1
|
Watson C, Saaid H, Vedula V, Cardenas JC, Henke PK, Nicoud F, Xu XY, Hunt BJ, Manning KB. Venous Thromboembolism: Review of Clinical Challenges, Biology, Assessment, Treatment, and Modeling. Ann Biomed Eng 2024; 52:467-486. [PMID: 37914979 DOI: 10.1007/s10439-023-03390-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023]
Abstract
Venous thromboembolism (VTE) is a massive clinical challenge, annually affecting millions of patients globally. VTE is a particularly consequential pathology, as incidence is correlated with extremely common risk factors, and a large cohort of patients experience recurrent VTE after initial intervention. Altered hemodynamics, hypercoagulability, and damaged vascular tissue cause deep-vein thrombosis and pulmonary embolism, the two permutations of VTE. Venous valves have been identified as likely locations for initial blood clot formation, but the exact pathway by which thrombosis occurs in this environment is not entirely clear. Several risk factors are known to increase the likelihood of VTE, particularly those that increase inflammation and coagulability, increase venous resistance, and damage the endothelial lining. While these risk factors are useful as predictive tools, VTE diagnosis prior to presentation of outward symptoms is difficult, chiefly due to challenges in successfully imaging deep-vein thrombi. Clinically, VTE can be managed by anticoagulants or mechanical intervention. Recently, direct oral anticoagulants and catheter-directed thrombolysis have emerged as leading tools in resolution of venous thrombosis. While a satisfactory VTE model has yet to be developed, recent strides have been made in advancing in silico models of venous hemodynamics, hemorheology, fluid-structure interaction, and clot growth. These models are often guided by imaging-informed boundary conditions or inspired by benchtop animal models. These gaps in knowledge are critical targets to address necessary improvements in prediction and diagnosis, clinical management, and VTE experimental and computational models.
Collapse
Affiliation(s)
- Connor Watson
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA
| | - Hicham Saaid
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA
| | - Vijay Vedula
- Department of Mechanical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
| | - Jessica C Cardenas
- Department of Surgery and the Center for Translational Injury Research, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Franck Nicoud
- CNRS, IMAG, Université de Montpellier, Montpellier, France
- Institut Universitaire de France, Paris, France
| | - Xiao Yun Xu
- Department of Chemical Engineering, Imperial College London, London, UK
| | - Beverley J Hunt
- Department of Thrombosis and Haemostasis, King's College, London, UK
- Thrombosis and Haemophilia Centre, Guy's & St Thomas' NHS Trust, London, UK
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, 122 Chemical and Biomedical Engineering Building, University Park, PA, 16802-4400, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA.
| |
Collapse
|
2
|
Abdelghani E, Agarwal S, Stanek J, Sankar A, Kerlin BA, Rodriguez V. Pediatric arterial thrombosis: A single-institution cohort study of patient characteristics and thrombosis outcomes. Pediatr Blood Cancer 2024; 71:e30756. [PMID: 37902500 DOI: 10.1002/pbc.30756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Arterial thrombosis (AT) is an increasingly recognized complication in pediatrics. Consensus clinical practice guidelines suggest immediate removal of the indwelling arterial catheter and a short course (5-7 days) of anticoagulation. The optimal duration and modality of antithrombotic therapy in children are yet to be determined. AIMS Describe treatment patterns and outcomes in pediatric patients with AT and explore predictors for complete thrombus resolution or long-term complications. METHODS Single-institution retrospective study. Patients were identified by ICD-9 and ICD-10 codes for the diagnosis of AT or reports of AT on ultrasound from January 1, 2012, to October 1, 2022. Descriptive and logistic regression analyses were used. RESULTS 101 patients were included. The median age was 2.2 months. The most common underlying diagnoses were congenital heart disease (39.6%) and infection (22.8%). A majority of patients had symptomatic thrombosis in an extremity, and 78% were catheter-associated. 81% of patients received anticoagulation with a median duration of 35 days. Out of the 70 patients who were treated with anticoagulation alone and had a follow-up imaging, 70% had complete resolution after 90 days of anticoagulation. No clear predictors of complete resolution were identified. Eighteen patients had long-term sequelae secondary to arterial insufficiency. Those with infection-associated AT were more likely to have long-term complications. The major and clinically relevant non-major bleeding rate was 11%. CONCLUSION Duration of anticoagulation was widely variable, and 70% of patients achieved complete resolution by 90 days of anticoagulation. A significant proportion of patients developed long-term sequelae secondary to arterial insufficiency. Sepsis/infection at the time of diagnosis with AT was more likely to be associated with long-term complications.
Collapse
Affiliation(s)
- Eman Abdelghani
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Shreya Agarwal
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph Stanek
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Biostatistics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amanda Sankar
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Bryce A Kerlin
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| |
Collapse
|
3
|
Henke PK, Nicklas JM, Obi A. Immune cell-mediated venous thrombus resolution. Res Pract Thromb Haemost 2023; 7:102268. [PMID: 38193054 PMCID: PMC10772895 DOI: 10.1016/j.rpth.2023.102268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/23/2023] [Accepted: 11/07/2023] [Indexed: 01/10/2024] Open
Abstract
Herein, we review the current processes that govern experimental deep vein thrombus (DVT) resolution. How the human DVT resolves at the molecular and cellular level is not well known due to limited specimen availability. Experimentally, the thrombus resolution resembles wound healing, with early neutrophil-mediated actions followed by monocyte/macrophage-mediated events, including neovascularization, fibrinolysis, and eventually collagen replacement. Potential therapeutic targets are described, and coupling with site-directed approaches to mitigate off-target effects is the long-term goal. Similarly, timing of adjunctive agents to accelerate DVT resolution is an area that is only starting to be considered. There is much critical research that is needed in this area.
Collapse
Affiliation(s)
- Peter K. Henke
- Department of Surgery, University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - John M. Nicklas
- Department of Medicine, Brown University Medical School, Providence, Rhode Island, USA
| | - Andrea Obi
- Department of Surgery, University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| |
Collapse
|
4
|
Makedonov I, Kahn S, Abdulrehman J, Schulman S, Delluc A, Gross PL, Galanaud JP. TILE pilot trial study protocol: Tinzaparin Lead-in to Prevent the Post-Thrombotic syndrome study protocol. BMJ Open 2023; 13:e064715. [PMID: 37907305 PMCID: PMC10618981 DOI: 10.1136/bmjopen-2022-064715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/11/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency due to a prior ipsilateral deep venous thrombosis (DVT). This is a frequent complication that develops in 20%-50% of patients after a proximal DVT and is associated with significant healthcare, economic and societal consequences. In the absence of effective and well-tolerated treatment options for established PTS, effective preventative measures are needed. Anticoagulation itself reduces the risk of PTS, and low-molecular-weight heparin may reduce this further through anti-inflammatory properties targeting the initial acute inflammatory phase of DVT. METHODS AND ANALYSIS The Tinzaparin Lead-In to Prevent the Post-Thrombotic syndrome pilot trial is an investigator-initiated, multicentre, open-label assessor-blinded trial that will randomise patients with first acute symptomatic common femoral or iliac DVT to receive either a 3-week lead-in course of tinzaparin, followed by rivaroxaban (experimental arm) or rivaroxaban alone (control arm). Its primary objectives are to assess: (1) proportion of PTS at 6 months using the Villalta scale and (2) study feasibility, which consists of (a) the proportion of screened patients eligible for the study, (2) the proportion of eligible patients recruited and (c) the proportion of recruited patients adherent to treatment (defined as at least 80% of drug taken). This study will determine the feasibility of a subsequent larger definitive trial. Secondary outcomes include change of quality of life scores, PTS severity, global improvement, patient satisfaction, bleeding, recurrent venous thromboembolism, leg pain, death and lost to follow-up. Target recruitment will be a total of 60 participants, recruited at 5-6 centres. ETHICS AND DISSEMINATION Primary ethics approval was received from the Sunnybrook Health Sciences Center Research Ethics Board (approval ID 3315). Results of the study will be disseminated via peer-reviewed presentation at scientific conferences and open access publication. TRIAL REGISTRATION NUMBER NCT04794569.
Collapse
Affiliation(s)
- Ilia Makedonov
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Susan Kahn
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
| | - Jameel Abdulrehman
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aurelien Delluc
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter L Gross
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
5
|
Necroptosis Plays a Crucial Role in Vascular Injury during DVT and Is Enhanced by IL-17B. J Immunol Res 2022; 2022:6909764. [PMID: 36046722 PMCID: PMC9424031 DOI: 10.1155/2022/6909764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/16/2022] [Indexed: 12/16/2022] Open
Abstract
Background. This study investigated whether vascular endothelial necroptosis is involved in deep vein thrombosis (DVT) and how IL-17B facilitates necroptosis signaling. Methods. The DVT mouse model was induced by ligation of the IVC. The cross-sectional area of thrombus increases and the thrombus occupied the entire venous lumen at 48 h after ligation. Meanwhile, the increased expression of p-RIP3/RIP3 was most pronounced at 48 h after ligation, and the p-MLKL/MLKL peaked at 72 h. Results. Based on Illumina sequencing and KEGG pathway analyses, the activated RIP3/MLKL is associated with increased IL-17B. With thrombus formation, IL-17B was upregulated and enhanced the expression of RIP3 and MLKL in the IVC wall, as well as their phosphorylation levels (all
, the comparison group consisted of the control group, DVT group, DVT/IL-17B group, and DVT/anti-IL-17B group). The p-RIP3/RIP3 and p-MLKL/MLKL ratios were reduced by anti-IL-17B. Similarly, the weight and cross-sectional area of the thrombi were increased by IL-17B and decreased by the IL-17B antibody. IL-17B had a smaller effect on thrombosis in knockout mice compared with WT mice. In vitro, the IL-17B protein expression and the level of RIP3 and MLKL phosphorylation increased high in the OGD cells, accompanied by increased expression of IL-6 and TNF-α. IL-17B enhanced the expression of IL-6 and TNF-α but had little effect on the IL-6 and TNF-α after transfected with siRIP3 or siMLKL. Similarly, the plasma IL-17B, IL-6, and TNF-α were significantly increased after thrombosis in WT mice, and enhanced by IL-17B. But IL-17B did not increase the plasma IL-6 and TNF-α in knockout mice. Conclusions. In conclusion, those results suggest that vascular endothelial necroptosis plays a crucial role in vascular injury and IL-17B could enhance the necroptosis pathway.
Collapse
|
6
|
Dowling AR, Luke CE, Cai Q, Pellerito AM, Obi AT, Henke PK. Modulation of interleukin-6 and its effect on late vein wall injury in a stasis mouse model of deep vein thrombosis. JVS Vasc Sci 2022; 3:246-255. [PMID: 35647566 PMCID: PMC9133633 DOI: 10.1016/j.jvssci.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
Abstract
Objective Deep vein thrombosis (DVT) and its sequela, post-thrombotic syndrome (PTS), remain a clinically significant problem. Interleukin-6 (IL-6) is a proinflammatory cytokine that is elevated in patients who develop PTS. We hypothesized that genetic deletion of IL-6 and the use of anti-IL-6 pharmacologic agents would be associated with decreased late vein wall injury. Methods Wild-type C57BL/6J (WT) and IL-6-/- mice underwent induction of stasis venous thrombosis by ligation of the infrarenal IVC. Vein wall inferior vena cava and thrombus were harvested at 21 days after ligation and analyzed by Western blot and immunohistochemistry of the vein wall using monocyte markers CCR2 and arginase 1, the endothelial marker CD31, and fibroblast markers DDR2 and FSP-1. Two anti-IL-6 pharmacologic agents (gp130 [glycoprotein 130] and tocilizumab) were tested and compared with low-molecular-weight heparin (LMWH) as the reference standard in WT mice. Plasma was collected at 4 and 48 hours to confirm the pharmacologic agents' effects. Results Less fibrosis but no increase in luminal endothelialization was found in IL-6-/- mice compared with WT mice at 21 days. The IL-6-/- mice had fewer DDR2- and arginase 1-positive cells in the vein wall compared with the WT mice. However, no difference was found in the CCR2+ cells. Despite documented in vivo activity, exogenous gp130 and tocilizumab were not associated with decreased vein wall fibrosis or increased endothelial luminal coverage at 21 days. LMWH therapy, both before and after treatment, was not associated with decreased vein wall fibrosis at 21 days. Conclusions IL-6 genetic deletion was associated with less fibrotic vein wall injury at a late time point, consistent with the PTS timeframe. However, neither the standard of care LMWH nor two available anti-IL-6 agents showed antifibrotic biologic effects in this model.
Collapse
Affiliation(s)
- Abigail R. Dowling
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Catherine E. Luke
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Qing Cai
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Antonio M. Pellerito
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Andrea T. Obi
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| | - Peter K. Henke
- Conrad Jobst Vascular Surgery Research Laboratories, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
- Vascular Surgery Section, Department of Surgery, College of Medicine, University of Michigan, Ann Arbor, MI
| |
Collapse
|
7
|
Makedonov I, Kahn SR, Abdulrehman J, Schulman S, Delluc A, Gross PL, Galanaud JP. Prevention of the post thrombotic syndrome with anticoagulation: a narrative review. Thromb Haemost 2021; 122:1255-1264. [PMID: 34852380 DOI: 10.1055/a-1711-1263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The post thrombotic syndrome (PTS) is chronic venous insufficiency secondary to a prior deep vein thrombosis (DVT). It is the most common complication of VTE and, while not fatal, it can lead to chronic, unremitting symptoms as well as societal and economic consequences. The cornerstone of PTS treatment lies in its prevention after DVT. Specific PTS preventative measures include the use of elastic compression stockings (ECS) and pharmacomechanical catheter directed thrombolysis (PCDT). However, the efficacy of these treatments has been questioned by large RCTs. So far, anticoagulation, primarily prescribed to prevent DVT extension and recurrence, appears to be the only unquestionably effective treatment for the prevention of PTS. In this literature review we present pathophysiological, biological, radiological and clinical data supporting the efficacy of anticoagulants to prevent PTS and the possible differential efficacy among available classes of anticoagulants (vitamin K antagonists (VKA), low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs)). Data suggest that LMWHs and DOACs are superior to VKAs, but no head-to-head comparison is available between DOACs and LMWHs. Owing to their potentially greater anti-inflammatory properties, LMWHs could be superior to DOACs. This finding may be of interest particularly in patients with extensive DVT at high risk of moderate to severe PTS, but needs to be confirmed by a dedicated RCT.
Collapse
Affiliation(s)
- Ilia Makedonov
- Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | | | | | - Peter L Gross
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | | |
Collapse
|
8
|
Henke P, Sharma S, Wakefield T, Myers D, Obi A. Insights from experimental post-thrombotic syndrome and potential for novel therapies. Transl Res 2020; 225:95-104. [PMID: 32442728 PMCID: PMC7487018 DOI: 10.1016/j.trsl.2020.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 12/20/2022]
Abstract
Post-thrombotic syndrome (PTS) is an end stage manifestation of deep vein thrombosis. This is an inherently inflammatory process, with consequent fibrosis. Multiple cellular types are involved, and are likely driven by leukocytes. Herein, we review the current gaps in therapy, and insights from rodent models of venous thrombosis that suggest possible targets to treat and prevent PTS.
Collapse
Affiliation(s)
- Peter Henke
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI.
| | - Sriganesh Sharma
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
| | - Thomas Wakefield
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
| | - Dan Myers
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
| | - Andrea Obi
- From the University of Michigan Health System, Frankel Cardiovascular Center, Ann Arbor, MI
| |
Collapse
|
9
|
Prevention and Management of the Post-Thrombotic Syndrome. J Clin Med 2020; 9:jcm9040923. [PMID: 32230912 PMCID: PMC7230648 DOI: 10.3390/jcm9040923] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 12/13/2022] Open
Abstract
The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency secondary to prior deep vein thrombosis (DVT). It affects up to 50% of patients after proximal DVT. There is no effective treatment of established PTS and its management lies in its prevention after DVT. Optimal anticoagulation is key for PTS prevention. Among anticoagulants, low-molecular-weight heparins have anti-inflammatory properties, and have a particularly attractive profile. Elastic compression stockings (ECS) may be helpful for treating acute DVT symptoms but their benefits for PTS prevention are debated. Catheter-directed techniques reduce acute DVT symptoms and might reduce the risk of moderate-severe PTS in the long term in patients with ilio-femoral DVT at low risk of bleeding. Statins may decrease the risk of PTS, but current evidence is lacking. Treatment of PTS is based on the use of ECS and lifestyle measures such as leg elevation, weight loss and exercise. Venoactive medications may be helpful and research is ongoing. Interventional techniques to treat PTS should be reserved for highly selected patients with chronic iliac obstruction or greater saphenous vein reflux, but have not yet been assessed by robust clinical trials.
Collapse
|
10
|
Nicklas JM, Gordon AE, Henke PK. Resolution of Deep Venous Thrombosis: Proposed Immune Paradigms. Int J Mol Sci 2020; 21:E2080. [PMID: 32197363 PMCID: PMC7139924 DOI: 10.3390/ijms21062080] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/14/2020] [Accepted: 03/15/2020] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE) is a pathology encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE) associated with high morbidity and mortality. Because patients often present after a thrombus has already formed, the mechanisms that drive DVT resolution are being investigated in search of treatment. Herein, we review the current literature, including the molecular mechanisms of fibrinolysis and collagenolysis, as well as the critical cellular roles of macrophages, neutrophils, and endothelial cells. We propose two general models for the operation of the immune system in the context of venous thrombosis. In early thrombus resolution, neutrophil influx stabilizes the tissue through NETosis. Meanwhile, macrophages and intact neutrophils recognize the extracellular DNA by the TLR9 receptor and induce fibrosis, a complimentary stabilization method. At later stages of resolution, pro-inflammatory macrophages police the thrombus for pathogens, a role supported by both T-cells and mast cells. Once they verify sterility, these macrophages transform into their pro-resolving phenotype. Endothelial cells both coat the stabilized thrombus, a necessary early step, and can undergo an endothelial-mesenchymal transition, which impedes DVT resolution. Several of these interactions hold promise for future therapy.
Collapse
Affiliation(s)
| | | | - Peter K. Henke
- School of Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; (J.M.N.); (A.E.G.)
| |
Collapse
|
11
|
Metz AK, Luke CE, Dowling A, Henke PK. Acute experimental venous thrombosis impairs venous relaxation but not contraction. J Vasc Surg 2019; 71:1006-1012.e1. [PMID: 31248758 DOI: 10.1016/j.jvs.2019.03.064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 03/27/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Venous thrombosis (VT) damages the vein wall, both physically by prolonged distension and from inflammation. These factors contribute to post-thrombotic syndrome (PTS). Interleukin (IL)-6 might play a role in experimental PTS and vein wall responses. Previous assessments of post-thrombotic vein wall injury used static measures such as histologic examination and immunologic assays. The purpose of the present study was to use myography to quantify the changes in contraction and relaxation of murine vessels exposed to an acute VT. METHODS Wild-type (WT) C57BL/6 mice were used to determine the baseline vein wall passive tension on a DMT 610m myograph (DMT-USA, Inc., Ann Arbor, Mich), including dosing concentrations of phenylephrine (Phe) and acetylcholine (Ach). WT and IL-6-/- mice underwent VT using inferior vena cava (IVC) ligation (complete stasis) and stenosis (partial stasis), with no-surgery mice used as controls. The mice were harvested at 2 days (2D) and analyzed using a myograph. The vessels were stimulated with Phe and Ach to stimulate a contraction and relaxation response. The endothelial responses to VT were quantified by CD31 immunohistochemistry, Greiss assay, polymerase chain reaction, and Evans blue assay. RESULTS Optimal passive tension was determined to be 2 mN, with an optimal concentration of Phe and Ach of 7E-3M and 1E-5M, respectively. No significant differences were found in the contractions when exposed to Phe between the WT control, WT 2D ligation, and WT 2D stenosis IVC segments and the IL-6-/- mice with and without thrombus (P > .05 for all). When treated with Ach, significantly more relaxation was found in the nonthrombosed control IVC segments than in those IVC segments that had had a 2D thrombus from either ligation- or stenosis-derived thrombotic mechanisms in both WT and IL-6-/- mice. CD31 staining showed ∼20% less luminal endothelium after stasis thrombosis (P ≤ .01) but no loss in the controls (P > .05). Evans blue staining showed a trend toward increased leakiness in post-thrombotic vein walls. No significant difference in the endothelial gene markers or nitric oxide production was found. CONCLUSIONS Compared with the controls, acute thrombosis in the total or partial stasis models did not impair IVC contractile responses, suggesting no effect on the medial vascular smooth muscle response. The relaxation response was significantly reduced in the post-thrombotic groups, likely from direct endothelial injury. These findings suggest, at acute points, that VT impairs the endothelial function of a vein wall while retaining the vascular smooth muscle cell function and might be a mechanism that promotes PTS.
Collapse
Affiliation(s)
- Allan K Metz
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Cathy E Luke
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Abigail Dowling
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Peter K Henke
- Jobst Vascular Research Laboratory, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich.
| |
Collapse
|
12
|
Affiliation(s)
- Jacob F Bentzon
- From the Experimental Pathology of Atherosclerosis, Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (J.F.B.); and Department of Clinical Medicine, Aarhus University, Denmark (J.F.B., E.F.).
| | - Erling Falk
- From the Experimental Pathology of Atherosclerosis, Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (J.F.B.); and Department of Clinical Medicine, Aarhus University, Denmark (J.F.B., E.F.)
| |
Collapse
|
13
|
Mosevoll KA, Johansen S, Wendelbo Ø, Nepstad I, Bruserud Ø, Reikvam H. Cytokines, Adhesion Molecules, and Matrix Metalloproteases as Predisposing, Diagnostic, and Prognostic Factors in Venous Thrombosis. Front Med (Lausanne) 2018; 5:147. [PMID: 29872658 PMCID: PMC5972295 DOI: 10.3389/fmed.2018.00147] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/30/2018] [Indexed: 12/31/2022] Open
Abstract
The inflammatory response is a well-established part of, and a prerequisite for, venous thrombosis. To better understand the pathophysiology of venous thrombosis and to identify improved diagnostic biomarkers, further studies of the relationship between inflammation and coagulation are needed. We review previous studies concerning inflammatory biomarkers in venous thromboembolism, in particular cytokines, soluble adhesion molecules and matrix metalloproteases as predisposing, diagnostic and prognostic factors in venous thrombosis. Elevated cytokines and genetic alterations coding for cytokines are found in several patient cohorts which indicate that cytokines are involved as predisposing factors in venous thrombosis development. Increased levels of pro-inflammatory cytokines are detected both in animal models and in patients with acute venous thrombosis and clinical trials, although currently without evident diagnostic value. Adhesion molecules are crucial in the development of venous thrombosis, especially P-selectin seems important in initiating leukocyte accumulation and adhesion to endothelium for subsequent platelet accumulation. Several studies have demonstrated increased soluble P-selectin levels in patients with venous thrombosis, emphasizing its potential role as diagnostic marker and also as a therapeutic target. Matrix metalloproteases are essential effectors during venous thrombosis resolution and may impact vessel wall fibrosis, and together with their natural occurring inhibitors are crucial in acute and chronic thrombosis pathophysiology. Furthermore, studies in animal models of venous thrombosis have demonstrated anti-inflammatory treatment to be effective in terms of thrombus resolution and reduction of vessel wall damage, without increase in bleeding risk during the course of treatment. Thus, soluble mediators should be further investigated both as possible biomarkers and therapeutic targets in venous thromboembolic disease.
Collapse
Affiliation(s)
- Knut A Mosevoll
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Silje Johansen
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Wendelbo
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Ina Nepstad
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Section for Hematology, Institute of Clinical Science, University of Bergen, Bergen, Norway
| | - Håkon Reikvam
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Section for Hematology, Institute of Clinical Science, University of Bergen, Bergen, Norway
| |
Collapse
|
14
|
Obi AT, Diaz JA, Ballard-Lipka NL, Roelofs KJ, Farris DM, Lawrence DA, Henke PK, Wakefield TW. Low-molecular-weight heparin modulates vein wall fibrotic response in a plasminogen activator inhibitor 1-dependent manner. J Vasc Surg Venous Lymphat Disord 2014; 2:441-450.e1. [PMID: 25419511 PMCID: PMC4235166 DOI: 10.1016/j.jvsv.2014.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Treatment with low-molecular-weight heparin (LMWH) favorably alters the vein wall response to deep venous thrombosis (DVT), although the mechanisms remain unclear. Previous studies have suggested that LMWH alters the levels of circulating plasminogen activator inhibitor 1 (PAI-1), a known mediator of fibrosis, and may improve endogenous fibrinolysis. We hypothesized that LMWH favorably alters the vein wall response by binding of PAI-1 and acceleration of fibrinolysis. METHODS Wild-type and PAI-1 -/- mice underwent treatment with LMWH after induction of occlusive DVT. Vein wall and plasma were harvested and analyzed by enzyme-linked immunosorbent assay, zymography, real-time polymerase chain reaction, and immunohistochemistry. RESULTS Wild-type mice treated with LMWH exhibited diminished vein wall fibrosis (0.6 ± 0.6 vs 1.4 ± 0.2; P < .01; n = 5) and elevation of circulating PAI-1 (1776 ± 342 vs 567 ± 104 ρg/mL; P < .01; n = 5) compared with untreated controls after occlusive DVT. PAI-1-/- mice treated with LMWH were not similarly protected from fibrosis, despite improved thrombus resolution. Treatment with LMWH was associated with decreased intrathrombus interleukin-lβ (68.6 ± 31.0 vs 223.4 ± 28.9 ρg/mg total protein; P < .01; n = 5) but did not alter inflammatory cell recruitment to the vein wall. PAI-1 -/- mice exhibited significantly elevated intrathrombus (257.2 ± 51.5 vs 4.3 ± 3.8 ρg/mg total protein; n = 5) and vein wall interleukin-13 (187.2 ± 57.6 vs 9.9 ± 1.1 ρg/mg total protein; P < .05; n = 5) as well as vein wall F4/80 positively staining monocytes (53 ± 11 vs 16 ± 2 cells/5 high-power fields; P < .05; n = 4). CONCLUSIONS LMWH did not accelerate venous thrombosis resolution but did protect against vein wall fibrosis in a PAI-1-dependent manner in an occlusive DVT model. Lack of PAI-1 correlated with accelerated venous thrombosis resolution but no protection from fibrosis. PAI-1 inhibition as a treatment strategy for DVT is likely to accelerate clearance of the thrombus but may come at the expense of increased vein wall fibrosis. CLINICAL RELEVANCE The pathophysiologic mechanism of post-thrombotic syndrome is not well understood clinically or experimentally. In this study, we evaluated the effect of the prominent fibrinolytic mechanism, plasminogen activator inhibitor 1 (PAI-1), and low-molecular-weight heparin (LMWH) on vein wall injury after thrombosis. We show here that LMWH is protective from vein wall fibrosis, but this is abrogated in PAI-1-deleted mice. This is also correlated with monocyte vein wall influx. These data support the clinical observation that LMWH may be protective from post-thrombotic vein wall injury in a PAI-1-dependent manner.
Collapse
Affiliation(s)
- Andrea T. Obi
- Section of Vascular Surgery, Department of Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, Mich
| | - Jose A. Diaz
- Section of Vascular Surgery, Department of Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, Mich
| | - Nicole L. Ballard-Lipka
- Section of Vascular Surgery, Department of Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, Mich
| | - Karen J. Roelofs
- Section of Vascular Surgery, Department of Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, Mich
| | - Diana M. Farris
- Section of Vascular Surgery, Department of Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, Mich
| | - Daniel A. Lawrence
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Mich
| | - Peter K. Henke
- Section of Vascular Surgery, Department of Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, Mich
| | - Thomas W. Wakefield
- Section of Vascular Surgery, Department of Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, Mich
| |
Collapse
|
15
|
Obi AT, Diaz JA, Ballard-Lipka NL, Roelofs KJ, Farris DM, Lawrence DA, Wakefield TW, Henke PK. Plasminogen activator-1 overexpression decreases experimental postthrombotic vein wall fibrosis by a non-vitronectin-dependent mechanism. J Thromb Haemost 2014; 12:1353-63. [PMID: 24943740 PMCID: PMC4127110 DOI: 10.1111/jth.12644] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/12/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Factors associated with postthrombotic syndrome are known clinically, but the underlying cellular processes at the vein wall are not well delineated. Prior work suggests that vein wall damage does not correlate with thrombus resolution but rather with plasminogen activator-1 (PAI-1) and matrix metalloproteinase (MMP) activity. OBJECTIVE We hypothesized that PAI-1 would confer post venous thrombosis (VT) vein wall protection via a vitronectin (Vn)-dependent mechanism. METHODS A stasis model of VT was used with harvest over 2 weeks, in wild-type, Vn(-/-) , and PAI-1-overexpressing mice (PAI-1 Tg). RESULTS PAI-1 Tg mice had larger VT at 6 and 14 days, compared to controls, but Vn(-/-) mice had no alteration of VT resolution. Gene deletion of Vn resulted in an increase in, rather than the expected decrease in, circulating PAI-1 activity. While both Vn(-/-) and PAI-1 Tg had attenuated intimal fibrosis, PAI-1 Tg had significantly less vein wall collagen and a compensatory increase in collagen III gene expression. Both Vn(-/-) and PAI-1 Tg vein wall had less monocyte chemotactic factor-1 and fewer macrophages (F4/80), with significantly less MMP-2 activity and decreased TIMP-1 antigen. Ex vivo assessment of transforming growth factor β-mediated fibrotic response showed that PAI-1 Tg vein walls had increased profibrotic gene expression (collagens I and III, MMP-2, and α-smooth muscle actin) compared with controls, opposite of the in vivo response. CONCLUSIONS The absence of Vn increases circulating PAI-1, which positively modulates vein wall fibrosis in a dose-dependent manner. Translationally, PAI-1 elevation may decrease vein wall damage after deep vein thrombosis, perhaps by decreasing macrophage-mediated activities.
Collapse
Affiliation(s)
- A T Obi
- Conrad Jobst Vascular Research Laboratory, Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Laser A, Elfline M, Luke C, Slack D, Shah A, Sood V, Deatrick B, McEvoy B, Ostra C, Comerota A, Kunkel S, Hogaboam C, Henke PK. Deletion of cysteine-cysteine receptor 7 promotes fibrotic injury in experimental post-thrombotic vein wall remodeling. Arterioscler Thromb Vasc Biol 2013; 34:377-85. [PMID: 24311382 DOI: 10.1161/atvbaha.113.302428] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Deep vein thrombosis (VT) can result in vein wall injury, which clinically manifests as post-thrombotic syndrome. Postinjury fibrosis may be modulated in part through cellular cysteine-cysteine receptor 7 (CCR7)-mediated events. We tested the hypothesis that late vein wall fibrotic remodeling is dependent on CCR7. APPROACH AND RESULTS CCR7(-/-) and C57BL/6 wild-type mice had inferior vena cava VT induced by nonstasis or stasis mechanisms. In both models, VT size was largest at day 1 and trended down by day 21, and CCR7(+) cells peaked at day 8 in wild-type mice. No significant differences in VT resolution were found in CCR7(-/-) as compared with wild type in either model. In the nonstasis VT model, vein wall changes consistent with fibrotic injury were evidenced by significant increases in collagen I, III, matrix metalloproteinase 2, and transforming growth factor-β gene expression, increases in α-smooth muscle actin and fibroblast specific protein-1 antigen, and total collagen at 8 days. Correspondingly, SM22α and fibroblast specific protein-1, but not DDR2(+) cells, were increased at 8 days. Early wild-type thrombus exposure inhibited profibrotic gene expression in CCR7(-/-) in ex vivo vein wall culture. Bone marrow chimera experiments further showed that circulating CCR7(+) leukocytes partially rescued midterm profibrotic changes in CCR7(-/-) mice. In human histological sections of chronic thrombosed femoral veins, CCR7(+) cells were present in the fibrotic areas. CONCLUSIONS Post-thrombotic vein wall remodeling is impaired in CCR7(-/-) mice, with a profibrotic phenotype, is dependent on the thrombotic mechanism, and is mediated by circulating CCR7(+) cells. Unlike other postinjury fibrotic responses, CCR7(+) signaling may be important for positive vein wall remodeling after VT.
Collapse
Affiliation(s)
- Adriana Laser
- From the Jobst Vascular Surgery Laboratory, Section of Vascular Surgery, Department of Surgery (A.L., M.E., C.L., D.S., A.S., V.S., B.D., B.M., S.K., C.H., P.K.H.) and Department of Pathology (A.L., M.E., C.L., D.S., A.S., V.S., B.D., B.M., S.K., C.H., P.K.H.), University of Michigan Medical School, Ann Arbor; and Jobst Vascular Center, Toledo, OH (C.O, A.C.)
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Deatrick KB, Luke CE, Elfline MA, Sood V, Baldwin J, Upchurch GR, Jaffer FA, Wakefield TW, Henke PK. The effect of matrix metalloproteinase 2 and matrix metalloproteinase 2/9 deletion in experimental post-thrombotic vein wall remodeling. J Vasc Surg 2013; 58:1375-1384.e2. [PMID: 23490298 PMCID: PMC3688659 DOI: 10.1016/j.jvs.2012.11.088] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 11/14/2012] [Accepted: 11/21/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Vein wall fibrotic injury following deep venous thrombosis (VT) is associated with elevated matrix metalloproteinases (MMPs). Whether and by what mechanism MMP2 contributes to vein wall remodeling after VT is unknown. METHODS Stasis VT was produced by ligation of the inferior vena cava and tissue was harvested at 2, 8, and 21 days in MMP2 -/- and genetic wild type (WT) mice. Tissue analysis by immunohistochemistry, enzyme-linked immunosorbent assay, real-time polymerase chain reaction, and zymography was performed. RESULTS Thrombus resolution was less at 8 days in MMP2 -/- compared with WT, evidenced by a 51% increase in VT size (P < .01), and threefold fewer von Willebrand's factor positive channels (P < .05). In MMP2 -/- mice, the main phenotypic fibrotic differences occurred at 8 days post-VT, with significantly less vein wall collagen content (P = .013), fourfold lower procollagen III gene expression (P < .01), but no difference in procollagen I compared with WT. Decreased inflammation in MMP2 -/- vein walls was suggested by ∼ threefold reduced TNFα and IL-1β at 2 days and 8 days post-VT (P < .05). A fourfold increase in vein wall monocytes (P = .03) with threefold decreased apoptosis (P < .05), but no difference in cellular proliferation at 8 days was found in MMP2 -/- compared with WT. As increased compensatory MMP9 activity was observed in the MMP2 -/-mice, MMP2/9 double null mice had thrombus induced with VT harvest at 8 days. Consistently, twofold larger VT, a threefold decrease in vein wall collagen, and a threefold increase in monocytes were found (all P < .05). Similar findings were observed in MMP9 -/- mice administered an exogenous MMP2 inhibitor. CONCLUSIONS In stasis VT, deletion of MMP2 was associated with less midterm vein wall fibrosis and inflammation, despite an increase in monocytes. Consideration that VT resolution was impaired with MMP2 (and MMP2/9) deletion suggests direct inhibition will likely also require anticoagulant therapy.
Collapse
Affiliation(s)
- Kristopher B Deatrick
- Conrad Jobst Vascular Research Laboratory, Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Deatrick KB, Obi A, Luke CE, Elfline MA, Sood V, Upchurch GR, Jaffer F, Wakefield TW, Henke PK. Matrix metalloproteinase-9 deletion is associated with decreased mid-term vein wall fibrosis in experimental stasis DVT. Thromb Res 2013; 132:360-6. [PMID: 23978304 PMCID: PMC3777801 DOI: 10.1016/j.thromres.2013.06.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 06/26/2013] [Accepted: 06/28/2013] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Post thrombotic syndrome therapy is primarily palliative, and the associated vein wall inflammatory mechanisms are unclear. Vein wall fibrotic injury following deep venous thrombosis (VT) is associated with elevated matrix metalloproteinases (MMPs). Whether and by what mechanism MMP9 directly contributes to vein wall remodeling after VT is unknown. METHODS WT and MMP9 -/- mice underwent stasis VT by ligation of the inferior vena cava (IVC) and tissue was harvested at 2, 8, and 21days. Assessment of thrombus size, and gene, protein and structural vein wall determinations were done. RESULTS VT resolution was increased in MMP9-/- mice as compared with controls at 21d only. The primary phenotypic fibrotic vein wall differences occurred at 8d post VT, with significantly less vein wall collagen content as assessed by Picosirius red staining in MMP9 -/- mice as compared with WT. Increased monocytic vein wall influx with less IL-1b and TGFb was found in MMP9 -/- vein walls as compared with WT. Corresponding levels of PAI-1 were increased in MMP9 -/- compared with WT, and no difference in FSP-1+cells as compared with controls. CONCLUSIONS In stasis VT, MMP9 modulates midterm vein wall collagen content, with an altered local inflammatory and profibrotic environment, likely directed by monocytes. Thus, MMP9 plays a role in both vein wall responses as well as late thrombus resolution.
Collapse
Affiliation(s)
- Kristopher B Deatrick
- Conrad Jobst Vascular Research Laboratory, Section of Vascular Surgery, Department of Surgery, University of Michigan Medical School, Boston MA, United States
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Wang C, Yang F, Xu Z, Shi D, Chen D, Dai J, Gu N, Jiang Q. Intravenous release of NO from lipidic microbubbles accelerates deep vein thrombosis resolution in a rat model. Thromb Res 2013. [DOI: 10.1016/j.thromres.2012.11.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
20
|
Baldwin JF, Sood V, Elfline MA, Luke CE, Dewyer NA, Diaz JA, Myers DD, Wakefield T, Henke PK. The role of urokinase plasminogen activator and plasmin activator inhibitor-1 on vein wall remodeling in experimental deep vein thrombosis. J Vasc Surg 2012; 56:1089-97. [PMID: 22796119 DOI: 10.1016/j.jvs.2012.02.054] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 02/22/2012] [Accepted: 02/26/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Deep vein thrombosis (DVT) resolution instigates an inflammatory response, resulting in vessel wall damage and scarring. Urokinase-plasminogen activator (uPA) and its inhibitor, plasminogen activator inhibitor-1 (PAI-1), are integral components of the fibrinolytic system, essential for venous thrombosis (VT) resolution. This study determined the vein wall response when exposed to increased and decreased plasmin activity. METHODS A mouse inferior vena cava (IVC) ligation model in uPA -/- or PAI-1 -/- and their genetic wild types (B6/SvEv and C57/BL6, respectively) was used to create stasis thrombi, with tissue harvest at either 8 or 21 days. Tissue analysis included gene expression of vascular smooth muscle cells (alpha smooth muscle actin [αSMA], SM22) and endothelial marker (CD31), by real-time polymerase chain reaction, enzyme-linked immunosorbent assay, matrix metalloproteinase (MMP)-2 and -9 activity by zymography, and vein wall collagen by picro-Sirius red histologic analysis. A P < .05 was considered significant. RESULTS Thrombi were significantly larger in both 8-day and 21-day uPA -/- as compared with wild type (WT) and were significantly smaller in both 8-day and 21-day PAI-1 -/- as compared with WT. Correspondingly, 8-day plasmin levels were reduced in half in uPA -/- and increased three-fold in PAI-1 -/- when compared with respective WT thrombi (P < .05; n = 5-6). The endothelial marker CD31 was elevated two-fold in PAI-1 -/- mice at 8 days, but reduced 2.5-fold at 21 days in uPA -/- as compared with WT (P = .02; n = 5-6), suggesting less endothelial preservation. Vein wall vascular smooth muscle cell (VSMC) gene expression showed that 8-day and 21-day PAI-1 -/- mice had 2.3- and 3.8-fold more SM22 and 1.8- and 2.3-fold more αSMA expression than respective WT (P < .05; n = 5-7), as well as 1.8-fold increased αSMA (+) cells (P ≤ .05; n = 3-5). No significant difference in MMP-2 or -9 activity was found in the PAI-1 -/- mice compared with WT, while 5.4-fold more MMP-9 was present in 21-day WT than 21-day uPA -/- (P = .03; n = 5). Lastly, collagen was ∼two-fold greater at 8 days in PAI-1 -/- IVC as compared with WT (P = .03; n = 6) with no differences observed in uPA -/- mice. CONCLUSIONS In stasis DVT, plasmin activity is critical for thrombus resolution. Divergent vein wall responses occur with gain or loss of plasmin activity, and despite smaller VT, greater vein wall fibrosis was associated with lack of PAI-1.
Collapse
Affiliation(s)
- Joe F Baldwin
- Jobst Vascular Surgery Laboratory, Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Henke PK, Mitsuya M, Luke CE, Elfline MA, Baldwin JF, Deatrick KB, Diaz JA, Sood V, Upchurch GR, Wakefield TW, Hogaboam C, Kunkel SL. Toll-like receptor 9 signaling is critical for early experimental deep vein thrombosis resolution. Arterioscler Thromb Vasc Biol 2011; 31:43-9. [PMID: 20966396 PMCID: PMC3005132 DOI: 10.1161/atvbaha.110.216317] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Toll-like receptors (TLR) bridge innate immunity and host responses, including inflammation. Sterile inflammation such as a venous thrombus (Vt) may involve TLR signaling, including TLR9. METHODS AND RESULTS TLR9 signaling on thrombus resolution was investigated using a mouse model of stasis Vt. Vt were significantly larger in TLR9-/- mice compared with wild-type (WT) at 2 and 8 days, despite a 2-fold increase in thrombus polymorphonucleic neutrophils at 2 days and monocytes at 8 days, whereas thrombus collagen and neovascularization was 55% and 37% less, respectively, at 8 days. Coincidently, decreased fibrinogen and increased thrombin-antithrombin complex were observed in TLR9-/- mouse thrombi. Vein wall interferon-α, interleukin-1α, and interleukin-2 were significantly reduced in TLR9-/- mice compared with WT. Thrombus cell death pathway markers were not significantly altered at 2 days, but caspase-1 was reduced in TLR9-/- thrombi at 8 days. MyD88 confers TLR9 intracellular signaling, but MyD88-/- mice had Vt resolution similar to that of WT. However, inhibition of the NOTCH ligand δ-like 4 was associated with larger Vt. Finally, stimulation with a TLR9 agonist was associated with smaller Vt. CONCLUSIONS TLR9 signaling is integral for early and mid-Vt resolution through modulation of sterile inflammation, maintaining a TH1 milieu, and effects on the thrombosis pathway.
Collapse
|
22
|
Deatrick KB, Elfline M, Baker N, Luke CE, Blackburn S, Stabler C, Wakefield TW, Henke PK. Postthrombotic vein wall remodeling: preliminary observations. J Vasc Surg 2011; 53:139-46. [PMID: 20869834 PMCID: PMC3010467 DOI: 10.1016/j.jvs.2010.07.043] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Revised: 07/20/2010] [Accepted: 07/22/2010] [Indexed: 01/02/2023]
Abstract
BACKGROUND Postthrombotic syndrome is characterized by a fibrotic vein injury following deep vein thrombosis (DVT). We sought to quantify the change in vein wall thickness in patients who fail to resolve DVT by 6 months and whether there were differences in blood or plasma levels of inflammatory proteins associated with venous remodeling. METHODS Patients presenting with confirmed lower extremity DVT were prospectively recruited for this study. Duplex imaging of the lower extremity venous system was performed, and blood was collected at entrance and repeat evaluation with blood draw and ultrasound imaging at 1 and 6 months. DVT resolution and thickness of the vein wall was quantified by ultrasound imaging in each segment affected by thrombus, and a contralateral, unaffected vein wall served as a control. Gene and protein expression of inflammatory markers were examined from leukocytes and serum, respectively. Analysis of variance or Student t-tests were used, and a P < .05 was significant. N = 10 to 12 for all analyses. RESULTS Thirty-two patients (12 patients with DVT resolution at 6 months, 10 patients with persistent thrombus at 6 months, and 10 healthy controls) were compared. Both resolving and nonresolving DVT were associated with a 1.5- to 1.8-fold increased vein wall thickness at 6 months (P = .008) as compared with nonaffected vein wall segments. However, the thickness of the affected segments was 1.4-fold greater in patients who had total resolution of the DVT by 6 months than in patients who had persistent chronic thrombus 6 months after presentation (P = .01). There was a four- to five-fold increased level of matrix metalloproteinase-9 (MMP-9) antigen in thrombosed patients compared with nonthrombosed patient controls (P < .05), while Toll-like receptor-9 (TLR-9) gene expression was three-fold less than controls (P < .05) at enrollment. D-dimer and P-selectin were higher in thrombosed as compared to controls at diagnosis but not at 6 months. Both TLR-4 (marker of inflammation) and P-selectin gene expression were higher in leukocytes from patients with chronic DVT compared with those who resolved at 1 month after diagnosis (P < .05). CONCLUSIONS This preliminary study suggests ongoing vein wall remodeling after DVT, measurable by ultrasound and associated with certain biomarkers. At 6 months, the vein wall is markedly thickened and directly correlates with resolution. This suggests that the vein wall response is initiated early following thrombus formation and persists even in the presence of total resolution.
Collapse
Affiliation(s)
- Kristopher B Deatrick
- Section of Vascular Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | | | | | | | | | | | | |
Collapse
|
23
|
An update on etiology, prevention, and therapy of postthrombotic syndrome. J Vasc Surg 2010; 53:500-9. [PMID: 21129900 DOI: 10.1016/j.jvs.2010.08.050] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 08/19/2010] [Accepted: 08/19/2010] [Indexed: 11/20/2022]
Abstract
Postthrombotic syndrome is a common sequelae resulting from deep venous thrombosis. The primary interventions are prevention and treatment, both of which many vascular specialists may not always recognize. We review the definition, epidemiology, the basic pathophysiology, and preventative management for postthrombotic syndrome. The current primary medical and interventional treatment modalities to decrease the occurrence of postthrombotic syndrome are also highlighted. Many of these treatments are currently available and simply need to be adhered to, whereas others are a shift in the paradigm, focusing on active thrombus removal.
Collapse
|
24
|
Sood V, Luke C, Miller E, Mitsuya M, Upchurch GR, Wakefield TW, Myers DD, Henke PK. Vein wall remodeling after deep vein thrombosis: differential effects of low molecular weight heparin and doxycycline. Ann Vasc Surg 2010; 24:233-41. [PMID: 20142002 DOI: 10.1016/j.avsg.2009.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 10/28/2009] [Accepted: 11/06/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thrombus resolution sets up an early intense inflammatory reaction, from which vein wall damage results. Tissue response to injury includes matrix metalloproteinase (MMP) activation and extracellular matrix protein turnover. This study sought to determine the effect of exogenous MMP inhibition and its potential attenuation of early vein wall injury. METHODS Rats received treatment beginning 24 hr after a stasis venous thrombosis by near occlusive ligation and until harvest at day 7. Three groups were evaluated: (1) vehicle saline controls (NaCl), (2) low molecular weight heparin (LMWH; Lovenox, 3 mg/kg daily SQ), and (3) doxycycline (DOXY, 30 mg/kg daily PO). Thrombus size (mg/mm), levels of tumor necrosis factor alpha (TNF alpha) and D-dimer by colorimetric assay, and monocytes counts by immunohistochemistry were assessed. Vein wall assessment included stiffness by tensiometry, interleukin 1beta (IL-1 beta protein levels by enzyme-linked immunosorbent assay, MMP2 and -9 by zymography, and histological analysis of intimal thickness (IT). Comparisons were by t-test to control. p < 0.05 was considered significant. RESULTS Thrombus sizes were similar at days 2 and 7 for all three groups, while thrombus TNFalpha was increased in 2-day LMWH- and DOXY-treated groups (NaCl = 1.0 +/- 0.8, LWMH = 9 +/- 3, DOXY = 27 +/- 5 pg/mg protein, n = 6-8, p < 0.05) and at 7 days in the DOXY group (NaCl = 3.0 +/- 2.5, DOXY = 23 +/- 4.2 pg/mg protein, n = 5, p < 0.05). Vein wall stiffness at 7 days was less with LMWH treatment, but not with DOXY, compared to controls (NaCl = 0.33 +/- 0.05, LMWH = 0.17 +/- 0.03, DOXY = 0.43 +/- 0.09 N/mm, n = 5-7, p < 0.05). Vessel-wall IL-1 beta was reduced only in the DOXY group at 7 days (NaCl = 26 +/- 3, LMWH = 38 +/- 17, DOXY = 6 +/- 3 pg/mg protein, n = 4-6, p < 0.05), as was the IT score versus controls (NaCl = 2.2 +/- 0.6, LMWH =1.7 +/- 0.3, DOXY = 0.8 +/- 0.20, n = 4-6, p < 0.05). Zymographic MMP9 activity was significantly reduced at 2 days in the LMWH and DOXY groups (NaCl = 85 +/- 24, LMWH = 23 +/- 7( *), DOXY = 13 +/- 5 U/mg protein, n = 6-8, p < 0.05). MMP2 zymographic activity, thrombus monocyte cell counts, and D-dimer activity were not significantly different across groups. CONCLUSION Treatment with LMWH or DOXY did not alter the size of deep vein thrombosis, mildly altered thrombus composition, and differentially affected vein wall injury, despite similar reductions in early MMP9 activity. Whether exogenous MMP inhibition affects long-term vein wall fibrosis will require further study.
Collapse
Affiliation(s)
- Vikram Sood
- Jobst Vascular Surgery Laboratory, Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | | | | | | | | | | |
Collapse
|
25
|
CHANGES IN THE FATTY ACID COMPOSITION OF THE LIVER WITH THE ADMINISTRATION OF N-3 POLYUNSATURATED FATTY ACIDS AND THE EFFECTS ON WARM ISCHEMIA/REPERFUSION INJURY IN THE RAT LIVER. Shock 2010; 33:306-14. [DOI: 10.1097/shk.0b013e3181b2ffd2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
26
|
The Impact of Different Concentrations of Sodium Tetradecyl Sulphate and Initial Balloon Denudation on Endothelial Cell Loss and Tunica Media Injury in a Model of Foam Sclerotherapy. Eur J Vasc Endovasc Surg 2010; 39:366-71. [DOI: 10.1016/j.ejvs.2009.12.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2009] [Accepted: 12/21/2009] [Indexed: 11/19/2022]
|
27
|
Henke PK, Wakefield T. Thrombus resolution and vein wall injury: dependence on chemokines and leukocytes. Thromb Res 2009; 123 Suppl 4:S72-8. [PMID: 19303509 DOI: 10.1016/s0049-3848(09)70148-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Chronic venous insufficiency resulting in post-thrombotic syndrome occurs commonly after acute deep vein thrombosis, and is a prevalent cause of vascular disease morbidity in the community. Therefore, a better understanding of the pathophysiologic mechanisms that promote the development of chronic venous insufficiency could lead to novel approaches to interrupt the natural history and prevent post-thrombotic syndrome. In this paper, we will review the evidence that venous thrombus resolution is an inflammatory process that is dependent on chemokines and leukocytes.
Collapse
|
28
|
Roumen-Klappe EM, Janssen MCH, Van Rossum J, Holewijn S, Van Bokhoven MMJA, Kaasjager K, Wollersheim H, Den Heijer M. Inflammation in deep vein thrombosis and the development of post-thrombotic syndrome: a prospective study. J Thromb Haemost 2009; 7:582-7. [PMID: 19175493 DOI: 10.1111/j.1538-7836.2009.03286.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether inflammatory markers (interleukin-6 [IL-6] and C-reactive protein [CRP]) in the acute phase of deep vein thrombosis (DVT) are associated with elevated venous outflow resistance (VOR), thrombosis score (TS), reflux and the development of clinical post-thrombotic syndrome (PTS). METHODS In 110 patients with a first DVT, plasma concentrations of IL-6 and CRP were determined on the day of admission. VOR, TS and reflux were measured 7 days, 1 and 3 months after diagnosis. After 1 year patients were evaluated for PTS using the Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) classification and Villalta scale. RESULTS Median levels of IL-6 and CRP were 7 pg mL(-1) and 21 mg L(-1), respectively. After 3 months, VOR was elevated in 33 patients (30%), TS in 33 (30%) and reflux in 57 (52%). Incidence of PTS was 36.7% using CEAP>or=3 and 35.4% using Villalta-scale>or=5. Elevated levels of IL-6 and CRP were related to higher outcomes of VOR after 3 months [relative risks (RR) 2.4 (95% CI 1.5-3.9) and 1.4 (1.1-3.3), respectively] and for IL-6 to TS [1.5 (1.1-2.1)]. For reflux no relation was found. After 90 days, elevated outcomes of VOR, TS and reflux were related to PTS after 1 year. The association of IL-6 and CRP with PTS was weak using the CEAP classification with a RR of 1.2 (0.7-2.2) and 1.8 (0.9-3.3) and absent according to the Villalta scale 0.6 (0.2-1.4) and 1.2 (0.6-2.5), respectively. CONCLUSION The results of this study suggest that inflammation might play a role in incomplete thrombus clearance, venous outflow obstruction and the development of PTS after 1 year.
Collapse
Affiliation(s)
- E M Roumen-Klappe
- Department of General Internal Medicine, Radbound University Nijmegen Medical Centre, and Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|