The effect of transluminal endothelial seeding on myointimal hyperplasia following angioplasty

Development of In Vitro Endothelialised Stents - Review

Endovascular treatment is prevalent as a primary treatment for coronary and peripheral arterial diseases. Although the introduction of drug-eluting stents (DES) dramatically reduced the risk of in-stent restenosis, stent thrombosis persists as an issue. Notwithstanding improvements in newer generation DES, they are yet to address the urgent clinical need to abolish the late stent complications that result from in-stent restenosis and are associated with late thrombus formation. These often lead to acute coronary syndromes with high mortality in coronary artery disease and acute limb ischemia with a high risk of limb amputation in peripheral arterial disease. Recently, a significant amount of research has focused on alternative solutions to improve stent biocompatibility by using tissue engineering. There are two types of tissue engineering endothelialisation methods: in vitro and in vivo. To date, commercially available in vivo endothelialised stents have failed to demonstrate antithrombotic or anti-stenosis efficacy in clinical trials. In contrast, the in vitro endothelialisation methods exhibit the advantage of monitoring cell type and growth prior to implantation, enabling better quality control. The present review discusses tissue-engineered candidate stents constructed by distinct in vitro endothelialisation approaches, with a particular focus on fabrication processes, including cell source selection, stent material composition, stent surface modifications, efficacy and safety evidence from in vitro and in vivo studies, and future directions.

Homocysteine lowering interventions for peripheral arterial disease and bypass grafts

BACKGROUND

Elevated plasma levels of the amino acid homocysteine (hyperhomocysteinaemia) are associated with narrowing or blocking of the arteries (atherosclerosis). Treatment to lower homocysteine levels has been shown to be both effective and cheap in healthy volunteers. However, the impact of reducing homocysteine levels on the progression of atherosclerosis and patency of the vessels after treatment for atherosclerosis is still unknown and forms the basis for this review. This is the second update of a review first published in 2002.

OBJECTIVES

To assess the effects of plasma homocysteine lowering therapy on the clinical progression of disease in people with peripheral arterial disease (PAD) and hyperhomocysteinaemia including, as a subset, those who have undergone surgical or radiological intervention.

SEARCH METHODS

For this update, the Cochrane Peripheral Vascular Disease Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12). Trial databases were searched by the TSC (January 2013) for details of ongoing and unpublished studies. We also searched the reference lists of relevant articles.

SELECTION CRITERIA

Randomised trials in which participants with PAD and hyperhomocysteinaemia were allocated to either homocysteine lowering therapy or no treatment, including participants before and after surgical or radiological interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data. Information on adverse events was collected from the trials.

MAIN RESULTS

Two randomised trials with a total of 161 participants were included in this review. The studies did not report on mortality and rate of limb loss. One randomised trial with a total of 133 participants showed that there was a significant improvement in ankle brachial index (ABI) in participants who received folic acid compared with placebo (mean difference (MD) 0.07, 95% confidence interval (CI) 0.04 to 0.11, P < 0.001) and in participants who received 5-methyltetrahydrofolate (5-MTHF) versus placebo (MD 0.05, 95% CI 0.01 to 0.10, P = 0.009). A second trial with a total of 18 participants showed that there was no difference (P non-significant) in ABI in participants who received a multivitamin B supplement (mean ± SEM: 0.7 ± 01) compared with placebo (mean ± SEM: 0.8 ± 0.1). No major events were reported.

AUTHORS' CONCLUSIONS

Currently, no recommendation can be made regarding the value of treatment of hyperhomocysteinaemia in peripheral arterial disease. Further, well constructed trials are urgently required.

Isolation of functional human endothelial cells from small volumes of umbilical cord blood

Endothelial cells (ECs) isolated from endothelial progenitor cells in blood have great potential as a therapeutic tool to promote vasculogenesis and angiogenesis and treat cardiovascular diseases. However, current methods to isolate ECs are limited by a low yield with few colonies appearing during isolation. In order to utilize blood-derived ECs for therapeutic applications, a simple method is needed that can produce a high yield of ECs from small volumes of blood without the addition of animal-derived products. For the first time, we show that human ECs can be isolated without the prior separation of blood components through the technique of diluted whole blood incubation (DWBI) utilizing commercially available human serum. We isolated ECs from small volumes of blood (~10 mL) via DWBI and characterized them with flow cytometry, immunohistochemistry, and uptake of DiI-labeled acetylated low density lipoprotein (DiI-Ac-LDL). These ECs are functional as demonstrated by their ability to form tubular networks in Matrigel, adhere and align with flow under physiological fluid shear stress, and produce increased nitric oxide under fluid flow. An average of 7.0 ± 2.5 EC colonies that passed all functional tests described above were obtained per 10 mL of blood as compared to only 0.3 ± 0.1 colonies with the traditional method based on density centrifugation. The time until first colony appearance was 8.3 ± 1.2 days for ECs isolated with the DWBI method and 12 ± 1.4 days for ECs isolated with the traditional isolation method. A simplified method, such as DWBI, in combination with advances in isolation yield could enable the use of blood-derived ECs in clinical practice.

Human umbilical cord blood-derived endothelial cells reendothelialize vein grafts and prevent thrombosis

OBJECTIVE

To accelerate vein graft reendothelialization and reduce vein graft thrombosis by infusing human umbilical cord blood-derived endothelial cells (hCB-ECs) because loss of endothelium contributes to vein graft thrombosis and neointimal hyperplasia.

METHODS AND RESULTS

Under steady flow conditions in vitro, hCB-ECs adhered to smooth muscle cells 2.5 to 13 times more than ECs derived from peripheral blood or human aorta (P<0.05). Compared with peripheral blood and human aorta ECs, hCB-ECs had 1.4-fold more cell surface α(5)β(1) integrin heterodimers per cell (P<0.05) and proliferated on fibronectin 4- to 10-fold more rapidly (P<0.05). Therefore, we used hCB-ECs to enhance reendothelialization of carotid interposition vein grafts implanted in NOD.CB17-Prkdc(scid)/J mice. Two weeks postoperatively, vein grafts from hCB-EC-treated mice demonstrated approximately 55% reendothelialization and no luminal thrombosis. In contrast, vein grafts from sham-treated mice demonstrated luminal thrombosis in 75% of specimens (P<0.05) and only approximately 14% reendothelialization. In vein grafts from hCB-EC-treated mice, 33±10% of the endothelium was of human origin, as judged by human major histocompatibility class I expression.

CONCLUSIONS

The hCB-ECs adhere to smooth muscle cells under flow conditions in vitro, accelerate vein graft reendothelialization in vivo, and prevent vein graft thrombosis. Thus, hCB-ECs offer novel therapeutic possibilities for vein graft disease.

Characterization of umbilical cord blood-derived late outgrowth endothelial progenitor cells exposed to laminar shear stress

Endothelial progenitor cells isolated from umbilical cord blood (CB-EPCs) represent a promising source of endothelial cells for synthetic vascular grafts and tissue-engineered blood vessels since they are readily attainable, can be easily isolated, and possess a high proliferation potential. The objective of this study was to compare the functional behavior of late outgrowth CB-EPCs with human aortic endothelial cells (HAECs). CB-EPCs and HAECs were cultured on either smooth muscle cells in a coculture model of a tissue-engineered blood vessels or fibronectin adsorbed to Teflon-AF-coated glass slides. Late outgrowth CB-EPCs expressed endothelial cell-specific markers and were negative for the monocytic marker CD14. CB-EPCs have higher proliferation rates than HAECs, but are slightly smaller in size. CB-EPCs remained adherent under supraphysiological shear stresses, oriented and elongated in the direction of flow, and expressed similar numbers of alpha(5)beta(1) and alpha(v)beta(3) integrins and antithrombotic genes compared to HAECs. There were some differences in mRNA levels of E-selectin and vascular cell adhesion molecule 1 between CB-EPCs and HAECs; however, protein levels were similar on the two cell types, and CB-EPCs did not support adhesion of monocytes in the absence of tumor necrosis factor-alpha stimulation. Although CB-EPCs expressed significantly less endothelial nitric oxide synthase protein after exposure to flow than HAECs, nitric oxide levels induced by flow were not significantly different. These results suggest that late outgrowth CB-EPCs are functionally similar to HAECs under flow conditions and are a promising cell source for cardiovascular therapies.

Poly(N-isopropylacrylamide) copolymer films as vehicles for the sustained delivery of proteins to vascular endothelial cells

The aim of this study was to establish the capacity of thermoresponsive poly(N-isopropylacrylamide) copolymer films to deliver bioactive concentrations of vascular endothelial growth factor (VEGF165) to human aortic endothelial cells (HAEC) over an extended time period. Films were prepared using a 50:50 (w/w) mixture of non-crosslinkable and crosslinkable copolymers of the following monomer compositions (w/w): 85:15, N-isopropylacrylamide (NiPAAm):N-tert-butylacrylamide (NtBAAm); and 85:13:2 NiPAAm:NtBAAm:acrylamidobenzophenone (ABzPh, crosslinking agent), respectively. After crosslinking by UV irradiation, the ability of films to incorporate a fluorescently labeled carrier protein (FITC-labeled BSA, 1 mg loaded per film), at 4 degrees C, was first established. Incorporation into the matrix was confirmed by the observation that increasing film thickness from 5 to 10 microm increased release from collapsed films at 37 degrees C (1.76 +/- 0.15 and 10.98 +/- 3.38 microg/mL, respectively, at 24 h postloading) and that this difference was maintained at 5 days postloading (1.81 +/- 0.25 and 13.8 +/- 2.3 microg/mL, respectively). Incorporation was also confirmed by visualization using confocal microscopy. When 10-microm films were loaded with a BSA solution (1 mg/mL) containing VEGF165 (3 microg/mL), sustained release of VEGF165 was observed (10.75 +/- 3.11 ng at 24 h; a total of 31.32 +/- 8.50 ng over 7 days). Furthermore, eluted VEGF165 increased HAEC proliferation by 18.2% over control. The absence of cytotoxic species in medium released from the copolymer films was confirmed by the lack of effect of medium (incubated with copolymer films for 3 days) on HAEC viability. In conclusion this study has shown that NiPAAm:NtBAAm copolymers can be loaded with a therapeutic protein and can deliver bioactive concentrations to human vascular endothelial cells over an extended time period.

Fabrication of endothelial progenitor cell (EPC)-seeded intravascular stent devices and in vitro endothelialization on hybrid vascular tissue

Rapid re-endothelialization at an atherosclerotic lesion after balloon inflation or stent deployment may be essential for reducing or preventing local thrombus formation and restenosis. In order to prevent these complications via enhanced rapid re-endothelialization, we fabricated two types of endothelial progenitor cell (EPC)-seeded intravascular stent devices. One was a photocured gelatin-coated metallic stent, and the other was a microporous thin segmented polyurethane (SPU) film-covered stent on which photocured gelatin was coated. Both devices were seeded with ex vivo expanded EPCs obtained from canine peripheral blood. Seeded EPCs formed confluent monolayers onto surfaces of both photocured gelatin-coated stent struts and SPU film, and a majority of cells remained on surfaces of stents after stent expansion. The EPC-seeded stent was expanded in a tubular hybrid vascular medial tissue composed of vascular smooth muscle cells and collagen as an arterial media mimic. After 7-day culture, EPCs, which migrated from the stent struts, proliferated and endothelialized the luminal surfaces of the hybrid vascular medial tissue. This in vitro pilot study prior to in vivo experiments suggests that on-stent cell delivery of EPCs may be novel therapeutic devices for re-endothelialization or endothelium lining or paving at an atherosclerotic arterial wall, resulting in the prevention of on-stent thrombus formation and in-stent restenosis, as well as the rapid formation of normal tissue architecture.

Intralumenal tissue-engineered therapeutic stent using endothelial progenitor cell-inoculated hybrid tissue and in vitro performance

Rapid reendothelialization at an atherosclerotic lesion after balloon or stent inflation may be essential for maintaining homeostatic tissue function, which could reduce or prevent restenosis. We devised an endothelial progenitor cell (EPC)-enriched tubular hybrid tissue and mounted it on a small-diameter metallic stent (outer diameter, 1.5 mm), which is used for intravascular angioplasty to atherosclerotic lesions. This study addressed the fabrication technique and in vitro performance to verify lumenal endothelialization. A thin collagenous tubular tissue was prepared by contraction of collagen fibers by inoculated EPCs, which were isolated from canine peripheral blood and expanded ex vivo, in a collagen gel formed in a mold. An EPC-inoculated hybrid tissue-covered stent, loaded on a balloon catheter, was inserted into a tubular hybrid vascular medial tissue inoculated with smooth muscle cells (SMCs) as an arterial media mimic, and subjected to balloon inflation for enlargement (outer diameter, 3 mm), followed by balloon deflation. The EPC-inoculated hybrid tissue-covered stent tightly adhered to the lumenal surface of the hybrid medial tissue. On culture, EPCs in the hybrid tissue migrated and proliferated to form a completely endothelialized lumenal surface at stented sites as well as sites adjacent to the vascular hybrid medial tissue with the prolongation of culture. This in vitro pilot study before in vivo experiments suggests that an EPC-inoculated hybrid tissue-covered stent may be a novel therapeutic device for reendothelialization or paving with EPC-enriched tissue at an atherosclerotic arterial wall, resulting in the prevention of restenosis and the rapid formation of normal tissue.

Contaminants from the transplant contribute to intimal hyperplasia associated with microvascular endothelial cell seeding

OBJECTIVES

seeding prosthetic grafts with fat-derived microvascular endothelial cells (MVEC) results not only in a non-thrombogenic EC layer, but also in intimal hyperplasia. Here we investigated incidence, composition, progression, and cause of this intimal hyperplasia.

DESIGN

EPTFE grafts with MVEC were implanted as carotid interpositions in six dogs with 1 month, and in three dogs with 4, 8 and 12 months follow-up. Grafts seeded without cells, implanted in the contralateral carotid, served as a control. In another three dogs labelled cells were seeded to investigate the contribution of the seeded cells (2-3 weeks).

MATERIALS AND METHODS

MVEC were isolated from the falciform ligament. Cells were pressure seeded on ePTFE grafts. Labelling was performed using retroviral gene transduction. The grafts were analysed with immunohistochemical techniques.

RESULTS

after 1 month, all patent non-seeded grafts (5/6) showed fibrin and platelet deposition, and all patent seeded grafts (5/6) were covered with a confluent endothelial monolayer on top of a multilayer of myofibroblasts, elastin and collagen. After long term follow-up, all non-seeded grafts were occluded, all patent seeded grafts (4 and 12 months) were covered with an EC-layer with intimal hyperplasia underneath. The thickness of the intima did not progress after 1 month. Transduced cells were found in the endothelial monolayer, hyperplastic intima and luminal part of the prosthesis.

CONCLUSIONS

MVEC seeding in dogs results in intimal hyperplasia in all patent grafts, which contains myofibroblasts. Contaminants from the transplant contribute to this intimal hyperplasia.

Homocysteine lowering interventions for peripheral arterial disease and bypass grafts

BACKGROUND

Elevated plasma levels of the amino acid homocysteine (hyperhomocysteinaemia) are associated with hardening or blocking of the arteries (atherosclerosis) In addition, there is a poorer prognosis, both in the progression of the disease and outcome after therapy. Treatment to lower homocysteine levels has been shown to be both effective and cheap in healthy volunteers. However, the impact of reducing homocysteine levels on the progression of atherosclerosis and patency of vessels after treatment for atherosclerosis is still unknown and forms the basis for this review.

OBJECTIVES

To assess the effects of plasma homocysteine-lowering therapy on the clinical progression of disease in patients with peripheral arterial disease (PAD) and hyperhomocysteinaemia, including, as a subset, those who have undergone surgical or radiological intervention.

SEARCH STRATEGY

The reviewers (MH,GS) searched the Cochrane Peripheral Vascular Diseases Group trials register, the Cochrane Controlled trials register (2002, Issue 1), MEDLINE, EMBASE and reference lists of relevant articles.

SELECTION CRITERIA

Randomised trials of the treatment of hyperhomocysteinaemia in patients with peripheral arterial disease, before and after surgical or radiological intervention versus no treatment for hyperhomocysteinaemia.

DATA COLLECTION AND ANALYSIS

Two reviewers (MH,GS) independently assessed trial quality and extracted data. Information on adverse events was collected from the trials.

MAIN RESULTS

There are currently no randomised trials available for analysis.

REVIEWER'S CONCLUSIONS

Well constructed trials assessing the impact of the treatment of hyperhomocysteinaemia in patients with peripheral arterial disease are urgently required.

Endoluminal smooth muscle cell seeding limits intimal hyperplasia

PURPOSE

Intimal hyperplasia is one of the main responses of the vascular wall to injury. In the current study, we tested the hypothesis that endoluminal seeding of host syngeneic vascular cells could limit intimal hyperplasia induced by either mechanical deendothelialization or chronic allograft rejection in rat aorta.

METHODS

An experimental model of in situ seeding of syngeneic endothelial cells, smooth muscle cells (SMCs), and fibroblasts (FIBs) was used in mechanically deendothelialized and allografted aortas. In a preliminary study, the ability of the three cell types (n = 5 per group) to seed on the deendothelialized luminal surface of the aortic wall was evaluated after 2 days, with the use of fluorescent PKH as marker. In the first model, the abdominal aorta of Lewis rats was deendothelialized (n = 6) or deendothelialized and seeded with either SMCs (n = 6) or FIBs (n = 6) before flow was restored. In the allograft model, aortas were harvested from dark agouti rats and orthotopically grafted in Lewis receivers, directly (n = 6) or after deendothelialization. Deendothelialization was performed alone (n = 6) or associated with the seeding of similar host (Lewis) syngeneic SMCs (n = 6) or FIBs (n = 6). Results were evaluated at 2 months with histologic and morphometric methods.

RESULTS

SMCs and FIBs were able to adhere in situ to the deendothelialized aortic wall, whereas endothelial cells were not. In mechanically deendothelialized aortas, the seeding of syngeneic SMCs led to a significant reduction in intimal thickness compared with deendothelialized aortas or FIB-seeded aortas (26.9 +/- 1.7 microm vs 55.5 +/- 1.7 and 56.7 +/- 1.7 microm, respectively), and a lower nuclear content (382.2 +/- 35.7 microm(2) vs 779.6 +/- 65.9 and 529.6 +/- 24.3 microm(2), respectively) of neointima. After SMC seeding, intimal hyperplasia was richer in elastin, whereas after FIB seeding it was richer in collagen. In allografts, the seeding of syngeneic SMC led to a significant reduction in intimal thickness compared with control aortas, deendothelialized aortas, or FIB-seeded aortas (31.6 +/- 1.1 microm vs 88.55 +/- 2.8, 74.6 +/- 2.9, and 85.7 +/- 2.6 microm, respectively), and a reduced nuclear content of the neointima (444.9 +/- 23.4 microm(2) vs 1529.1 +/- 116, 972.3 +/- 50, and 645.2 +/- 32.4 microm(2), respectively). Differences observed in the extracellular matrix composition were equivalent to those observed in the mechanically deendothelialized model.

CONCLUSIONS

Our results suggest that endoluminal seeding of syngeneic SMCs can be effective in reducing intimal hyperplasia both in a deendothelialization model and in arterial allografts. SMC and FIB endoluminal seeding led to a significatively different accumulation of extracellular matrix in the intima.

Monocyte adhesion to balloon-injured arteries: the influence of endothelial cell seeding

OBJECTIVE

Deendothelialization of injuries of the artery disrupts normal vascular homeostasis, affecting both the structural integrity of the blood vessel wall, as well as the interaction of the arterial surface with blood components such as platelets, leukocytes, and circulating proteins. Leukocyte and, in particular, monocyte recruitment to damaged vessels has been implicated in the pathogenesis of intimal hyperplasia. We hypothesize that reendothelialization is an important modulator of monocyte adhesion to healing arterial surfaces.

METHODS

New Zealand white rabbits (n = 20) were subjected to bilateral iliofemoral artery balloon injury. Cultured, autologous venous endothelial cells (ECs) were immediately seeded onto one vessel, whereas the contralateral artery received medium alone, to accelerate endothelial relining. Vessels were harvested (5-9 days after injury) for analysis of permeability (Evans Blue dye exclusion), endothelial coverage (anti-CD31 immunohistochemistry), monocyte adhesion (ex vivo binding of 51Na2CrO4-labeled monocytic THP-1 cells), and monocyte recruitment (RAM-11 immunohistochemistry).

RESULTS

Improved EC coverage was evidenced by positive staining for CD31 in the seeded vessels. Vessel wall permeability was markedly reduced in EC-seeded arteries (29% +/- 10% vs 99% +/- 0% surface Evans blue staining, P <.005), consistent with restoration of a functional endothelial barrier. EC seeding significantly reduced ex vivo THP-1 binding to vessels explanted at a mean of 8 days after injury (45,170 +/- 8939 vs 85,994 +/- 16,500 cells/cm2, P <.05). However, RAM-11 staining revealed no significant difference in overall macrophage accumulation between seeded and control vessels 1 week after injury (111 +/- 22 vs 95 +/- 14 cells/section, P =.36).

CONCLUSIONS

Immediate seeding of a balloon-injured rabbit artery with cultured ECs results in accelerated restoration of the endothelial lining. At 1 week, barrier function is improved, and the seeded vessel surface is less adhesive to activated monocytes ex vivo, as compared with injured controls. Nonetheless, EC-seeded and nonseeded arteries demonstrate similar total macrophage accumulation over 1 week. These data suggest that after mechanical arterial injury, endothelial coverage may be one important variable influencing leukocyte adhesion.

Effectiveness of endothelial cell seeding on patency of damaged vascular surfaces in a canine model

The effects of endothelial cell seeding, which is assumed to be an effective technique to improve patency rates of denuded vascular surfaces, were investigated in an experimental model. In this study, after anesthetic induction, jugular veins of 16 dogs were harvested bilaterally. Endothelial cells were extracted enzymatically by collagenase from these veins and were passaged into a culture medium until they grew to a reasonable number. After 3 weeks, dogs were anesthetized again in a similar fashion and bilateral femoral veins were exposed and experimental intimal denudation was performed. Subsequently, one femoral artery was injected with cell solution and the other with saline solution as a control. Two weeks after the injections, arteriographic studies of femoral arteries were performed and arterial specimens were taken for histological evaluation. Our results suggest that endothelial seeding might improve the patency rate in elective but urgent cases in which endarterectomy, percutaneous transluminal angioplasty, or similar vascular procedures are considered.

Polypyrrole-heparin composites as stimulus-responsive substrates for endothelial cell growth

Heparin is a potent anticoagulant which can be immobilized on biomaterial surfaces to increase their hemocompatability. In the present work, we have electrochemically synthesized composites comprising heparin and the electrically conducting polymer polypyrrole. The incorporation and exposure of heparin were controlled by varying key conditions of polymer synthesis (i.e., applied current and synthesis time). The resulting composite polymers were electroactive after synthesis and the amount of heparin exposed in the polymer could be increased (up to threefold) by switching the polymers from their oxidized to reduced states. Polymer reduction was achieved by either application of negative potentials (-0.4 to -0.7 V for 90 s) or exposure to aqueous reductant (0.1M sodium dithionite for 30 min). Heparin-polypyrrole composites remained stable after autoclaving, displaying no significant loss of electroactivity, and had a shelf life of at least 2 years postautoclaving. Finally, the composites were found to be excellent substrates for the growth of human endothelial cells.

Culture of human adult endothelial cells on endarterectomy surfaces

OBJECTIVES

Endothelial cell seeding of prosthetic grafts has not been as successful as initially hoped and the application of seeding technology to alternative reconstructive procedures such as endarterectomy and angioplasty has been increasingly considered. The success of such seeding depends on the ability of the seeded cells to attach to, and form a monolayer on the endarterectomised vessel wall which was the aim of this study.

METHODS

Using a seeding chamber model, heterologous human adult endothelial cells were seeded onto fresh human endarterectomy specimens and cultured. Studies of endothelial call adherence to endarterectomy specimens were performed using 111-Indium oxine labelled cells using methodology analogous to graft seeding.

RESULTS

Mean endothelial cell adherence of 70% (S.D. 10%) after 1 h incubation was achieved and the successful development of a monolayer of human adult venous endothelial cells on endarterectomised arteries was demonstrated in vitro.

CONCLUSIONS

These results indicate that closed endarterectomy appears to offer a surface with cell attachment that is superior to prosthetic grafts. Where femoral endarterectomy is appropriate, endothelial seeding potentially offers a method of reducing thrombogenicity and intimal hyperplasia, improving patency and avoiding a prosthetic graft whilst preserving collateral circulation and autologous vein.