Nitric oxide in flow-through venous flaps and effects of L-arginine and nitro-L-arginine methyl ester (L-NAME) on nitric oxide and flap survival in rabbits

Unconventional Perfusion Flaps in the Experimental Setting: A Systematic Review and Meta-Analysis

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Background:

Unconventional perfusion flaps offer multiple potential advantages compared with traditional flaps. Although there are numerous experimental articles on unconventional perfusion flaps, the multiple animal species involved, the myriad vascular constructions used, and the frequently conflicting data reported make synthesis of this information challenging. The main aim of this study was to perform a systematic review and meta-analysis of the literature on the experimental use of unconventional perfusion flaps, to identify the best experimental models proposed and to estimate their global survival rate.

Methods:

The authors performed a systematic review and meta-analysis of all articles written in English, French, Italian, Spanish, and Portuguese on the experimental use of unconventional perfusion flaps and indexed to PubMed from 1981 until February 1, 2017.

Results:

A total of 68 studies were found, corresponding to 86 optimized experimental models and 1073 unconventional perfusion flaps. The overall unconventional perfusion flap survival rate was 90.8 percent (95 percent CI, 86.9 to 93.6 percent; p < 0.001). The estimated proportion of experimental unconventional perfusion flaps presenting complete survival or nearly complete survival was 74.4 percent (95 percent CI, 62.1 to 83.7 percent; p < 0.001). The most commonly reported animal species in the literature were the rabbit (57.1 percent), the rat (26.4 percent), and the dog (14.3 percent). No significant differences were found in survival rates among these species, or among the diverse vascular patterns used.

Conclusion:

These data do not differ significantly from those reported regarding the use of unconventional perfusion flaps in human medicine, suggesting that rabbit, rat, and canine experimental unconventional perfusion flap models may adequately mimic the clinical application of unconventional perfusion flaps.

Thrombospondin-1-CD47 blockade and exogenous nitrite enhance ischemic tissue survival, blood flow and angiogenesis via coupled NO-cGMP pathway activation

Tissue ischemia and ischemia-reperfusion (I/R) remain sources of cell and tissue death. Inability to restore blood flow and limit reperfusion injury represents a challenge in surgical tissue repair and transplantation. Nitric oxide (NO) is a central regulator of blood flow, reperfusion signaling and angiogenesis. De novo NO synthesis requires oxygen and is limited in ischemic vascular territories. Nitrite (NO(2-)) has been discovered to convert to NO via heme-based reduction during hypoxia, providing a NO synthase independent and oxygen-independent NO source. Furthermore, blockade of the matrix protein thrombospondin-1 (TSP1) or its receptor CD47 has been shown to promote downstream NO signaling via soluble guanylate cyclase (sGC) and cGMP-dependant kinase. We hypothesized that nitrite would provide an ischemic NO source that could be potentiated by TSP1-CD47 blockade enhancing ischemic tissue survival, blood flow and angiogenesis. Both low dose nitrite and direct blockade of TSP1-CD47 interaction using antibodies or gene silencing increased acute blood flow and late tissue survival in ischemic full thickness flaps. Nitrite and TSP1 blockade both enhanced in vitro and in vivo angiogenic responses. The nitrite effect could be abolished by inhibition of sGC and cGMP signaling. Potential therapeutic synergy was tested in a more severe ischemic flap model. We found that combined therapy with nitrite and TSP1-CD47 blockade enhanced flap perfusion, survival and angiogenesis to a greater extent than either agent alone, providing approximately 100% flap survival. These data provide a new therapeutic paradigm for hypoxic NO signaling through enhanced cGMP mediated by TSP1-CD47 blockade and nitrite delivery.