3, 7, 14 or 28 days after the balloon injury, were injected with HPD. These rabbits were sacrificed 24h after HPD administration, and HPD fluorescence was investigated in the injured arteries by fluorescence microscopy. Other groups of rabbits were injected with HPD 24h before PDT, and they were then subjected to intravascular Hg-Xe flash-lamp irradiation immediately after (0D-PDT), or 3 days (3D-PDT), 7 days (7D-PDT), or 14 days (14D-PDT) after the balloon injury. All rabbits were sacrificed 28 days after the balloon injury, and histological sections of PDT-treated arteries were examined by light microscopy. Slight, uniform HPD accumulation was observed in the injured media immediately after the balloon injury, and throughout the entire media and the neointima on day 7. On day 14, HPD accumulation had diminished in the media and increased in the intima, and on day 28 no HPD remained in the media. In the 0D- or 3D-PDT groups, no inhibition of intimal hyperplasia was observed. In contrast, there was significant inhibition of intimal hyperplasia in the 7D- and 14D-PDT groups, and the most effective inhibition was in the 7D-PDT group. This study demonstrated that PDT with HPD inhibits smooth muscle cell growth and decreases the intimal hyperplasia response in rabbits.

Intra-arterial photodynamic therapy using 5-ALA in a swine model

OBJECTIVES

To test the hypothesis that intravascular light could be delivered via a balloon catheter for arterial photodynamic therapy (PDT).

DESIGN

Pig non-injury model.

MATERIALS

Clinical catheter equipment.

METHODS

Large White pigs (15-20 micrograms) were photosensitised with 5-aminolaevulinic acid (5-ALA) induced protoporphyrin IX (PpIX) at a concentration of 120 mg/kg. Arterial biopsies were taken at intervals between 30 mins and 24 h and frozen sections analysed using a CCD camera to give a temporal profile of fluorescence in each arterial layer. PDT was given to normal arterial segments via a 4 mm transparent PTA balloon inflated so as to occlude flow, but not distend the artery. Animals were culled at 3 and 14 days and the above segments harvested.

RESULTS

Fluorescence peaked in the adventitia, intima and medial layers at 1.5, 4 and 6 h respectively. PDT at all time points produced VSMC depletion compared with controls. The degree of depletion mirrored the fluorescence profile of PpIX.

CONCLUSIONS

PDT can be delivered via a standard PTA balloon with a transparent channel. This depletes the VSMC population within the arterial wall without complications. Intra-arterial PDT is therefore a potential therapy to reduce the incidence of restenosis post-angioplasty.

Inhibitory effect of photooxidation on intimal and medial thickening of saphenous vein

BACKGROUND

The inhibitory effect of short-term photooxidation on medial and neointimal proliferation of human saphenous vein was investigated.

METHODS

Culture medium-filled surgically prepared saphenous vein segments were photooxidized in 0.01% methylene blue solution for 5 minutes. Photooxidized and nonphotooxidized saphenous veins were checked for viability of endothelial cells by culturing vein segments for 21 days followed by histologic and immunohistochemical studies.

RESULTS

Endothelial cells of saphenous vein segments remained unaffected after photooxidation. Both the intima and media of nonphotooxidized veins became highly cellular and thickened because of the proliferation and migration of smooth muscle cells. Like precultured fresh saphenous vein, intimal (0.031+/-0.017 mm; p=0.0067) and medial thicknesses (0.702+/-0.123 mm; p < 0.0001) and proliferating cell nuclear antigen-positive cell count (14+/-8/mm2; p=0.0005) of cultured photooxidized veins were significantly less than those of cultured nonphotooxidized veins (intimal thickness, 0.059+/-0.041 mm; medial thickness, 0.997+/-0.228 mm; proliferating cell nuclear antigen positive cell count, 34+/-16/mm2.

CONCLUSIONS

Methylene blue-induced short-term photooxidation is effective in inhibition of intimal and medial thickening of saphenous vein.

Delivery of benzoporphyrin derivative, a photosensitizer, into atherosclerotic plaque of Watanabe heritable hyperlipidemic rabbits and balloon-injured New Zealand rabbits

In this study we compared the plasma distribution and arterial accumulation of a photosensitizer, benzoporphyrin derivative (BPD), in two models of atherosclerosis: the spontaneous lesions of the Watanabe heritable hyperlipidemic (WHHL) rabbit and induced lesions of the balloon-injured, cholesterol-fed New Zealand white (NZW) rabbit. Selective uptake and retention of a photosensitizer by the abnormal portion of a vessel is a necessity in order for photodynamic therapy to become a successful modality for inhibition of intimal hyperplasia, selective removal of atherosclerotic tissue or imaging of diseased arteries. Liposome-based formulations were compared to freshly isolated native low density lipoprotein (LDL) and acetylated-LDL (Ac-LDL) as delivery vehicles for BPD. Plasma distribution of the photosensitizer was analyzed by KBr density gradient ultracentrifugation. Although the delivery vehicle influenced plasma distribution immediately postinjection, BPD subsequently partitioned according to the plasma concentration of the lipoproteins. Photosensitizer level in plaque and normal artery specimens was determined by ethyl acetate extraction and spectrofluorometric measurement. The measurement of BPD in normal and atherosclerotic arterial tissue demonstrated a selective accumulation in atherosclerotic tissue. Preassociation with LDL and Ac-LDL enhanced accumulation of BPD in atherosclerotic tissue when compared with normal artery (mean ratios of 2.8 and 4.1 were achieved, respectively). These results indicate that the preferential uptake of BPD by atherosclerotic plaque can be enhanced by preassociation with plasma lipoproteins, suggesting that light activation could lead to a highly selective destruction of diseased vascular tissue.

Cytotoxic effect of photodynamic therapy with Photofrin II on intimal hyperplasia

This study evaluates the effect of photodynamic therapy using Photofrin II on prevention and treatment of intimal hyperplasia in a rabbit model of common carotid artery balloon injury. An established model was used. One week after injury (inhibition arm) or 6 weeks after injury (treatment arm), each common carotid artery was exposed to continuous external laser irradiation 48 hours after a 5 mg/kg intravenous dose of Photofrin II (fluency = 7.6 joules/cm2, lambda = 630 nm). Histologic evaluation was performed 6 weeks following therapy in the inhibition arm and 1 day, 1 week, and 6 weeks following therapy in the treatment arm. Each arm included four subgroups (N = 10/subgroup): control, drug only, laser only, and drug plus laser. The first two subgroups underwent sham reoperations without laser exposure. In the inhibition arm no effect was seen on intimal cell density or area stenosis 6 weeks after photodynamic therapy. In the treatment arm intimal cell density was markedly diminished in the drug plus laser subgroup sacrificed 1 day and 1 week (but not 6 weeks) after treatment as compared to the remaining subgroups. There was no significant impact on area of stenosis. A marked acute cytotoxic effect of photodynamic therapy on intimal hyperplasia was verified in vivo in the treatment arm. The extracellular matrix was not affected. Cellular repopulation of the treatment zone was observed. No sustained benefit was seen in either the inhibition or the treatment arm. Refinements in dosimetry will be necessary to achieve long-term benefits.

Effects of ultraviolet light in vascular cells in vitro and in intact atherosclerotic explants: potential role of apoptosis in vascular biology

Complex cell-to-cell interactions are known to participate during vascular injury and remodeling, resulting in smooth muscle cell proliferation. Mechanical interventions have yielded little benefit in limiting this process and several site-specific genetic therapies are not yet clinically available. The aim of this study was to delineate the effect of very short wavelength ultraviolet (UVC) light therapy on the viability of macrophage and smooth muscle cells. Vascular cells were both treated in vitro and in intact explanted atherosclerotic aortic segments ex vivo with UVC light. Brief exposure to short wavelength UVC light in the absence of photosensitizers elicited a differential temporal and functional response among treated cells. However, dramatic reduction in both cellular viability and proliferative capacity with eventual cell demise was observed in all UVC-treated cells. Flow cytometry and immunohistochemical analyses revealed the presence of extensive DNA fragmentation, suggestive of apoptosis as a predominant pathway of cell death in these cells exposed to UVC light. We hypothesize that selective induction of apoptosis, in contrast to necrosis, with UVC light may represent a beneficial approach to interdict the complex biologic cascade of messengers that participate in the restenotic response to vascular injury.

Inhibition of intimal hyperplasia in balloon injured arteries with adjunctive phthalocyanine sensitised photodynamic therapy

OBJECTIVES

We investigated the effects of Photodynamic therapy (PDT) using Aluminium disulphonated phthalocyanine (AlS2Pc) on experimental intimal hyperplasia (FCIH).

MATERIALS AND METHODS

(a) Pharmacokinetics: Normal rats were injected with Als2Pc and carotid artery fluorescence was measured. (b) Normal artery PDT: Sensitised rats underwent carotid artery laser irradiation (50J/cm2, 675nm) and were assessed after 3 and 14 days and 1-6 months. (c) PDT: Rats underwent standard carotid artery balloon injury immediately prior to PDT and arteries were assessed at 2 to 26 weeks, together with laser, AlS2Pc, and untreated controls.

CHIEF OUTCOME MEASURES

(a) Fluorescence intensity in different arterial layers. (b) Medial smooth muscle cell counts per high power field (light microscopic). (c) Percentage amount of FCIH (area of intimal hyperplasia) as a ratio of the IEL (area enclosed by the internal elastic lamina).

RESULTS

(a) AlS2Pc fluorescence intensity increased with increasing dosage, with maximal fluorescence in the arterial media at 30 min. (b) PDT produced medial cell depletion at 3 days and persisted over 6 months without loss of vessel integrity. (c) PDT completely inhibited FCIH at 2 and 4 weeks. This was partial at 6 to 26 weeks (51% of untreated level). PDT inhibition of FCIH was significantly greater than in any of the control groups. p < 0.0001. Mann-Whitney Test.

CONCLUSION

Adjunctive AlS2Pc sensitised photodynamic therapy inhibits experimental intimal hyperplasia, by causing medial smooth muscle cell depletion. This offers a new approach to the management of angioplasty restenosis in patients.

Dosage and timing of Photofrin for photodynamic therapy of intimal hyperplasia

Photodynamic therapy has been recommended as a method of preventing intimal hyperplasia. The purpose of this study was to determine the dose and timing of Photofrin porfimer sodium needed to achieve a 3:1 or higher ratio between injured and control arteries after balloon endothelial injury. New Zealand White rabbits were anesthetized and their right femoral artery surgically exposed. A 4Fr Fogarty balloon catheter was passed retrograde into the lower abdominal aorta, inflated and pulled distally into the external iliac artery six times. All rabbits received heparin 100 IU/kg. Arteriotomies were closed and the animals recovered. Rabbits (n = 5 per group) were given intravenous Photofrin at a dose and time according to the following scheme: group I, 5.0 mg/kg immediately after balloon injury; group II, 2.5 mg/kg immediately after injury; group III, 5.0 mg/kg after 1 week; group IV, 5.0 mg/kg after 2 weeks; or group V, 2.5 mg/kg after 2 weeks. Animals were killed 24h after drug administration and the aortoiliac segments removed for spectrophotofluorometric determination of Photofrin levels from injured and control segments. Mean(s.d.) ratios of injured: control arteries for groups I to V were 4.8 (2.6), 2.8 (1.2), 3.0 (1.0), 1.4 (0.3) and 1.0 (0.0) respectively. This ratio was significantly higher for group I rabbits compared with groups IV and V (P < 0.01, ANOVA). Fluorescence and light microscopy showed that Photofrin was localized primarily in the tunica media, and that the drug must be administered before significant intimal hyperplasia occurs.(ABSTRACT TRUNCATED AT 250 WORDS)

Photodynamic therapy in a cell culture model of human intimal hyperplasia

OBJECTIVE

To investigate the effectiveness of photodynamic therapy (PDT) in eliminating proliferating vascular smooth muscle cells (VSMCs). This may have a potential role in reducing restenosis rates clinically.

MATERIALS AND METHODS

Human VSMCs were successfully cultured from 15 long saphenous veins (SV) and seven restenotic lesions (RL) removed during revision coronary and peripheral vein graft surgery. Cultured VSMCs were incubated with photofrin at doses of 0-5 micrograms/ml for 48 h, and then exposed to 4 J/cm2 of polychromatic light. Cell destruction was quantified by a colorimetric assay using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide.

RESULTS

Results are expressed as a mean percentage survival +/- standard error. Cells were minimally affected by either photofrin alone (SV: 95.5% +/- 5.3; RL: 119.8 +/- 4.8) or light alone (SV: 75.38% +/- 3.99; RL: 100.1 +/- 11.0). The combination of 2 micrograms/ml of photofrin and 4 J/cm2 of polychromatic light energy, i.e. PDT, was severely toxic to cells derived from saphenous veins (5.52% +/- 0.85) as well as cells derived from restenotic lesions (9.6 +/- 2.3). These doses are comparable to doses that can be achieved in vivo.

CONCLUSION

PDT in the appropriate drug and light doses can eliminate human VSMCs, including those responsible for vascular restenosis.

Photodynamic therapy of normal and balloon-injured rat carotid arteries using 5-amino-levulinic acid

BACKGROUND

Although the management of atherosclerotic disease by the use of balloon angioplasty is widespread, the treatment is limited by restenosis in 30% to 50% of cases. Fibrocellular intimal hyperplasia, the main cause of restenosis, arises from proliferation and migration of medial smooth muscle cells (SMC) into the intimal layer. Factors leading to intimal hyperplasia are incompletely understood, and drugs have universally failed to influence clinical restenosis. Photodynamic therapy (PDT), the light activation of photosensitizing drugs to generate cytotoxic mediators, may have potential as prophylaxis for intimal hyperplasia. 5-Amino-levulinic acid-induced protoporphyrin IX (ALA-PPIX), a naturally occurring porphyrin precursor, and its product, -PPIX, offers a novel method of sensitization for PDT. We have investigated the pharmacokinetics of ALA in arteries and the effects of ALA-PPIX-sensitized PDT on normal and balloon-injured arteries.

METHODS AND RESULTS

ALA (20 to 200 mg/kg) was injected into healthy rats, and PPIX fluorescence was measured in the carotid arteries. In a second group of rats, the exposed carotid artery was laser illuminated (50 J/cm2, 630 nm) 30 to 90 minutes after sensitization. Three and 14 days after PDT, histological sections from treated arteries were analyzed by light microscopy. Subsequently, two new groups of rats underwent PDT (ALA, 100 mg/kg; laser, 50 J/cm2, 630 nm [at 60 to 90 minutes]). The left carotid arteries underwent balloon angioplasty by intraluminal passage of a Fogarty FG2 catheter immediately before irradiation. These rats were killed at 14 and 28 days together with laser-only, ALA-only, and untreated control rats. The arteries were perfusion-fixed in vivo. ALA-PPIX induced arterial media fluorescence in a dose-dependent manner. In the normal arteries, PDT produced a dose-dependent cellular depletion in the treated arterial segment at 3 days, and this was complete with 100 and 200 mg/kg of ALA. At 14 days, the media remained acellular, although the endothelial lining had regenerated. In the balloon-injured arteries, PDT produced complete inhibition of intimal hyperplasia at both 14 and 28 days (0%). This was significantly greater than that produced by any of the control rats (34% to 69% and 37% to 66% at the two times, respectively). Significance was at 99% using ANOVA and Fisher's PLSD test. No hemorrhage, thrombosis, or aneurysm formation was seen.

CONCLUSIONS

ALA-PPIX-sensitized PDT applied at the time of angioplasty effectively inhibits experimental intimal hyperplasia development in rats. This may offer a new approach to the management of angioplasty restenosis in patients.

Preventing intimal hyperplasia with photodynamic therapy using an intravascular probe

The purpose of this study was to determine the efficacy of intravascular photodynamic therapy (PDT) to prevent the development of intimal hyperplasia. Anesthetized New Zealand white rabbits underwent placement of Fogarty balloon catheters introduced via femoral artery cutdowns. Catheters were passed retrograde 10 cm into the lower abdominal aorta, inflated six times, and withdrawn toward the inguinal ligament. Rabbits were then randomly assigned to one of the following groups: group 1, drug with no light; group 2, no drug with 240 joules of light; group 3, drug plus 120 joules of light; or group 4, drug plus 240 joules of light. Uninjured carotid arteries served as negative control vessels (N) and injured but non-PDT-treated iliac artery segments served as positive controls (P). Porfimer sodium (photofrin) was administered in a dose of 5.0 mg/kg. Light was provided by a fiberoptic probe with a 1 cm cylindric diffuser attached to an argon pumped dye laser tuned to 630 nm to provide 1 W of laser light for 120 or 240 seconds. One month after PDT, rabbits were killed, perfusion fixed with glutaraldehyde, and vessels removed and examined microscopically. Intimal thickness (mean +/- SD) was calculated and expressed as ratios of the intima/media at four equal positions. Results for N, P, and groups 1, 2, 3, and 4 were 0.02 +/- 0.00, 1.18 +/- 0.71, 0.76 +/- 0.33, 0.96 +/- 0.43, 0.14 +/- 0.22, and 0.36 +/- 0.16, respectively. Intimal thickness was significantly reduced in groups 3 and 4 when compared with P, group 1, and group 2 (p < 0.001, ANOVA). These results showed that intravascular PDT was effective in reducing intimal hyperplasia following arterial injury. This may be a practical method of delivering light for PDT.

Inhibition of smooth muscle cell proliferation by visible light-activated psoralen

The present study was designed to evaluate the effect of 8-methoxypsoralen (8-MOP) activated with visible light (419 nm) on the suppression of smooth muscle cell (SMC) proliferation in vitro. We hypothesize that if visible light (VL) instead of UVA is used to photoactivate 8-MOP, cytotoxic 8-MOP-DNA cross-link formation can be minimized. Bovine aorta SMCs (2 x 10(4)/cm2) were incubated with 8-MOP (1 micrograms/mL) for 30 minutes (in the dark) and exposed to a range of VL (2 to 69 J/cm2) to determine the dose of VL that inhibits SMC proliferation with minimal toxicity. The results show that 8-MOP in combination with 2 to 12 J/cm2 VL reversibly inhibited SMC proliferation for up to 5 days after treatment. SMC viability was confirmed by trypan blue exclusion. 8-MOP in combination with 23- or 69-J/cm2 VL irreversibly inhibited SMC proliferation. In cell cycle studies, 12-J/cm2 VL was used to activate 8-MOP. A phase-specific G2 blockade that correlated temporally with recovery of SMC replication was observed. Photoadduct repair studies showed that cell proliferation rates recovered when 60% of the adducts had been removed. These results demonstrate for the first time the possibility of using VL to activate 8-MOP to inhibit cell proliferation and suggest that 8-MOP/VL photochemotherapy can be used to control SMC growth.

Prospects for site-specific delivery of pharmacologic and molecular therapies

The local delivery of therapeutic agents to the arterial wall represents a new strategy for the treatment of vascular diseases, including restenosis. Approaches for local, intravascular, site-specific delivery include 1) direct deposition of therapeutic agents into the vessel wall through an intravascular delivery system; 2) systemic administration of inactive agents followed by local activation; and 3) systemic administration of fusion toxins that have a specific affinity to proliferating smooth muscle cells at the angioplasty site. In addition to conventional drugs, new therapeutic agents based on molecular mechanisms, including recombinant genes and antisense oligonucleotides, are now under investigation. Although development of intravascular drug delivery devices, including those tailored to accommodate novel therapeutic agents, offers new treatment options for restenosis and other vascular diseases, certain issues that currently limit the safety and efficacy of these approaches remain to be addressed.

Photodynamic therapy inhibition of experimental intimal hyperplasia: acute and chronic effects

PURPOSE

Intimal hyperplasia (IH) is a focal arterial problem that still eludes successful therapy. We have previously demonstrated the feasibility of use of photodynamic therapy (PDT) for the acute treatment of experimental IH with light to activate an otherwise biologically inert photosensitizer. The purpose of this study was to determine the acute and long-term effects of PDT inhibition of IH on the artery wall.

METHODS

Segmental IH was induced by balloon injury localized to the cervical common carotid artery of 33 rats. The photosensitizer chloroaluminum sulfonated phthalocyanine (5 mg/kg) for the experimental group or saline solution for the control group was administered intravenously. Twenty-four hours later, all instrumented portions of arteries were irradiated at 675 nm to induce cytotoxic injury in the PDT-treated arteries as compared with laser only-treated arteries for controls. Animals were killed at 1, 2, 4, and 16 weeks.

RESULTS

There were no untoward side effects in either group. All PDT-treated arteries were devoid of smooth muscle or inflammatory cells in the treated media. There was no evidence of arterial degeneration of PDT-treated arteries. Only three arteries in the PDT group developed IH, whereas it was universal in all controls. In control arteries, immunocytochemistry with bromodeoxyuridine revealed maximal intimal and medial cell proliferation at 1 week, and morphometric analysis demonstrated a maximal IH at 2 weeks. Immunocytochemistry staining for smooth muscle cell actin was positive for the IH in control and when present in PDT-treated arteries, whereas the adventitia of PDT-treated arteries were positive after 2 weeks. Electron microscopy demonstrated early myofibroblast migration to the adventitia, and at 16 weeks occasional myofibroblasts were noted in the media of PDT-treated arteries. There was complete reendothelial cell covering of the intima by 4 weeks.

CONCLUSIONS

These in vivo data demonstrate that PDT is an effective local method for the treatment of experimental IH. There is no evidence of significant recurrence of IH or arterial degeneration. Further studies with PDT may provide novel approaches to the understanding and treatment of arterial IH.

Cardiovascular applications of laser technology

Laser technology has been evaluated for the treatment of coronary artery disease, ventricular and supraventricular arrythmias, hypertrophic cardiomyopathy, and congenital heart disease. Developments in laser angioplasty, laser thrombolysis, transmyocardial laser revascularization, photochemotherapy, laser treatment of arrhythmias and/or laser diagnostics are directed at improving upon conventional non-laser approaches, and providing new therapeutic and diagnostic options. This review will summarize the current status of the multiple applications of laser technology for cardiovascular diagnosis and therapy.

Immunodetection of human atherosclerotic plaque with 125I-labeled monoclonal antifibrin antibodies

To test the affinity of a new F(ab')2 monoclonal antibody (TRF1) against human fragment D dimer of cross-linked fibrin for atherosclerotic plaques free of detectable thrombi, 6 atherosclerotic segments of carotid and femoral artery, and as a control 5 segments of atherosclerosis-free internal mammary artery, were drawn from 11 male patients undergoing bypass surgery. All segments were carefully washed in order to remove possible endoluminal thrombi, and cut to obtain pairs of intimal fragments of similar weight, containing either plaques (n = 16), or fatty streaks (n = 12), or normal endothelium (n = 20). Each fragment underwent a direct binding test to TRF1, or to a non-specific antibody, both labeled with 125I. The activity in each fragment was measured after 3 h of incubation at 37 degrees C, and after washing the fragments every hour for 3 h. TRF1 binding (as percentage of initial activity) was significantly higher (P < 0.001) in atherosclerotic than in normal fragments (26% +/- 11.5%, vs. 9.2% +/- 3.9% in fatty streaks, and 1.9% +/- 0.6% in normal endothelium), and indirect immunofluorescence confirmed TRF1 uptake within the plaque wall. By contrast, the non-specific antibody did not show any significant binding. These preliminary results demonstrate the high specific affinity of TRF1 for atherosclerotic plaques, probably due to the hemorheologic phenomena that activate platelets and provoke the formation of fragment D dimers of cross-linked fibrin on the plaque surface.

Application of photodynamic therapy to the treatment of atherosclerotic plaques

Photodynamic therapy is a therapeutic modality long studies for its application to the treatment of malignant neoplasms. Recently, studies have suggested its potential use in the treatment of atherosclerosis. In this study, two atherosclerotic plaques were induced in the abdominal aortas of 35 rabbits. The animals then received Photofrin II (Quadralogic Technologies Inc., Pearl River, NY), a photosensitizer, at doses of 5 mg/kg and 2.5 mg/kg. After 48 hours, the plaques were irradiated by a fiberoptic connected to an argon ion laser. Fluency rates from 32 mW to 256 mW and energy doses from 1.6 to 60 joules were applied. Only one of the paired plaques was irradiated, the other remaining as a control. Four weeks after treatment, the vessels were assessed. Of 26 plaques treated with photodynamic therapy, 22 were no longer grossly visible, while the nine animals that received light irradiation but no Photofrin II all had visible plaque (P < 0.001). Studies of the vessel sections confirmed a reduction in intimal thickness from 0.74 +/- 0.15 mm in matched controls as compared with 0.51 +/- 0.13 mm in animals with treated plaques. There was a concomitant enlargement of the luminal diameter from 1.13 +/- 0.51 to 1.41 +/- 0.72. On the microscopic level, plaque reduction was most complete in the groups treated with 40 and 60 joules. Different fluency rates and drug dosages did not lead to differing outcomes. Our findings indicate that photodynamic therapy with dihematoporphyrin ether met our goal of reducing plaque size and may represent a means of treating atherosclerotic plaques.

Photoinhibition of smooth muscle cell migration: potential therapy for restenosis

Evidence from animal, autopsy, and atherectomy studies demonstrates that migration and proliferation of smooth muscle cells of medial origin result in neointima formation and decreased luminal cross-sectional area. The purpose of this study was to evaluate whether low energy light irradiation can inhibit smooth muscle cell migration and therefore potentially reduce the degree of neointima formation and the incidence of restenosis. The migration kinetics of bovine aortic smooth muscle cell monolayers were examined using a fence assay. The effect on smooth muscle cell migration of irradiation with monochromatic light at wave-lengths ranging from 400 to 700 nm was compared to the migration of cells irradiated with broadband white light or maintained in the dark. Wavelength specific photoinhibition of smooth muscle cell migration was observed; 594-600 nm light reproducibly inhibited migration by 12-29% (P < 0.05). Migration rate was significantly reduced following daily radiant exposures of 1.0 J/cm2 as well as following a single radiant exposure of 0.09 or 0.9 J/cm2. The decrease in migration was not associated with any change in cell proliferation or [3H] thymidine incorporation. We conclude that 594-600 nm light inhibits smooth muscle cell migration in vitro and may potentially be used in vivo to decrease fibrointimal thickening following arterial injury. This application of photoinhibition may be useful in retarding restenosis following angioplasty.

8-Methoxypsoralen and longwave ultraviolet irradiation are a novel antiproliferative combination for vascular smooth muscle

BACKGROUND

Smooth muscle cell proliferation plays a major role in the genesis of restenosis after angioplasty or vascular injury. Although the effects of arterial exposure to high-energy radiation sources such as laser have been investigated in detail, the effects on vascular cells of low-intensity radiant energy in combination with photoactive agents have not been extensively characterized. Psoralens are photoactive agents that are known to be well tolerated when used in conjunction with local exposure to ultraviolet light in the A band (UVA) for the treatment of various dermatologic proliferative disorders.

METHODS AND RESULTS

We have investigated the effects of psoralen/UVA (PUVA) exposure on the proliferation of bovine aortic smooth muscle cells. Proliferation and viability were assessed over a 14-day period by trypan blue exclusion counts. Cell cycle effects were evaluated by thymidine incorporation and flow cytometry with DNA quantitation after addition of serum or platelet-derived growth factor B-chain (PDGF-BB) to subconfluent cells synchronized by serum withdrawal. No effect was observed after exposure to 8-methoxypsoralen (8-MOP) at concentrations up to 10 microM or UVA irradiation at energies up to 2.5 J/cm2. Longwave ultraviolet light and 8-MOP were found to behave synergistically as potent inhibitors of DNA synthesis in bovine aortic smooth muscle cells with the EC50 in combination ranging from 7 microM at 0.35 J/cm2 to 0.2 microM at 2.1 J/cm2. Similar antiproliferative effects were obtained by an inverse variation of dose and energy delivered. After serum stimulation, inhibition of DNA synthesis was found with either an immediate or delayed (16-hour) application of PUVA. This effect was independent of subsequent 8-MOP washout. Flow cytometry of cells treated with PUVA at several times after serum stimulation demonstrated for each time point a block in further cell cycle progression for cells in all phases of the cell cycle. Evaluation of [125I]-labeled PDGF and epidermal growth factor (EGF) binding revealed no effect of PUVA on the apparent number or affinity of PDGF binding sites present but did reveal a dose-dependent inhibition by PUVA of EGF binding. This inhibition of EGF binding occurred increasingly at higher PUVA doses than the cell cycle inhibition and accordingly did not appear to represent a critical mechanism for the antiproliferative effect. Cell counting after a single exposure to PUVA (1 microM, 1.5 J/cm2) revealed complete stasis of cell proliferation over a 28-day period without recurrent exposure. No increase in trypan-positive cells was noted over this period.

CONCLUSIONS

PUVA treatment represents a novel method for locally inhibiting proliferation of vascular smooth muscle cells without producing cytolysis.

Inhibition of intimal hyperplasia by photodynamic therapy using photofrin

Photodynamic therapy using photofrin and light energy inhibits human myofibroblast proliferation in cell culture. The purpose of this study is to evaluate its influence on intimal hyperplasia in vivo. Twenty New Zealand White rabbits underwent a standardized intimal injury to both common carotid arteries with a 2 Fr balloon catheter. One week later, half of the animals received photofrin (5 mg/kg) intravenously. The remaining 10 rabbits received no photofrin. Two days later, all neck incisions were reopened and a 1-cm segment of each of the 40 carotid arteries was exposed for 5 min to 80 mW of 630 nm light energy from a continuous wave tunable dye laser (fluence = 7.6 J/cm2). All vessels were harvested 5 weeks post-laser treatment following in vivo fixation with formalin. From each artery, separate cross-sections taken from both the lasered and non-lasered regions of each vessel were mounted and stained for histologic evaluation. Analyzed segments were then divided into four different treatment groups: group I segments consisted of arterial cross-sections which were taken from vessel regions that were injured but received neither photofrin nor laser treatment (group I, n = 20); group II segments also did not receive photofrin but were exposed to light energy (group II, n = 20); group III segments received photofrin but no light energy (group III, n = 20); and cross-sections in group IV were taken from those segments which received both photofrin and laser treatment. Using planimetry, the ratio of the area of intimal hyperplasia (IH) to the area enclosed by the internal elastic lamina (IEL) was measured for each specimen (IH/IEL).(ABSTRACT TRUNCATED AT 250 WORDS)

Photodynamic therapy of arteries. A novel approach for treatment of experimental intimal hyperplasia

BACKGROUND

Photodynamic therapy (PDT) uses light activation of otherwise nontoxic dyes for the production of reactive oxygen species that cause cell injury and death.

METHODS AND RESULTS

The inhibition of intimal hyperplasia (IH) by PDT was studied in the balloon injury model of the rat carotid artery. Chloroaluminum-sulfonated phthalocyanine (CASPc) was the drug chosen for PDT because it does not produce skin photosensitivity and has a high absorption peak of light at 675 nm, a wavelength with good tissue penetration. A pilot study indicated that CASPc administration with laser radiant exposure of 100 J/cm2 resulted in a homogeneous, circumferential effect on the whole artery. Male Sprague-Dawley rats received the balloon catheter injury to the left common carotid artery (day 0) and were equally divided into two groups. Nine rats received either CASPc (5 mg/kg i.v., n = 6) or saline (n = 3) at day 2, before IH was present, and nine rats received CASPc or saline in the same manner on day 7, when IH was already present. Twenty minutes after drug injection, the distal left common carotid artery was irradiated under saline with 675-nm laser light at 100 mW/cm2 for 10(3) seconds (100 J/cm2). At this low laser irradiance, there are no thermal effects, but photoactivation of CASPc occurs. The rats were killed at day 14 after balloon injury when IH reaches a maximum. The arteries were harvested after perfusion-fixation for light microscopy, histological and computerized morphometric evaluation, and transmission electron microscopy (TEM) analysis. The cross-sectional areas of the neointima were measured in the PDT-treated arteries and in the laser-only control arteries. There was a significant mean +/- SD decrease of IH in the PDT-irradiated segments of the arteries (0.06 +/- 0.05 mm2) versus the laser-only control ones (0.17 +/- 0.07 mm2) (t test, p less than 0.001), with no statistical difference between the day 2 and day 7 treated rats. Lack of IH was correlated in 90% of cases with histological absence of medial smooth muscle cells or inflammatory cells, but no other structural injury was identified. TEM analysis showed early evidence of PDT-mediated cytotoxic effects at 4 hours and the absence of collagen or elastic tissue structural alterations.

CONCLUSIONS

These data demonstrated that PDT can effectively inhibit the IH response when it is used before or during induction of cellular proliferation in this acute model. Although the long-term implications of PDT in arteries need to be defined, this technique may offer a new method for understanding and treating IH.

Experimental models of coronary artery restenosis

The study of potentially effective drug therapies and mechanical devices for the prevention of restenosis after percutaneous coronary revascularization has relied heavily on the use of experimental animal models. To date, greater than 50 experimental studies have been reported and have suggested that at least nine different classes of pharmacologic agents inhibit the intimal proliferative response to arterial injury. However, no pharmacologic intervention has yet been shown to reproducibly reduce the incidence of restenosis after coronary balloon angioplasty in humans. To identify the reasons for the apparent nonspecificity of the animal models and to determine which model should most reliably predict the efficacy of individual therapies in humans, the distinguishing characteristics of the experimental models were compared. Particular attention was paid to the size and morphologic structure of the treated artery, the susceptibility of the species to spontaneous and diet-induced arterial disease, the nature of the stimulus to intimal proliferation and several practical and logistic considerations. Finally, the reported efficacies of specific drug therapies in the respective animal models and in humans were compared. This review suggests that significant interspecies and occasionally intraspecies differences do exist among the respective animal models, particularly in the extent and composition of the neointimal thickening.(ABSTRACT TRUNCATED AT 250 WORDS)

Preclinical examination of first and second generation photosensitizers used in photodynamic therapy

Numerous photosensitizers with absorption peaks spanning the 600-800 nm "therapeutic window" have been and continue to be synthesized. Structural modifications of the dyes can then be made in order to improve tumor deliverability and retention. Chemical alterations can also enhance the yields of light generated reactive oxygen species. Utilization of lipoproteins, emulsions and antibody conjugates can enhance the selectivity of drug localization. Most cell types and subcellular structures are highly photosensitive and biochemical analysis indicates that cellular target sites associated with PDT correlate with photosensitizer location. In vivo data suggest that vascular and direct tumor cell damage as well as systemic and local immunological reactions are involved in PDT responsiveness. Additional mechanistic, synthetic and developmental studies are required in order to fully appreciate the potentials of PDT. However, continued enthusiasm and support for basic PDT research (as observed during the past 8 years) will depend to a large extent on the outcome of the current clinical trials.

In vivo canine coronary artery laser irradiation: photodynamic therapy using dihematoporphyrin ether and 632 nm laser. A safety and dose-response relationship study

This study examined the safety and dose-response relationships of 632-nm laser irradiation of photosensitized normal coronary arteries in 27 dogs. Fifteen received 2.5 mg/kg dihematoporphyrin ether (DHE), seven received no sensitizer, and five had coronary instrumentation but no laser (sham laser procedures) at nine coronary sites--four sensitized, five non-sensitized. Laser energy of 82 to 1,640 J/cm2 was delivered via a 584 microns diffusing-tip optical fiber, providing estimated tissue fluences of 20 to 410 J/cm2. Serial electrocardiograms and selective coronary arteriograms were performed up to 1 month post laser irradiation. Histologic examination was performed of all treated sites. Tissue fluences less than 200 J/cm2 produced no permanent electrocardiographic or angiographic changes; reversible spasm occurred in 2/8 photosensitized-lased, 0/2 non-photosensitized-lased. Minor medial damage occurred in 1/8 sensitized-lased, 1/2 non-sensitized-lased, and 0/9 sham-lased sites. At tissue fluences greater than 200 J/cm2 4/7 sensitized-lased animals died prematurely--one due to immediate and irreversible coronary spasm and Q wave infarction, one due to fibrillation during 48-hour follow-up coronary angiography (normal angiograms), two with normal electrocardiograms and angiograms within one day of undetermined death; 0/5 non-sensitized-lased animals expired or had coronary spasm; and 3/7 sensitized-lased and 0/5 non-sensitized/lased had significant medial to adventitial histologic damage. Coronary irradiation at less than 200 J/cm2 appears to be safe for photodynamic treatment of atherosclerotic lesions. Pretreatment for coronary spasm is appropriate.