Atherosclerotic Yucatan microswine: an animal model with high-grade, fibrocalcific, nonfatty lesions suitable for testing catheter-based interventions

Stabilizing Peri-Stent Restenosis Using a Novel Therapeutic Carrier

Late in-stent restenosis remains a significant problem. Bare-metal stents were implanted into peripheral arteries in miniature swine, followed by direct intra-arterial infusion of nitric oxide-loaded echogenic liposomes (ELIPs) and anti-intercellular adhesion molecule-1 conjugated ELIPs loaded with pioglitazone exposed to an endovascular catheter with an ultrasonic core. Ultrasound-facilitated delivery of ELIP formulations into stented peripheral arteries attenuated neointimal growth. Local atheroma-targeted, ultrasound-triggered delivery of nitric oxide and pioglitazone, an anti-inflammatory peroxisome proliferator-activated receptor-γ agonist, into stented arteries has the potential to stabilize stent-induced neointimal growth and obviate the need for long-term antiplatelet therapy.

Trans-Stent B-Mode Ultrasound and Passive Cavitation Imaging

Angioplasty and stenting of a stenosed artery enable acute restoration of blood flow. However, restenosis or a lack of re-endothelization can subsequently occur depending on the stent type. Cavitation-mediated drug delivery is a potential therapy for these conditions, but requires that particular types of cavitation be induced by ultrasound insonation. Because of the heterogeneity of tissue and stochastic nature of cavitation, feedback mechanisms are needed to determine whether the sustained bubble activity is induced. The objective of this study was to determine the feasibility of passive cavitation imaging through a metal stent in a flow phantom and an animal model. In this study, an endovascular stent was deployed in a flow phantom and in porcine femoral arteries. Fluorophore-labeled echogenic liposomes, a theragnostic ultrasound contrast agent, were injected proximal to the stent. Cavitation images were obtained by passively recording and beamforming the acoustic emissions from echogenic liposomes insonified with a low-frequency (500 kHz) transducer. In vitro experiments revealed that the signal-to-noise ratio for detecting stable cavitation activity through the stent was greater than 8 dB. The stent did not significantly reduce the signal-to-noise ratio. Trans-stent cavitation activity was also detected in vivo via passive cavitation imaging when echogenic liposomes were insonified by the 500-kHz transducer. When stable cavitation was detected, delivery of the fluorophore into the arterial wall was observed. Increased echogenicity within the stent was also observed when echogenic liposomes were administered. Thus, both B-mode ultrasound imaging and cavitation imaging are feasible in the presence of an endovascular stent in vivo. Demonstration of this capability supports future studies to monitor restenosis with contrast-enhanced ultrasound and pursue image-guided ultrasound-mediated drug delivery to inhibit restenosis.

The impact of atherosclerosis and vascular collagen on energy-based vessel sealing

BACKGROUND

Bipolar energy ligation of vessels in surgery is common. Although rare, serious failures occur. Atherosclerosis may contribute to seal failures by altering vascular compressibility and collagen content; however, no data exist.

MATERIALS AND METHODS

Femoral and iliac arteries of six Yucatan swine with an identified genetic locus predisposing them to atherosclerosis were denuded with a Fogarty catheter. Animals were fed a high-fat diet for 28 wk. A Yorkshire pig was used as a normal control and fed a standard diet. At 28 wk, arteries were measured for their diameters, sealed, and divided in vivo with LigaSure. The sealed artery sections were excised and subjected to burst pressure testing. Half of the seal distal to the aorta was kept intact for histology and collagen and elastin quantification. A multiple linear regression model was used to assess variables contributing to burst pressure. Covariates included were vessel diameter, degree of atherosclerosis, and collagen content.

RESULTS

Experimental animals were hypercholesterolemic. Atherosclerosis occurred in 90% of seals in induced animals, with severe atherosclerosis in 62% of seals. There was site-selective deposition of atherosclerotic plaques in larger diameter iliac vessels. A model including collagen and size best predicted burst pressure. Every 10-U increase in collagen resulted in 15% increase in burst pressure (95% confidence interval = 0.2%-32%, P = 0.047, R(2) = 0.36). Atherosclerosis was unrelated to burst pressure controlling for collagen and size.

CONCLUSIONS

Collagen and size provide the best model fit for predicting burst pressure. Quantitative research in human vasculature is warranted to better understand the influence of atherosclerosis and collagen content on seal failures.

Animal models of atherosclerosis

Cardiovascular disease is currently the predominant cause of mortality worldwide and its incidence is expected to increase significantly during the next decades owing to the unhealthy effects of modern lifestyle habits (e.g., obesity and lack of physical exercise). Cardiovascular death is frequently associated with acute myocardial infarction or stroke, which are generally the ultimate consequence of an underlying atherosclerotic process. Small and big animal models are valuable tools to understand the molecular mechanisms underlying atherosclerotic plaque formation and progression, as well as the occurrence of associated ischemic events. Moreover, animal models of atherosclerosis are pivotal for testing mechanistic hypothesis and for translational research, including the assessment of dietary and/or pharmacological interventions and the development of imaging technologies and interventional devices. In this chapter, we will describe the most widely used animal models that have permitted major advances in atherosclerosis research and significant improvements in the treatment and diagnosis of atherosclerotic disease.

Plasma lipid profiling across species for the identification of optimal animal models of human dyslipidemia

In an attempt to understand the applicability of various animal models to dyslipidemia in humans and to identify improved preclinical models for target discovery and validation for dyslipidemia, we measured comprehensive plasma lipid profiles in 24 models. These included five mouse strains, six other nonprimate species, and four nonhuman primate (NHP) species, and both healthy animals and animals with metabolic disorders. Dyslipidemic humans were assessed by the same measures. Plasma lipoprotein profiles, eight major plasma lipid fractions, and FA compositions within these lipid fractions were compared both qualitatively and quantitatively across the species. Given the importance of statins in decreasing plasma low-density lipoprotein cholesterol for treatment of dyslipidemia in humans, the responses of these measures to simvastatin treatment were also assessed for each species and compared with dyslipidemic humans. NHPs, followed by dog, were the models that demonstrated closest overall match to dyslipidemic humans. For the subset of the dyslipidemic population with high plasma triglyceride levels, the data also pointed to hamster and db/db mouse as representative models for practical use in target validation. Most traditional models, including rabbit, Zucker diabetic fatty rat, and the majority of mouse models, did not demonstrate overall similarity to dyslipidemic humans in this study.

Preclinical Models of Restenosis and Their Application in the Evaluation of Drug-Eluting Stent Systems

Coronary arterial disease (CAD) is the leading cause of death in the United States, the European Union, and Canada. Percutaneous coronary intervention (PCI) has revolutionized the treatment of CAD, and it is the advent of drug-eluting stent (DES) systems that has effectively allayed much of the challenge of restenosis that has plagued the success of PCI through its 30-year history. However, DES systems have not been a panacea: There yet remain the challenges associated with interventions involving bare metallic stents as well as newly arisen concerns related to the application of DES systems. To effectively address these novel and ongoing issues, animal models are relied on both to project the safety and efficacy of endovascular devices and to provide insight into the pathophysiology underlying the vascular response to injury and mechanisms of restenosis. In this review, preclinical models of restenosis are presented, and their application and limitation in the evaluation of device-based interventional technologies for the treatment of CAD are discussed.

Vulnerable plaque in a Swine model of carotid atherosclerosis

BACKGROUND AND PURPOSE

Distal embolism and acute thrombosis due to rupture of a vulnerable atherosclerotic plaque are the common mechanisms of stroke in patients with carotid disease. The purpose of this study was to develop the first animal model of vulnerable carotid atherosclerotic plaque.

MATERIALS AND METHODS

Carotid atherosclerotic models were created in 12 Yucatan minipigs by using a combination of partial ligation and high cholesterol diet. Retia mirabilia from these animals were examined histopathologically to identify distal embolism. The association of distal embolism with advanced atherosclerosis and a thin fibrous cap was analyzed by using the Fisher exact test.

RESULTS

Typical features of vulnerable plaques, including a thin fibrous cap, necrotic core, and intraplaque hemorrhage, were observed in this swine model of carotid atherosclerosis. Distal embolism was detected in retia mirabilia supplied by 7 of 10 carotid arteries with advanced atherosclerotic plaques, compared with 3 of 14 carotid arteries without advanced plaque (P < .05).

CONCLUSIONS

This swine model of carotid atherosclerosis contains the salient features of vulnerable plaques, including plaque rupture and distal embolism.

The effect of intracoronary fibroblast growth factor-2 on restenosis after primary angioplasty or stent placement in a pig model of atherosclerosis

BACKGROUND

Therapeutic angiogenesis, if combined with primary percutaneous transluminal coronary angioplasty or stent placement, could improve the outcome of patients suffering from multifocal coronary disease.

HYPOTHESIS

Because of the concern that angiogenic growth factors might promote restenosis, we studied the effect of a single intracoronary administration of recombinant fibroblast growth factor (rFGF)-2 on restenosis after balloon angioplasty and stent placement in a pig model of coronary atherosclerosis.

METHODS

In 24 Yucatan minipigs, coronary lesions were induced by arterial injury and 3 months of atherogenic diet. After 3 months, repeat catheterization was performed with balloon dilation or stent placement at the injured sites, with a follow-up of 6 weeks. Results were monitored using quantitative angiography, intravascular ultrasound (IVUS), and histomorphometry.

RESULTS

Intracoronary rFGF-2 2 microg/kg did not affect neointima formation or remodeling in this model. A small but significant aggravation of late lumen loss was observed in the reference segments of the rFGF-2-treated group. Angiographic and echographic late lumen loss, intimal hyperplasia, and arterial remodeling, as well as histologic neointima were all similar in the rFGF-2- and the vehicle-treated group. Confirming earlier studies from our group and those of others, stented arteries compared with balloon-dilated arteries had increased angiographic late lumen loss, a trend toward increased intimal hyperplasia and decreased remodeling.

CONCLUSION

We conclude that rFGF-2 does not aggravate restenosis after balloon dilation or stenting in this pig model of coronary atherosclerosis. Future combinations of angioplasty and therapeutic angiogenesis in a single session should be pursued as a feasible and safe strategy.

Gadofluorine-enhanced magnetic resonance imaging of carotid atherosclerosis in Yucatan miniswine

OBJECTIVE

The aim of this study was to determine whether gadofluorine, a paramagnetic magnetic resonance imaging (MRI) contrast agent, selectively enhances carotid atherosclerotic plaques in Yucatan miniswine.

METHODS

Atherosclerotic plaques were induced in the left carotid arteries (LCA) of Yucatan miniswine (n=3) by balloon denudation and high cholesterol diet. T1-weighted MRI was performed before and 24 hours after gadofluorine injection (at a dose of 100 micromol/kg) to assess the enhancement of the balloon-injured LCA wall relative to healthy, uninjured right carotid artery (RCA) wall. Histopathology was performed to verify the presence and composition of the atherosclerotic plaques imaged with MRI.

RESULTS

Gadofluorine was found to enhance LCA atherosclerotic lesions relative to RCA wall by 21% (P<0.025) 24 hours after contrast injection. Enhancement of healthy LCA wall relative to healthy RCA wall was not observed.

CONCLUSION

Gadofluorine selectively enhances carotid atherosclerotic plaques in Yucatan miniswine. Gadofluorine appears to be a promising MR contrast agent for detection of atherosclerotic plaques in vivo.

Lipoplex gene transfer of inducible nitric oxide synthase inhibits the reactive intimal hyperplasia after expanded polytetrafluoroethylene bypass grafting

OBJECTIVE

Intimal hyperplasia (IH) is most commonly the cause of graft occlusion in infrainguinal bypass grafting for arterial occlusive disease. We investigated the influence of nitric oxide on the IH of the arterial vessel wall at the region of prosthetic bypass anastomoses.

METHODS

Experiments were performed in 10 Foxhound dogs. We used a technique of inducible nitric oxide synthase (iNOS) overexpression by a non-virus-mediated, liposome-based iNOS gene transfer. The plasmid pSCMV-iNOS, which drives the expression of iNOS under control of the cytomegalovirus promoter, was complexed with cationic liposomes (lipoplexes). Segments of both carotid arteries were pretreated by intramural injection of a lipoplex solution by using an infiltrator balloon catheter (Infiltrator Drug Delivery Balloon System). In each dog, iNOS was administered at one side, and a control vector (pSCMV2) was administered at the contralateral side. Carotid arteries were ligated, and bypass grafts (expanded polytetrafluoroethylene, 6-mm, ring enforced) were implanted on both sides. The proximal and distal anastomoses (end-to-side fashion; running nonabsorbable sutures) were placed in the pretreated regions. After 6 months, the prostheses were excised, and the intimal thicknesses of 50 cross sections (orcein staining) of each anastomosis were measured planimetrically.

RESULTS

The average reduction of the neointima thickness of the iNOS side in proximal anastomoses at the prosthetic wall, suture region, and arterial wall was 43%, 52%, and 81%, respectively. In distal anastomoses, the average reduction was 40%, 47%, and 52%, respectively. All differences of neointima thickness between the iNOS and control sides were statistically significant (Wilcoxon test; P < or = .05).

CONCLUSIONS

Inducible NOS expression is an efficient approach for inhibition of IH. In contrast to earlier studies, which investigated the efficacy of gene therapeutic NOS expression at 3 to 4 weeks after intervention, the novelty of our findings is that a single local lipoplex-mediated transfection of the vascular wall with iNOS-expressing plasmids leads to a reduction of IH in a prosthetic in vivo model even after 6 months. Because all components can be manufactured under Good Manufacturing Practice conditions (the quality-management system of the European pharmaceutical industry based on ISO 9000), this approach is also amenable to human therapy.

Regional material property alterations in porcine femoral arteries with atheroma development

We have developed a novel methodology that permits assessment of regional vascular mechanical property alterations in the presence of atheroma in vivo employing a Yucatan miniswine model with induced lesions. Femoral arteries were imaged with intravascular ultrasound. Image data were segmented and, following three-dimensional reconstruction, underwent finite element and sensitivity analysis with optimization to identify regions with altered vascular mechanical properties. All regions were compared to histological analysis. In 12 animals with 8 weeks of endothelial cell denudation and high cholesterol diet (induced atherosclerosis), the elastic modulus initially decreased with early lesion development and then increased with increasing fibrosis-(elastic modulus-all values x10(4)Pa-mean+/-SEM) histologically normal (non-denuded control segment) elements 9.73+/-0.01, fatty elements 9.53+/-0.01, fibrofatty elements 9.41+/-0.03, and fibrous elements 9.68+/-0.02 (all p<0.001 vs. normal elements). Wall thickness, however, increased with atheroma formation. These data demonstrate decreasing vascular material properties with early lesions, followed by an increase as lesions progress. This methodology permits determination of areas with early atheroma development, follow atheroma progression, and potentially evaluate interventions aimed at decreasing atheroma load and normalizing vascular material properties.

Endovascular needle injection of cholesteryl linoleate into the arterial wall produces complex vascular lesions identifiable by intravascular ultrasound: early development in a porcine model of vulnerable plaque

BACKGROUND

We attempted to create a pig model of complex arterial lesions through the percutaneous injection of cholesteryl linoleate into the vessel wall.

METHODS AND RESULTS

A total of 81 arterial segments (27 arteries) underwent percutaneous intramural injection of cholesteryl linoleate, in eight pigs. Intravascular ultrasound (IVUS) analysis and corresponding histology were obtained for analysis at 2 and 4 weeks after injection. Overall, 18 out of 27 (67%) of the injected arterial segments displayed lesions identifiable by IVUS as an eccentric echolucent zone present within the deeper layer of the lesion. Quantitative IVUS analysis demonstrated that these lesions were non-occlusive (36+/-8% area stenosis), eccentric (eccentricity index, 0.78+/-0.07) and located into positively remodeled vessels (remodeling index, 1.45+/-0.24). By histology, these lesions were eccentric and comprised less than a third of the vessel circumference. Medial thickening and a thickened intima containing lipid droplets and mononuclear cells were consistently found. The presence of lipids or local wall thickening seen by histology colocalized with the presence of echolucent structures seen by IVUS in 65% of the coronary segments and 70% of the iliac segments.

CONCLUSIONS

The intramural deposition of cholesteryl linoleate results in the development of complex, lipid-containing inflammatory lesions in less than 4 weeks. These lesions are already identifiable by IVUS at 2 weeks and colocalize with histologic findings. Further development of this model may allow the validation of technologies designed to detect and treat high-risk atherosclerotic lesions.

Porcine carotid arterial material property alterations with induced atheroma: an in vivo study

OBJECTIVE

A novel methodology has been developed to evaluate regional alterations in arterial wall material properties with induced atheroma in an animal model.

METHODS

Atheromatous lesions (fatty, fibro-fatty, and fibrous) were induced in the carotid arteries of a Yucatan miniswine model by endothelial cell denudation and high cholesterol diet. The images at base line and 8 weeks after denudation were obtained using intravascular ultrasound (IVUS) imaging along with hemodynamic data. Finite element analysis (FEA) along with optimization was employed to assess regional alterations in elastic modulus in the presence of atheroma confirmed by histology.

RESULTS

In animals with 8 weeks of induced atherosclerosis, the elastic modulus increased-(elastic modulus-all values x 10(4) Pa, mean+/-S.D.) normal elements (9.34+/-0.36) compared to abnormal elements (9.52+/-0.36) (p<0.05 versus normal elements). Wall thickness increased with atheroma formation. These data demonstrate stiffening vascular wall elastic modulus with lesion progression. This is different from the behavior of femoral arteries, where the elastic modulus decreases with early stages of atheroma development followed by an increase as lesions progress.

CONCLUSIONS

This methodology permits determination of areas with early atheroma development, follow atheroma progression, and potentially evaluate interventions aimed at decreasing atheroma load and normalizing vascular material properties.

Metalloproteinase inhibition by batimastat does not reduce neointimal thickening in stented atherosclerotic porcine femoral arteries

BACKGROUND

Vascular injury results in specific temporal patterns of increased matrix metalloproteinase (MMP) activity. MMPs are known to play a role in remodeling and neointimal (NI) thickening. Although in vitro data on the role of metalloproteinases and their inhibitors on smooth muscle cell migration and proliferation are compelling, evidence for inhibition of NI thickening in vivo is inconsistent and is mostly generated in models of balloon angioplasty instead of the more prevalent stent placement. Data from atherosclerotic models are scarce. The objective of the study was to investigate whether the nonspecific MMP inhibitor batimastat, in concentrations known to influence remodeling, could also inhibit NI thickening following stent placement in an atherosclerotic model.

METHODS

Stents were placed in atherosclerotic femoral arteries in Yucatan micropigs on a high cholesterol diet and followed for 6 weeks. Batimastat or vehicle was administered intraperitoneally. NI thickening was assessed by morphometry.

RESULTS

The main finding was that batimastat did not result in a significant decrease in NI thickness. Only following correlation to the amount of preexisting plaque was the difference of 146 microm (19%) statistically significant. Batimastat did not impair wound healing following stenting.

CONCLUSION

Batimastat does not significantly influence the degree of NI thickening at 6 weeks following stenting of atherosclerotic porcine femoral arteries, except when correlated to plaque thickness. Batimastat does not affect vascular wound healing.

A method for in-vivo analysis for regional arterial wall material property alterations with atherosclerosis: preliminary results

Atherosclerosis is a diffuse arterial disease developing over many years and resulting in a complicated three-dimensional arterial morphology. The arterial wall material properties have been demonstrated to show regional alterations with atheroma development and growth. We present a mechanical analysis of diseased arterial segments reconstructed from intravascular ultrasound images in order to quantitatively identify regional alterations in the elastic constants with atherosclerotic lesions. We employ a finite element and a displacement sensitivity analysis to divide the arterial segment into regions with different material properties and use an optimization algorithm to identify the elastic constants in these regions. The results with regional variations identified with this method correlated qualitatively with the extent and location of atherosclerotic lesions identified by visual inspection of the affected arteries. The optimized elastic modulus in regions affected by early atherosclerotic lesions ranged from 90.9 to 93.0 kPa where as the corresponding magnitudes in normal arterial segments ranged from 97.9 to 101.0 kPa. This method can be potentially employed to identify the extent and location of atherosclerotic lesions in a systematic analysis and may potentially be used for the early detection of lesion growth.

Development of an animal model of selective coronary atherosclerosis

BACKGROUND

Atherosclerosis causes over 40% of all deaths in the USA and Western Europe. Although several hypotheses have been proposed, the etiology and pathogenesis of the atherosclerosis remain unknown.

OBJECTIVE

To develop a model of selective coronary atherosclerosis in pigs.

DESIGN

An animal model of selective coronary atherosclerosis was developed by combining a guide-wire-induced endothelial injury and cholesterol-enriched diet.

METHODS

Twelve pigs were subjected to guide-wire-induced injury to endothelium of left anterior descending (LAD) coronary artery. Six animals (control group) were fed a standard pig food; the remaining six animals (cholesterol group) were fed a 6%-cholesterol-enriched diet. Three animals from the control group were killed immediately after the endothelial injury (acute control group). The other three animals in the control group (chronic control group) and all animals in the cholesterol-fed group were killed 4 weeks after the injury.

RESULTS

The endothelial surface and the media of the left circumflex coronary artery LCX in all animals were intact. Long eccentric areas of endothelial injury were found in the LAD coronary arteries of animals in the acute control group. Numerous fibrous atherosclerotic plaques in LAD coronary arteries were found in animals in the chronic control group as well as in animals in the cholesterol-fed group, but were highly pronounced in animals in the last group. No accumulation of lipids was found in the plaques of animals in both groups.

CONCLUSIONS

Administration of a 6%-cholesterol diet for 6 weeks is not sufficient to cause coronary atherosclerosis in pigs. Selective coronary atherosclerosis can be induced within 4 weeks with the same diet when the blood vessel has been injured with a guide wire.

Animal models for atherosclerosis, restenosis, and endovascular graft research

Animal models have significantly advanced our understanding of the mechanisms of atherosclerosis and restenosis formation and the evaluation of therapeutic options. The current focus of research is on preventive strategies against restenosis and includes pharmacologic and biologic interventions directed primarily against smooth muscle cell proliferation, endovascular devices for recanalization and/or drug delivery, and an integrated approach using both devices and pharmacobiologic agents. Devices aimed at the percutaneous endoluminal exclusion of aortic aneurysms have also generated interest recently. The experience over many decades with animal models in vascular research has established that a single, ideal, naturally available model for atherosclerosis, restenosis, or for that matter aneurysm formation, does not exist. Presently, rabbits and pigs are favored for the former two areas of study, and dogs and sheep appear to provide suitable models for testing devices for endoluminal repair of aneurysms. The development of transgenic variants of currently available models may widen our options in the future. Nevertheless, an appreciation of the individual features of natural or stimulated disease in each species is of the utmost importance for the proper design and execution of relevant experiments.

Cultured porcine coronary artery smooth muscle cells. A new model with advanced differentiation

Arterial intimal thickening after endothelial injury induced in rodents has proven to be a relatively unreliable model of restenosis for testing clinically useful compounds. The same has been found for cultured rat or rabbit vascular smooth muscle cells (SMCs). To test alternative possibilities, we have studied several differentiation features of porcine coronary artery SMCs, cultured up to the 5th passage after enzymatic digestion of the media. The effects of heparin, transforming growth factor (TGF)-beta1 or TGF-beta2, and all-trans-retinoic acid (tRA) on proliferation, migration, and differentiation of these cells also were examined. Porcine arterial SMCs in culture not only express high levels of alpha-smooth muscle (SM) actin but, contrary to rodent SMCs, also maintain an appreciable expression of SM myosin heavy chain isoforms 1 and 2, desmin, and smoothelin, a recently described late differentiation marker of vascular SMCs. We demonstrate for the first time that smoothelin is colocalized with alpha-SM actin in these cells. Finally, we show that in the porcine model, heparin is more potent than TGF-beta1 or TGF-beta2 and tRA in terms of inhibition of proliferation and migration and of increasing the expression of differentiation markers. This model should be a useful complement to in vivo studies of SMC differentiation and of pathological situations such as restenosis and atheromatosis.

A noninjury, diet-induced swine model of atherosclerosis for cardiovascular-interventional research

To investigate whether atherosclerotic vascular disease in the microswine model can be induced by atherogenic diet alone and does not require balloon injury or endothelial denudation as widely stated in the literature, 28 female Yucatan microswine were fed a high-fat, high-cholesterol diet, including 2% sodium cholate, for an average of 310 +/- 13 days. Four control swine were placed on a regular diet for an average of 287.2 +/- 7.8 days. Selective coronary arteriography and morphologic and histologic studies were performed at the end of this period. Coronary arteries were fixed in vivo by pressure perfusion of formalin. Angiograms and sequential histologic sections were reviewed by a double-blind team. The angiography did not show apparent disease in all vessels but generally revealed mild irregularity. Quantitatively, there was a 30.5 +/- 3.5% stenosis (mean +/- standard error, P < 0.05 vs. control) in left anterior descending (LAD), 40.7 +/- 4.5% of stenosis in right coronary artery (RCA) (P < 0.01 vs. control), and 24.8 +/- 3.7% of stenosis in left circumflex artery (LCX). The lesions were eccentric in 95% of LCA, 95.8% of RCA, and 75% of LCX, and the remainder were concentric lesions. Typical lesions were characterized by significant intimal proliferation, cholesterol clefts, necrotic cores, heavy extracellular fat deposition, and calcification. Control animals had only occasional, minimal intimal lipid deposition in coronary arteries. These findings suggest that the Yucatan microswine is an ideal coronary atherosclerosis animal model for vascular research. Lesions can be induced by atherogenic diet alone. Cholesterol uptake is increased by adding sodium cholate to the feed. Moreover, balloon injury of the intima or media is not required to induce significant atherosclerotic lesions in coronary arteries.

Development of an avian model for restenosis

Recurrence of atherosclerotic plaque growth after interventional therapy, restenosis, is a significant clinical problem occurring in 20%-50% of cases. We have developed a new avian model for the investigation of restenosis after arterial injury in cholesterol fed White Leghorn roosters. Atherosclerotic plaque growth 1-30 weeks after angioplasty balloon mediated endothelial injury in the abdominal aorta was studied in 37 roosters. Roosters were maintained on either normal poultry diet or high cholesterol diet. Twelve cholesterol fed roosters were also fed a hormone supplemented diet in order to modify plaque morphology. The procedural success rate was high. Angiographic stenoses (mean 36% with maximum of 74%) were detectable in cholesterol fed roosters after balloon angioplasty with associated histological evidence of plaque growth (P < 0.017). Cholesterol feeding enhanced fatty plaque growth; hormone manipulation increased calcific and ulcerated plaque but with high associated morbidity. Three interventional devices were subsequently examined in 32 roosters (16 laser angioplasty, 7 atherectomy, and 9 stent implant). Plaque development was again assessed by contrast angiography and histological analysis. We conclude that balloon mediated arterial injury in cholesterol fed roosters produces early proliferative and late, complex atherosclerotic lesions providing an inexpensive model for plaque development after intimal injury.

Vascular effects of diet-induced hypercalcemia after balloon artery injury in giant Flemish rabbits

To determine whether metastatic calcification during neointima formation can result in neointimal calcification that simulates advanced human atherosclerosis, 32 giant Flemish rabbits (weight 5.5 +/- 0.6 kg) underwent overstretch balloon injury of bilateral iliac arteries and received diet therapy for 8 weeks: high cholesterol (2%) and low calcium-vitamin D2 regimen (250 mg of calcium carbonate orally 5 times weekly and 50,000 U of calciferol intramuscularly 3 times weekly; group 1; n = 5); low cholesterol (0.5%) and high calcium-vitamin D2 regimen (500 mg of calcium carbonate orally 5 times weekly and 100,000 U of calciferol intramuscularly three times weekly; group 2; n = 19); or 0% cholesterol and high calcium-vitamin D2 regimen (group 3; n = 8). The incidence of vascular calcification was highest (71.4%) in group 2. Eighty-one percent of calcification was medial. Residual strain measurements of 7 thoracic aortas from group 2 compared to normal thoracic aortas from 8 control rabbits showed that residual strain was significantly increased in the calcified atherosclerotic aortas (12.3% vs 5.2%; p = 0.001). We conclude that diet-induced hypercalcemia predominantly affects the media despite the presence of concomitant neointima formation from balloon artery injury with or without hypercholesterolemia and increases the residual strain more than twofold compared to normal thoracic aortas.

Noninvasive localization of experimental atherosclerotic lesions with mouse/human chimeric Z2D3 F(ab')2 specific for the proliferating smooth muscle cells of human atheroma. Imaging with conventional and negative charge-modified antibody fragments

BACKGROUND

A murine monoclonal antibody designated Z2D3 (IgM) generated against homogenized human atherosclerotic plaques was demonstrated to be highly specific for proliferating smooth muscle cells. The primary clone subsequently was genetically engineered to provide a mouse/human chimeric antibody with human IgG1 constant region expressed in a rat myeloma cell line. The resulting Z2D3-73.30 chimeric retained the immunoreactivity relative to the parent Z2D3-IgM and was pepsin-digested to yield F(ab')2. 111In-labeled chimeric Z2D3 F(ab')2 was then used for noninvasive imaging of experimental atherosclerotic lesions. To improve the imaging characteristics, we modified chimeric Z2D3 F(ab')2 fragments to carry a high negative charge. Improved visualization of targets with 111In-labeled, negatively charged, polymer-modified antibodies most probably is the result of faster blood clearance and a decrease in nontarget background activity.

METHODS AND RESULTS

Experimental atherosclerotic lesions were induced in rabbits by deendothelialization of the infradiaphragmatic aorta followed by a 6% peanut oil-2% cholesterol diet. After 12 weeks, localization of the conventionally labeled 111In-Z2D3 F(ab')2 (24 Mbq [650 microCi]/500 to 750 micrograms) (n = 4) was compared with 111In-labeled, negatively charged, polymer-modified Z2D3 F(ab')2 (24 Mbq [650 microCi]/25 to 50 micrograms) in eight atherosclerotic rabbits. Three control rabbits also received radiolabeled polymer-modified Z2D3. Ten rabbits with atherosclerotic lesions received 111In-labeled nonspecific human IgG1 F(ab')2 with (n = 6) or without (n = 4) negative charge modification. Atherosclerotic lesions were visualized in all rabbits with the conventional Z2D3 F(ab')2 at 48 hours. However, unequivocal lesion visualization was possible at 24 hours only with negatively charged, polymer-modified Z2D3 F(ab')2. Quantitative uptake of F(ab')2 fragments was essentially determined by the presence of atherosclerotic lesions (F1.37 = 69.8; P < .0001) and the specificity of the antibody (F1.37 = 36.6; P < .0001). Uptake of the conventional Z2D3 in atherosclerotic lesions (mean +/- SEM percent injected dose per gram, 0.112 +/- 0.024%) was six times higher than background activity in the normal aortic segments (nondenuded thoracic aorta; mean percent injected dose per gram, 0.019 +/- 0.003%). Uptake of the conventional Z2D3 was also significantly higher than that of nonspecific human IgG1 F(ab')2 (0.027 +/- 0.004%). Specific uptake of the conventional Z2D3 in the lesions was comparable to the charge-modified Z2D3 uptake (0.084 +/- 0.017; P = .20). Uptake of negative charge-modified Z2D3 in the lesions was significantly higher than in the corresponding background activity in normal thoracic aorta (0.021 +/- 0.002). Uptake of negative charge-modified Z2D3 F(ab')2 in the lesions was higher than the uptake of negative charge-modified nonspecific IgG1 F(ab')2 (0.020 +/- 0.002) in the lesions. Uptake of charge-modified Z2D3 in the atherosclerotic lesions was also significantly higher than the corresponding regions of the aorta of the control rabbits (0.017 +/- 0.002; F1.18 = 27.9; P = .0001). There was, however, no difference in the specific lesion uptake of negative charge-modified Z2D3 at 24 hours (0.079 +/- 0.014) and 48 hours (0.084 +/- 0.0017; P = .99) after intravenous administration. Nontarget organ activities were lower with negative charge-modified 111In-labeled Z2D3 F(ab')2 than with the conventional Z2D3 F(ab')2. Mean kidney activity was fourfold less with the modified (0.45 +/- 0.06) than with the conventionally radiolabeled (1.67 +/- 0.264; P = .001) Z2D3 F(ab')2.

The biologic behavior of balloon hyperinflation-induced arterial lesions in hypercholesterolemic pigs depends on the presence of foam cells

Lack of a large-animal model of accelerated atherosclerosis has limited study of the biologic behavior of atherosclerotic lesions. We hypothesized that mechanical vascular trauma combined with diet-induced hypercholesterolemia would result in rapid development of complex atherosclerosis-like lesions. Accordingly, we induced deep injury to a carotid artery by repetitive balloon hyperinflations in minipigs that were fed either an atherogenic diet (n = 30) or a standard diet (controls, n = 4) and examined the resultant lesions 1 month later. The neointimal lesions that evolved in 23 patent vessels from cholesterol-fed animals were complex, exhibiting infiltration of smooth muscle and foam cells and evidence of organized thrombus, recent thrombus, hemorrhage, and calcification. Lesions were separable histologically into two groups: foam-cell rich (n = 12), with 33 +/- 10 foam cells per high-power field, and foam-cell poor (n = 11), with 4 +/- 1 foam cells per high-power field. Minipigs with foam cell-rich lesions had higher serum cholesterol levels than those with foam cell-poor lesions (712 +/- 178 vs 468 +/- 240 mg/dL, P < .02). The incidence of intralesional thrombus was also significantly greater in foam cell-rich than in foam cell-poor lesions (50% vs 9%, P < .04). In addition, the degree of luminal stenosis was greater in the presence of lesions containing thrombus compared with those without thrombus (60 +/- 38% vs 30 +/- 29%, P = .05). Lesions in the control animals were fibrocellular and lacked foam cells and thrombus. Thus, hypercholesterolemia appeared to affect lesion composition and behavior.(ABSTRACT TRUNCATED AT 250 WORDS)

Animal evaluation of the prototype omnicath atherectomy catheter

A prototype directional atherectomy catheter (Omnicath) was evaluated in four Yucatan microswines. Atherectomy was performed on iliac or aortic target lesions. After control angiography, the animals were sacrificed and the target arteries were examined histologically. Atherectomy resulted in arterial ruptures in three cases, and the track of the blade was measured to be of an average depth of 0.38 mm. Maneuverability was satisfactory but aspiration was not efficient. Precise localization of the atherectomy window was difficult. We conclude that modification of the catheter seems mandatory before use in humans.

Local intramural drug delivery using an infusion balloon following angioplasty in normal and atherosclerotic vessels

Local intramural delivery of various pharmacologic agents following angioplasty has been proposed as a means of reducing restenosis. This study tested whether local intramural delivery of aqueous solutions using an infusion balloon could be accomplished safely in normal vessels and whether such infusion was safe following standard angioplasty in diseased vessels. Infusion of aqueous agents into normal canine arteries had no adverse effect. Infusion of several aqueous agents (< or = 4 cc at 4 atm) into diseased swine iliac arteries following balloon angioplasty did not worsen existing or create new dissections. Histologically, infusion treated vessels did not differ in either model from vessels treated with angioplasty alone. We conclude that local intramural drug infusion does not create new, or worsen existing, dissections produced during standard balloon angioplasty in diseased vessels.

Induction of neointimal hyperplasia by coronary angioplasty balloon overinflation: comparison of feeder pigs to Yucatan minipigs

We evaluated the use of simple balloon overinflation to induce neointimal hyperplasia in a porcine model of coronary artery restenosis. By using standard percutaneous transluminal coronary angioplasty techniques, left anterior descending (LAD) and/or left circumflex (LCX) coronary arteries of either juvenile feeder pigs or adult Yucatan minipigs were intentionally overinflated. Four weeks later, resultant neointimal hyperplastic responses (neointima/media area; NI/M) were quantitated morphometrically. At all ballooned sites neointimal hyperplasia occurred only when the internal elastic lamina (IEL) was ruptured; the degree of hyperplasia correlated directly with the injury index, that is, the percentage of IEL circumference that fractured (r = 0.74; n = 25; p < 0.05). Despite similar injury indexes in the LAD bed, there was a trend (p = 0.07; analysis of variance) toward greater NI/M ratios in the Yucatan minipig versus the feeder pig group (1.14 +/- 0.21 vs 0.73 +/- 0.09, n = 7/group). We found no such trend in the LCX bed, where the injury index (25.7% +/- 3.5%) was significantly greater than that of the LAD (18.2% +/- 1.2%, p < 0.05). If variations in balloon-induced vascular injury are accounted for, the technique of balloon overinflation of coronary arteries should prove useful in testing potential antirestenotic agents in either adult or juvenile pigs.

Experimental studies on prevention of atherosclerotic arterial stenosis and restenosis after angioplasty with Andrographis Paniculata Nees and fish oil

In order to search for effective drugs to reduce restenosis incidence after coronary angioplasty, we studied the effects of a Chinese herb, extract of Andrographis Paniculata Nees (APN), and Fish Oil (FO) on atherosclerotic stenosis and restenosis after experimental angioplasty. Preliminary results showed that APN can significantly alleviate atherosclerotic iliac artery stenosis induced by both deendothelialization and high cholesterol diet (control group, stenosis incidence 100%, stenotic severe degree 60.53 +/- 31.03%, of which 30% arteries (6) are total occlusion; FO group: stenotic incidence and severe degree are 77% and 53.00 +/- 21.17%, respectively, and in APN group they are 70% and 25.39 +/- 10.52%, respectively, P < 0.01), and follow-up angiography 4 weeks after angioplasty showed that dilated iliac arteries in control group all had severe restenosis, but in APN group no or only mild restenosis occurs, and in FO group restenosis is as severe as stenotic degree prior to angioplasty. These preliminary results suggest that APN and FO can significantly alleviate stenosis induced by deendothelialization and high cholesterol diet and restenosis after angioplasty, while the former has a more marked effect. The above findings lead the authors to conclude that APN may play an important role in preventing restenosis after coronary angioplasty, but FO may be useful in reducing the extent of of restenosis after coronary angioplasty.

Inhibition of acyl-CoA cholesterol O-acyltransferase reduces the cholesteryl ester enrichment of atherosclerotic lesions in the Yucatan micropig

Atherosclerotic lesion development may be altered indirectly by regulating plasma cholesterol or directly by inhibition of acyl-CoA cholesterol O-acyltransferase (ACAT) within cells of the artery. Yucatan micropigs were meal-fed a 2% cholesterol, 8% peanut oil, 8% coconut oil purified diet for 1 month prior to administration of the potent, bioavailable ACAT inhibitor CI-976, and induction of atherosclerotic lesions by chronic endothelial damage. After 84-108 days of therapy, CI-976 decreased mean plasma VLDL-cholesterol 85-91% and cumulative VLDL-exposure (area under VLDL-time curve) by 65%. However, overall plasma total, LDL and HDL cholesterol and triglyceride levels were unchanged. CI-976 decreased liver cholesteryl ester (CE) content 65% without significantly affecting adrenal CE content. The CE content of the injured left femoral, left iliac and abdominal aorta and uninjured right femoral and iliac arteries and thoracic aorta was reduced 62-78% by CI-976. Systemic plasma CI-976 levels measured 24 h post-dose ranged from 2.26 to 4.05 micrograms/ml and significantly correlated with the reduction in both VLDL and vessel CE content. Thus, we conclude that inhibition of ACAT can blunt the cholesteryl ester enrichment of developing atherosclerotic lesions by preventing reesterification and storage of lipoprotein cholesterol within vascular cells and by reducing the plasma level and delivery to the arterial wall of such atherogenic lipoproteins as VLDL.

Intramural methotrexate therapy for the prevention of neointimal thickening after balloon angioplasty

OBJECTIVES

The study was performed to test the hypothesis that high local, intramural concentrations of antineoplastic agents at the site of balloon injury inhibit vascular smooth muscle cell proliferation without systemic toxicity.

BACKGROUND

The predominant mechanism for recurrent stenosis after coronary balloon angioplasty is neointimal thickening due to medial smooth muscle cell proliferation. The clinical use of potent antiproliferative agents to prevent restenosis has been limited by the potential for severe systemic side effects. Local therapy with these agents may be effective and free of systemic complications.

METHODS

After bilateral balloon angioplasty of the carotid arteries of 14 juvenile farm pigs, the dilated arterial segments were treated locally with methotrexate (6.25 mg/ml, total dose 25 mg) or 0.9% saline solution through a perforated balloon catheter. The animals were then killed 30 days after balloon injury to determine the effects of this therapy on neointimal thickness. In an additional six animals, tritium-labeled methotrexate was used to determine the concentration and duration of detectability of methotrexate in the wall of the treated arteries and in the systemic circulation.

RESULTS

Two hours after drug instillation the concentration of labeled drug was greater than 1,000-fold greater in the wall of the treated artery than in circulating blood, and this ratio remained between 50 and 100 for at least 7 days. Despite this difference, the mean intimal thickness 30 days after the procedure was similar in the 10 methotrexate-treated arteries and the 18 saline-treated arteries (59 +/- 30 vs. 56 +/- 25 microns, p = 0.6). The morphologic appearance of the neointima was similar in each group and suggested an important role for mural thrombus in the genesis of the intimal thickening.

CONCLUSIONS

Treatment with intramural methotrexate, delivered through a perforated balloon catheter at the selected concentration and total dose, failed to prevent intimal thickening after balloon injury. Nonetheless, the perforated balloon catheter appears to be a promising means of delivering a high local concentration of drugs with potentially life-threatening systemic side effects. The optimal concentrations and combinations of candidate drug therapies warrant further evaluation.

Percutaneous delivery of low-level laser energy reverses histamine-induced spasm in atherosclerotic Yucatan microswine

BACKGROUND

Previous in vitro experiments performed in our laboratory have shown that low-level laser energy may produce prompt reduction in isometric tension of vascular smooth muscle. The present study was designed to extend these previous in vitro findings to an in vivo model and thereby investigate the hypothesis that laser light delivered percutaneously in vivo could successfully reverse arterial spasm.

METHODS AND RESULTS

Spasm defined as greater than 50% reversible reduction in luminal diameter persisting for greater than or equal to 5 minutes was successfully provoked by injection of histamine (100-400 micrograms/kg) in 13 arteries among 10 atherosclerotic Yucatan microswine; the magnitude of histamine-induced vasoconstriction was then documented angiographically by repeated injections of contrast media for as long as 30 minutes (controls). After return of angiographic luminal diameter to baseline, spasm was reproduced with a second injection of histamine into the same artery. Representative wavelengths generated by ultraviolet (UV), visible, and infrared lasers were then delivered percutaneously via conventional fiberoptics to the site of spasm, and angiographic assessment was repeated for as long as 30 minutes (treatment trial). In three arteries treated with UV (351 nm) light from an excimer laser, angiographic luminal diameter narrowing decreased from 100% to 23.9%, 50.0% to 9.3%, and 76.0% to 42.3%, respectively. The magnitude of laser-induced increase in luminal diameter was 50.2 +/- 22.7%, which was significantly greater than the magnitude of relaxation observed spontaneously during the control trials (10.9 +/- 9.8%, p = 0.02). Visible light from a helium-neon (632 nm) laser accomplished complete reversal of histamine-induced spasm in two of four arteries; in the remaining two arteries, luminal diameter narrowing percentages were reduced from 57.0% to 20.0% and from 76.5% to 30.8%, respectively. The magnitude of helium-neon laser-induced relaxation (55.8 +/- 17.9%) was again significantly greater than that observed during the control trials (0.9 +/- 1.9%, p = 0.01). Finally, infrared irradiation from a diode-pumped neodymium:yttrium aluminum garnet (1,064 nm) laser decreased histamine-induced luminal diameter narrowing in three arteries from 100% to 21.4%, 56.0% to 8.7%, and 68.3% to 35.3%, respectively. The magnitude of infrared laser-induced improvement in luminal diameter narrowing was 53.0 +/- 23.3%, which was significantly greater than that observed during the control trials (12.9 +/- 10.7%, p = 0.01). In three additional arteries, fiberoptic sham trials (without laser irradiation) failed to produce relaxation of histamine-induced spasm.

CONCLUSIONS

These findings document for the first time that light-induced relaxation of vascular smooth muscle, previously documented in vitro, may be reproduced in vivo.

Experimental models of coronary artery restenosis

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

Restenosis after coronary angioplasty: an overview

Despite substantial basic and clinical efforts to address the problem of restenosis after percutaneous coronary intervention, effective preventive therapies have not yet been developed. Nevertheless, the accumulated information has provided much insight into the process of restenosis in addition to allowing standards to be developed for adequate clinical trials. The pathophysiology of restenosis increasingly appears to be distinct from that of primary atherosclerosis. Restenosis involves elastic recoil, incorporation of thrombus into the lesion and fibrocellular proliferation in varying degrees in different patients. Lack of an animal model that satisfactorily mimics restenosis is a major impediment to further understanding of the process. Clinical studies are hampered by difficulties in finding a single unifying definition of restenosis and by variable methods of reporting follow-up. Reporting of clinical outcomes of all patients in angiographic substudies would allow a more satisfactory interpretation of the results of clinical trials. Current noninvasive test results are not accurate enough to substitute for angiographic and clinical outcome data in intervention trials. In the majority of observational studies, only diabetes and unstable angina have emerged as consistently associated with restenosis; whereas most of the standard risk factors for atherosclerosis have a less consistent relation. Disappointingly, the new atherectomy and laser technologies have not affected restenosis rates. The one possible exception is coronary stenting, as a result of the larger luminal diameter achieved by the placement of the stent. In conclusion, although substantial continued effort is necessary to explore the basic aspects of cellular proliferation and mechanical alteration of atherosclerotic vessels, attention to the principles of clinical trials and observation are required to detect the impact of risk factors and interventions on the multifactorial problem of restenosis. Adequate sample sizes, collection of clinical and angiographic outcomes and factorial study designs hold promise for unraveling this important limitation of percutaneous intervention.