Vascular Smooth Muscle Cell Apoptosis Induced by “Supercooling” and Rewarming

Comparison of tandem ureteral stents, cryoplasty, and cutting balloon ureteroplasty in treatment of refractory transplant ureteral strictures

The objective of study was to compare clinical outcome of cryoplasty, tandem stents, and cutting balloon ureteroplasty as "bailout procedures" to prevent surgical intervention or stent dependency in renal transplant patients with refractory ureteral stricture. All patients who underwent a bailout procedure from June 11, 2003, to August 8, 2015, at a single institution were reviewed retrospectively. Refractory ureteral stricture was defined as ureteral stenosis not responding to at least two prior percutaneous plain balloon ureteroplasties. Primary patency was defined as stable allograft function following the procedure with unobstructed urine outflow, not requiring indwelling ureteral stent, repeat ureteroplasty, or surgical revision. Sixty-one procedures were performed on 51 patients. Patients were followed up for a median of 286 days. Overall primary patency rate was 26.1%. Primary patency rate by method was 38.1%, 23.1%, and 14.3% after cryoplasty, tandem stent placement, and cutting balloon dilatation, respectively (P = .260). Primary patency rate was higher in early (<3 months post-transplant) ureteral strictures (35.7% vs 13.3%; P = .047). More complications identified in patients who had tandem ureteral stents (P = .00754). As some renal transplant patients may not be good operative candidates for ureteral revision, it would be reasonable to attempt one of these "bailout" interventions as long as the clinical team and patient are aware of overall low potential for achieving primary patency.

An overview of optimal endovascular strategy in treating the femoropopliteal artery: mechanical, biological, and procedural factors

Treatment of the femoropopliteal (FP) artery remains a challenge to the endovascular specialist. Long-term patency is low with a high rate of target lesion revascularization. The true patency rate varies considerably between studies partly because there is a lack of uniform performance criteria and reporting standards in peripheral arterial interventions. Literature review supports three principles that emerge as important components of an optimal strategy in treating the FP artery: (1) improving vessel compliance and subsequently less dissections and bailout stenting, (2) reducing smooth muscle cell proliferation, and (3) protecting outflow vessels from distal embolization. In this overview, we examine current data that support the validity of this strategy.

Subfreezing versus room-temperature balloon dilation of benign tracheal stenosis: a pilot study in rabbits

We conducted an experiment to compare collagen deposition in tracheal stenoses dilated with room-temperature balloons and stenoses dilated with balloons at a subfreezing temperature (-10°C). Six New Zealand white rabbits underwent endoscopic tracheal injury. Tracheal dilation was performed at 3 weeks postinjury with either a room-temperature balloon or a vascular cryoplasty balloon. Five surviving rabbits were sacrificed at either 2 weeks (n = 3) or 4 weeks (n = 2) postdilation (1 rabbit that was not able to tolerate dilation was euthanized during the procedure). A blinded pathologist graded histologic sections of the injured tracheas for collagen content. The tracheal collagen deposits in the 3 animals sacrificed at 2 weeks postdilation were all graded as moderate. However, at the 4-week postdilation examination, there was a marked difference in collagen deposition between the rabbit that underwent room-temperature dilation and the rabbit that underwent subfreezing dilation; while the former showed moderate collagen deposition, the deposition in the latter was only mild. In conclusion, this pilot study showed that tracheal dilation with balloon cryotherapy decreased collagen deposition in the injured airway of 1 animal. Larger studies are required to determine whether balloon cryotherapy improves the long-term patency of immature tracheal stenosis.

Subfreezing versus Room-Temperature Balloon Dilation of Benign Tracheal Stenosis: A Pilot Study in Rabbits

We conducted an experiment to compare collagen deposition in tracheal stenoses dilated with room-temperature balloons and stenoses dilated with balloons at a subfreezing temperature (-10°C). Six New Zealand white rabbits underwent endoscopic tracheal injury. Tracheal dilation was performed at 3 weeks postinjury with either a room-temperature balloon or a vascular cryoplasty balloon. Five surviving rabbits were sacrificed at either 2 weeks (n = 3) or 4 weeks (n = 2) postdilation (1 rabbit that was not able to tolerate dilation was euthanized during the procedure). A blinded pathologist graded histologic sections of the injured tracheas for collagen content. The tracheal collagen deposits in the 3 animals sacrificed at 2 weeks postdilation were all graded as moderate. However, at the 4-week postdilation examination, there was a marked difference in collagen deposition between the rabbit that underwent room-temperature dilation and the rabbit that underwent subfreezing dilation; while the former showed moderate collagen deposition, the deposition in the latter was only mild. In conclusion, this pilot study showed that tracheal dilation with balloon cryotherapy decreased collagen deposition in the injured airway of 1 animal. Larger studies are required to determine whether balloon cryotherapy improves the long-term patency of immature tracheal stenosis.

Lower extremity limb salvage with cryoplasty: a single-center cohort study

Endovascular techniques have been playing an increasing role in managing lower extremity chronic critical limb ischemia (CLI) in patients considered poor or non-candidates for surgical revascularization secondary to co-morbidities such as coronary artery disease, uncontrolled hypertension, diabetes mellitus or inadequate conduit. This study reviews our recent clinical experience in the treatment of peripheral artery disease solely using cryoplasty. A retrospective cohort study was performed. The cohort consisted of 88 patients who underwent lower extremity revascularization utilizing cryoplasty between December 2003 and August 2007. Indications for intervention included poor wound healing after forefoot amputation or persistent ulceration of the foot, disabling claudication and rest pain. Kaplan–Meier analysis was performed to assess salvage rates. One hundred twenty-six lesions were treated in 88 patients. Technical success rate was 97%. Limb salvage rates were 75 and 63% for patients with critical limbs ischemia after one and three years, respectively. A history of smoking was associated with a threefold increased risk of limb loss. In conclusion, endovascular management of lower extremity lesions with cryoplasty is an emerging and viable paradigm in the treatment of CLI in an attempt to preserve limbs and avoid major amputations.

The use of cryoplasty in a benign ureteric stricture

Ureteral stricture is one of the most common complications following renal transplant. Current treatment options are limited to mainly surgery or balloon dilation, but mixed results and refractory cases present the opportunity for alternative treatments. Anterograde balloon cryoplasty of a benign ureteric stricture was performed in a renal transplant patient, after attempts with ballooning and stenting had failed. A 2-year follow-up demonstrates normal creatinine and no hydronephrosis on US images.

The effects of freezing versus supercooling on vascular cells: implications for balloon cryoplasty

PURPOSE

To investigate the effects of supercooling, a phase whereby cells are below 0 degrees C but still in a liquid state, and freezing, the phase when cells become solid, of vascular cells in culture.

MATERIALS AND METHODS

Bovine aortic endothelial cells and smooth muscle cells were supercooled to -10 degrees C with or without freezing for 3, 30, or 60 seconds and then rewarmed to 37 degrees C for 24 hours. Viability was assessed by means of trypan blue exclusion, and apoptosis was assessed with the TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling) assay.

RESULTS

Viability of smooth muscle cells decreased 49% after freezing versus supercooling (P< .05). Endothelial cells maintained greater viability rates. A 19.5% smooth muscle cell apoptotic rate was observed after freezing, whereas smooth muscle cell supercooling yielded rates of only 11% (P< .05). A 4.17% endothelial cell apoptotic rate was observed after freezing, whereas supercooled endothelial cells yielded a 1.76% rate (P< .05).

CONCLUSIONS

Freezing results in decreased viability and increased apoptosis compared to supercooling in both cell lines. Smooth muscle cells appear more susceptible to freezing. The biologic effects of freezing on vascular cells may elucidate the mechanisms behind the enhanced patency after cryoplasty of atherosclerotic lesions.

Experimental cryosurgery investigations in vivo

Cryosurgery is the use of freezing temperatures to elicit an ablative response in a targeted tissue. This review provides a global overview of experimentation in vivo which has been the basis of advancement of this widely applied therapeutic option. The cellular and tissue-related events that underlie the mechanisms of destruction, including direct cell injury (cryolysis), vascular stasis, apoptosis and necrosis, are described and are related to the optimal methods of technique of freezing to achieve efficacious therapy. In vivo experiments with major organs, including wound healing, the putative immunological response following thawing, and the use of cryoadjunctive strategies to enhance cancer cell sensitivity to freezing, are described.

Irreversible electroporation attenuates neointimal formation after angioplasty

Restenosis following coronary angioplasty represents a major clinical problem. Irreversible electroporation (IRE) is a nonthermal, nonpharmacological cell ablation method. IRE utilizes a sequence of electrical pulses that produce permanent damage to tissue within a few seconds.

METHODS AND RESULTS

The left carotid arteries of eight rats underwent in vivo intimal damage using two Fogarty angioplasty catheters. The procedure was immediately followed by IRE ablation in four rats, while the remaining four were used as the control group. The IRE ablation was performed using a sequence of ten dc pulses of 3800 V/cm, 100 micros each, at a frequency of ten pulses per second, applied across the blood vessel between two parallel electrodes. The electrical conductance of the treated tissue was measured during the electroporation to provide real-time feedback of the process. Left carotid arteries were excised and fixated after a 28-day follow-up period. Neointimal formation was evaluated histologically. The use of IRE was successful in three out of four animals in a way that is consistent with the measurements of blood vessel electrical properties. The integrity of the endothelial layer was recovered in the IRE-treated animals, compared with control. Successful IRE reduced neointima to media ratio (0.57 +/-0.4 versus 1.88 +/-1.0, P = 0.02).

CONCLUSIONS

We report for the first time the in vivo results of attenuation of neointimal formation using IRE. Our study shows that IRE might be able to attenuate neointimal formation after angioplasty damage in a rodent model of restenosis. This approach may open new venues in the treatment of coronary artery restenosis after balloon angioplasty.

Synergistic effect of cool/thaw cycles on vascular cells in an in vitro model of cryoplasty

PURPOSE

Cryoplasty combines mechanical dilation with supercooling of the vessel and has shown encouraging preliminary results in the management of atherosclerotic lesions. However, the mechanisms of action and the optimum inflation regimen are still not well established. This study investigates the effects of single and dual supercooling and rewarming cycles on the survival responses of smooth muscle cells (SMCs) and endothelial cells (ECs).

MATERIALS AND METHODS

Bovine aortic SMCs and ECs were cultured separately in six-well plates with medium supplemented with 10% fetal bovine serum. In the one-cycle treatment group, the cells were supercooled for 60 seconds to -10 degrees C and then rewarmed rapidly in a water bath at 37 degrees C for another 60 seconds. Two-cycle treatment was done by supercooling and rewarming the cells twice. The samples were then put into an incubator at 37 degrees C for 0, 6, 12, and 24 hours. Terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling was used to measure apoptosis and phospho-Akt immunohistochemistry and immunoblot analysis were employed to assess activation of Akt.

RESULTS

A significant increase of apoptotic cells was observed in the two-cycle procedure versus the one-cycle procedure. In both groups, there were more apoptotic SMCs than ECs. Akt activation was higher in ECs by a factor of three compared with SMCs (P < .05).

CONCLUSIONS

The higher apoptotic rate and the absence of Akt activation of SMCs versus controls in both treatment groups may imply the potential of a lower restenosis rate, especially after two cycles of supercooling and rewarming. Further in vivo and clinical investigations are needed to confirm results of the in vitro testing.

Direct comparison of endothelial cell and smooth muscle cell response to supercooling and rewarming

BACKGROUND

Cryoplasty combines mechanical dilatation with the delivery of hypothermia to atherosclerotic plaques. The response of vascular smooth muscle cells (SMCs) and endothelial cells (ECs) to supercooling and subsequent rewarming is still not clear. This study investigated the differential effects of vascular cell survival and proliferation in an in vitro model simulating cryoplasty.

METHODS

Bovine aortic ECs and SMCs were cultured separately with medium supplemented with 10% fetal bovine serum. The samples were supercooled to -10 degrees C for 0, 60, or 120 seconds on a cooling stage and then rewarmed in an incubator at 37 degrees C for 0, 6, 12, or 24 hours. Terminal deoxynucleotide transferase-mediated deoxy uridine triphosphate nick-end labeling (TUNEL) and 5'-bromo-2'-deoxyuridine incorporation were used to measure the degree of apoptosis and proliferation respectively. Activation of protein kinase B (AKT), P70 S6 kinase, and P44/42 mitogen-activated protein kinase (MAPK) were assessed by Western blot and quantified using densitometry. Results are given as mean +/- standard error of mean and analyzed by analysis of variance.

RESULTS

SMC and EC apoptosis were significantly increased with increasing supercooling and rewarming time, with a higher rate in SMCs. SMC apoptosis was maximal at 60 seconds cooling, followed by 24 hours rewarming (17.05% +/- 0.44%), whereas maximal EC apoptosis was after 120 seconds cooling, followed by 24 hours rewarming (4.21% +/- 0.22%, P < .05). Higher AKT activation was observed in ECs, with a maximum obtained of 3.34-fold at 120 seconds cooling with 24 hours rewarming (P < .05); only modest activation was found in SMCs. ECs had a decreased proliferation with cooling and rewarming time, and although SMCs maintained their low proliferative rate, ECs still had a higher overall proliferation rate that was statistically significant at 60 and 120 seconds cooling without rewarming compared with noncooling and nonrewarming (P < .05). Both p70S6 kinase and p44/42 MAPK activities decreased in SMCs, with significant drop at 60 seconds cooling, followed by 12 hours rewarming (P < .05). However, ECs showed a significant rise of P70 S6 kinase activity at 60 seconds cooling with 12 hours rewarming by 1.62-fold and P44/42 MAPK at 120 seconds cooling with 24 hours rewarming by 1.74-fold (P < .05).

CONCLUSION

The higher apoptosis and lower proliferation of SMCs compared with ECs demonstrate the different effects of supercooling and rewarming on different vascular cell types. This information may be important in helping to understand the mechanism by which cryoplasty of atherosclerotic lesions may result in less restenosis.