Perivascular responses after angioplasty which may contribute to postangioplasty restenosis: a role for circulating myofibroblast precursors?

Anti-Thrombogenicity Study of a Covalently-Attached Monolayer on Stent-Grade Stainless Steel

Implantable devices fabricated from austenitic type 316L stainless steel have been employed significantly in medicine, principally because the material displays excellent mechanical characteristics and corrosion resistance. It is well known, however, that interaction of exposure of such a material to blood can initiate platelet adhesion and blood coagulation, leading to a harmful medical condition. In order to prevent undesirable surface platelet adhesion on biomaterials employed in procedures such as renal dialysis, we developed an ultrathin anti-thrombogenic covalently attached monolayer based on monoethylene glycol silane chemistry. This functions by forming an interstitial hydration layer which displays restricted mobility in the prevention of surface fouling. In the present work, the promising anti-thrombogenic properties of this film are examined with respect to platelet aggregation on 316L austenitic stainless steel exposed to whole human blood. Prior to exposure with blood, all major surface modification steps were examined by X-ray photoelectron spectroscopic analysis and surface free-angle measurement by contact angle goniometry. End-stage anti-thrombogenicity detection after 20 min of blood exposure at 100 s^-1, 300 s^-1, 600 s^-1, 750 s^-1, and 900 s^-1 shear rates revealed that a significant reduction (>90%) of platelet adhesion and aggregation was achieved for surface-modified steel, compared with untreated material. This result is confirmed by experiments conducted in real time for 60-minute exposure to blood at 100 s^-1, 600 s^-1, and 900 s^-1 shear rates.

Single-Cell Transcriptomic Atlas of Different Human Cardiac Arteries Identifies Cell Types Associated With Vascular Physiology

[Figure: see text].

Extreme Diversity of the Human Vascular Mesenchymal Cell Landscape

Background Human mesenchymal cells are culprit factors in vascular (patho)physiology and are hallmarked by phenotypic and functional heterogeneity. At present, they are subdivided by classic umbrella terms, such as "fibroblasts," "myofibroblasts," "smooth muscle cells," "fibrocytes," "mesangial cells," and "pericytes." However, a discriminative marker-based subclassification has to date not been established. Methods and Results As a first effort toward a classification scheme, a systematic literature search was performed to identify the most commonly used phenotypical and functional protein markers for characterizing and classifying vascular mesenchymal cell subpopulation(s). We next applied immunohistochemistry and immunofluorescence to inventory the expression pattern of identified markers on human aorta specimens representing early, intermediate, and end stages of human atherosclerotic disease. Included markers comprise markers for mesenchymal lineage (vimentin, FSP-1 [fibroblast-specific protein-1]/S100A4, cluster of differentiation (CD) 90/thymocyte differentiation antigen 1, and FAP [fibroblast activation protein]), contractile/non-contractile phenotype (α-smooth muscle actin, smooth muscle myosin heavy chain, and nonmuscle myosin heavy chain), and auxiliary contractile markers (h1-Calponin, h-Caldesmon, Desmin, SM22α [smooth muscle protein 22α], non-muscle myosin heavy chain, smooth muscle myosin heavy chain, Smoothelin-B, α-Tropomyosin, and Telokin) or adhesion proteins (Paxillin and Vinculin). Vimentin classified as the most inclusive lineage marker. Subset markers did not separate along classic lines of smooth muscle cell, myofibroblast, or fibroblast, but showed clear temporal and spatial diversity. Strong indications were found for presence of stem cells/Endothelial-to-Mesenchymal cell Transition and fibrocytes in specific aspects of the human atherosclerotic process. Conclusions This systematic evaluation shows a highly diverse and dynamic landscape for the human vascular mesenchymal cell population that is not captured by the classic nomenclature. Our observations stress the need for a consensus multiparameter subclass designation along the lines of the cluster of differentiation classification for leucocytes.

Cytochrome P450 1B1 Is Critical for Neointimal Growth in Wire-Injured Carotid Artery of Male Mice

Background We have reported that cytochrome P450 1B1 ( CYP 1B1), expressed in cardiovascular tissues, contributes to angiotensin II -induced vascular smooth muscle cell ( VSMC ) migration and proliferation and development of hypertension in various experimental animal models via generation of reactive oxygen species. This study was conducted to determine the contribution of CYP 1B1 to platelet-derived growth factor-BB-induced VSMC migration and proliferation in vitro and to neointimal growth in vivo. Methods and Results VSMC s isolated from aortas of male Cyp1b1 +/+ and Cyp1b1 -/- mice were used for in vitro experiments. Moreover, carotid arteries of Cyp1b1 +/+ and Cyp1b1 -/- mice were injured with a metal wire to assess neointimal growth after 14 days. Platelet-derived growth factor- BB -induced migration and proliferation and H2O2 production were found to be attenuated in VSMC s from Cyp1b1 -/- mice and in VSMC s of Cyp1b1 +/+ mice treated with 4-hydroxy-2,2,6,6-tetramethylpiperidin-1-oxyl, a superoxide dismutase and catalase mimetic. In addition, wire injury resulted in neointimal growth, as indicated by increased intimal area, intima/media ratio, and percentage area of restenosis, as well as elastin disorganization and adventitial collagen deposition in carotid arteries of Cyp1b1 +/+ mice, which were minimized in Cyp1b1 -/- mice. Wire injury also increased infiltration of inflammatory and immune cells, as indicated by expression of CD 68+ macrophages and CD 3+ T cells, respectively, in the injured arteries of Cyp1b1 +/+ mice, but not Cyp1b1 -/- mice. Administration of 4-hydroxy-2,2,6,6-tetramethylpiperidin-1-oxyl attenuated neointimal growth in wire-injured carotid arteries of Cyp1b1 +/+ mice. Conclusions These data suggest that CYP 1B1-dependent oxidative stress contributes to the neointimal growth caused by wire injury of carotid arteries of male mice.

Periadventitial local drug delivery to target restenosis

The adventitia functions as a dynamic compartment for cell trafficking into and out of the artery wall, and communicates with medial and intimal cells. The resident cells in the tunica adventitia play an integral role in the regulation of vessel wall structure, repair, tone, and remodeling. Following injury to the vascular wall, adventitial fibroblasts are activated, which proliferate and differentiate into migratory myofibroblasts, and initiate inflammation through the secretion of soluble factors such as chemokines, cytokines, and adhesion molecules. The secreted factors subsequently promote leukocyte recruitment and extravasation into the media and intima. The adventitia generates reactive oxygen species and growth factors that participate in cell proliferation, migration, and hypertrophy, resulting in intimal thickening. The adventitial vasa vasorum undergoes neovascularization and serves as a port of entry for the delivery of inflammatory cells and resident stem/progenitor cells into the intima, and thus facilitates vascular remodeling. This review highlights the contribution of multilineage cells in the adventitia along with de-differentiated smooth muscle-like cells to the formation of neointimal hyperplasia, and discusses the potential of periadventitial local drug delivery for the prevention of vascular restenosis.

Cell Based Therapeutic Approach in Vascular Surgery: Application and Review

Multipotent stem cells - such as mesenchymal stem/stromal cells and stem cells derived from different sources like vascular wall are intensely studied to try to rapidly translate their discovered features from bench to bedside. Vascular wall resident stem cells recruitment, differentiation, survival, proliferation, growth factor production, and signaling pathways transduced were analyzed. We studied biological properties of vascular resident stem cells and explored the relationship from several factors as Matrix Metalloproteinases (MMPs) and regulations of biological, translational and clinical features of these cells. In this review we described a translational and clinical approach to Adult Vascular Wall Resident Multipotent Vascular Stem Cells (VW-SCs) and reported their involvement in alternative clinical approach as cells based therapy in vascular disease like arterial aneurysms or peripheral arterial obstructive disease.

Progenitor Cells for Arterial Repair: Incremental Advancements towards Therapeutic Reality

Coronary revascularization remains the standard treatment for obstructive coronary artery disease and can be accomplished by either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. Considerable advances have rendered PCI the most common form of revascularization and improved clinical outcomes. However, numerous challenges to modern PCI remain, namely, in-stent restenosis and stent thrombosis, underscoring the importance of understanding the vessel wall response to injury to identify targets for intervention. Among recent promising discoveries, endothelial progenitor cells (EPCs) have garnered considerable interest given an increasing appreciation of their role in vascular homeostasis and their ability to promote vascular repair after stent placement. Circulating EPC numbers have been inversely correlated with cardiovascular risk, while administration of EPCs in humans has demonstrated improved clinical outcomes. Despite these encouraging results, however, advancing EPCs as a therapeutic modality has been hampered by a fundamental roadblock: what constitutes an EPC? We review current definitions and sources of EPCs as well as the proposed mechanisms of EPC-mediated vascular repair. Additionally, we discuss the current state of EPCs as therapeutic agents, focusing on endogenous augmentation and transplantation.

Enhanced neointimal fibroblast, myofibroblast content and altered extracellular matrix composition: Implications in the progression of human peripheral artery restenosis

BACKGROUND AND AIMS

Neointimal cellular proliferation of fibroblasts and myofibroblasts is documented in coronary artery restenosis, however, their role in peripheral arterial disease (PAD) restenosis remains unclear. Our aim was to investigate the role of fibroblasts, myofibroblasts, and collagens in restenotic PAD.

METHODS

Nineteen PAD restenotic plaques were compared with 13 de novo plaques. Stellate cells (H&E), fibroblasts (FSP-1), myofibroblasts (α-actin/vimentin/FSP-1), cellular proliferation (Ki-67), and apoptosis (caspase-3 with poly ADP-ribose polymerase) were evaluated by immunofluorescence. Collagens were evaluated by picro-sirius red stain with polarization microscopy. Smooth muscle myosin heavy chain (SMMHC), IL-6 and TGF-β cytokines were analyzed by immunohistochemistry.

RESULTS

Restenotic plaques demonstrated increased stellate cells (2.7 ± 0.15 vs.1.3 ± 0.15) fibroblasts (2282.2 ± 85.9 vs. 906.4 ± 134.5) and myofibroblasts (18.5 ± 1.2 vs.10.6 ± 1.0) p = 0.0001 for all comparisons. In addition, fibroblast proliferation (18.4% ± 1.2 vs.10.4% ± 1.1; p = 0.04) and apoptosis (14.6% ± 1.3 vs.11.2% ± 0.6; p = 0.03) were increased in restenotic plaques. Finally, SMMHC (2.6 ± 0.12 vs.1.4 ± 0.15; p = 0.0001), type III collagen density (0.33 ± 0.06 vs. 0.17 ± 0.07; p = 0.0001), IL-6 (2.08 ± 1.7 vs.1.03 ± 2.0; p = 0.01), and TGF-β (1.80 ± 0.27 vs. 1.11 ± 0.18; p = 0.05) were increased in restenotic plaques.

CONCLUSIONS

Our study suggests proliferation and apoptosis of fibroblast and myofibroblast with associated increase in type III collagen may play a role in restenotic plaque progression. Understanding pathways involved in proliferation and apoptosis in neointimal cells, may contribute to future therapeutic interventions for the prevention of restenosis in PAD.

In vitro and in vivo cell-capture strategies using cardiac stent technology - A review

Stenosis is a symptom of coronary artery disease (CAD), and is caused by narrowing of arteries in the heart. Over the last several decades, medical implants such as cardiac stents have been developed to counter stenosis. Upon implantation of a stent to open up a restricted artery, narrowing of the artery can reoccur (restenosis), due to an immune response launched by the body towards the stent. Currently, restenosis is a major health concern for patients who have undergone heart surgery for coronary artery disease. Recently, there have been new methods developed to combat restenosis, which have shown potential signs of success. One proposed method is the use of stents to capture cells, thereby reducing immune response. This review will explore the different methods for cell capture both in vitro and in vivo. Biological modifications of the stent will be surveyed, as well as the use of surface science to immobilize biological probes. Immobilization of proteins and nucleotides, as well as use of magnetic field are all methods that will be further discussed. Finally, concluding remarks and future prospects will be presented.

Adult vascular wall resident multipotent vascular stem cells, matrix metalloproteinases, and arterial aneurysms

Evidences have shown the presence of multipotent stem cells (SCs) at sites of arterial aneurysms: they can differentiate into smooth muscle cells (SMCs) and are activated after residing in a quiescent state in the vascular wall. Recent studies have implicated the role of matrix metalloproteinases in the pathogenesis of arterial aneurysms: in fact the increased synthesis of MMPs by arterial SMCs is thought to be a pivotal mechanism in aneurysm formation. The factors and signaling pathways involved in regulating wall resident SC recruitment, survival, proliferation, growth factor production, and differentiation may be also related to selective expression of different MMPs. This review explores the relationship between adult vascular wall resident multipotent vascular SCs, MMPs, and arterial aneurysms.

Current Phase II drugs under investigation for the treatment of limb ischemia

INTRODUCTION

More than 20 million people in Europe suffer from peripheral arterial disease and nearly 3% develop critical limb ischemia (CLI). Without any medical treatment, CLI has poor prognosis, resulting in limb loss and high mortality rate. Until today, no systemic drug is available for the treatment of CLI and the gold standard method of treatment includes risk factor modification and open surgical or endovascular revascularization. Endovascular local drug delivery devices and novel antithrombotic agents, currently under investigation, aim to improve outcomes of revascularization procedures. The pioneering concept of therapeutic angiogenesis induced by gene and stem cell therapy has been proposed, in an attempt to increase ischemic tissue perfusion.

AREAS COVERED

This review summarizes local and systemic pharmacological treatment of CLI using endovascular or pharmaco-biological therapy and focuses on Phase II trials available for these drugs.

EXPERT OPINION

Novel endovascular technologies combining angioplasty and local drug-delivery continuously improve and will come to be standard of practice for the management of limb ischemia, while new antithrombotic agents will further improve outcomes. Therapeutic angiogenesis represents a safe and promising treatment option. The combination of revascularization with microcirculation improvement induced by gene or stem cell therapy could enhance limb salvage.

The role of inflammation in hypoxic pulmonary hypertension: from cellular mechanisms to clinical phenotypes

Hypoxic pulmonary hypertension (PH) comprises a heterogeneous group of diseases sharing the common feature of chronic hypoxia-induced pulmonary vascular remodeling. The disease is usually characterized by mild to moderate pulmonary vascular remodeling that is largely thought to be reversible compared with the progressive irreversible disease seen in World Health Organization (WHO) group I disease. However, in these patients, the presence of PH significantly worsens morbidity and mortality. In addition, a small subset of patients with hypoxic PH develop "out-of-proportion" severe pulmonary hypertension characterized by pulmonary vascular remodeling that is irreversible and similar to that in WHO group I disease. In all cases of hypoxia-related vascular remodeling and PH, inflammation, particularly persistent inflammation, is thought to play a role. This review focuses on the effects of hypoxia on pulmonary vascular cells and the signaling pathways involved in the initiation and perpetuation of vascular inflammation, especially as they relate to vascular remodeling and transition to chronic irreversible PH. We hypothesize that the combination of hypoxia and local tissue factors/cytokines ("second hit") antagonizes tissue homeostatic cellular interactions between mesenchymal cells (fibroblasts and/or smooth muscle cells) and macrophages and arrests these cells in an epigenetically locked and permanently activated proremodeling and proinflammatory phenotype. This aberrant cellular cross-talk between mesenchymal cells and macrophages promotes transition to chronic nonresolving inflammation and vascular remodeling, perpetuating PH. A better understanding of these signaling pathways may lead to the development of specific therapeutic targets, as none are currently available for WHO group III disease.

Perivascular fat, AMP-activated protein kinase and vascular diseases

Perivascular adipose tissue (PVAT) is an active endocrine and paracrine organ that modulates vascular function, with implications for the pathophysiology of cardiovascular disease (CVD). Adipocytes and stromal cells contained within PVAT produce mediators (adipokines, cytokines, reactive oxygen species and gaseous compounds) with a range of paracrine effects modulating vascular smooth muscle cell contraction, proliferation and migration. However, the modulatory effect of PVAT on the vascular system in diseases, such as obesity, hypertension and atherosclerosis, remains poorly characterized. AMP-activated protein kinase (AMPK) regulates adipocyte metabolism, adipose biology and vascular function, and hence may be a potential therapeutic target for metabolic disorders such as type 2 diabetes mellitus (T2DM) and the vascular complications associated with obesity and T2DM. The role of AMPK in PVAT or the actions of PVAT have yet to be established, however. Activation of AMPK by pharmacological agents, such as metformin and thiazolidinediones, may modulate the activity of PVAT surrounding blood vessels and thereby contribute to their beneficial effect in cardiometabolic diseases. This review will provide a current perspective on how PVAT may influence vascular function via AMPK. We will also attempt to demonstrate how modulating AMPK activity using pharmacological agents could be exploited therapeutically to treat cardiometabolic diseases.

Perivascular adipose tissue in vascular function and disease: a review of current research and animal models

Perivascular adipose tissue (PVAT), long assumed to be nothing more than vessel-supporting connective tissue, is now understood to be an important, active component of the vasculature, with integral roles in vascular health and disease. PVAT is an adipose tissue with similarities to both brown and white adipose tissue, although recent evidence suggests that PVAT develops from its own precursors. Like other adipose tissue depots, PVAT secretes numerous biologically active substances that can act in both autocrine and paracrine fashion. PVAT has also proven to be involved in vascular inflammation. Although PVAT can support inflammation during atherosclerosis via macrophage accumulation, emerging evidence suggests that PVAT also has antiatherosclerotic properties related to its abilities to induce nonshivering thermogenesis and metabolize fatty acids. We here discuss the accumulated knowledge of PVAT biology and related research on models of hypertension and atherosclerosis.

Safety and feasibility of adjunctive dexamethasone infusion into the adventitia of the femoropopliteal artery following endovascular revascularization

OBJECTIVE

Restenosis following endovascular treatment of the femoropopliteal segment is associated with the inflammatory response produced in the artery wall at the time of the procedure. Although local drug delivery to the superficial femoral and popliteal arteries promises improved patency, data are currently limited. We hypothesized that improved percutaneous delivery of an anti-inflammatory compound into the adventitia of the femoropopliteal at the time of endovascular treatment would be safe, feasible, and decrease the inflammatory response.

METHODS

This was a prospective, investigator-initiated, phase I, first-in-man study testing the safety and feasibility of percutaneous adventitial delivery of dexamethasone. Following successful intervention, an adventitial microinfusion catheter was advanced over a 0.014-inch wire to the treated segment. Its microneedle (0.9 mm long × 140-μm diameter) was deployed into the adventitia to deliver dexamethasone (4 mg/mL) mixed with contrast agent (80:20 ratio), providing fluoroscopic visualization. The primary safety outcome measure was freedom from vessel dissection, thrombosis, or extravasation while the primary efficacy outcome was duplex-determined binary restenosis defined as a peak systolic velocity ratio >2.5.

RESULTS

Twenty patients with Rutherford clinical category 2-5 enrolled in this study. The mean age was 66, and 55% had diabetes mellitus. Treated lesion length was 8.9 ± 5.3 cm, and 50% were chronic total occlusions. Eighty percent of treated lesions were in the distal superficial femoral or popliteal arteries. All lesions were treated by balloon angioplasty with provisional stenting (n = 6) for suboptimal result. Three patients were treated with atherectomy as well. A mean of 1.6 ± 1.1 mg (0.5 ± 0.3 mL) of dexamethasone sodium phosphate was injected per centimeter of lesion length. In total, a mean of 12.1 ± 6.1 mg of dexamethasone was injected per patient. The mean number of injections required per lesion was 3.0 ± 1.3 cm, minimum one and maximum six injections. There was 100% technical success of drug delivery and no procedural or drug-related adverse events. The mean Rutherford score decreased from 3.1 ± .7 (median, 3.0) preoperatively to .5 ± .7 at 6 months (median, 0.0; P < .00001). Over this same time interval, the index leg ankle-brachial index increased from .68 ± .15 to .89 ± .19 (P = .0003). The preoperative C-reactive protein in this study was 6.9 ± 8.5 indicating severe baseline inflammation, which increased to 14.0 ± 23.1 mg/L (103% increase) at 24 hours following the procedure. However, this increase did not reach statistical significance of P = .14. Two patients met the primary efficacy end point of loss of primary patency by reoccluding their treated segment of the index lesion during the follow-up period.

CONCLUSIONS

Adventitial drug delivery via a microinfusion catheter is a safe and feasible alternative to intimal-based methods for adjunctive treatment in the femoropopliteal segment. The 6-month preliminary results suggest perivascular dexamethasone treatment may improve outcomes following angioplasty to the femoral and popliteal arteries, and support further clinical investigation of this approach.

Interfacial biology of in-stent restenosis

Percutaneous angioplasty is a nonsurgical method able to restore patency in atherosclerotic blood vessels through the expansion of a balloon. The clinical outcome of this technique has been significantly enhanced by the combined deployment of a stent. Although stents are successful in the majority of cases, a large percentage of patients (20-30%) still suffer a second vessel lumen reduction known as in-stent restenosis. In-stent restenosis is recognized to be caused by the mechanical and foreign body challenges elicited by the device. Drug-eluting stents have been recently made available to tackle restenosis, but their short clinical history and high costs may limit their future use. The present review links the most recent biologic findings related to in-stent restenosis to the devices' phyisico-chemical features in an attempt to demonstrate that a new generation of stents may be developed without the need of drug elution.

Nogo-B expression, in arterial intima, is impeded in the early stages of atherosclerosis in humans

Nogo-B (Reticulon 4B) is considered to be a novel vascular marker, which may have a protective role in injury-induced neointima formation and atherosclerosis. Nogo A/B is found to be crucial for monocyte/macrophage recruitment in acute inflammation and it is expressed in CD68 + macrophages. We hypothesize that macrophage infiltration in atherosclerosis is not dependent on Nogo-B expression in arterial wall. We have assessed Nogo-B expression and macrophage accumulation in the iliac arteries of healthy organ donors and organ donors with cardiovascular risk factors. Paraffin sections of 66 iliac arteries, from 44 deceased organ donors (17 women and 27 men), were studied. The healthy and cardiovascular risk (CVR) subgroups were created. With regard to staging of the atherosclerotic process, the thickness of arterial intima was measured in digitalized images of H+E stained tissue sections. Immunohistochemical reactions (Nogo-B and CD68) were carried out in all arteries (66 samples). Western blotting (WB-19 samples) and real-time PCR (27 samples) were performed on selected arteries. Significantly higher Nogo-B expression was demonstrated in the intima of the healthy subjects' subgroup, using immunohistochemistry. WB and real-time PCR revealed a trend toward lower Nogo-B expression in the adventitia of the CVR subgroup. Furthermore, the thickness of the intima was found to negatively correlate with the expression of Nogo-B in the intima and media (r = -0.32; p < 0.05; r = -0.32; p < 0.05). Macrophage infiltrates were more prominent in intima of CVR subjects (0.65 vs 3.52 a.u.; p < 0.01). Macrophage density in intima increased with atherosclerosis progression (r = 0.37; p < 0.01). CD68 macrophages density in adventitia was lower in CVR arteries than in healthy arteries. The expression of Nogo-B, in arterial intima, is impeded in the early stages of atherosclerosis. Accumulation of arterial intimal CD68 macrophages has been shown to progress; however, the overall macrophage density in the adventitia is reduced in arteries shown to have intimal thickening. Macrophage infiltration is not accompanied by Nogo-B expression in atherosclerotic arteries.

The adventitia: Essential role in pulmonary vascular remodeling

A rapidly emerging concept is that the vascular adventitia acts as a biological processing center for the retrieval, integration, storage, and release of key regulators of vessel wall function. It is the most complex compartment of the vessel wall and comprises a variety of cells including fibroblasts, immunomodulatory cells, resident progenitor cells, vasa vasorum endothelial cells, and adrenergic nerves. In response to vascular stress or injury, resident adventitial cells are often the first to be activated and reprogrammed to then influence tone and structure of the vessel wall. Experimental data indicate that the adventitial fibroblast, the most abundant cellular constituent of adventitia, is a critical regulator of vascular wall function. In response to vascular stresses such as overdistension, hypoxia, or infection, the adventitial fibroblast is activated and undergoes phenotypic changes that include proliferation, differentiation, and production of extracellular matrix proteins and adhesion molecules, release of reactive oxygen species, chemokines, cytokines, growth factors, and metalloproteinases that, collectively, affect medial smooth muscle cell tone and growth directly and that stimulate recruitment and retention of circulating inflammatory and progenitor cells to the vessel wall. Resident dendritic cells also participate in "sensing" vascular stress and actively communicate with fibroblasts and progenitor cells to simulate repair processes that involve expansion of the vasa vasorum, which acts as a conduit for further delivery of inflammatory/progenitor cells. This review presents the current evidence demonstrating that the adventitia acts as a key regulator of pulmonary vascular wall function and structure from the "outside in."

Adventitial stem cells in vein grafts display multilineage potential that contributes to neointimal formation

OBJECTIVE

This study was designed to carry out the characterization of stem cells within the adventitia and to elucidate their functional role in the pathogenesis of vein graft atherosclerosis.

APPROACH AND RESULTS

A mouse vein graft model was used to investigate the functional role of adventitial stem/progenitor cells on atherosclerosis. The adventitia of vein grafts underwent significant remodeling during early stages of vessel grafting and displayed markedly heterogeneous cell compositions. Immunofluorescence staining indicated a significant number of stem cell antigen-1-positive cells that were closely located to vasa vasorum. In vitro clonogenic assays demonstrated 1% to 11% of growing rates from adventitial cell cultures, most of which could be differentiated into smooth muscle cells (SMCs). These stem cell antigen-1-positive cells also displayed a potential to differentiate into adipogenic, osteogenic, or chondrogenic lineages in vitro. In light of the proatherogenic roles of SMCs in atherosclerosis, we focused on the functional roles of progenitor-SMC differentiation, in which we subsequently demonstrated that it was driven by direct interaction of the integrin/collagen IV axis. The ex vivo bioreactor system revealed the migratory capacity of stem cell antigen-1-positive progenitor cells into the vessel wall in response to stromal cell-derived factor-1. Stem cell antigen-1-positive cells that were applied to the outer layer of vein grafts showed enhanced atherosclerosis in apolipoprotein E-deficient mice, which contributed to ≈ 30% of neointimal SMCs.

CONCLUSIONS

We demonstrate that during pathological conditions in vein grafting, the adventitia harbors stem/progenitor cells that can actively participate in the pathogenesis of vascular disease via differentiation into SMCs.

The adventitia: essential regulator of vascular wall structure and function

The vascular adventitia acts as a biological processing center for the retrieval, integration, storage, and release of key regulators of vessel wall function. It is the most complex compartment of the vessel wall and is composed of a variety of cells, including fibroblasts, immunomodulatory cells (dendritic cells and macrophages), progenitor cells, vasa vasorum endothelial cells and pericytes, and adrenergic nerves. In response to vascular stress or injury, resident adventitial cells are often the first to be activated and reprogrammed to influence the tone and structure of the vessel wall; to initiate and perpetuate chronic vascular inflammation; and to stimulate expansion of the vasa vasorum, which can act as a conduit for continued inflammatory and progenitor cell delivery to the vessel wall. This review presents the current evidence demonstrating that the adventitia acts as a key regulator of vascular wall function and structure from the outside in.

Serial greyscale and radiofrequency intravascular ultrasound assessment of plaque modification and vessel geometry at proximal and distal edges of bare metal and first-generation drug-eluting stents

BACKGROUND

Little is known about the correlation between modifications in plaque composition at stent edges and the changes in vessel geometry. This study sought to evaluate, by serial greyscale intravascular ultrasound (IVUS) and Virtual Histology intravascular ultrasound (VH-IVUS), the modifications in plaque composition at the edges of drug-eluting and bare metal stents and the correlation of these findings with changes in the measurements of vessel, lumen and plaque area at those segments.

METHODS AND RESULTS

Single-centre, prospective and randomised (1:1) evaluation of 40 patients with acute coronary syndrome treated with bare metal (Driver; Medtronic, Santa Clara, CA, USA; n=20 patients) or drug-eluting stents (Cypher; Cordis, Miami Lakes, FL, USA; n=20 patients). IVUS and VH-IVUS assessments were done post-procedure and at nine months. Primary endpoint included the modification in vessel, lumen and plaque area and in the composition of the plaque in the mean time between the baseline and follow-up procedure. At the proximal edge of the vessel treated with the Cypher stent, a trend toward positive vessel remodelling (D=+0.6 mm², p=0.06) was observed while at the distal edge, less plaque growth (D=+0.2 mm² vs. D=+1.1 mm², p<0.001), resulted in a larger lumen area at follow-up. By VH, there was a marked reduction in the percentage of fibrotic tissue and necrotic core at the edges of both stents and a positive correlation was seen between increase in percentage of fibro-fatty component and increase in plaque area (r=0.78, p=0.01).

CONCLUSION

Patients treated with drug-eluting stents (DES) experienced less plaque growth, especially at the distal edge of the stents. Modifications in plaque composition, with increase in fibrofatty tissue component, may partially explain these findings.

Protein kinase C-delta mediates adventitial cell migration through regulation of monocyte chemoattractant protein-1 expression in a rat angioplasty model

OBJECTIVE

The adventitia is increasingly recognized as an important player during the development of intimal hyperplasia. However, the mechanism of adventitial cell recruitment to the subintimal space remains largely undefined. We have shown previously that gene transfer of protein kinase C-delta (PKCδ) increases apoptosis of smooth muscle cells following balloon injury. In the current study, we investigated a potential role of PKCδ in regulating the recruitment of adventitial cells.

METHODS AND RESULTS

Conditioned media from PKCδ-overexpressing smooth muscle cells stimulated migration and CCR2 expression of adventitial fibroblasts through a MCP-1 dependent mechanism. Following balloon injury of rat carotid arteries, overexpression of PKCδ in smooth muscle cells significantly increased MCP-1 and CCR2 expression and the number of adventitia-originated cells detected in the neointima. Administration of an anti-MCP-1 antibody markedly diminished the recruitment of adventitial cells. Combined PKCδ overexpression and anti-MCP-1 inhibited intimal hyperplasia more effectively than either approach alone.

CONCLUSIONS

Our data suggest that PKCδ regulates recruitment of adventitial cells to the neointima via a mechanism involving upregulation of the MCP-1/CCR2 signaling axis in injured arteries. Blockage of MCP-1 while enhancing apoptosis may serve as a potential therapeutic strategy to attenuate intimal hyperplasia.

Imaging of homeostatic, neoplastic, and injured tissues by HA-based probes

An increase in hyaluronan (HA) synthesis, cellular uptake, and metabolism occurs during the remodeling of tissue microenvironments following injury and during disease processes such as cancer. We hypothesized that multimodality HA-based probes selectively target and detectably accumulate at sites of high HA metabolism, thus providing a flexible imaging strategy for monitoring disease and repair processes. Kinetic analyses confirmed favorable available serum levels of the probe following intravenous (i.v.) or subcutaneous (s.c.) injection. Nuclear (technetium-HA, (99m)Tc-HA, and iodine-HA, (125)I-HA), optical (fluorescent Texas Red-HA, TR-HA), and magnetic resonance (gadolinium-HA, Gd-HA) probes imaged liver ((99m)Tc-HA), breast cancer cells/xenografts (TR-HA, Gd-HA), and vascular injury ((125)I-HA, TR-HA). Targeting of HA probes to these sites appeared to result from selective HA receptor-dependent localization. Our results suggest that HA-based probes, which do not require polysaccharide backbone modification to achieve favorable half-life and distribution, can detect elevated HA metabolism in homeostatic, injured, and diseased tissues.

Adventitial contributions of the extracellular signal-regulated kinase and Akt pathways to neointimal hyperplasia

BACKGROUND

We recently reported that the efficacy of nitric oxide (NO) appears to be based on both sex and hormone status. The mechanism responsible for this differential efficacy is unknown. The aim of this study was to characterize the effect of sex, hormones, and NO on the extracellular signal-regulated kinase (ERK) and Akt signaling pathways after arterial injury.

METHODS

Male and female Sprague-Dawley rats underwent castration or sham surgery. Two weeks later, they underwent carotid artery balloon injury. Treatment groups included the following: control, injury, and injury + 1-[2-(carboxylato)pyrrolidin-1-yl]diazen-1-ium-1,2-diolate (PROLI/NO) (n = 5 per group). Arteries were harvested 2 weeks after injury and assessed for phospho-ERK (pERK) and phospho-Akt (pAkt) expression.

RESULTS

After injury, more pERK and pAkt activity was seen in the adventitia than media in both sexes, regardless of hormone status (P < .05). In hormonally intact males, NO further increased pERK (44%) and pAkt (120%) after injury (P < .001). Castration attenuated the effects of NO. In hormonally intact females, NO caused the opposite pattern with pERK activity but did not affect pAkt activity.

CONCLUSIONS

After arterial injury, ERK and Akt activity is significantly greater in the adventitia than the media, and depends on sex, hormone status, and NO. Understanding adventitial regulation of proliferative signaling pathways will allow the development of targeted therapies for neointimal hyperplasia.

Adventitial biology: differentiation and function

Recent evidence indicates that stem/progenitor cells are present in the adventitia and participate in vascular repair and the formation of neointimal lesions in severely damaged vessels. Data have also demonstrated that these resident stem/progenitor cells could differentiate into endothelial or smooth muscle cells in response to different stimuli. Under pathological conditions, adventitial inflammation results in releasing a panel of cytokines, such as stromal cell-derived factor-1 and tumor necrosis factor-α, that may lead to local stem/progenitor mobilization and differentiation. Overall, these data support the impact of the adventitial progenitors in pathophysiological processes of lesion development in the arterial wall. In the present review, we aim to summarize the data concerning the presence of the resident stem cells and discuss the pathological impact of the adventitia in vascular diseases. We will also discuss the possible signal pathways orchestrating stem cell differentiation toward vascular lineage and highlight controversial issues related to the role of adventitial progenitors.

Impact of coronary calcium on outcome following sirolimus-eluting stent implantation

There remain a small but sizable number of patients who develop restenosis after sirolimus-eluting stent (SES) implantation. However, the cause of SES restenosis has not been fully elucidated. The study population consisted of 52 patients with 69 lesions who underwent noninvasive coronary imaging by 64-slice multidetector computed tomography before SES deployment. Agatston calcium scores in target lesions were measured. All patients underwent follow-up coronary angiography at 8 months. Three coronary segments (in stent, proximal edge, and distal edge) were analyzed by quantitative coronary angiography. Agatston calcium score in target lesions averaged 214.7. Late lumen losses in the proximal edge, stent, and distal edge were 0.16 ± 0.45, 0.47 ± 0.58, and 0.07 ± 0.29 mm, respectively. Lesions with restenosis at follow-up showed a trend to produce higher preprocedural calcium scores (629) compared to those without restenosis (153, p = 0.08). There was a significant positive correlation between lesion calcium score and in-stent late lumen loss (r = 0.47, p <0.01). In conclusion, assessment of coronary calcium by multidetector computed tomography might be useful to predict outcomes after SES implantation.

The role of tenascin C in cardiovascular disease

The extracellular matrix protein tenascin C (TnC) is expressed in a variety of embryonic tissues, but its expression in adult arteries is co-incident with sites of vascular disease. TnC expression has been linked to the development and complications of intimal hyperplasia, pulmonary artery hypertension, atherosclerosis, myocardial infarction, and heart failure. This review identifies the growing collection of evidence linking TnC with cardiovascular disease development. The transient upregulation of this extracellular matrix protein at sites of vascular disease could provide a means to target TnC in the development of diagnostics and new therapies. Studies in TnC-deficient mice have implicated this protein in the development of intimal hyperplasia. Further animal and human studies are required to thoroughly assess the role of TnC in some of the other pathologies it has been linked with, such as atherosclerosis and pulmonary hypertension. Large population studies are also warranted to clarify the diagnostic value of this extracellular matrix protein in cardiovascular disease, for example by targeting its expression using radiolabelled antibodies or measuring circulating concentrations of TnC.

iNOS expression in vascular resident macrophages contributes to circulatory dysfunction of splanchnic vascular smooth muscle contractions in portal hypertensive rats

Portal hypertension, a major complication of cirrhosis, is caused by both increased portal blood flow due to arterial vasodilation and augmented intrahepatic vascular resistance due to sinusoidal constriction. In this study, we examined the possible involvement of resident macrophages in the tone regulation of splanchnic blood vessels using bile duct ligated (BDL) portal hypertensive rats and an in vitro organ culture method. In BDL cirrhosis, the number of ED2-positive resident macrophages increased by two- to fourfold in the vascular walls of the mesenteric artery and extrahepatic portal vein compared with those in sham-operated rats. Many ED1-positive monocytes were also recruited into this area. The expression of inducible nitric oxide (NO) synthase (iNOS) mRNA was increased in the vascular tissues isolated from BDL rats, and accordingly, nitrate/nitrite production was increased. Immunohistochemistry revealed that iNOS was largely expressed in ED1-positive and ED2-positive cells. We further analyzed the effect of iNOS expression on vascular smooth muscle contraction using an in vitro organ culture system. iNOS mRNA expression and nitrate production significantly increased in vascular tissues (without endothelium) incubated with 1 μg/ml lipopolysaccharide (LPS) for 6 h. Immunohistochemistry indicated that iNOS was largely expressed in ED2-positive resident macrophages. α-Adrenergic-stimulated contractility of the mesenteric artery was greatly suppressed by LPS treatment and was restored by N(G)-nitro-L-arginine methyl ester (NO synthase inhibitor); in contrast, portal vein contractility was largely unaffected by LPS. Sodium nitroprusside (NO donor) and 8-bromo-cGMP showed greater contractile inhibition in the mesenteric artery than in the portal vein with decreasing myosin light chain phosphorylation. In the presence of an α-adrenergic agonist, the mesenteric artery cytosolic Ca(2+) level was greatly reduced by sodium nitroprusside; however, the portal vein Ca(2+) level was largely unaffected. These results suggest that the induction of iNOS in monocytes/macrophages contributes to a hypercirculatory state in the cirrhosis model rat in which the imbalance of the responsiveness of visceral vascular walls to NO (mesenteric artery >> portal vein) may account for the increased portal venous flow in portal hypertension.

Somatic cell plasticity and Niemann-Pick type C2 protein: fibroblast activation

A growing body of evidence points toward activated fibroblasts, also known as myofibroblasts, as one of the leading mediators in several major human pathologies including proliferative fibrotic disorders, invasive tumor growth, rheumatoid arthritis, and atherosclerosis. Niemann-Pick Type C2 (NPC2) protein has been recently identified as a product of the second gene in NPC disease. It encodes ubiquitous, highly conserved, secretory protein with the poorly defined function. Here we show that NPC2 deficiency in human fibroblasts confers their activation. The activation phenomenon was not limited to fibroblasts as it was also observed in aortic smooth muscle cells upon silencing NPC2 gene by siRNA. More importantly, activated synovial fibroblasts isolated from patients with rheumatoid arthritis were also identified as NPC2-deficient at both the NPC2 mRNA and protein levels. The molecular mechanism responsible for activation of NPC2-null cells was shown to be a sustained phosphorylation of ERK 1/2 mitogen-activated protein kinase (MAPK), which fulfills both the sufficient and necessary fibroblast activation criteria. All of these findings highlight a novel mechanism where NPC2 by negatively regulating ERK 1/2 MAPK phosphorylation may efficiently suppress development of maladaptive tissue remodeling and inflammation.

Modulation of TGF-β/BMP-6 expression and increased levels of circulating smooth muscle progenitor cells in a type I diabetes mouse model

Background

Diabetic patients experience exaggerated intimal hyperplasia after endovascular procedures. Recently it has been shown that circulating smooth muscle progenitor cells (SPC) contribute to intimal hyperplasia. We hypothesized that SPC differentiation would be increased in diabetes and focused on modulation of TGF-β/BMP-6 signaling as potential underlying mechanism.

Methods

We isolated SPC from C57Bl/6 mice with streptozotocin-induced diabetes and controls. SPC differentiation was evaluated by immunofluorescent staining for αSMA and collagen Type I. SPC mRNA expression of TGF-β and BMP-6 was quantified using real-time PCR. Intima formation was assessed in cuffed femoral arteries. Homing of bone marrow derived cells to cuffed arterial segments was evaluated in animals transplanted with bone marrow from GFP-transgenic mice.

Results

We observed that SPC differentiation was accelerated and numeric outgrowth increased in diabetic animals (24.6 ± 8.8 vs 8.3 ± 1.9 per HPF after 10 days, p < 0.05). Quantitative real-time PCR showed increased expression of TGF-β and decreased expression of the BMP-6 in diabetic SPC. SPC were MAC-3 positive, indicative of monocytic lineage. Intima formation in cuffed arterial segments was increased in diabetic mice (intima/media ratio 0.68 ± 0.15 vs 0.29 ± 0.06, p < 0.05). In GFP-chimeric mice, bone marrow derived cells were observed in the neointima (4.4 ± 3.3 cells per section) and particularly in the adventitia (43.6 ± 9.3 cells per section). GFP-positive cells were in part MAC-3 positive, but rarely expressed α-SMA.

Conclusions

In conclusion, in a diabetic mouse model, SPC levels are increased and SPC TGF-β/BMP-6 expression is modulated. Altered TGF-β/BMP-6 expression is known to regulate smooth muscle cell differentiation and may facilitate SPC differentiation. This may contribute to exaggerated intimal hyperplasia in diabetes as bone marrow derived cells home to sites of neointima formation.

Role of myofibroblasts in vascular remodelling: focus on restenosis and aneurysm

Myofibroblasts (MFs) are contractile cells deriving from a multiplicity of resident cells and/or circulating progenitors that are known to play a key role in wound healing. They were first discovered and analysed in the early 1970s in granulation tissue. Since their first identification, the role of MF and their mechanisms of differentiation have been highlighted in a number of diseases, including organ fibrosis and tumours, with particular attention devoted to the liver, kidney, and pulmonary fibrosis. The aim of this review is to summarize the current evidence for the role played by MFs in two frequent vascular diseases related to the remodelling of the vascular wall: the different forms of arterial restenosis and the most common forms of thoracic aortic aneurysm. The in-depth knowledge of the molecular pathways involved in MF differentiation, contraction, and survival/apoptosis could contribute to the identification of novel therapeutic strategies for anti-fibrotic and anti-remodelling therapy of vascular diseases in which these cells are involved.

Understanding the role of endothelial progenitor cells in percutaneous coronary intervention

Percutaneous coronary intervention is associated with mechanical endovascular injury and endothelial denudation. Re-endothelialization is essential for restoration of normal vascular homeostasis and regulation of neointimal hyperplasia. The endothelial progenitor cell recently emerged as an important component of the response to vascular injury, having the potential to accelerate vascular repair through rapid re-endothelialization. There remains considerable uncertainty over the precise identity and function of endothelial progenitor cells, and harnessing their therapeutic potential remains a challenge. A better understanding of the role of circulating progenitors in the response to vascular injury is necessary if we are to develop effective strategies to enhance vascular repair after percutaneous coronary intervention. In this review, we examine the preclinical and clinical evidence of a role for bone marrow-derived putative endothelial progenitor cells after iatrogenic vascular injury associated with balloon angioplasty and stent deployment. Therapies designed to mobilize endothelial progenitors or to increase their ability to home to the site of stent implantation may have a role in the future management of patients undergoing percutaneous coronary intervention.

Activation of adventitial fibroblasts in the early stage of the aortic transplant vasculopathy in rat

BACKGROUND

Transplant vasculopathy (TV) is the most significant obstacle to long-term success of organ transplantation. Increasing attention has been paid to the role of adventitia in vascular diseases. We evaluated the role of adventitial fibroblasts in the development of TV.

METHODS

Thoracic aortas from Sprague-Dawley (SD) rats transplanted into the abdominal aortas of Wistar rats worked as allografts, and isografts (SD to SD) were control. Grafts were removed on days 3, 7, and 14 for histologic, morphometric, and immunohistochemical detection of vimentin, alpha-smooth muscle actin, Ki-67, CD3, transforming growth factor-beta1 (TGF-beta1), monocyte chemoattractant protein-1 (MCP-1), matrix metalloproteinase-7 (MMP-7), and quantitative real-time reverse transcriptase polymerase chain reaction for TGF-beta1, MCP-1, MMP-7, tumor necrosis factor-alpha, and interleukin-1beta.

RESULTS

In the allografts, neointima thickness and neointima/media thickness ratios were slightly increased at 7 days and significantly increased at 14 days. Immunostaining of vimentin and alpha-smooth muscle actin showed adventitial fibroblasts activation and differentiation into myofibroblasts. Ki-67-positive nuclei were observed in the adventitia 3 days after allografting and subsequently in the neointima. No more than 4% CD3-positive cells were found in adventitia in all the groups. Compared with isografts, TGF-beta1, MMP-7, and MCP-1 were expressed in the adventitia before neointima formation and were significantly increased in allografts at all time points. Tumor necrosis factor-alpha and interleukin-1beta were also significantly increased in adventitia in allografts.

CONCLUSIONS

These results demonstrated that adventitial fibroblasts are activated and can produce cytokines and chemokines before the neointimal hyperplasia. They may exert a potential effect on the development of neointimal hyperplasia in TV.

Stromal cell biology--a way to understand the evolution of cardiovascular diseases

Stromal cells, composed of fibroblasts, microvascular endothelial cells, immune cells and inflammatory cells, are critical determinants of the mechanical properties and function of the heart and vasculature, and the mechanisms whereby these types of cells are activated are important to understand the progression of cardiovascular diseases. Emerging studies have suggested that the activation of autocrine and paracrine signaling pathways by stromal cell-derived growth factors, cytokines and bioactive molecules contributes to disease progression. Disruption of the stromal network will result in alterations in the geometry and function in these organs. Interventions targeting the stromal cells (eg, myofibroblasts, microvascular endothelial cells, inflammatory cells) by pharmacological agents or direct gene delivery/small interfering RNA would be potential novel therapeutic strategies to prevent/attenuate the progression of cardiovascular disorders.

Cardiac fibroblast: the renaissance cell

The permanent cellular constituents of the heart include cardiac fibroblasts, myocytes, endothelial cells, and vascular smooth muscle cells. Previous studies have demonstrated that there are undulating changes in cardiac cell populations during embryonic development, through neonatal development and into the adult. Transient cell populations include lymphocytes, mast cells, and macrophages, which can interact with these permanent cell types to affect cardiac function. It has also been observed that there are marked differences in the makeup of the cardiac cell populations depending on the species, which may be important when examining myocardial remodeling. Current dogma states that the fibroblast makes up the largest cell population of the heart; however, this appears to vary for different species, especially mice. Cardiac fibroblasts play a critical role in maintaining normal cardiac function, as well as in cardiac remodeling during pathological conditions such as myocardial infarct and hypertension. These cells have numerous functions, including synthesis and deposition of extracellular matrix, cell-cell communication with myocytes, cell-cell signaling with other fibroblasts, as well as with endothelial cells. These contacts affect the electrophysiological properties, secretion of growth factors and cytokines, as well as potentiating blood vessel formation. Although a plethora of information is known about several of these processes, relatively little is understood about fibroblasts and their role in angiogenesis during development or cardiac remodeling. In this review, we provide insight into the various properties of cardiac fibroblasts that helps illustrate their importance in maintaining proper cardiac function, as well as their critical role in the remodeling heart.

Adventitial lymphocytic inflammation in human coronary arteries with intimal atherosclerosis

BACKGROUND

The relationship between adventitial inflammation, plaque type, and culprit plaque morphology in the epicardial arterial circulation has not been studied in detail.

METHODS

We studied semiserial sections of coronary arteries at autopsy from patients dying with severe coronary disease, 81 men (age 50 + or - 12 years) and 13 women (age 52 + or - 13 years). Lesions were classified at 3- to 5-mm segments according to modified AHA criteria. Adventitial lymphocyte aggregates were assessed at every 5-mm interval and graded semiquantitatively. Macrophage density in the adventitial fat and intima was assessed with anti-CD68 staining.

RESULTS

Adventitial lymphocytic inflammation increased with percent stenosis (P<.0001) and not calcification (P>.2). Hemorrhage into late core, rupture, erosion, and thin caps all had greater adventitial lymphocytic inflammation independent of percent stenosis (P<.0001). Peri-adventitial adipose macrophage density was increased in plaques with atheromas (206 + or - 22 mm(2) vs. 121 + or - 15 mm(2) in fibrous plaques; P=.02) and correlated positively with adventitial lymphocytes (P<.0001) and intimal macrophage content (P<.0001).

CONCLUSIONS

Features associated with plaque instability are associated with significantly greater degrees of adventitial lymphocytic inflammation, both as lymphocyte aggregates and as adipocyte-derived macrophages. Further study is required to determine the nature of the association between intimal and adventitial lymphocytic inflammation.

Negligible contribution of coronary adventitial fibroblasts to neointimal formation following balloon angioplasty in swine

Adventitial fibroblasts have previously been proposed to be a major constituent of the neointima following coronary balloon angioplasty. The present study utilized the bromodeoxyuridine (BrdU) pulse-chase technique to track adventitial fibroblast migration early after balloon injury in swine. BrdU (30 mg/kg), a marker of proliferating cells, was given intravenously 1 or 2 days after balloon angioplasty. For each time point, one animal was euthanized 24 h after injection to identify the location of the proliferating cells, while a second animal was euthanized 25 days after angioplasty to determine whether the proliferating cells migrated to form the neointima. Our results demonstrate that BrdU-positive cells were located primarily in the adventitia with all three time points 24 h after balloon angioplasty. Furthermore, when BrdU was injected on day 1 or 2 only 0.65 +/- 0.17% and 1.7 +/- 0.64%, respectively, of neointimal cells were BrdU positive on day 25. In conclusion, these results demonstrate a negligible contribution of coronary adventitial fibroblasts to neointima formation following coronary balloon angioplasty, supporting the concept that the neointima is primarily of smooth muscle cell origin.

Aortic adventitial angiogenesis and lymphangiogenesis promote intimal inflammation and hyperplasia

INTRODUCTION

Adventitial inflammation is known to influence neointimal formation and vascular remodeling. The present study was aimed to clarify the relationship between neointima hyperplasia and adventitial angiogenesis and lymphangiogenesis after balloon-induced aortic endothelial injury.

METHODS

Seventy male Wistar rats were randomly divided into six interventional groups and one control group. The intimal area/medial area ratio (I/M ratio), the adventitial macrophage index, and the number of adventitial microvessels (Ad-MV) and lymphatic vessels (Ad-LV) in the aorta were measured, and the mRNA expressions of VEGF-A, VEGFR-1, VEGF-C, VEGFR-3, PDGF-B, and PDGFR-beta in the aortic wall were quantified by real-time RT-PCR.

RESULTS

Compared with the control group, the I/M ratio, macrophage index, Ad-MV, Ad-LV, and the mRNA expressions of VEGF-A, VEGFR-1, VEGF-C, VEGFR-3, PDGF-B, and PDGFR-beta in interventional groups increased significantly after balloon-induced injury. I/M ratio showed significant correlations with Ad-MV and Ad-LV after balloon intervention. Multiple linear regression analysis indicated that Ad-MV and Ad-LV were independent factors of intimal hyperplasia.

CONCLUSION

Adventitial angiogenesis and lymphangiogenesis are induced by intimal inflammation after balloon injury, and these neogenetic vessels in turn promote intimal inflammation and hyperplasia probably via delivery and activation of inflammatory cells.

The role of the adventitia in vascular inflammation

Traditional concepts of vascular inflammation are considered "inside-out" responses centered on the monocyte adhesion and lipid oxidation hypotheses. These mechanisms likely operate in concert, holding the central tenet that the inflammatory response is initiated at the luminal surface. However, growing evidence supports a new paradigm of an "outside-in" hypothesis, in which vascular inflammation is initiated in the adventitia and progresses inward toward the intima. Hallmarks of the outside-in hypothesis include population of the adventitia with exogenous cell types, including monocytes, macrophages, and lymphocytes, the phenotypic switch of adventitial fibroblasts into migratory myofibroblasts, and increased vasa vasorum neovascularization. The resident and migrating cells deposit collagen and matrix components, respond to and upregulate inflammatory chemokines and/or antigens, and regulate the local redox state of the adventitia. B cells and T cells generate local humoral immune responses against local antigen presentation by foam cells and antigen presenting cells. These events result in increased local expression of cytokines and growth factors, evoking an inflammatory response that propagates inward toward the intima. Ultimately, it appears that the basic mechanisms of cellular activation and migration in vascular inflammation are highly conserved across a variety of cardiovascular disease states and that major inflammatory events begin in the adventitia.

Restenosis after percutaneous angioplasty: the role of vascular inflammation

Restenosis after endovascular treatment of atherosclerotic lesions in the peripheral, cerebrovascular, and coronary circulation is the major drawback of this minimally invasive technique. Although certain advances have been made during recent years to improve patency rates after percutaneous angioplasty, restenosis remains a challenging clinical problem. Understanding factors that contribute to the pathophysiology of late lumen loss is an effective strategy to improving patients' postangioplasty outcome. Vascular inflammation after balloon angioplasty or stent implantation has been identified as a cornerstone of the restenotic process, and several markers of inflammation have been referred to as potential predictors of outcome. This article reviews recent findings on the issue of inflammation and restenosis after percutaneous angioplasty with special attention given to the role of inflammatory parameters as markers for the restenosis risk in the peripheral vessel area.

Activation of adventitial fibroblasts contributes to the early development of atherosclerosis: A novel hypothesis that complements the “Response-to-Injury Hypothesis” and the “Inflammation Hypothesis”

The role of the adventitia in vascular function and vascular lesion formation has been largely ignored. This article introduces the hypothesis that the activation of the adventitia, specifically the fibroblasts, contributes to the formation of intimal atherosclerotic lesions. The evidence for this hypothesis includes: (a) the early proliferative changes seen in fibroblasts found in the adventitia; (b) the increase and the alteration of extracellular matrix deposition in the adventitia; (c) fibroblast differentiation into myofibroblasts and migration into the intima; and (d) fibroblast synthesis and release of cytokines that have potent effects on neighboring smooth muscle and endothelial cells prior to intimal lesion formation. In conclusion, the activation of adventitial fibroblasts is a key regulator of vascular function and structure from the "outside-in" and contributes to the development of atherosclerotic lesions. The outer location of the adventitia makes it a suitable location for drug delivery and gene therapy aimed at preventing and treating atherosclerosis.