Molecular Imaging of Vascular Phenotype in Cardiovascular Disease: New Diagnostic Opportunities on the Horizon

Contrast-Enhanced Ultrasound Molecular Imaging in Atherosclerosis Research

The management of cardiovascular conditions will likely be improved by noninvasive in vivo molecular imaging technologies that can provide earlier or more accurate diagnosis. These techniques are already having a positive impact in preclinical research by providing insight into disease pathobiology or efficacy of new therapies. Contrast enhanced ultrasound (CEU) molecular imaging is a technique that relies on the ultrasound detection of targeted microbubble contrast agents to examine molecular or cellular events that occur at the blood pool-endothelial interface. For the most part, targeted contrast agents are composed of encapsulated gas microbubbles (MBs) that are 2-4 μm in diameter, or other acoustically active micro- or nanoparticles. These agents bear several tens of thousands of binding molecules per particle. Because nonadhered agent is cleared rapidly, CEU molecular imaging can be performed in a matter of minutes. MBs are detected using contrast-specific techniques that generate and receive nonlinear signals produced by MB cavitation, thereby increasing signal-to-noise ratio. Dedicated kinetic models for molecular imaging have been generated that permit the elimination of signal from nonadherent agent.

Seeing the Invisible-Ultrasound Molecular Imaging

Ultrasound molecular imaging has been developed in the past two decades with the goal of non-invasively imaging disease phenotypes on a cellular level not depicted on anatomic imaging. Such techniques already play a role in pre-clinical research for the assessment of disease mechanisms and drug effects, and are thought to in the future contribute to earlier diagnosis of disease, assessment of therapeutic effects and patient-tailored therapy in the clinical field. In this review, we first describe the chemical composition and structure as well as the in vivo behavior of the ultrasound contrast agents that have been developed for molecular imaging. We then discuss the strategies that are used for targeting of contrast agents to specific cellular targets and protocols used for imaging. Next we describe pre-clinical data on imaging of thrombosis, atherosclerosis and microvascular inflammation and in oncology, including the pathophysiological principles underlying the selection of targets in each area. Where applicable, we also discuss efforts that are currently underway for translation of this technique into the clinical arena.

Ultrasound molecular imaging: insights into cardiovascular pathology

Similar to what has already occurred in cancer medicine, the management of cardiovascular conditions will likely be improved by non-invasive molecular imaging technologies that can provide earlier or more accurate diagnosis. These techniques are already having a positive impact in pre-clinical research by providing insight into pathophysiology or efficacy of new therapies. Contrast enhanced ultrasound (CEU) molecular imaging is a technique that relies on the ultrasound detection of targeted microbubble contrast agents to examine molecular or cellular events that occur at the blood pool-endothelial interface. CEU molecular imaging techniques have been developed that are able to provide unique information on atherosclerosis, ischemia reperfusion injury, angiogenesis, vascular inflammation, and thrombus formation. Accordingly, CEU has the potential to be used in a wide variety of circumstances to detect disease early or at the bedside, and to guide appropriate therapy based on vascular phenotype. This review will describe the physical basis for CEU molecular imaging, and the specific disease processes for the pre-clinical translational research experience.

Ultrasound Molecular Imaging of Atherosclerosis Using Small-Peptide Targeting Ligands Against Endothelial Markers of Inflammation and Oxidative Stress

The aim of this study was to evaluate a panel of endothelium-targeted microbubble (MB) ultrasound contrast agents bearing small peptide ligands as a human-ready approach for molecular imaging of markers of high-risk atherosclerotic plaque. Small peptide ligands with established affinity for human P-selectin, VCAM-1, LOX-1 and von Willebrand factor (VWF) were conjugated to the surface of lipid-stabilized MBs. Contrast-enhanced ultrasound (CEUS) molecular imaging of the thoracic aorta was performed in wild-type and gene-targeted mice with advanced atherosclerosis (DKO). Histology was performed on carotid endarterectomy samples from patients undergoing surgery for unstable atherosclerosis to assess target expression in humans. In DKO mice, CEUS signal for all four targeted MBs was significantly higher than that for control MBs, and was three to sevenfold higher than in wild-type mice, with the highest signal achieved for VCAM-1 and VWF. All molecular targets were present on the patient plaque surface but expression was greatest for VCAM-1 and VWF. We conclude that ultrasound contrast agents bearing small peptide ligands feasible for human use can be targeted against endothelial cell adhesion molecules for inflammatory cells and platelets for imaging advanced atherosclerotic disease.

Endothelial vascular cell adhesion molecule 1 is a marker for high-risk carotid plaques and target for ultrasound molecular imaging

BACKGROUND

Molecular imaging of carotid plaque vulnerability to atheroembolic events is likely to lead to improvements in selection of patients for carotid endarterectomy (CEA). The aims of this study were to assess the relative value of endothelial inflammatory markers for this application and to develop molecular ultrasound contrast agents for their imaging.

METHODS

Human CEA specimens were obtained prospectively from asymptomatic (30) and symptomatic (30) patients. Plaques were assessed by semiquantitative immunohistochemistry for vascular cell adhesion molecule 1 (VCAM-1), lectin-like oxidized low-density lipoprotein receptor 1, P-selectin, and von Willebrand factor. Established small peptide ligands to each of these targets were then synthesized and covalently conjugated to the surface of lipid-shelled microbubble ultrasound contrast agents, which were then evaluated in a flow chamber for binding kinetics to activated human aortic endothelial cells under variable shear conditions.

RESULTS

Expression of VCAM-1 on the endothelium of CEA specimens from symptomatic patients was 2.4-fold greater than that from asymptomatic patients (P < .01). Expression was not significantly different between groups for P-selectin (P = .43), von Willebrand factor (P = .59), or lectin-like oxidized low-density lipoprotein receptor 1 (P = .99). Although most plaques from asymptomatic patients displayed low VCAM-1 expression, approximately one in five expressed high VCAM-1 similar to plaques from symptomatic patients. In vitro flow chamber experiments demonstrated that VCAM-1-targeted microbubbles bind cells that express VCAM-1, even under high-shear conditions that approximate those found in human carotid arteries, whereas binding efficiency was lower for the other agents.

CONCLUSIONS

VCAM-1 displays significantly higher expression on high-risk (symptomatic) vs low-risk (asymptomatic) carotid plaques. Ultrasound contrast agents bearing ligands for VCAM-1 can sustain high-shear attachment and may be useful for identifying patients in whom more aggressive treatment is warranted.

Quantitative investigation of the edge enhancement in in-line phase contrast projections and tomosynthesis provided by distributing microbubbles on the interface between two tissues: a phantom study

The objective of this study was to quantitatively investigate the ability to distribute microbubbles along the interface between two tissues, in an effort to improve the edge and/or boundary features in phase contrast imaging. The experiments were conducted by employing a custom designed tissue simulating phantom, which also simulated a clinical condition where the ligand-targeted microbubbles are self-aggregated on the endothelium of blood vessels surrounding malignant cells. Four different concentrations of microbubble suspensions were injected into the phantom: 0%, 0.1%, 0.2%, and 0.4%. A time delay of 5 min was implemented before image acquisition to allow the microbubbles to become distributed at the interface between the acrylic and the cavity simulating a blood vessel segment. For comparison purposes, images were acquired using three system configurations for both projection and tomosynthesis imaging with a fixed radiation dose delivery: conventional low-energy contact mode, low-energy in-line phase contrast and high-energy in-line phase contrast. The resultant images illustrate the edge feature enhancements in the in-line phase contrast imaging mode when the microbubble concentration is extremely low. The quantitative edge-enhancement-to-noise ratio calculations not only agree with the direct image observations, but also indicate that the edge feature enhancement can be improved by increasing the microbubble concentration. In addition, high-energy in-line phase contrast imaging provided better performance in detecting low-concentration microbubble distributions.

Ultrasound imaging for risk assessment in atherosclerosis

Atherosclerosis and its consequences like acute myocardial infarction or stroke are highly prevalent in western countries, and the incidence of atherosclerosis is rapidly rising in developing countries. Atherosclerosis is a disease that progresses silently over several decades before it results in the aforementioned clinical consequences. Therefore, there is a clinical need for imaging methods to detect the early stages of atherosclerosis and to better risk stratify patients. In this review, we will discuss how ultrasound imaging can contribute to the detection and risk stratification of atherosclerosis by (a) detecting advanced and early plaques; (b) evaluating the biomechanical consequences of atherosclerosis in the vessel wall;

Cardiovascular drug delivery with ultrasound and microbubbles

Microbubbles lower the threshold for cavitation of ultrasound and have multiple potential therapeutic applications in the cardiovascular system. One of the first therapeutic applications to enter into clinical trials has been microbubble-enhanced sonothrombolysis. Trials were conducted in acute ischemic stroke and clinical trials are currently underway for sonothrombolysis in treatment of acute myocardial infarction. Microbubbles can be targeted to epitopes expressed on endothelial cells and thrombi by incorporating targeting ligands onto the surface of the microbubbles. Targeted microbubbles have applications as molecular imaging contrast agents and also for drug and gene delivery. A number of groups have shown that ultrasound with microbubbles can be used for gene delivery yielding robust gene expression in the target tissue. Work has progressed to primate studies showing delivery of therapeutic genes to generate islet cells in the pancreas to potentially cure diabetes. Microbubbles also hold potential as oxygen therapeutics and have shown promising results as a neuroprotectant in an ischemic stroke model. Regulatory considerations impact the successful clinical development of therapeutic applications of microbubbles with ultrasound. This paper briefly reviews the field and suggests avenues for further development.

Feasibility of lactadherin-bearing clinically available microbubbles as ultrasound contrast agent for angiogenesis

OBJECTIVES

Phagocytosis of apoptotic cells is carried out through bridging of phosphatidylserine (PS)-expressing apoptotic cells and integrin αvβ3-expressing phagocytes with lactadherin. The objective of this study was to examine whether microbubbles targeted to integrin αvβ3 could be produced by conjugating a PS-containing clinically available ultrasound contrast agent with lactadherin.

MATERIALS AND METHODS

PS-containing perfluorobutane-filled microbubbles were incubated with R-phycoerythrin (PE)-labeled lactadherin, and the presence of PE-positive bubbles was examined by FACS analysis. Secondly, the attachment of lactadherin to integrin αvβ3-expressing cells (human umbilical vein endothelial cells (HUVEC)) was also examined by FACS analysis. Finally, the adhesion of PS-containing bubbles to HUVEC was examined using a parallel plate flow chamber. The number of adherent bubbles with or without the intermediation of lactadherin was compared.

RESULTS

The more lactadherin was added to the bubble suspension, the more PE-positive bubbles were detected. The size of bubbles was not increased even after conjugation with lactadherin (2.90 ± 0.04 vs. 2.81 ± 0.02 μm). Binding between lactadherin and HUVEC was also confirmed by FACS analysis. The parallel plate flow chamber study revealed that the number of PS-containing bubbles adherent to HUVEC was increased about five times by the intermediation of lactadherin (12.1 ± 6.0 to 58.7 ± 33.1 bubbles).

CONCLUSION

Because integrin αvβ3 is well-known to play a key role in angiogenesis, the complex of PS-containing bubbles and lactadherin has feasibility as a clinically translatable targeted ultrasound contrast agent for angiogenesis.

The cargo of CRPPR-conjugated liposomes crosses the intact murine cardiac endothelium

Ligand-conjugated liposomes and other nano-sized constructs are attractive drug carriers due to their extended plasma circulation; however, limited data are available as to whether their cargo can traverse the endothelium of solid organs. To determine whether the cargo of endothelially targeted liposomes is internalized by endothelial cells and transported into tissue, and to evaluate whether such liposomes can accumulate in models of cardiovascular disease, we tracked the fate of the cargo (a hydrophilic fluorescent dye) and shell (conjugated with a radioisotope) of a heart-homing liposome (CRPPR-conjugated). The ex vivo heart was imaged with confocal microscopy and the in vivo heart with positron emission tomography in sham-treated mice and models of ischemia/reperfusion (I/R) and myocardial infarction (MI). Within 30 min of injection of 20mg/kg CRPPR liposomes, fluorescence increased by 47 fold in the tissue surrounding the vascular lumen, as compared with non-targeted liposomes. Both the accumulation on the endothelium and the interstitial fluorescence saturated at an injected dose of 20mg/kg. In both I/R and MI models, CRPPR liposomes accumulated in diseased sites, although less than in surrounding healthy tissue. The accumulation in the diseased sites increased with time post-injury: the ratio of accumulated radioactivity in the diseased and healthy cardiac tissue increased from 0.20±0.04, to 0.58±0.12 and 0.61±0.19 for 1, 7, and 99 days post-MI, indicating the potential for adequate delivery and therapeutic efficacy if the targeted particles are injected at 7 or more days post-MI. In summary, CRPPR- liposomes accumulated in normal and diseased hearts, and the cargo accumulated in the tissue within minutes and remained detectable after 24 h.

Subclinical atherosclerosis as a risk factor of cardiovascular events

Subclinical atherosclerosis is an initial, latent stage of chronic progressing arterial inflammation. Destabilisation of asymptomatic, hemodynamically non-significant atherosclerotic plaques (AP) could lead to myocardial infarction, stroke, or sudden death. Since the assessment of AP stability is problematic in real-world clinical settings, the risk stratification should, at least, account for the presence of subclinical atherosclerosis. In 600 ambulatory patients from the Moscow City Western Administrative Okrug who had low and moderate SCORE-assessed cardiovascular risk levels, the prevalence of AP, based on the duplex carotid ultrasound results, was 59% (n=358). Presently, no standard guidelines exist on cardiovascular risk stratification which would include the assessment of subclinical atherosclerosis, despite the importance of the latter as a prognostic factor. Large clinical studies on prognosis in patients with subclinical atherosclerosis will clarify the role of this parameter as an independent cardiovascular risk factor and facilitate the development of respective clinical recommendations.