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Chen R, Zhang H, Tang B, Luo Y, Yang Y, Zhong X, Chen S, Xu X, Huang S, Liu C. Macrophages in cardiovascular diseases: molecular mechanisms and therapeutic targets. Signal Transduct Target Ther 2024; 9:130. [PMID: 38816371 PMCID: PMC11139930 DOI: 10.1038/s41392-024-01840-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 04/02/2024] [Accepted: 04/21/2024] [Indexed: 06/01/2024] Open
Abstract
The immune response holds a pivotal role in cardiovascular disease development. As multifunctional cells of the innate immune system, macrophages play an essential role in initial inflammatory response that occurs following cardiovascular injury, thereby inducing subsequent damage while also facilitating recovery. Meanwhile, the diverse phenotypes and phenotypic alterations of macrophages strongly associate with distinct types and severity of cardiovascular diseases, including coronary heart disease, valvular disease, myocarditis, cardiomyopathy, heart failure, atherosclerosis and aneurysm, which underscores the importance of investigating macrophage regulatory mechanisms within the context of specific diseases. Besides, recent strides in single-cell sequencing technologies have revealed macrophage heterogeneity, cell-cell interactions, and downstream mechanisms of therapeutic targets at a higher resolution, which brings new perspectives into macrophage-mediated mechanisms and potential therapeutic targets in cardiovascular diseases. Remarkably, myocardial fibrosis, a prevalent characteristic in most cardiac diseases, remains a formidable clinical challenge, necessitating a profound investigation into the impact of macrophages on myocardial fibrosis within the context of cardiac diseases. In this review, we systematically summarize the diverse phenotypic and functional plasticity of macrophages in regulatory mechanisms of cardiovascular diseases and unprecedented insights introduced by single-cell sequencing technologies, with a focus on different causes and characteristics of diseases, especially the relationship between inflammation and fibrosis in cardiac diseases (myocardial infarction, pressure overload, myocarditis, dilated cardiomyopathy, diabetic cardiomyopathy and cardiac aging) and the relationship between inflammation and vascular injury in vascular diseases (atherosclerosis and aneurysm). Finally, we also highlight the preclinical/clinical macrophage targeting strategies and translational implications.
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Affiliation(s)
- Runkai Chen
- Department of Cardiology, Laboratory of Heart Center, Heart Center, Translational Medicine Research Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou, 510280, China
| | - Hongrui Zhang
- Department of Cardiology, Laboratory of Heart Center, Heart Center, Translational Medicine Research Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou, 510280, China
| | - Botao Tang
- Department of Cardiology, Laboratory of Heart Center, Heart Center, Translational Medicine Research Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou, 510280, China
| | - Yukun Luo
- Department of Cardiology, Laboratory of Heart Center, Heart Center, Translational Medicine Research Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou, 510280, China
| | - Yufei Yang
- Department of Cardiology, Laboratory of Heart Center, Heart Center, Translational Medicine Research Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou, 510280, China
| | - Xin Zhong
- Department of Cardiology, Laboratory of Heart Center, Heart Center, Translational Medicine Research Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou, 510280, China
| | - Sifei Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Xinjie Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
| | - Shengkang Huang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
| | - Canzhao Liu
- Department of Cardiology, Laboratory of Heart Center, Heart Center, Translational Medicine Research Center, Zhujiang Hospital, Southern Medical University, 253 Industrial Avenue, Guangzhou, 510280, China.
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Todd M, Nair PK, Ohayon J, Pettigrew RI, Yazdani SK. Liquid Drug Delivery Approaches for the Treatment of Occlusive Arterial Disease: A Systematic Review. J Endovasc Ther 2024; 31:203-213. [PMID: 36052425 PMCID: PMC11149167 DOI: 10.1177/15266028221120755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Local Liquid drug (LLD) delivery devices have recently emerged as a novel approach to treat peripheral arterial disease. This systemic review aims to identify and evaluate the clinical utility of the most commonly used delivery devices. METHODS A systemic review was performed using the Medical Subjects Heading terms of "drug delivery," "liquid," "local," and "cardiovascular disease" in PubMed, Google Scholar, and Scopus. RESULTS Four commonly used delivery devices were identified, including (1) the Bullfrog Micro-Infusion Device, (2) the ClearWay RX Catheter, (3) the Occlusion Perfusion Catheter, and (4) the Targeted Adjustable Pharmaceutical Administration. All have shown to successfully deliver liquid therapeutic into the target lesion and have exhibited favorable safety and efficacy profiles in preclinical and clinical trials. The LLD devices have the ability to treat very long or multiple lesions with a single device, providing a more economical option. The safety profile in LLD clinical studies is also favorable in view of recent concerns regarding adverse events with crystalline-paclitaxel-coated devices. CONCLUSION There is clear clinical evidence to support the concept of local liquid delivery to treat occlusive arterial disease. CLINICAL IMPACT The 'leave nothing behind' strategy has been at the forefront of the most recent innovations in the field of interventional cardiology and vascular interventions. Although drug coated balloons have overcome limitations associated with plain old balloon angioplasty and peripheral stents, recent safety concerns and cost considerations have impacted their usage. In this review, various liquid drug delivery devices are presented, showcasing their capabilities and success in both preclinical and clinical settings. These innovative liquid delivery devices, capable of targeted delivery and their ability to be re-used for multiple treatment sites, may provide solutions for current unmet clinical needs.
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Affiliation(s)
- Meagan Todd
- Department of Engineering, Wake Forest University, Winston-Salem, NC, USA
| | | | - Jacques Ohayon
- Savoie Mont-Blanc University, Polytech Annecy-Chambéry, Le Bourget du Lac, France and Laboratory TIMC-IMAG, CNRS, UMR 5525, Grenoble-Alpes University, Grenoble, France
| | - Roderic I Pettigrew
- Texas A&M University and Houston Methodist Hospital, Engineering Medicine (EnMed), Houston, TX, USA
| | - Saami K Yazdani
- Department of Engineering, Wake Forest University, Winston-Salem, NC, USA
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Rahmani G, O'Sullivan GJ. Acute and chronic venous occlusion. Br J Radiol 2023; 96:20230242. [PMID: 37750946 PMCID: PMC10607425 DOI: 10.1259/bjr.20230242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/04/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023] Open
Abstract
This review article provides an overview of acute and chronic venous occlusion, a condition that can cause significant morbidity and mortality if not diagnosed and treated promptly. The article begins with an introduction to the anatomy of the venous system, followed by a discussion of the causes and clinical features of venous occlusion. The diagnostic tools available for the assessment of venous occlusion, including imaging modalities such as ultrasound, CT, and MRI, are then discussed, along with their respective advantages and limitations. The article also covers the treatment options for acute and chronic venous occlusion, including anticoagulant therapy and endovascular interventions. This review aims to provide radiologists with an updated understanding of the pathophysiology, diagnosis, and management of acute and chronic venous occlusion.
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Affiliation(s)
- George Rahmani
- Department of Interventional Radiology, Galway University Hospitals, Galway, Ireland
| | - Gerard J O'Sullivan
- Department of Interventional Radiology, Galway University Hospitals, Galway, Ireland
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Kim WJ, Samarage HM, Zarrin D, Goel K, Wang AC, Johnson J, Nael K, Colby GP. Endovascular transmural access to carotid artery perivascular tissues: safety assessment of a novel technique. J Neurointerv Surg 2023; 15:1007-1013. [PMID: 36319086 PMCID: PMC10149561 DOI: 10.1136/jnis-2022-019583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recent advances in endovascular devices have allowed access and targeting of perivascular tissues of the peripheral circulation. The perivascular tissues of the cervical and cranial circulations have many important structures of clinical significance, yet the feasibility and safety of such an approach has not been demonstrated. OBJECTIVE To evaluate the safety of a novel endovascular transmural approach to target the perivascular tissues of the common carotid artery in swine. METHODS A micro-infusion device was positioned in the carotid arteries of three Yorkshire pigs (six carotid arteries in total), and each carotid artery was punctured 10 times in the same location to gain access to the perivascular tissues. Digital subtraction angiography was used to evaluate vessel injury or contrast extravasation. MRI and MR angiography were used to evaluate evidence of cerebral ischemia or vessel injury. Post-mortem tissue analysis was performed to assess the level of extravascular hematoma and intravascular dissection. RESULTS None of the tested carotid arteries showed evidence of vessel injury (dissection or perforation) or intravascular thrombosis. MRI performed after repeated puncture was negative for neck hematoma and brain ischemia. Post-mortem tissue analysis of the carotid arteries showed mild adventitial staining with blood, but without associated hematoma and without vessel dissection. CONCLUSION Repeated puncture of the carotid artery to gain access to the perivascular tissues using a novel endovascular transmural approach is safe in a swine model. This represents a novel approach to various tissues in close proximity to the cervical and cranial vasculature.
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Affiliation(s)
- Wi Jin Kim
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Hasitha Milan Samarage
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - David Zarrin
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Anthony C Wang
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Jeremiah Johnson
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Kambiz Nael
- Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
- Department of Radiological Sciences, University of California Los Angeles, Los Angeles, California, USA
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Bechelli C, Macabrey D, Deglise S, Allagnat F. Clinical Potential of Hydrogen Sulfide in Peripheral Arterial Disease. Int J Mol Sci 2023; 24:9955. [PMID: 37373103 DOI: 10.3390/ijms24129955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
Peripheral artery disease (PAD) affects more than 230 million people worldwide. PAD patients suffer from reduced quality of life and are at increased risk of vascular complications and all-cause mortality. Despite its prevalence, impact on quality of life and poor long-term clinical outcomes, PAD remains underdiagnosed and undertreated compared to myocardial infarction and stroke. PAD is due to a combination of macrovascular atherosclerosis and calcification, combined with microvascular rarefaction, leading to chronic peripheral ischemia. Novel therapies are needed to address the increasing incidence of PAD and its difficult long-term pharmacological and surgical management. The cysteine-derived gasotransmitter hydrogen sulfide (H2S) has interesting vasorelaxant, cytoprotective, antioxidant and anti-inflammatory properties. In this review, we describe the current understanding of PAD pathophysiology and the remarkable benefits of H2S against atherosclerosis, inflammation, vascular calcification, and other vasculo-protective effects.
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Affiliation(s)
- Clémence Bechelli
- Department of Vascular Surgery, Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Diane Macabrey
- Department of Vascular Surgery, Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Sebastien Deglise
- Department of Vascular Surgery, Lausanne University Hospital, 1005 Lausanne, Switzerland
| | - Florent Allagnat
- Department of Vascular Surgery, Lausanne University Hospital, 1005 Lausanne, Switzerland
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Adventitial injection of HA/SA hydrogel loaded with PLGA rapamycin nanoparticle inhibits neointimal hyperplasia in a rat aortic wire injury model. Drug Deliv Transl Res 2022; 12:2950-2959. [PMID: 35378720 DOI: 10.1007/s13346-022-01158-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 12/16/2022]
Abstract
Neointimal hyperplasia is a persistent complication after vascular interventions, and it is also the leading cause of vascular graft restenosis and failure after arterial interventions, so novel treatment methods are needed to treat this complication. We hypothesized that adventitial injection of HA/SA hydrogel loaded with PLGA rapamycin nanoparticle (hydrogel-PLGA-rapamycin) could inhibit neointimal hyperplasia in a rat aortic wire injury model. The HA/SA hydrogel was fabricated by the interaction of hyaluronic acid (HA), sodium alginate (SA), and CaCO3; and loaded with PLGA rapamycin nanoparticle or rhodamine uniformly. A SD rat aortic wire injury induced neointimal hyperplasia model was developed, the control group only received wire injury, the adventitial application group received 10 μL hydrogel-PLGA-rapamycin after wire injury, and the adventitial injection group received 10 μL hydrogel-PLGA-rapamycin injected into the aortic adventitia after wire injury. Tissues were harvested at day 21 and analyzed by histology and immunohistochemical staining. Hydrogel loaded with rhodamine can be successfully injected into the aortic adventitia and was encapsuled by the adventitia. The hydrogel could be seen beneath the adventitia after adventitial injection but was almost degraded at day 21. There was a significantly thinner neointima in the adventitial application group and adventitial injection group compared to the control group (p = 0.0009). There were also significantly fewer CD68+ (macrophages) cells (p = 0.0012), CD3+ (lymphocytes) cells (p = 0.0011), p-mTOR+ cells (p = 0.0019), PCNA+ cells (p = 0.0028) in the adventitial application and adventitial injection groups compared to the control group. The endothelial cells expressed arterial identity markers (Ephrin-B2 and dll-4) in all these three groups. Adventitial injection of hydrogel-PLGA-rapamycin can effectively inhibit neointimal hyperplasia after rat aortic wire injury. This may be a promising drug delivery method and therapeutic choice to inhibit neointimal hyperplasia after vascular interventions.
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Cawich I, Armstrong EJ, George JC, Golzar J, Shishehbor MH, Razavi M, Lee V, Ouriel K. Temsirolimus Adventitial Delivery to Improve ANGiographic Outcomes Below the Knee. J Endovasc Ther 2022:15266028221131459. [PMID: 36320143 DOI: 10.1177/15266028221131459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Current endovascular treatments of below the knee (BTK) popliteal or tibial/peroneal arteries including investigational drug-coated balloons have limited long-term efficacy. OBJECTIVES This Phase 2 trial assessed the feasibility of adventitial deposition of temsirolimus to reduce neointimal hyperplasia and clinically relevant target lesion failure (CR-TLF) 6 months after BTK arterial revascularization. METHODS This prospective, multicenter, double-blinded, comparative, dose-escalation trial enrolled 61 patients with Rutherford 3 to 5 symptoms undergoing endovascular revascularization of ≥1 angiographically significant BTK lesions. Perivascular infusion after completion of arterial revascularization was randomized into control (saline) vs low-dose (0.1 mg/mL) temsirolimus groups for the first 30 patients. In the second part of the trial, patients were randomized to control versus high-dose (0.4 mg/mL) temsirolimus groups. Primary and secondary efficacy endpoints were target lesion (TL) transverse-view vessel area loss percentage (TVAL%) and CR-TLF at 6 months, respectively. CR-TLF was defined as a composite of ischemia-driven major amputation of the target limb, clinically driven target lesion revascularization (CD-TLR), and clinically relevant TL occlusion. The primary safety endpoint was freedom from major adverse limb events or perioperative death (MALE+POD) at 30 days. RESULTS There was no discernable difference in effect between temsirolimus doses; therefore, the low- and high-dose cohorts were pooled for the analyses. The principal analysis on the per protocol (PP) group of 53 patients revealed superior primary efficacy of the treatment arm, with reduction in TVAL% of 13.9% absolute (37.3% relative) and the rate of CR-TLF reduced by 27.1% absolute (51.3% relative), at 6 months. Subgroup analysis of all Trans-Atlantic Inter-Society Consensus (TASC) B to D lesions (N=36) revealed TVAL% reduction of 22.3% absolute (48.3% relative) and the rate of CR-TLF reduced by 39.2% absolute (56.6% relative). Freedom from 30-day MALE+POD was 100% in all groups. CONCLUSIONS This hypothesis-generating trial suggests that adventitial infusion of temsirolimus in BTK arteries improves TVAL% and CR-TLF with no adverse safety signals through 6 months, supporting the move to a Phase 3 trial. CLINICAL IMPACT There remain gaps in the endovascular treatment of patients with atherosclerotic lesions of below-the-knee (BTK) arteries. The TANGO trial evaluated the use of sub-adventitial temsirolimus with the Bullfrog micro-infusion device during BTK interventions. The therapy was safe and effective. Compared with controls, vessel lumen area patency was improved, and target lesion failure was less frequent. The effects were most appreciable in subjects with higher baseline TASC lesions (B, C, or D). Sub-adventitial temsirolimus offers the potential to improve the results of BTK interventions in this challenging patient population.
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Affiliation(s)
- Ian Cawich
- Arkansas Heart Hospital, Little Rock, AR, USA
| | | | - Jon C George
- Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | | | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, USA
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Mosarla RC, Armstrong E, Bitton-Faiwiszewski Y, Schneider PA, Secemsky EA. State-of-the-Art Endovascular Therapies for the Femoropopliteal Segment: Are We There Yet? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1. [PMID: 36268042 PMCID: PMC9581461 DOI: 10.1016/j.jscai.2022.100439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Peripheral arterial disease is an increasingly prevalent condition with significant associated morbidity, mortality, and health care expenditure. Endovascular interventions are appropriate for most patients with either ongoing symptoms of intermittent claudication despite lifestyle and medical optimization or chronic limb-threatening ischemia. The femoropopliteal segment is the most common arterial culprit responsible for claudication and the most commonly revascularized segment. Endovascular approaches to revascularization of the femoropopliteal segment are advancing with an evolving landscape of techniques for arterial access, device-based therapies, vessel preparation, and intraprocedural imaging. These advances have been marked by debate and controversy, notably related to the safety of paclitaxel-based devices and necessity of atherectomy. In this review, we provide a critical overview of the current evidence, practice patterns, emerging evidence, and technological advances for endovascular intervention of the femoropopliteal arterial segment.
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Affiliation(s)
| | - Ehrin Armstrong
- Adventist Heart and Vascular Institute, St Helena, California
| | | | | | - Eric A. Secemsky
- Harvard Medical School, Boston, Massachusetts
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Corresponding author: (E.A. Secemsky)
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Jiang Y, Cai Y, Hu J, Zhang X, Lei J, Peng Z, Huang Q, Xu Z, Li B, Qin J, Li W, Sun D, Ye K, Lu X. Adhesive hydrogel wrap loaded with Netrin-1-modified adipose-derived stem cells: An effective approach against periarterial inflammation after endovascular intervention. Front Bioeng Biotechnol 2022; 10:944435. [PMID: 35935480 PMCID: PMC9355160 DOI: 10.3389/fbioe.2022.944435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Endovascular interventions, such as balloon dilation and stent implantation, are currently recommended as the primary treatment for patients with peripheral artery disease (PAD), greatly improving patient prognosis. However, the consequent lumen restenosis that occurs after endovascular interventions has become an important clinical problem. Inflammation has been proven to be crucial to postoperative restenosis. In previous studies we have identified that Netrin-1-modified adipose-derived stem cells (N-ADSCs) transplantation is an effective anti-inflammatory strategy to repair vascular damage. Nevertheless, it remained to be explored how one could constantly deliver N-ADSCs onto damaged arteries. Therefore, we developed an adhesive double network (DN) hydrogel wrap loaded with N-ADSCs for sustained perivascular delivery. Inspired by the adhesion mechanism of mussels, we developed an adhesive and tough polyacrylamide/calcium-alginate/reduced graphene oxide/polydopamine (PAM/CA/rGO/PDA) hydrogel. Dopamine was attached to graphene sheets and limitedly oxidized to generate free catechol groups. The hydrogel could wrap damaged arteries and induce anti-inflammatory effects through N-ADSCs. In vitro experiments demonstrated that N-ADSCs significantly promoted the M2 polarization of macrophages to anti-inflammatory phenotypes and reduced the expression of inflammatory factors. In vivo experiments in a rat carotid artery guidewire injury model showed that the adhesive hydrogel wrap loaded with N-ADSCs could significantly reduce arterial inflammation, inhibit intimal hyperplasia and improve re-endothelialization. Altogether, this newly developed N-ADSCs-loaded hydrogel wrap provides an effective slow-releasing system, which may be a promising way to prevent and treat restenosis after endovascular interventions.
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Affiliation(s)
- Yihong Jiang
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuting Cai
- Department of Chemical and Biological Engineering, William Mong Institute of Nano Science and Technology, The Hong Kong University of Science and Technology, Kowloon, Hong Kong SAR, China
- Guangdong Provincial Key Laboratory of Functional Oxide Materials and Devices, Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Jiateng Hu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xing Zhang
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Xing Zhang, ; Dazhi Sun, ; Kaichuang Ye, ; Xinwu Lu,
| | - Jiahao Lei
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaoxi Peng
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qun Huang
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhijue Xu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bo Li
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinbao Qin
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weimin Li
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dazhi Sun
- Guangdong Provincial Key Laboratory of Functional Oxide Materials and Devices, Southern University of Science and Technology, Shenzhen, Guangdong, China
- *Correspondence: Xing Zhang, ; Dazhi Sun, ; Kaichuang Ye, ; Xinwu Lu,
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Xing Zhang, ; Dazhi Sun, ; Kaichuang Ye, ; Xinwu Lu,
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Xing Zhang, ; Dazhi Sun, ; Kaichuang Ye, ; Xinwu Lu,
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Pharmacological prevention of intimal hyperplasia: A state-of-the-art review. Pharmacol Ther 2022; 235:108157. [PMID: 35183591 DOI: 10.1016/j.pharmthera.2022.108157] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 02/06/2023]
Abstract
Intimal hyperplasia (IH) occurs in a considerable number of cases of blood vessel reconstruction by stenting or balloon angioplasty, venous bypass grafting, and arteriovenous dialysis accesses. It is triggered by endothelial injury during the vascular intervention and leads to vessel restenosis with life-threatening consequences for patients. To date, the drugs used for IH prevention in clinics-paclitaxel and rapalog drugs-have been focusing primarily on the vascular smooth muscle cell (VSMC) proliferation pathway of IH development. Limitations, such as endothelial toxicity and inappropriate drug administration timing, have spurred the search for new and efficient pharmacological approaches to control IH. In this state-of-the-art review, we present the pathways of IH development, focusing on the key events and actors involved in IH. Subsequently, we discuss different drugs and drug combinations interfering with these pathways based on their effect on peripheral circulation IH models in animal studies, or on clinical reports. The reports were obtained through an extensive search of peer-reviewed publications in Pubmed, Embase, and Google Scholar, with search equations composed based on five concepts around IH and their various combinations. To improve vascular intervention outcomes, rethinking of conventional therapeutic approaches to IH prevention is needed. Exploring local application of drugs and drug combinations acting on different pathophysiological pathways of IH development has the potential to provide effective and safe restenosis prevention.
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Abstract
Atherosclerosis is a chronic inflammatory disease of the arterial wall, characterized by the formation of plaques containing lipid, connective tissue and immune cells in the intima of large and medium-sized arteries. Over the past three decades, a substantial reduction in cardiovascular mortality has been achieved largely through LDL-cholesterol-lowering regimes and therapies targeting other traditional risk factors for cardiovascular disease, such as hypertension, smoking, diabetes mellitus and obesity. However, the overall benefits of targeting these risk factors have stagnated, and a huge global burden of cardiovascular disease remains. The indispensable role of immunological components in the establishment and chronicity of atherosclerosis has come to the forefront as a clinical target, with proof-of-principle studies demonstrating the benefit and challenges of targeting inflammation and the immune system in cardiovascular disease. In this Review, we provide an overview of the role of the immune system in atherosclerosis by discussing findings from preclinical research and clinical trials. We also identify important challenges that need to be addressed to advance the field and for successful clinical translation, including patient selection, identification of responders and non-responders to immunotherapies, implementation of patient immunophenotyping and potential surrogate end points for vascular inflammation. Finally, we provide strategic guidance for the translation of novel targets of immunotherapy into improvements in patient outcomes. In this Review, the authors provide an overview of the immune cells involved in atherosclerosis, discuss preclinical research and published and ongoing clinical trials assessing the therapeutic potential of targeting the immune system in atherosclerosis, highlight emerging therapeutic targets from preclinical studies and identify challenges for successful clinical translation. Inflammation is an important component of the pathophysiology of cardiovascular disease; an imbalance between pro-inflammatory and anti-inflammatory processes drives chronic inflammation and the formation of atherosclerotic plaques in the vessel wall. Clinical trials assessing canakinumab and colchicine therapies in atherosclerotic cardiovascular disease have provided proof-of-principle of the benefits associated with therapeutic targeting of the immune system in atherosclerosis. The immunosuppressive adverse effects associated with the systemic use of anti-inflammatory drugs can be minimized through targeted delivery of anti-inflammatory drugs to the atherosclerotic plaque, defining the window of opportunity for treatment and identifying more specific targets for cardiovascular inflammation. Implementing immunophenotyping in clinical trials in patients with atherosclerotic cardiovascular disease will allow the identification of immune signatures and the selection of patients with the highest probability of deriving benefit from a specific therapy. Clinical stratification via novel risk factors and discovery of new surrogate markers of vascular inflammation are crucial for identifying new immunotherapeutic targets and their successful translation into the clinic.
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Arbeiter D, Reske T, Teske M, Bajer D, Senz V, Schmitz KP, Grabow N, Oschatz S. Influence of Drug Incorporation on the Physico-Chemical Properties of Poly(l-Lactide) Implant Coating Matrices-A Systematic Study. Polymers (Basel) 2021; 13:292. [PMID: 33477626 PMCID: PMC7831498 DOI: 10.3390/polym13020292] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/15/2022] Open
Abstract
Local drug delivery has become indispensable in biomedical engineering with stents being ideal carrier platforms. While local drug release is superior to systemic administration in many fields, the incorporation of drugs into polymers may influence the physico-chemical properties of said matrix. This is of particular relevance as minimally invasive implantation is frequently accompanied by mechanical stresses on the implant and coating. Thus, drug incorporation into polymers may result in a susceptibility to potentially life-threatening implant failure. We investigated spray-coated poly-l-lactide (PLLA)/drug blends using thermal measurements (DSC) and tensile tests to determine the influence of selected drugs, namely sirolimus, paclitaxel, dexamethasone, and cyclosporine A, on the physico-chemical properties of the polymer. For all drugs and PLLA/drug ratios, an increase in tensile strength was observed. As for sirolimus and dexamethasone, PLLA/drug mixed phase systems were identified by shifted drug melting peaks at 200 °C and 240 °C, respectively, whereas paclitaxel and dexamethasone led to cold crystallization. Cyclosporine A did not affect matrix thermal properties. Altogether, our data provide a contribution towards an understanding of the complex interaction between PLLA and different drugs. Our results hold implications regarding the necessity of target-oriented thermal treatment to ensure the shelf life and performance of stent coatings.
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Affiliation(s)
- Daniela Arbeiter
- Institute for Biomedical Engineering, Rostock University Medical Center, Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany; (M.T.); (D.B.); (V.S.); (K.-P.S.); (N.G.); (S.O.)
| | - Thomas Reske
- Institute for Implant Technology and Biomaterials e.V., Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany;
| | - Michael Teske
- Institute for Biomedical Engineering, Rostock University Medical Center, Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany; (M.T.); (D.B.); (V.S.); (K.-P.S.); (N.G.); (S.O.)
| | - Dalibor Bajer
- Institute for Biomedical Engineering, Rostock University Medical Center, Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany; (M.T.); (D.B.); (V.S.); (K.-P.S.); (N.G.); (S.O.)
| | - Volkmar Senz
- Institute for Biomedical Engineering, Rostock University Medical Center, Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany; (M.T.); (D.B.); (V.S.); (K.-P.S.); (N.G.); (S.O.)
| | - Klaus-Peter Schmitz
- Institute for Biomedical Engineering, Rostock University Medical Center, Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany; (M.T.); (D.B.); (V.S.); (K.-P.S.); (N.G.); (S.O.)
- Institute for Implant Technology and Biomaterials e.V., Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany;
| | - Niels Grabow
- Institute for Biomedical Engineering, Rostock University Medical Center, Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany; (M.T.); (D.B.); (V.S.); (K.-P.S.); (N.G.); (S.O.)
| | - Stefan Oschatz
- Institute for Biomedical Engineering, Rostock University Medical Center, Friedrich-Barnewitz-Straße 4, 18119 Rostock, Germany; (M.T.); (D.B.); (V.S.); (K.-P.S.); (N.G.); (S.O.)
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Kim TI, Schneider PA. New Innovations and Devices in the Management of Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 27:524-539. [PMID: 32419596 DOI: 10.1177/1526602820921555] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
As the number of patients afflicted by chronic limb-threatening ischemia (CLTI) continues to grow, new solutions are necessary to provide effective, durable treatment options that will lead to improved outcomes. The diagnosis of CLTI remains mostly clinical, and endovascular revascularization remains mostly balloon-based. Multiple innovative techniques and technologies are in development or in early usage that may provide new solutions. This review categorizes areas of advancement, highlights recent developments in the management of CLTI and looks forward to novel devices that are currently under investigation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
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Kokkinidis DG, Armstrong EJ. Current developments in endovascular therapy of peripheral vascular disease. J Thorac Dis 2020; 12:1681-1694. [PMID: 32395311 PMCID: PMC7212127 DOI: 10.21037/jtd.2019.12.130] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
More than 200 million people worldwide have peripheral artery disease (PAD) or its most severe manifestation, critical limb ischemia (CLI). While endovascular treatment has become first line therapy in most cases, a number of challenges remain for optimal treatment of femoropopliteal (FP) or infrapopliteal (IP) disease, especially when these lesions are severely calcified, chronic total occlusions (CTOs) or in-stent restenosis (ISR). Continued evolution of technologies has significantly improved the outcomes for endovascular treatment. A number of new devices are in the pipeline right now, including new paclitaxel eluting stents and balloons, intravascular lithotripsy to treat severely calcified lesions, adventitial delivery of anti-restenotic agents to limit restenosis rates, and percutaneous femoro-popliteal bypass.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Aurora, CO, USA
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15
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Chowdhury MM, Tarkin JM, Albaghdadi MS, Evans NR, Le EP, Berrett TB, Sadat U, Joshi FR, Warburton EA, Buscombe JR, Hayes PD, Dweck MR, Newby DE, Rudd JH, Coughlin PA. Vascular Positron Emission Tomography and Restenosis in Symptomatic Peripheral Arterial Disease: A Prospective Clinical Study. JACC Cardiovasc Imaging 2020; 13:1008-1017. [PMID: 31202739 PMCID: PMC7136751 DOI: 10.1016/j.jcmg.2019.03.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 03/26/2019] [Accepted: 04/12/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study determined whether in vivo positron emission tomography (PET) of arterial inflammation (18F-fluorodeoxyglucose [18F-FDG]) or microcalcification (18F-sodium fluoride [18F-NaF]) could predict restenosis following PTA. BACKGROUND Restenosis following lower limb percutaneous transluminal angioplasty (PTA) is common, unpredictable, and challenging to treat. Currently, it is impossible to predict which patient will suffer from restenosis following angioplasty. METHODS In this prospective observational cohort study, 50 patients with symptomatic peripheral arterial disease underwent 18F-FDG and 18F-NaF PET/computed tomography (CT) imaging of the superficial femoral artery before and 6 weeks after angioplasty. The primary outcome was arterial restenosis at 12 months. RESULTS Forty subjects completed the study protocol with 14 patients (35%) reaching the primary outcome of restenosis. The baseline activities of femoral arterial inflammation (18F-FDG tissue-to-background ratio [TBR] 2.43 [interquartile range (IQR): 2.29 to 2.61] vs. 1.63 [IQR: 1.52 to 1.78]; p < 0.001) and microcalcification (18F-NaF TBR 2.61 [IQR: 2.50 to 2.77] vs. 1.69 [IQR: 1.54 to 1.77]; p < 0.001) were higher in patients who developed restenosis. The predictive value of both 18F-FDG (cut-off TBRmax value of 1.98) and 18F-NaF (cut-off TBRmax value of 2.11) uptake demonstrated excellent discrimination in predicting 1-year restenosis (Kaplan Meier estimator, log-rank p < 0.001). CONCLUSIONS Baseline and persistent femoral arterial inflammation and micro-calcification are associated with restenosis following lower limb PTA. For the first time, we describe a method of identifying complex metabolically active plaques and patients at risk of restenosis that has the potential to select patients for intervention and to serve as a biomarker to test novel interventions to prevent restenosis.
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Affiliation(s)
- Mohammed M. Chowdhury
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom,Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom,Address for correspondence: Mr. Mohammed M. Chowdhury, Divisions of Vascular Surgery and Cardiovascular Medicine, University of Cambridge, Box 212, Addenbrooke’s Cambridge University Hospital, Hills Road, Cambridge CB2 2QQ, United Kingdom.
| | - Jason M. Tarkin
- Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Mazen S. Albaghdadi
- Cardiovascular Research Center, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas R. Evans
- Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Elizabeth P.V. Le
- Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Thomas B. Berrett
- Statistical Laboratory, Department of Pure Mathematics and Mathematical Sciences, University of Cambridge, United Kingdom
| | - Umar Sadat
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | | | | | - John R. Buscombe
- Department of Nuclear Medicine, Addenbrooke’s Hospital, University of Cambridge United Kingdom
| | - Paul D. Hayes
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Marc R. Dweck
- British Heart Foundation for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E. Newby
- British Heart Foundation for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - James H.F. Rudd
- Department of Cardiovascular Medicine, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
| | - Patrick A. Coughlin
- Division of Vascular Surgery, Department of Surgery, Addenbrooke’s Hospital, University of Cambridge, United Kingdom
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16
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Ang HY, Xiong GM, Chaw SY, Phua JL, Ng JCK, Wong PEH, Venkatraman S, Chong TT, Huang Y. Adventitial injection delivery of nano-encapsulated sirolimus (Nanolimus) to injury-induced porcine femoral vessels to reduce luminal restenosis. J Control Release 2019; 319:15-24. [PMID: 31863795 DOI: 10.1016/j.jconrel.2019.12.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
Endovascular therapy in peripheral intervention has grown exponentially in the past decade, but the issue of high restenosis rates in lower extremity arteries still persist. While drug-coated balloons (DCB) have been the device of choice, recent controversary regarding the long-term safety of paclitaxel have raised concern over current DCBs. In our study, we proposed that the direct injection of a sirolimus nanoliposomal formulation (Nanolimus) using a infusion catheter can attenuate inflammation response in injured vessels. In vitro characterization showed retention of the nanoliposomes size and detectable drug amount up to 336 days in storage. For in vivo study, four female, mixed breed swines were subjected to balloon injury of the femoral arteries before treatment with either injection of saline (n = 4) or Nanolimus (n = 12) using the Bullfrog catheter. Pharmacokinetic analysis demonstrated sustained sirolimus release in the arteries and undetectable systemic drug level at 28 days. Arteries treated with Nanolimus showed significant reduction in neointima area (0.2 ± 0.3 mm2 vs 2.0 ± 1.2 mm2, p < 0.01) and luminal stenosis (14.2 ± 7.2% vs. 67.7 ± 24.8%, p < 0.01) compared to controls. In summary, adventitial delivery of sirolimus using an infusion catheter is a feasible and safe method to reduce vascular restenosis.
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Affiliation(s)
- Hui Ying Ang
- National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore; Department of Biomedical Engineering, National University of Singapore, 4 Engineering Drive 3, 117583, Singapore
| | - Gordon Minru Xiong
- School of Materials Science and Engineering, Nanyang Technological University, Nanyang Avenue, 639798, Singapore
| | - Su Yin Chaw
- School of Materials Science and Engineering, Nanyang Technological University, Nanyang Avenue, 639798, Singapore
| | - Jie Liang Phua
- School of Materials Science and Engineering, Nanyang Technological University, Nanyang Avenue, 639798, Singapore
| | - Jaryl Chen Koon Ng
- National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore; Department of Biomedical Engineering, National University of Singapore, 4 Engineering Drive 3, 117583, Singapore
| | - Philip En Hou Wong
- National Heart Centre Singapore, 5 Hospital Drive, 169609, Singapore; Duke-NUS Medical School, 8 College Road, 169857, Singapore
| | - Subbu Venkatraman
- School of Materials Science and Engineering, Nanyang Technological University, Nanyang Avenue, 639798, Singapore
| | - Tze Tec Chong
- Duke-NUS Medical School, 8 College Road, 169857, Singapore; Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Yingying Huang
- School of Materials Science and Engineering, Nanyang Technological University, Nanyang Avenue, 639798, Singapore.
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Karzar Jeddi M, Mahkam M. Magnetic nano carboxymethyl cellulose-alginate/chitosan hydrogel beads as biodegradable devices for controlled drug delivery. Int J Biol Macromol 2019; 135:829-838. [PMID: 31158422 DOI: 10.1016/j.ijbiomac.2019.05.210] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/16/2022]
Abstract
For the first time, nano carboxymethyl cellulose (NCMC) was synthesized via cellulose nanocrystal carboxymethylation. This nanomaterial was magnetized and used in bilayer alginate-chitosan hydrogel beads formulation to develop eco-friendly, smart, and magnetic sensitive hydrogel beads for the controlled pH-sensitive release of dexamethasone as a model drug. Water-soluble nanocrystalline cellulose (NCMC) and bilayer hydrogel beads were characterized in terms of size, surface morphology, surface modification, crystallinity, drug loading content, and in vitro drug release profile using various technics. Furthermore, the swelling behavior of hydrogels was examined and reported in three buffer media. The NCMCs improved drug loading capacity and swelling properties and also regulated drug release behavior of hydrogels. The hydrogel beads swelling specification exhibited a higher index in phosphate buffer at pH 5.8 than at pH 1.2 and 7.4. Besides, in vitro release of beads revealed excellent pH-sensitive drug release profiles and prevented release in the gastrointestinal tract. The beads showed high pH sensitivity for dexamethasone drug in pH 5.8 in compared to other pH media. The obtained results could introduce hydrogel beads as a high potential drug delivery system.
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Affiliation(s)
- Mohammad Karzar Jeddi
- Department of Chemistry, Faculty of Science, Azarbaijan Shahid Madani University, P.O. Box 53714-161, Tabriz, Iran
| | - Mehrdad Mahkam
- Department of Chemistry, Faculty of Science, Azarbaijan Shahid Madani University, P.O. Box 53714-161, Tabriz, Iran.
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Needle-Delivered Drug Elution in Femoral Artery Disease. JACC Cardiovasc Interv 2018; 11:932-933. [DOI: 10.1016/j.jcin.2018.01.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 01/14/2018] [Indexed: 11/21/2022]
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