Restenosis following coronary balloon angioplasty

Do statins have a role in reduction/prevention of post-PCI restenosis?

The pathophysiology of post-PCI restenosis involves neointimal formation that consists of three phases: thrombosis (within 24 h), recruitment (3-8 days), and proliferation, which starts on day 8 of PCI. Various factors suggested to be predictors/risks for restenosis include C-reactive protein (CRP), inflammatory mediators (cytokines and adhesion molecules), oxygen radicals, advanced glycation end products (AGEs) and their receptors (RAGE), and soluble RAGE (sRAGE). The earlier noted factors produce thrombogenesis, vascular smooth muscle cell proliferation, and extracellular matrix formation. Statins have pleiotropic effects. Besides lowering serum cholesterol, they have various other biological effects including antiinflammatory, antithrombotic, CRP-lowering, antioxidant, antimitotic, and inhibition of smooth muscle cell proliferation. They inhibit matrix metalloproteinase and cyclooxygenase-2, lower AGEs, decrease expression of RAGE and increase levels of serum sRAGE. They also increase the synthesis of nitric oxide (NO) by increasing endothelial NO synthase expression and activity. Preprocedural statin therapy is known to reduce peri- and post-PCI myonecrosis and reduce the need for repeat revascularization. There is evidence that statin-eluting stents inhibit in-stent restenosis in animal models. It is concluded that because of the above attributes of statins, they are suitable candidates for reduction of post-PCI restenosis and post-PCI myonecrosis. The future directions for the use of statins in reduction of post-PCI restenosis and myonecrosis have been discussed.

A novel organ culture method to study intimal hyperplasia at the site of a coronary artery bypass anastomosis

BACKGROUND

Intimal hyperplasia or restenosis at the site of a coronary artery bypass anastomosis contributes to early graft failure, and growth factor release in response to construction of the anastomotic site strongly influences this process. Due to the difficulties in studying restenosis after coronary artery bypass graft surgery, we have tested whether an organ culture model we have developed can simulate the early events associated with intimal hyperplasia.

METHODS

End-to-side anastomosis of porcine radial artery to porcine coronary artery were constructed. The vessels were trimmed and incubated under standard tissue culture conditions for 14 days. Appropriate controls were treated similarly. The vessels were frozen, cryosectioned, and immunostained for the expression of the proliferation marker proliferating cell nuclear antigen (PCNA). A proliferative index (PCNA positive nuclei/total nuclei) was calculated for comparative purposes.

RESULTS

Limited PCNA staining was observed in noncultured vessel segments (0.046+/-0.045). A slight increase in this index was observed in vessels that had been placed into culture without manipulation (0.230+/-0.141) and in vessels subjected to an arteriotomy (0.462+/-0.249). However, the most significant increase was obtained after construction of an anastomosis (4.98+/-6.66). No change in total cell number was evident over the course of the experiment or in relation to the treatment.

CONCLUSIONS

Culture conditions and incision slightly stimulate cell proliferation in porcine coronary artery segments when compared with basal conditions of a native artery. In contrast, construction of an anastomosis increases proliferation 108-fold. Therefore, surgical manipulation of arterial conduits during construction of an anastomotic site is the primary trigger for intimal hyperplasia, independent of dissection and incision of the vessel. Furthermore, these data indicate the organ culture model we have developed will be useful for examining the cellular and molecular mechanisms that mediate intimal hyperplasia at the site of a coronary artery bypass graft anastomosis.

Structure-activity relationships for a novel series of pyrido[2,3-d]pyrimidine tyrosine kinase inhibitors

Screening of a compound library for inhibitors of the fibroblast growth factor (FGFr) and platelet-derived growth factor (PDGFr) receptor tyrosine kinases led to the development of a novel series of ATP competitive pyrido[2,3-d]pyrimidine tyrosine kinase inhibitors. The initial lead, 1-[2-amino-6-(2,6-dichlorophenyl)pyrido[2,3-d]pyrimidin-7-yl]-3- tert-butylurea (4b, PD-089828), was found to be a broadly active tyrosine kinase inhibitor. Compound 4b inhibited the PDGFr, FGFr, EGFr, and c-src tyrosine kinases with IC50 values of 1.11, 0.13, 0.45, and 0.22 microM, respectively. Subsequent SAR studies led to the synthesis of new analogs with improved potency, solubility, and bioavailability relative to the initial lead. For example, the introduction of a [4-(diethylamino)butyl]amino side chain into the 2-position of 4b afforded compound 6c with enhanced potency and bioavailability. Compound 6c inhibited PDGF-stimulated vascular smooth muscle cell proliferation with an IC50 of 0.3 microM. Furthermore, replacement of the 6-(2,6-dichlorophenyl) moiety of 4b with a 6-(3',5'-dimethoxyphenyl) functionality produced a highly selective FGFr tyrosine kinase inhibitor 4e. Compound 4e inhibited the FGFr tyrosine kinase with an IC50 of 0.060 microM, whereas IC50s for the inhibition of the PDGFr, FGFr, EGFr, c-src, and InsR tyrosine kinases for this compound (4e) were all greater than 50 microM.

Depolymerized holothurian glycosaminoglycan (DHG) prevents neointimal formation in balloon-injured rat carotid artery

The in vivo activity of depolymerized holothurian glycosaminoglycan (DHG), a newly developed polysaccharide anticoagulant, on neointimal formation induced by a balloon catheter in the left common carotid artery of rats was investigated. In every Sprague-Dawley rat weighing approximately 400 g, a Forgaty 2Fr balloon catheter was inserted from the left femoral artery to the left common carotid artery, and was passed through three times in order to denude the endothelium of the artery. These rats were divided into four groups by the following treatment protocols; DHG was given to rats by daily subcutaneous injection into their abdomens at a dose of 3 mg/kg or 10 mg/kg (D3 or D10 group). For controls, 250 microl saline was injected daily (C group). Furthermore, 1 mg/kg of unfractionated heparin was also injected daily as a comparison to DHG (H group). Each treatment was performed in six rats, and the injections were continued for two weeks after the catheterization. The area ratio of thickened intima/media (I/M ratio) treated with DHG decreased in a dose-dependent manner compared to the control. In addition, the ratio in the D10 group was significantly lower than in the control (P < 0.01). However, the ratio in the H group did not decrease. By anti-a smooth muscle actin antibody staining the intimal thickening layers were seen to be completely occupied by proliferated smooth muscle cells, and their amount in these layers was attenuated by the DHG treatment. This indicated that DHG has an inhibitory effect on intimal thickening induced by balloon catheterization, and that this might be due to the inactivation of aberrant smooth muscle cells by this agent.

Comparison of the effects of the thrombin inhibitor r-hirudin in four animal models of neointima formation after arterial injury

Thrombin has been implicated as a contributing factor to restenosis after vessel reopening procedures. We compared the ability of the direct thrombin inhibitor recombinant (r-) hirudin to reduce neointimal growth in different animal models of arterial injury. Carotid arteries of rats, rabbits, and hypercholesterolemic minipigs were injured by withdrawal of an inflated balloon catheter. In addition, we used a double-lesion model in rabbits, which involved balloon angioplasty of a preexisting lesion induced by carotid denudation 4 weeks earlier. r-Hirudin was given in all four animal models as a short-term application (bolus of 1 mg/kg i.v. immediately before injury, followed by infusion of 1 mg.kg-1.h-1 for 2 hours, and an injection of 6 mg/kg SC). Additionally, we investigated the effects of prolonged treatment (intravenous infusion for 3 and 14 days) in rats. Inhibition of thrombin was monitored by determination of activated partial thromboplastin time, and histomorphometric analysis of the arteries was performed after 2 (rats) or 4 (rabbits and minipigs) weeks. In rabbits, short-term r-hirudin treatment reduced neointimal area by 59% (single-injury model, P = .05) and 44% (double-injury model, P = .02). In rats and minipigs no inhibition of neointimal growth was observed after short-term r-hirudin application. A 3- or 14-day infusion of r-hirudin in rats, however, resulted in 25% (P = .007) and 27% (P = .003) reductions in neointimal area, respectively. In conclusion, there is considerable interspecies variation in the time frame of susceptibility for reduction of neointimal growth by inhibition of thrombin after arterial injury. These results demonstrate the importance of testing potential antirestenotic treatments in an array of different animal models.

FK409, a new nitric-oxide donor, suppresses smooth muscle proliferation in the rat model of balloon angioplasty

The effect of FK409, a new nitric-oxide (NO) donor, on neointimal formation of rat carotid arteries following balloon injury was studied. The intimal thickening at 14 days was strongly suppressed by twice daily administration of FK409 at 10 mg/kg from 2 days before to 13 days after injury. The neointima area and neointima/media ratio were decreased by 48.0% (P < 0.01) and 38.5% (P < 0.01), respectively, compared with control. On the other hand, isosorbide dinitrate (ISDN), a classical nitro-vasodilator, did not suppress intimal thickening even at 100 mg/kg twice a day. An in vivo 5-bromo-2'-dedoxyuridine (BrdU) uptake study revealed that FK409 inhibited the proliferative response of smooth muscle cells (SMC) in media at early stage of injury. In fact, the neointimal formation at 14 days was inhibited by the short term administration of FK409 only from the day of injury to 4 days after at 10 mg/kg twice a day. In cultured rat SMC, FK409 (1-10 mumol/l) markedly enhanced intracellular c-GMP and inhibited the proliferation in 10% FBS-containing medium. These results suggest that FK409 suppresses intimal thickening following balloon injury of the rat carotid artery by inhibition of SMC proliferation.

Effect of nonanticoagulant heparin (Astenose) on restenosis after balloon angioplasty in the atherosclerotic rabbit

PURPOSE

To determine whether intravenous administration of Astenose, a high-molecular-weight nonanticoagulant heparin, can reduce restenosis following balloon angioplasty in a rabbit model.

MATERIALS AND METHODS

Focal atherosclerosis was induced in 54 rabbits (89 vessel), and angioplasty was performed after animals were randomized into five groups. Group 1 vessels (control) were treated with lactated Ringer solution for 28 days (n = 19); group 2, Astenose at 0.10 mg/kg per hour for 28 days (n = 16); group 3, Astenose at 0.33 mg/kg per hour for 28 days (n = 16); group 4, Astenose at 0.60 mg/kg per hour for 28 days (n = 17); and group 5, Astenose at 0.33 mg/kg per hour for 14 days (n = 21). Arteriograms were obtained to measure minimal luminal diameters before, immediately after, and 28 days after angioplasty, and the rabbits were killed for histologic analysis.

RESULTS

Angiographically demonstrated restenosis was significantly reduced in groups 3 (18.9% +/- 3.7, P = .04) and 4 (20.2% +/- 3.1, P = .04) compared with the control group (32.4% +/- 4.8). Group 5 showed a nonsignificant trend toward reduced restenosis (23.1% +/- 2.9, P = .09), and group 2 showed restenosis similar to that in group 1 (31.0% +/- 2.5, P = .80). However, quantitative histopathologic analysis detected no differences among the groups in absolute plaque area. Medial area was significantly smaller in groups 2 and 5 (P < or = .002) than in group 1, and there was a nonsignificant trend toward reduced medial area in groups 3 and 4 (P = .12).

CONCLUSION

Long-term intravenous Astenose therapy resulted in a modest but statistically significant reduction in angiographically demonstrated restenosis after angioplasty in this atherosclerotic rabbit model.

Polymorphonuclear leukocytes enhance release of growth factors by cultured endothelial cells

Porcine aortic endothelial cells (PAECs) in culture constitutively secrete polypeptide (endothelium-derived) growth factors (EDGFs) into the surrounding medium. Incubation of PAECs with human peripheral blood polymorphonuclear leukocytes (PMNs) caused a significant increase in EDGF release as assessed by [3H]thymidine incorporation into BALB/c 3T3 mouse fibroblasts and cell proliferation assay. The effect was time dependent and correlated with the number of PMNs, reaching a maximum with a 1:1 PAEC to PMN ratio. Generation of mitogenic activity was prevented by cycloheximide, indicating a requirement for de novo protein synthesis. Antibody-mediated inhibition assays suggested that mitogenic activity was due to platelet-derived growth factor and basic fibroblast growth factor. When supernatant from N-formyl-methionyl-leucyl-phenylalanine-stimulated PMNs was substituted for PMNs during incubation with PAECs, powerful mitogenic activity was generated, indicating the involvement of soluble mediators. A role for free oxygen radicals was ruled out by experiments in which superoxide dismutase and catalase did not prevent the increase in mitogenic activity. By contrast, serine protease inhibitors such as soybean trypsin inhibitor, alpha 1-antitrypsin, and eglin C reduced the PMN-stimulating activity by 70%, 80%, and 100%, respectively. The possible involvement of cathepsin G and elastase was investigated. Cathepsin G and elastase, when substituted for PMNs, increased the release of EDGFs in a dose-dependent fashion, mimicking the effect of PMNs. These findings suggest a new role for leukocyte-vessel wall interactions in the proliferative feature of atherosclerosis.

C-type natriuretic peptide inhibits growth factor-dependent DNA synthesis in smooth muscle cells

We have examined the ability of C-type natriuretic peptide (CNP) to interact with guanylate cyclase-coupled natriuretic peptide receptors by measuring its ability to stimulate intracellular guanosine 3',5'-cyclic monophosphate (cGMP) accumulation in cultured bovine aortic endothelial (BAE) and bovine aortic smooth muscle (BASM) cells. Our experiments indicate that CNP is unable to stimulate the production of cGMP in BAE cells, whereas both atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) markedly elevate cGMP levels in these cells (ANP = BNP >> CNP). In contrast, CNP is the most effective of the three peptides with respect to the stimulation of cGMP levels in BASM cells, fetal human vascular smooth muscle cells, and rat A10 cells (CNP >> ANP > BNP), with the maximal level of stimulation being approximately 5- to 10-fold over that observed for ANP. We have also shown that CNP is able to inhibit serum- and growth factor-induced DNA synthesis in BASM cells. Low concentrations of CNP (20 x 10(-9) M) inhibit up to 80% of the [3H]-thymidine incorporation induced by basic fibroblast growth factor, platelet derived growth factor, epidermal growth factor (EGF), and heparin binding EGF-like growth factor. These data indicate that, although CNP has been detected only in the central nervous system and not in the circulation, it may possess multiple effects on vascular tissue.

Low level in vivo gene transfer into the arterial wall through a perforated balloon catheter

BACKGROUND

Gene transfer into the arterial wall may provide a novel therapeutic strategy for the treatment of coronary artery restenosis. Previously described methods for gene transfer into the arterial wall require total vessel occlusion for 30 minutes. We sought to develop a protocol for gene transfer within a more clinically relevant time frame.

METHODS AND RESULTS

We used a perforated balloon (Wolinsky) catheter to inject retroviral vector-containing virions into rabbit aortas in vivo. The virions were injected within 1 minute. Aortas were removed 5-14 days after injection and analyzed for evidence of gene transfer. In initial studies, nine rabbits were injected with a vector expressing the beta-galactosidase gene, and nine rabbits were injected with either non-beta-galactosidase-containing vectors or with a vehicle control. Histochemical staining of aortic tissues revealed blue (positive) cells in eight of nine experimental rabbits and six of nine controls. Because of the lack of specificity of the beta-galactosidase detection system, we adopted a polymerase chain reaction-based protocol in which oligonucleotide primers were used to amplify specific vector-related sequences from aortic tissue extracts. The polymerase chain reaction protocol, calibrated with standards containing known numbers of transduced cells, revealed low amounts of vector-related sequences in six of 12 vector-injected rabbits and in one of 13 controls (p less than 0.03). Comparison with standards indicated that fewer than 100 transduced cells were present in a 2-cm length of the injected aortic tissue.

CONCLUSIONS

Although in vivo gene transfer through an infusion balloon catheter can be accomplished within 1 minute, the therapeutic use of this protocol is limited by the small number of cells that are transduced.