Frontiers in positron emission tomography imaging of the vulnerable atherosclerotic plaque

Reactive oxygen species-responsive nano-platform with dual-targeting and fluorescent lipid-specific imaging capabilities for the management of atherosclerotic plaques

Atherosclerosis (AS), a pathological cause of cardiovascular disease, results from endothelial injury, local progressive inflammation, and excessive lipid accumulation. AS plaques rich in foam cells are prone to rupture and form thrombus, which can cause life-threatening complications. Therefore, the assessment of atherosclerotic plaque vulnerability and early intervention are crucial in reducing the mortality rates associated with cardiovascular disease. In this work, A fluorescent probe FC-TPA was synthesized, which switches the fluorescence state between protonated and non-protonated, reducing background fluorescence and enhancing imaging signal-to-noise ratio. On this basis, FC-TPA is loaded into cyclodextrin (CD) modified with phosphatidylserine targeting peptide (PTP) and coated with hyaluronic acid (HA) to construct the intelligent responsive diagnostic nanoplatform (HA@PCFT). HA@PCFT effectively targets atherosclerotic plaques, utilizing dual targeting mechanisms. HA binds strongly to CD44, while PTP binds to phosphatidylserine, enabling nanoparticle aggregation at the lesion site. ROS acts as a smart release switch for probes. Both in vitro and in vivo evaluations confirm impressive lipid-specific fluorescence imaging capabilities of HA@PCFT nanoparticles (NPs). The detection of lipid load in atherosclerotic plaque by fluorescence imaging will aid in assessing the vulnerability of atherosclerotic plaque. STATEMENT OF SIGNIFICANCE: Currently, numerous fluorescent probes have been developed for lipid imaging. However, some challenges including inadequate water solubility, nonspecific distribution patterns, and fluorescence background interference, have greatly limited their further applications in vivo. To overcome these limitations, a fluorescent molecule has been designed and synthesized, thoroughly investigating its photophysical properties through both theoretical and experimental approaches. Interestingly, this fluorescent molecule exhibits the reversible fluorescence switching capabilities, mediated by hydrogen bonds, which effectively mitigate background fluorescence interference. Additionally, the fluorescent molecules has been successfully loaded into nanocarriers functionalized with the active targeting abilities, which has significantly improved the solubility of the fluorescent molecules and reduced their nonspecific distribution in vivo for an efficient target imaging in atherosclerosis. This study provides a valuable reference for evaluating the performance of such fluorescent dyes, and offers a promising perspective on the design of the target delivery systems for atherosclerosis.

Assessment of the alpha 7 nicotinic acetylcholine receptor as an imaging marker of cardiac repair-associated processes using NS14490

BACKGROUND

Cardiac repair and remodeling following myocardial infarction (MI) is a multifactorial process involving pro-reparative inflammation, angiogenesis and fibrosis. Noninvasive imaging using a radiotracer targeting these processes could be used to elucidate cardiac wound healing mechanisms. The alpha7 nicotinic acetylcholine receptor (ɑ7nAChR) stimulates pro-reparative macrophage activity and angiogenesis, making it a potential imaging biomarker in this context. We investigated this by assessing in vitro cellular expression of ɑ7nAChR, and by using a tritiated version of the PET radiotracer [18F]NS14490 in tissue autoradiography studies.

RESULTS

ɑ7nAChR expression in human monocyte-derived macrophages and vascular cells showed the highest relative expression was within macrophages, but only endothelial cells exhibited a proliferation and hypoxia-driven increase in expression. Using a mouse model of inflammatory angiogenesis following sponge implantation, specific binding of [3H]NS14490 increased from 3.6 ± 0.2 µCi/g at day 3 post-implantation to 4.9 ± 0.2 µCi/g at day 7 (n = 4, P < 0.01), followed by a reduction at days 14 and 21. This peak matched the onset of vessel formation, macrophage infiltration and sponge fibrovascular encapsulation. In a rat MI model, specific binding of [3H]NS14490 was low in sham and remote MI myocardium. Specific binding within the infarct increased from day 14 post-MI (33.8 ± 14.1 µCi/g, P ≤ 0.01 versus sham), peaking at day 28 (48.9 ± 5.1 µCi/g, P ≤ 0.0001 versus sham). Histological and proteomic profiling of ɑ7nAChR positive tissue revealed strong associations between ɑ7nAChR and extracellular matrix deposition, and rat cardiac fibroblasts expressed ɑ7nAChR protein under normoxic and hypoxic conditions.

CONCLUSION

ɑ7nAChR is highly expressed in human macrophages and showed proliferation and hypoxia-driven expression in human endothelial cells. While NS14490 imaging displays a pattern that coincides with vessel formation, macrophage infiltration and fibrovascular encapsulation in the sponge model, this is not the case in the MI model where the ɑ7nAChR imaging signal was strongly associated with extracellular matrix deposition which could be explained by ɑ7nAChR expression in fibroblasts. Overall, these findings support the involvement of ɑ7nAChR across several processes central to cardiac repair, with fibrosis most closely associated with ɑ7nAChR following MI.

68Ga-bisphosphonates for the imaging of extraosseous calcification by positron emission tomography

Radiolabelled bisphosphonates (BPs) and [18F]NaF (18F-fluoride) are the two types of radiotracers available to image calcium mineral (e.g. bone), yet only [18F]NaF has been widely explored for the non-invasive molecular imaging of extraosseous calcification (EC) using positron emission tomography (PET) imaging. These two radiotracers bind calcium mineral deposits via different mechanisms, with BPs chelating to calcium ions and thus being non-selective, and [18F]NaF being selective for hydroxyapatite (HAp) which is the main component of bone mineral. Considering that the composition of EC has been reported to include a diverse range of non-HAp calcium minerals, we hypothesised that BPs may be more sensitive for imaging EC due to their ability to bind to both HAp and non-HAp deposits. We report a comparison between the 68Ga-labelled BP tracer [68Ga]Ga-THP-Pam and [18F]NaF for PET imaging in a rat model of EC that develops macro- and microcalcifications in several organs. Macrocalcifications were identified using preclinical computed tomography (CT) and microcalcifications were identified using µCT-based 3D X-ray histology (XRH) on isolated organs ex vivo. The morphological and mineral analysis of individual calcified deposits was performed using scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDX). PET imaging and ex vivo analysis results demonstrated that while both radiotracers behave similarly for bone imaging, the BP-based radiotracer [68Ga]Ga-THP-Pam was able to detect EC more sensitively in several organs in which the mineral composition departs from that of HAp. Our results strongly suggest that BP-based PET radiotracers such as [68Ga]Ga-THP-Pam may have a particular advantage for the sensitive imaging and early detection of EC by being able to detect a wider array of relevant calcium minerals in vivo than [18F]NaF, and should be evaluated clinically for this purpose.

Increased 68Ga-FAPI Uptake in Active Atherosclerotic Plaque

ABSTRACT

A 67-year-old man with esophageal cancer was included in a clinical trial of a 68Ga-FAPI PET/CT study on tumors (ChiCTR2100044131). Increased tracer uptake was noted in the esophageal cancer with esophagitis. In addition, active coronary atherosclerotic plaque also revealed increased FAPI activity.

Intracellular and Intravascular Oxygen Sensing of Pancreatic Tissues Based on Phosphorescence Lifetime Imaging Microscopy Using Lipophilic and Hydrophilic Iridium(III) Complexes

Simultaneous imaging of intracellular and blood oxygen levels in tissues provides valuable information on the dynamic behavior of molecular oxygen (O₂) in normal and diseased tissues. Here, to achieve this goal, we developed green-emitting intracellular O₂ probes based on the Ir(III) complex, PPY (tris(2-phenylpyridinato)iridium(III)), and investigated the possibility of multicolor O₂ imaging by co-staining tissues with a red-emitting intravascular probe BTP-PEG₄₈. The newly synthesized complexes possess modified 2-phenylpyridinato ligand(s) with a cationic or hydrophilic substituent, such as a dimethylamino group, triphenylphosphonium cation, or hydroxy group, in order to enhance cellular uptake efficiency. The photophysical and cellular properties of these complexes were systematically investigated to evaluate their ability as O₂ probes. Among these complexes, PPYDM and PPY2OH, which have a dimethylamino group and two hydroxy groups, respectively, exhibited much higher cellular uptake efficiencies compared with PPY and showed high O₂ sensitivity in HeLa cells. Phosphorescence lifetime imaging microscopy (PLIM) measurements of HeLa cells co-stained with PPYDM and hydrophilic BTP-PEG₄₈ allowed for the evaluation of intracellular and extracellular O₂ levels in cell culture. We took PLIM images of the pancreas following intravenous administration of PPYDM and BTP-PEG₄₈ into anesthetized mice. The PLIM measurements using these probes allowed simultaneous O₂ imaging of acinar cells and capillaries in the pancreas with cellular-level resolution. From the phosphorescence lifetimes of PPYDM and BTP-PEG₄₈ and the calibration curves evaluated in rat pancreatic acinar cells and blood plasma, we found that the average oxygen partial pressures of acinar cells and capillaries were almost equal at about 30 mmHg.

P2X7 receptor-specific radioligand 18F-FTTM for atherosclerotic plaque PET imaging

PURPOSE

P2X7 receptors have been considered as a promising biomarker for vulnerable atherosclerotic plaques, which are highly expressed by that instability-associated factors such as macrophages. Thus, we aim to investigate the feasibility of using specific P2X7-targeted ¹⁸F-labeled tracer ¹⁸F-FTTM ((2-chloro-3-[¹⁸F]fluorophenyl)[1,4,6,7-tetrahydro-1-(2-pyrimidinyl)-5H-1,2,3-triazolo[4,5-c]pyridin-5-yl]methanone) for PET study of vulnerable atherosclerotic plaques identification.

METHOD

The radioligand ¹⁸F-FTTM was achieved based on the copper-mediated radiofluorination of arylstannane. In vitro and in vivo experiments were performed to verify the biochemical properties. Dynamic ¹⁸F-FTTM Micro-PET/CT imaging was performed for 1 h on ApoE^-/- mice (10, 20, 30 weeks on high-fat diet) and wild-type C57BL/6 J mice on normal diet. Ex vivo PET imaging was conducted to verify the specificity of the radioligand. Serum inflammatory cytokines, lipids, and lipoproteins profiles were detected by ELISA. The lipid distribution and morphology of plaques were evaluated by Oil Red O, HE, Masson, and immunofluorescence stainings.

RESULTS

¹⁸F-FTTM was afforded with decay-corrected radiochemical yields of 5-10%, specific activity of 269-320 MBq/nmol (n = 8, EOS), and radiochemical purity of above 99%. ¹⁸F-FTTM showed excellent stability in vitro, rapid blood clearance in mice, good affinity to RAW264.7 cells. We observed an increase in both in vivo and ex vivo imagings as disease progressed, and the imaging signatures correlated with histopathological features. Furthermore, compared with ¹⁸F-FDG imaging, the SUV_max values of ¹⁸F-FTTM at the aortic arch of ApoE^-/- mice of high-fat feeding for 20 and 30 weeks were 43% and 53% higher than those of the control group, respectively.

CONCLUSION

We innovatively apply a new type P2X7-targeted PET probe (¹⁸F-FTTM) to identify vulnerable atherosclerotic plaques, to detect the inflammatory response of atherosclerosis, and to provide a powerful non-invasive method for the diagnosis of atherosclerotic lesions and new drug screening for accurate treatment.

Molecular Imaging of Vulnerable Coronary Plaque with Radiolabeled Somatostatin Receptors (SSTR)

Atherosclerosis is responsible for the majority of heart attacks and is characterized by several modifications of the arterial wall including an inflammatory reaction. The silent course of atherosclerosis has made it necessary to develop predictors of disease complications before symptomatic lesions occur. Vulnerable to rupture atherosclerotic plaques are the target for molecular imaging. To this aim, different radiopharmaceuticals for PET/CT have emerged for the identification of high-risk plaques, with high specificity for the identification of the cellular components and pathophysiological status of plaques. By targeting specific receptors on activated macrophages in high-risk plaques, radiolabelled somatostatin analogues such as ⁶⁸Ga-DOTA-TOC, TATE,0 or NOC have shown high relevance to detect vulnerable, atherosclerotic plaques. This PET radiopharmaceutical has been tested in several pre-clinical and clinical studies, as reviewed here, showing an important correlation with other risk factors.

Feasibility of in vivo Imaging of Fibroblast Activation Protein in Human Arterial Walls

Increased expression of fibroblast activating protein (FAP) in fibrous caps may contribute to progression of atherosclerotic plaques. Methods: Forty-one patients who underwent gallium-68-conjugated quinoline-based FAP inhibitor (⁶⁸Ga-FAPI-04) PET/CT for non-cardiovascular indications were retrospectively analyzed. Correlations were assessed between the uptake of ⁶⁸Ga-FAPI-04 in large arterial walls (SUV_max and target-to-background ratio, TBR) and degree of calcification and cardiovascular risk factors. Results: Focal arterial uptake of ⁶⁸Ga-FAPI-04 or calcification was detected in 1,177 arterial segments in all 41 patients. TBR was negatively correlated with the degree of calcification (HU) (r = -0.27, P < 0.01). Mean TBR in higher-risk patients was greater than lower-risk patients (2.2 ± 0.3 vs. 1.8 ± 0.3, P < 0.01). Immunohistochemical labeling of carotid plaques exhibited prominent FAP expression in a thin fibrous cap and moderate FAP expression in a thick cap. Conclusion: ⁶⁸Ga-FAPI-04 PET/CT might have potential for imaging fibroblastic activation in the arterial wall.

Molecular Imaging of Cardiovascular Inflammation

Cardiovascular diseases (CVD), including atherosclerosis, are chronic inflammatory diseases characterised by a complex and evolving tissue micro-environment. Molecular heterogeneity of inflammatory responses translates into clinical outcomes. However, current medical imaging modalities are unable to reveal the cellular and molecular events at a level of detail that would allow more accurate and timely diagnosis and treatment. This is an inherent limitation of the current imaging tools which are restricted to anatomical or functional data. Molecular imaging - the visualization and quantification of molecules in the body - is already established in the clinic in the form of Positron Emitted Tomography (PET), yet the use of PET in CVD is limited. In this visual review, we will guide you through the current state of molecular imaging research, assessing the respective strengths and weaknesses of molecular imaging modalities, including those already being used in the clinic such as PET and magnetic resonance imaging (MRI) and emerging technologies at pre-clinical stage, such as photoacoustic imaging. We discuss the basic principles of each technology and provide key examples of their application in imaging inflammation in CVD and the added value into the diagnostic decision-making process. Finally, we discuss barriers for rapid successful clinical translation of these novel diagnostic modalities.

Molecular Imaging and Non-molecular Imaging of Atherosclerotic Plaque Thrombosis

Thrombosis in the context of atherosclerosis typically results in life-threatening consequences, including acute coronary events and ischemic stroke. As such, early detection and treatment of thrombosis in atherosclerosis patients is essential. Clinical diagnosis of thrombosis in these patients is typically based upon a combination of imaging approaches. However, conventional imaging modalities primarily focus on assessing the anatomical structure and physiological function, severely constraining their ability to detect early thrombus formation or the processes underlying such pathology. Recently, however, novel molecular and non-molecular imaging strategies have been developed to assess thrombus composition and activity at the molecular and cellular levels more accurately. These approaches have been successfully used to markedly reduce rates of atherothrombotic events in patients suffering from acute coronary syndrome (ACS) by facilitating simultaneous diagnosis and personalized treatment of thrombosis. Moreover, these modalities allow monitoring of plaque condition for preventing plaque rupture and associated adverse cardiovascular events in such patients. Sustained developments in molecular and non-molecular imaging technologies have enabled the increasingly specific and sensitive diagnosis of atherothrombosis in animal studies and clinical settings, making these technologies invaluable to patients' health in the future. In the present review, we discuss current progress regarding the non-molecular and molecular imaging of thrombosis in different animal studies and atherosclerotic patients.

Imaging and Targeting Coronary Artery Inflammation

Significance: Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality across the world despite significant progress in the prevention, diagnosis, and treatment of atherosclerotic disease. Recent Advances: The focus of the cardiovascular community has shifted toward seeking a better understanding of the inflammatory mechanisms driving residual CAD risk that is not modulated by current therapies. Significant progress has been achieved in revealing both proinflammatory and anti-inflammatory mechanisms, and how shift of the balance in favor of the former can drive the development of disease. Critical Issues: Advances in the noninvasive detection of coronary artery inflammation have been forthcoming. These advances include multiple imaging modalities, with novel applications of computed tomography both with and without positron emission tomography, and experimental ultrasound techniques. These advances will enable better selection of patients for anti-inflammatory treatments and assessment of treatment response. The rapid advancement in pharmaceutical design has enabled the production of specific antibodies against inflammatory pathways of atherosclerosis, with modest success to date. The pursuit of demonstrating the efficacy and safety of novel anti-inflammatory and/or proinflammatory resolution therapies for atherosclerotic CAD has become a major focus. Future Directions: This review seeks to provide an update of the latest evidence of all three of these highly related but disparate areas of inquiry: Our current understanding of the key mechanisms by which inflammation contributes to coronary artery atherosclerosis, the evidence for noninvasive assessment of coronary artery inflammation, and finally, the evidence for targeted therapies to treat coronary inflammation for the reduction of CAD risk. Antioxid. Redox Signal. 34, 1217-1243.

Autoradiographical assessment of inflammation-targeting radioligands for atherosclerosis imaging: potential for plaque phenotype identification

PURPOSE

Many radioligands have been developed for the visualization of atherosclerosis by targeting inflammation. However, interpretation of in vivo signals is often limited to plaque identification. We evaluated binding of some promising radioligands in an in vitro approach in atherosclerotic plaques with different phenotypes.

METHODS

Tissue sections of carotid endarterectomy tissue were characterized as early plaque, fibro-calcific plaque, or phenotypically vulnerable plaque. In vitro binding assays for the radioligands [111In]In-DOTATATE; [111In]In-DOTA-JR11; [67Ga]Ga-Pentixafor; [111In]In-DANBIRT; and [111In]In-EC0800 were conducted, the expression of the radioligand targets was assessed via immunohistochemistry. Radioligand binding and expression of radioligand targets was investigated and compared.

RESULTS

In sections characterized as vulnerable plaque, binding was highest for [111In]In-EC0800; followed by [111In]In-DANBIRT; [67Ga]Ga-Pentixafor; [111In]In-DOTA-JR11; and [111In]In-DOTATATE (0.064 ± 0.036; 0.052 ± 0.029; 0.011 ± 0.003; 0.0066 ± 0.0021; 0.00064 ± 0.00014 %Added activity/mm2, respectively). Binding of [111In]In-DANBIRT and [111In]In-EC0800 was highest across plaque phenotypes, binding of [111In]In-DOTA-JR11 and [67Ga]Ga-Pentixafor differed most between plaque phenotypes. Binding of [111In]In-DOTATATE was the lowest across plaque phenotypes. The areas positive for cells expressing the radioligand's target differed between plaque phenotypes for all targets, with lowest percentage area of expression in early plaque sections and highest in phenotypically vulnerable plaque sections.

CONCLUSIONS

Radioligands targeting inflammatory cell markers showed different levels of binding in atherosclerotic plaques and among plaque phenotypes. Different radioligands might be used for plaque detection and discerning early from vulnerable plaque. [111In]In-EC0800 and [111In]In-DANBIRT appear most suitable for plaque detection, while [67Ga]Ga-Pentixafor and [111In]In-DOTA-JR11 might be best suited for differentiation between plaque phenotypes.

Atherosclerosis Imaging with 18F-Sodium Fluoride PET

The evidence on atherosclerosis imaging with ¹⁸F-sodium-fluoride (NaF) positron emission tomography (PET) is hotly debated because of the different patient characteristics, methodology, vascular beds, etc. in reported studies. This review is a continuation of a previous review on this topic, which covered the period 2010-2018. The purpose was to examine whether some of the most important questions that the previous review had left open had been elucidated by the most recent literature. Using principles of a systematic review, we ended analyzing 25 articles dealing with the carotids, coronary arteries, aorta, femoral, intracranial, renal, and penile arteries. The knowledge thus far can be summarized as follows: by targeting active arterial microcalcification, NaF uptake is considered a marker of early stage atherosclerosis, is age-dependent, and consistently associated with cardiovascular risk. Longitudinal studies on NaF uptake, conducted in the abdominal aorta only, showed unchanged uptake in postmenopausal women for nearly four years and varying uptake in prostate cancer patients over 1.5 years, despite constant or increasing calcium volume detected by computed tomography (CT). Thus, uncertainty remains about the transition from active arterial wall calcification marked by increased NaF uptake to less active or consolidated calcification detected by CT. The question of whether early-phase atherosclerosis and calcification can be modified remains also unanswered due to lack of intervention studies.

Swine Disease Models for Optimal Vascular Engineering

Swine disease models are essential for mimicry of human metabolic and vascular pathophysiology, thereby enabling high-fidelity translation to human medicine. The worldwide epidemic of obesity, metabolic disease, and diabetes has prompted the focus on these diseases in this review. We highlight the remarkable similarity between Ossabaw miniature swine and humans with metabolic syndrome and atherosclerosis. Although the evidence is strongest for swine models of coronary artery disease, findings are generally applicable to any vascular bed. We discuss the major strengths and weaknesses of swine models. The development of vascular imaging is an example of optimal vascular engineering in swine. Although challenges regarding infrastructure and training of engineers in the use of swine models exist, opportunities are ripe for gene editing, studies of molecular mechanisms, and use of swine in coronary artery imaging and testing of devices that can move quickly to human clinical studies.