Antisense therapy for angioplasty restenosis. Some critical considerations

Carvacrol inhibits atherosclerotic neointima formation by downregulating reactive oxygen species production in vascular smooth muscle cells

OBJECTIVE

Carvacrol (2-methyl-5-(1-methylethyl) phenol), a cyclic monoterpene, exerts protective activities in a variety of pathological states including tumor growth, inflammation, and oxidative stress. However, it is unknown whether carvacrol affects events in vascular cells during the development of atherosclerotic neointima. We investigated the effects of carvacrol on the migration and proliferation of rat aortic smooth muscle cells (RASMCs) and on vascular neointima formation.

METHODS AND RESULTS

Carvacrol significantly inhibited platelet-derived growth factor (PDGF)-BB-stimulated RASMC migration and proliferation in a concentration-dependent manner. Cell viability was not affected by treatment with carvacrol. Carvacrol attenuated the expression of NADPH oxidase (NOX) 1 and the phosphorylation of p38 mitogen-activated protein kinase (MAPK) and extracellular signal-regulated kinase 1/2 in response to PDGF-BB. Moreover, carvacrol suppressed the PDGF-BB-stimulated generation of H2O2 and inhibited the activity of NOX in RASMCs. Treatment with carvacrol inhibited PDGF-BB-induced aortic sprout outgrowth, balloon injury-evoked vascular neointima formation, and expression of proliferating cell nuclear antigen in the neointima.

CONCLUSION

These findings indicate that carvacrol inhibits migration and proliferation of RASMCs by suppressing the reactive oxygen species-mediated MAPK signaling pathway in these cells, thereby attenuating vascular neointimal formation. Carvacrol may be a promising agent for preventing vascular restenosis or atherosclerosis.

Proliferating cell nuclear antigen shRNA treatment attenuates chronic proliferative cholangitis in rats

BACKGROUND AND AIM

Chronic proliferative cholangitis (CPC) is currently considered as a pathological basis and major cause for the high recurrence rate of intrahepatic stones. Since CPC is a form of chronic proliferative disease, this study was designed to preliminarily investigate the inhibitory effect of proliferating cell nuclear antigen (PCNA) shRNA on the hyperplastic behavior and lithogenic potentiality of CPC.

METHODS

The rat model of CPC was given an intralumenal administration of 0.5 mL PCNA shRNA through a 20-gauge venous retained needle. PCNA shRNA-mediated effects on CPC-associated hyperplastic behavior and lithogenic potential were assessed by investigating histological changes, immunohistochemistry for Ki-67, biochemistry for beta-glucuronidase, real-time polymerase chain reaction, and western blot analysis of PCNA, procollagen I, and mucin-3.

RESULTS

PCNA shRNA treatment could efficiently inhibit the mRNA and protein expressions of the proliferation-related gene, PCNA, and Ki-67, which efficiently inhibited the hyperplastic behavior of the biliary epithelium, submucosal gland, and collagen fibers in the diseased bile duct wall. This novel treatment could efficiently inhibit the formation of acidic mucus glands, the expression of mucin-3 mRNA, and the secretion of endogenous beta-glucuronidase, thus effectively inhibiting the lithogenic potentiality of CPC. A further analysis revealed that PCNA shRNA-1 might display a more robust inhibitory effect on CPC-associated hyperplastic behavior and lithogenic potential than other gene sequences targeted in this study.

CONCLUSIONS

PCNA shRNA-1 treatment could effectively inhibit the hyperplastic behavior and lithogenic potentiality of CPC, which might facilitate the prevention of stone recurrence and biliary restenosis.

Treatment of chronic proliferative cholangitis with c-myc shRNA

AIM: To investigate the feasibility and effectiveness of c-myc shRNA in inhibiting the hyperplastic behavior and lithogenic potentiality of chronic proliferative cholangitis (CPC), in order to prevent stone recurrence and biliary restenosis.

METHODS: An animal model of CPC was established by giving intralumenally 0.5 mL of c-myc shRNA. Then, the effects of c-myc shRNA on hyperplastic behavior and lithogenic potentiality of CPC were evaluated by histological observation, immunohistochemistry, real-time PCR and Western blotting for c-myc, proliferating cell nuclear antigen (PCNA), procollagen III, mucin 5AC, enzymatic histochemistry for β-glucuronidase, and biochemistry for hydroxyproline in the diseased bile duct.

RESULTS: Treatment with c-myc shRNA efficiently suppressed the hyperplasia of biliary epithelium, submucosal gland, and collagen fiber by inhibiting mRNA and protein expression of c-myc. More importantly, it decreased the lithogenic potentiality of CPC by inhibiting the expression of mucin 5AC and the secretion of endogenous β-glucuronidase. Further investigation indicated that c-myc shRNA-3 had a better inhibitory effect on CPC.

CONCLUSION: Treatment with c-myc shRNA-3 can control CPC and reduce the lithogenic potentiality of CPC.

Inhibition of MMP-2 gene expression with small interfering RNA in rabbit vascular smooth muscle cells

Matrix metalloproteinase-2 (MMP-2) is constitutively expressed in vascular smooth muscle cells (VSMCs). Using small interfering RNA (siRNA), we evaluated the effect of MMP-2 inhibition in VSMCs in vitro and ex vivo. Rabbit VSMCs were transfected in vitro with 50 nmol/l MMP-2 siRNA or scramble siRNA. Flow cytometry and confocal microscopy showed cellular uptake of siRNA in ∼80% of VSMCs. MMP-2 mRNA levels evaluated by real-time RT-PCR, pro-MMP-2 activity from conditioned culture media evaluated by gelatin zymography, and VSMC migration were reduced by 44 ± 19%, 43 ± 14%, and 36 ± 14%, respectively, in MMP-2 siRNA-transfected compared with scramble siRNA-transfected VSMCs ( P < 0.005 for all). Ex vivo MMP-2 siRNA transfection was performed 2 wk after balloon injury of hypercholesterolemic rabbit carotid arteries. Fluorescence microscopy showed circumferential siRNA uptake in neointimal cells. Gelatin zymography of carotid artery culture medium demonstrated a significant decrease of pro-MMP-2 activity in MMP-2 siRNA-transfected compared with scramble siRNA-transfected arteries ( P < 0.01). Overall, our results demonstrate that in vitro MMP-2 siRNA transfection in VSMCs markedly inhibits MMP-2 gene expression and VSMC migration and that ex vivo delivery of MMP-2 siRNA in balloon-injured arteries reduces pro-MMP-2 activity in neointimal cells, suggesting that siRNA could be used to modify arterial biology in vivo.

Acetylbritannilactone Inhibits Neointimal Hyperplasia after Balloon Injury of Rat Artery by Suppressing Nuclear Factor-{kappa}B Activation

Based on our previous observations that 1-O-acetylbritannilactone (R)-4((3aS,4S,7aR)-4-hydroxy-6-methyl-3-methylene-2-oxo-2,3,3a,4,7,7a-hexahydrobenzofuran-5-yl)pentyl acetate (ABL) suppresses prostaglandin E(2) and nitric oxide synthesis in macrophages, the present study was designed to explore the effect of ABL on neointimal hyperplasia after balloon injury and its mechanism of action. In male Sprague-Dawley rats, 26 mg/kg ABL or polyglycol (control) was administered daily from 3 days before injury to 2 weeks after conventional balloon injury. ABL administration led to a significant reduction in neointimal formation (neointima to media ratio, 1.94 +/- 0.43 versus 0.84 +/- 0.29, P < 0.01) and proliferative activity of vascular smooth muscle cells after balloon injury in rats. Western blot analysis revealed that this is correlated to the inhibition of nuclear factor (NF)-kappaB activation and to the reduced expression of cyclooxygenase-2. Investigation of potential signaling pathways demonstrated that ABL inhibited NF-kappaB activation via the blockade of the inhibitor of NF-kappaB kinase-beta activation and the suppression of the degradation of the inhibitors of NF-kappaB-alpha. These findings suggest that ABL is a potential inhibitor of neointimal formation because it blocks injury-induced NF-kappaB activation and may have beneficial effects in reducing the risk of restenosis after angioplasty.

Brothers in arms: DNA enzymes, short interfering RNA, and the emerging wave of small-molecule nucleic acid-based gene-silencing strategies

The past decade has seen the rapid evolution of small-molecule gene-silencing strategies, driven largely by enhanced understanding of gene function in the pathogenesis of disease. Over this time, many genes have been targeted by specifically engineered agents from different classes of nucleic acid-based drugs in experimental models of disease to probe, dissect, and characterize further the complex processes that underpin molecular signaling. Arising from this, a number of molecules have been examined in the setting of clinical trials, and several have recently made the successful transition from the bench to the clinic, heralding an exciting era of gene-specific treatments. This is particularly important because clear inadequacies in present therapies account for significant morbidity, mortality, and cost. The broad umbrella of gene-silencing therapeutics encompasses a range of agents that include DNA enzymes, short interfering RNA, antisense oligonucleotides, decoys, ribozymes, and aptamers. This review tracks current movements in these technologies, focusing mainly on DNA enzymes and short interfering RNA, because these are poised to play an integral role in antigene therapies in the future.

Direct comparison of the specificity of gene silencing using antisense oligonucleotides and RNAi

RNAi (RNA interference) and ASO (antisense oligonucleotide) technologies are the most commonly used approaches for silencing gene expression. However, the specificity of such powerful tools is an important factor to correctly interpret the biological consequences of gene silencing. In the present study, we examined the effects of acute loss of Ser/Thr kinase PDK1 (3-phosphoinositide-dependent kinase 1) expression using ASO and RNAi, and compared, for the first time, these two techniques using Affymetrix microarrays. We show that both ASO- and siRNA (small interfering RNA)-mediated knock-down of PDK1 expression strongly inhibited cell proliferation, although by different mechanisms, thereby questioning the specificity of these reagents. Using microarray analysis, we characterized the specificity of the ASO- and siRNA-mediated gene silencing of PDK1 by examining expression profiles 48 and 72 h following oligonucleotide transfection. At 48 h, a PDK1-dependent pattern of gene alterations was detectable, despite a large number of non-specific changes due to transfection of control nucleic acids. These non-specific alterations became more apparent at the 72 h time point, and obscured any PDK1-specific pattern. This study underscores the importance of defining appropriate control ASOs and siRNAs, using multiple oligonucleotides for each target and preferably short time points following transfection to avoid misinterpretation of the phenotype observed.

Inhibition of MD-1 expression by immunosuppressants or antisense oligodeoxynucleotides on skin allograft survival in mice

AIM

The aim of this study was to investigate the effects of inhibition of MD-1 expression using nonspecific immunosuppressants and specific antisense oligodeoxynucleotides (AS-ODNs) treatment on skin allograft survival in mice.

METHODS

C57BL/6 to Balb/c skin allograft model was used in all groups, followed by Cyclosporine (CsA), Tacrolimus (FK506), Mycophenolate Mofetil (MMF), and Sirolimus (SRL) intraperitaneally, as well as AS-ODNs intravenously. Recipients were humanely killed at 11 days after transplantation. MD-1 expression was determined using flow cytometric analysis (FACS). AlamarBlue was used to evaluate proliferation. And serum levels of interleukin (IL)-2 and IL-10 were detected using enzyme-linked immunosorbent assay (ELISA).

RESULTS

Compared with saline controls, the mean survival times (MST) of skin allografts in all of the immunosuppressants and AS-ODNs treated groups were significantly prolonged (P < .05). CsA, MMF, and AS-ODNs inhibited MD-1 expression and lymphocyte proliferation, as well as decreased serum level of IL-2 and increased that of IL-10; FK506, treatment showed all the effects mentioned above but up-regulated the IL-10 level; SRL had no significant influence on either MD-1 expression or IL-2 and IL-10 level, although it equally suppressed the proliferation (P < .05 vs controls). The negative correlation between MD-1 expression and lymphocyte proliferation or IL-2 level was significant, as was the positive correlation between it and IL-10 level (P < .01).

CONCLUSIONS

CsA, FK506, MMF, and AS-ODNs can efficiently inhibit MD-1 expression. The effects of the immunosuppressants are seemingly associated with the down-regulation of the IL-2 serum level. MD-1 was theorized to play an important role in rejection promotion, although the precise relationship between it and allograft survival still remains ambiguous.

Intratumoural administration of dendritic cells: hostile environment and help by gene therapy

Like paratroopers in special operations, dendritic cells (DCs) can be deployed behind the enemy borders of malignant tissue to ignite an antitumour immune response. 'Cross-priming T cell responses' is the code name for their mission, which consists of taking up antigen from transformed cells or their debris, migrating to lymphoid tissue ferrying the antigenic cargo, and meeting specific T cells. This must be accomplished in such an immunogenic manner that specific T lymphocytes would mount a robust enough response as to fully reject the malignancy. To improve their immunostimulating activity, local gene therapy can be very beneficial, either by transfecting DCs with genes enhancing their performance, or by preparing tumour tissue with pro-inflammatory mediators. In addition, endogenous DCs from the tumour host can be attracted into the malignant tissue following transfection of certain chemokine genes into tumour cells. On their side, tumour stroma and malignant cells set up a hostile immunosuppressive environment for artificially released or attracted DCs. This milieu is usually rich in transforming growth factor-beta, vascular endothelial growth factor, and IL-10, -6 and -8, among other substances that diminish DC performance. Several molecular strategies are being devised to interfere with the immunosuppressive actions of these substances and to further enhance the level of anticancer immunity achieved after artificial release of DCs intratumourally.

Down-regulation of plasminogen activator inhibitor 1 expression promotes myocardial neovascularization by bone marrow progenitors

Human adult bone marrow–derived endothelial progenitors, or angioblasts, induce neovascularization of infarcted myocardium via mechanisms involving both cell surface urokinase-type plasminogen activator, and interactions between β integrins and tissue vitronectin. Because each of these processes is regulated by plasminogen activator inhibitor (PAI)-1, we selectively down-regulated PAI-1 mRNA in the adult heart to examine the effects on postinfarct neovascularization and myocardial function. Sequence-specific catalytic DNA enzymes inhibited rat PAI-1 mRNA and protein expression in peri-infarct endothelium within 48 h of administration, and maintained down-regulation for at least 2 wk. PAI-1 inhibition enhanced vitronectin-dependent transendothelial migration of human bone marrow–derived CD34⁺ cells, and resulted in a striking augmentation of angioblast-dependent neovascularization. Development of large, thin-walled vessels at the peri-infarct region was accompanied by induction of proliferation and regeneration of endogenous cardiomyocytes and functional cardiac recovery. These results identify a causal relationship between elevated PAI-1 levels and poor outcome in patients with myocardial infarction through mechanisms that directly inhibit bone marrow–dependent neovascularization. Strategies that reduce myocardial PAI-1 expression appear capable of enhancing cardiac neovascularization, regeneration, and functional recovery after ischemic insult.

[Gene therapy of restenosis and atherosclerosis: hopes and facts]

Stents are the main technique of coronary revascularization in France and western countries. However, a better understanding of the pathophysiology of in-stent restenosis and the well-recognized roles played by inflammation and cell proliferation led to the development of drug-eluting stents, which have nearly eliminated the risk of restenosis. In this context, the success of gene therapy will depend on our ability to simplify and optimize current protocols of arterial gene transfer. For the time being, arterial gene therapy remains a powerful tool for deciphering the complex pathophysiology of restenosis and will certainly have far-reaching implications in the fields of vascular biology and therapeutics.

Antisense inhibition of Flk-1 by oligonucleotides composed of 2'-deoxy-2'-fluoro-beta-D-arabino- and 2'-deoxy-nucleosides

The design of new antisense oligomers with improved binding affinity for targeted RNA, while still activating RNase H, is a major research area in medicinal chemistry. RNase H recognizes the RNA-DNA duplex and cleaves the complementary mRNA strand, providing the main mechanism by which antisense oligomers elicit their activities. It has been shown that configuration inversion at the C2' position of the DNA sugar moiety (arabinonucleic acid, ANA), combined with the substitution of the 2'OH group by a fluorine atom (2'F-ANA) increases the oligomer's binding affinity for targeted RNA. In the present study, we evaluated the antisense activity of mixed-backbone phosphorothioate oligomers composed of 2'-deoxy-2'-fluoro-beta-D-arabinose and 2'-deoxyribose sugars (S-2'F-ANA-DNA chimeras). We determined their abilities to inhibit the protein expression and phosphorylation of Flk-1, a vascular endothelial growth factor receptor (VEGF), and VEGF biological effects on endothelial cell proliferation, migration, and platelet-activating factor synthesis. Treatment of endothelial cells with chimeric oligonucleotides reduced Flk-1 protein expression and phosphorylation more efficiently than with phosphorothioate antisenses (S-DNA). Nonetheless, these two classes of antisenses inhibited VEGF activities equally. Herein, we also demonstrated the capacity of the chimeric oligomers to elicit RNase H activity and their improved binding affinity for complementary RNA as compared with S-DNA.

Down-regulation of the ERK1 and ERK2 mitogen-activated protein kinases using antisense oligonucleotides inhibits intimal hyperplasia in a porcine model of coronary balloon angioplasty

OBJECTIVE

Neointimal hyperplasia is a central feature in the pathogenesis of a variety of vascular pathologies. Mitogen-activated protein kinases (MAPK) are involved in the downstream transduction of signals from receptors for many of the molecules known to be instrumental in this process and thus represent a potential target for the modification of the proliferative response. We examined the hypothesis that down-regulation of MAPK would inhibit neointima formation in a porcine coronary injury model.

METHODS

Balloon angioplasty was performed on 38 coronary arteries from 23 large white pigs. Antisense oligonucleotides to the p42 and p44 MAPK were locally delivered to the site of injury immediately after balloon injury. At 7 or 21 days, arteries were harvested for morphometry, determination of cell proliferation and assessment of MAPK protein levels.

RESULTS

At 7 days, neointima formation was significantly reduced compared to controls (corrected intima/media ratio (IMR) 1.01+/-0.13 vs. 1.61+/-0.07, P<0.01) and this was associated with a 58% and 23% down-regulation of p42 and p44 protein levels, respectively. Intimal and medial proliferation rates were also reduced by 32% and 26%, respectively. At 21 days however, the effect of the treatment on MAPK protein levels was no longer significant and this correlated with a loss of the effects on IMR and cell proliferation.

CONCLUSIONS

Down-regulation of MAPK inhibits early smooth muscle cell (SMC) proliferation and neointimal thickening in response to arterial injury, implying that it plays an important role in determining the early vascular response to injury. Inhibitory effects were less apparent at 21 days after a single delivery of oligonucleotide, implying that more sustained local delivery may be required to achieve longer term therapeutic benefit.

Downregulation of the ERK 1 and 2 mitogen activated protein kinases using antisense oligonucleotides inhibits proliferation of porcine vascular smooth muscle cells

The current model of the arterial response to injury suggests that proliferation of vascular smooth muscle cells is a central event. Mitogen activated protein kinases are part of the final common pathway of intracellular signalling involved in cell division and thus constitute an attractive target in attempting to inhibit this proliferation. We hypothesised that antisense oligonucleotides to mitogen activated protein kinase would inhibit serum induced smooth muscle cell proliferation by downregulating the protein. Porcine vascular smooth muscle cells were cultured and an antisense oligonucleotide sequence against the ERK family of mitogen activated protein kinases (AMK1) was introduced by liposomal transfection. Sense oligonucleotides and a random sequence were used as controls. Proliferation was inhibited by AMK1 versus the sense controls, as assessed by tritiated thymidine incorporation (P<0.01). Immunoblots revealed downregulation of the target protein by AMK1 by 63% versus the sense control (P<0.05). In conclusion, antisense oligonucleotides specifically inhibited proliferation and downregulated the target protein. This is consistent with a central role for mitogen activated protein kinases in vascular smooth muscle cell proliferation in the porcine model. In addition, the data suggest a possible role for antisense oligonucleotides in the modulation of the arterial injury response.

Gene Therapy for Cardiovascular Disease

During the past decade, gene therapy for the treatment of many inherited and acquired medical problems has become the subject of increasing focus in both the scientific litera ture and the lay press. This review examines the history and current status of gene therapy for advanced chronic periph eral and myocardial ischemia.

Platelets and restenosis

Restenosis is currently the major limitation of percutaneous transluminal coronary angioplasty (PTCA). Factors such as elastic recoil, migration of vascular smooth muscle cells from media to intima, neointimal proliferation and vascular remodeling underly the restenotic process. Presently there is no effective therapy available for restenosis. The role of platelets in the development of thrombosis and abrupt closure after PTCA is well recognized. However, the effects of platelets in PTCA extend well beyond the early phase. Although antiplatelet agents such as glycoprotein IIb/IIIa antagonists have been reported to reduce target vessel revascularization, major unresolved controversies still exist. This report reviews the potential role of platelets in restenosis. Various drugs, successfully tested in experimental studies and in a small number of human studies, that inhibit the effect of platelets on the restenotic process are also reviewed.

Antisense strategies to inhibit restenosis

Restenosis after percutaneous transluminal coronary angioplasty (PTCA) and coronary stenting remains a major clinical problem. Vascular smooth muscle cell (SMC) proliferation and migration from the arterial wall media into the intima are believed to play a critical role in the pathogenesis of restenosis. Several studies have demonstrated that phosphorothioate (PS) oligodeoxynucleotides targeted against genes involved in SMC proliferation inhibit in vitro SMC proliferation and migration. Moreover, PS oligodeoxynucleotides targeted against the genes c-myb, c-myc, cdc2 kinase, cdk2 kinase, and proliferating cell nuclear antigen (PCNA) when delivered adventitially or intraluminally inhibit in vivo neointimal formation after balloon injury in both the rat carotid and porcine coronary artery models. The inhibitory effects of these PS oligodeoxynucleotides may be the result of their suppression of migration of medial SMC rather than suppression of medial or intimal cell proliferation. Other studies have demonstrated the presence of the potent guanosine or G-quartet aptameric inhibitory effect of the PS oligodeoxynucleotides. Experiments with cytidine homopolymers such as S-dC28, which lack guanosines, reveal the presence of potent non-G-quartet, non-sequence-specific inhibitory effects on in vitro SMC proliferation, migration, and adhesion as well as in vivo neointimal formation after rat carotid artery balloon injury. This is owing to the avid binding of these PS oligodeoxynucleotides to the SMC mitogens and chemoattractants platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF). The extent to which hybridization-dependent antisense, G-quartet aptameric, or non-G-quartet, non-sequence-specific inhibitory effects occurs is the result of PS oligodeoxynucleotide sequence, length, and concentration. The 18-mer guanosine-rich PS oligodeoxynucleotide ZK10 is a more potent in vitro SMC proliferation inhibitor than S-dC28, although both compounds manifest comparable in vivo inhibitory effects on neointimal formation in the rat carotid artery model of balloon injury. PS oligodeoxynucleotides also possess non-sequence-specific immunomodulatory effects, including the induction of interferon-gamma and the unmethylated CpG motif, which exhibits numerous immunomodulatory effects. Novel strategies to inhibit restenosis include the development of E2F transcription decoys that inhibit several cell cycle regulatory genes and diminish neointimal lesion formation. In addition, antisense oligonucleotides targeted against the anti-apoptotic gene bcl-xL, which when transfected into the vessel wall inhibits bcl-xl expression, induce a five-fold increase in apoptotic SMC intimal cells, and effect a marked attenuation of in vivo lesion dimensions, thereby suggesting frank vascular lesion regression.

Vascular smooth muscle cell proliferation and regrowth after mechanical injury in vitro are Egr-1/NGFI-A-dependent

Smooth muscle cell (SMC) proliferation is a key event in renarrowing of blood vessels after balloon angioplasty. Mechanical injury imparted to the arterial wall in experimental models induces the expression of the immediate-early gene, egr-1. Egr-1 binds to and activates expression from the proximal promoters of multiple genes whose products can, in turn, influence the vascular response to injury. Here, we used antisense strategies in vitro to inhibit rat vascular SMC proliferation by directly targeting Egr-1. A series of phosphorothioate antisense oligonucleotides of 15 base length and complementary to various theoretically accessible regions within Egr-1 mRNA were synthesized and assessed for their ability to selectively inhibit SMC proliferation in an Egr-1-dependent manner. Western blot analysis revealed that two oligonucleotides, AS2 and E11, inhibited Egr-1 synthesis in cells exposed to serum without affecting levels of the zinc finger protein Sp1. AS2 and E11 inhibited serum-inducible [(3)H]thymidine incorporation into DNA, as well as serum stimulation of total cell numbers. Size-matched phosphorothioate oligonucleotides with random, scrambled, sense or mismatch sequences failed to inhibit. Antisense Egr-1 inhibition was nontoxic and reversible. These oligonucleotides also inhibited SMC regrowth after mechanical injury in vitro. Egr-1 thus plays a key regulatory role in SMC proliferation and repair following injury.

Gene therapy as a therapeutic intervention for vascular disease

Gene therapy for the treatment of many medical problems, including vascular disease, has become the subject of increasing discussion in both the scientific literature and the national press over the past decade. This review will examine the history and current status of gene therapy for vascular proliferative disorders and advanced chronic peripheral and cardiac ischemia.

Adenoviral-mediated gene transfer of a constitutively active form of the retinoblastoma gene product attenuates neointimal thickening in experimental vein grafts

PURPOSE

Inappropriate or excessive vascular smooth muscle cell proliferation leads to the development of occlusive lesions in up to 50% of vein grafts. The purpose of this study was to test the hypothesis that induced overexpression of a cytostatic nonphosphorylatable form of the retinoblastoma protein (DeltaRb) would attenuate neointimal thickening in experimental vein grafts.

METHODS

A replication-deficient adenovirus vector that encoded a nonphosphorylatable, constitutively active form of DeltaRb was constructed (AdDeltaRb) and contained an NH2-terminal epitope tag from the influenza hemagglutinin molecule (HA). Forty-eight male New Zealand white rabbits underwent surgical exposure of the external jugular vein for transfection with either 3 x 10(10) plaque-forming units/mL AdDeltaRb (n = 16), 3 x 10(10) plaque-forming units/mL control adenovirus (AdBglII, n = 15), or vehicle (n = 17) for 10 minutes at 120 mm Hg. After vector exposure, the vein was excised and interposed end-to-end into the carotid circulation. After 5 days, 12 grafts (four from each group) were excised and assayed for genomic DeltaRb DNA with the polymerase chain reaction or for hemagglutinin molecule expression and localization with immunohistochemistry. The remainder of the grafts (n = 36) were perfusion-fixed after 4 weeks, and 5 microm sections prepared for digital planimetric analysis.

RESULTS

Polymerase chain reaction results identified the DeltaRb gene only in the grafts that were transfected with AdDeltaRb. Immunohistochemical analysis results revealed transgene expression in most of the endothelial cells and in many of the smooth muscle cells. After 4 weeks, the grafts that were exposed to AdDeltaRb exhibited a 22% reduction in neointimal thickness (vehicle, 77 +/- 7 microm; AdBglII, 75 +/- 5 microm; AdDeltaRb, 60 +/- 5 microm; P =.05), and medial thickness, luminal diameter, and other parameters were unchanged (medial thickness: vehicle, 72 +/- 10 microm; AdBglII, 85 +/- 7 microm; AdDeltaRb, 69 +/- 9 microm; P = NS; luminal diameter: vehicle, 4.5 +/- 0.2 mm; AdBglII, 4.4 +/- 0.2 mm; AdDeltaRb, 4.7 +/- 0.1 mm; P = NS).

CONCLUSION

With this delivery system, adenoviral-mediated gene transfer is highly efficient and induced overexpression of DeltaRb leads to a reduction in vein graft neointimal thickening.

Differential effects of IFN-beta1b on the proliferation of human vascular smooth muscle and endothelial cells

The effect of human interferon (IFN)-beta1b (Betaseron) on the proliferation of cultured human vascular smooth muscle and endothelial cells was tested in vitro. IFN-beta1b inhibited thymidine incorporation and growth of primary cultures of human aortic and coronary artery smooth muscle in a concentration-dependent manner. The same concentrations of IFN-beta1b did not inhibit thymidine incorporation or growth of primary cultures of human aortic or coronary artery endothelial cells. IFN-beta1b induced the expression of MxA (an antiviral protein induced by type I IFNs) in both smooth muscle and endothelial cells, suggesting that both cell types express receptors for type I IFNs. The growth-inhibitory effect of IFN-beta1b could be mimicked by commercially available human IFN-beta, but not by IFN-alpha2 or IFN-alpha8. The effect of IFN-beta1b was species specific, as it did not inhibit thymidine incorporation in aortic smooth muscle cells derived from pig, rabbit, rat, or mouse. The action of IFN-beta1b on smooth muscle cells persisted for at least 4 days following a 24 h preincubation with IFN-beta1b. Human vascular smooth muscle cells treated with IFN-beta1b did not release lactate dehydrogenase, nor did they show any morphologic change, suggesting that IFN-beta1b was not toxic to the human vascular smooth muscle cells. IFN-beta1b inhibited vascular smooth muscle growth while having no growth-inhibitory effect on endothelial cells obtained from the same blood vessel, making it a potential candidate for treating pathologic conditions where abnormal vascular smooth muscle proliferation is implicated, such as restenosis following balloon angioplasty or smooth muscle proliferation following vascular stenting.

Intracorporal injection of hSlo cDNA in rats produces physiologically relevant alterations in penile function

The Ca2+-sensitive K+ channel (maxi-K+) is an important modulator of corporal smooth muscle tone. The goal of these studies was twofold: 1) to determine the feasibility of transfecting corporal smooth muscle cells in vivo with the hSlo cDNA, which encodes for the human smooth muscle maxi-K+ channel, and 2) to determine whether transfection of the maxi-K+ channel would affect the physiological response to cavernous nerve stimulation in a rat model in vivo. Intracorporal microinjection of pCMVbeta/Lac Z DNA in 10-wk-old rats resulted in significant incorporation and expression of beta-galactosidase activity in 10 of 12 injected animals for up to 75 days postinjection. Moreover, electrical stimulation of the cavernous nerve revealed that, relative to the responses obtained in age-matched control animals (N = 12), intracavernous injection of naked pcDNA/hSlo DNA was associated with a statistically significant elevation in the mean amplitude of the intracavernous pressure response at all levels of current stimulation (range 0.5-10 mA) at both 1 mo (N = 5) and 2 mo (N = 8) postinjection. Furthermore, qualitatively similar observations were made at 3 mo (N = 2) and 4 mo (N = 2) postinjection. These data indicate that naked hSlo DNA is quite easily incorporated into corporal smooth muscle and, furthermore, that expression is sustained for at least 2 mo in corporal smooth muscle cells in vivo. Finally, after expression, hSlo is capable of measurably altering nerve-stimulated penile erection. Taken together, these data provide compelling evidence for the potential utility of gene therapy in the treatment of erectile dysfunction.

Phosphorothioate Oligodeoxynucleotide Inhibition of Restenosis

Antisense therapy with phosphorothioate oligodeoxynucleotides (PS oligos) has emerged as a potentially useful strategy for inhibiting angioplasty restenosis. Several groups have reported that PS oligos inhibit in vitro vascular smooth muscle cell (SMC) proliferation as well as in vivo neointimal formation after rat carotid artery balloon injury. More recent studies have revealed the presence of a PS oligo G-quartet inhibitory effect, reflecting binding of oligonucleotides to cellular proteins, which is distinct from a hybridization-dependent antisense effect. Studies with the 28-mer phosphorothioate cytidine homopolymer S-dC28 have demonstrated the presence of a non-G-quartet, non-sequence-specific inhibitory effect on SMC proliferation and migration in vitro and neointimal hyperplasia after rat carotid balloon injury in vivo. These effects are the result, in part, of the avid binding of the polyanion PS oligos to heparin-binding growth factors, such as platelet-derived growth factor (PDGF) and basic fibroblast growth factor. Moreover, S-dC28 attenuates PDGF-induced SMC tissue plasminogen activator antigen levels without affecting SMC plasminogen activator inhibitor-1 levels, thereby suggesting a PS oligo net antifibrinolytic effect that would impede SMC migration. Therefore, the further development of these drugs to inhibit angioplasty restenosis must consider the hybridization-specific antisense effects, the non-G-quartet inhibitory effects, and the non-G-quartet, non-sequence-specific inhibitory effects of the pleiotropic PS oligos.

Antisense approaches for investigating mechanisms of abnormal development

Although the use of antisense oligodeoxynucleotides in cell culture systems has been beneficial for examining functional roles of genes in biological processes, very few studies have adapted this valuable approach to developmental studies. This oversight may be due to the fact that many scientists are not familiar with the numerous in vitro approaches available for use as developmental system models. Increased knowledge concerning the mechanisms by which oligonucleotides are incorporated into the cell and how these molecules disrupt targeted gene expression has resulted in improved oligonucleotide design and better controls for these studies. The combined use of developmental in vitro approaches, with improved antisense oligodeoxynucleotide strategies presents valuable experimental models for examining functions and interactions of genes in embryogenesis. This review focuses on a comprehensive description of the characterized properties of oligodeoxynucleotides, control design, and various developmental in vitro approaches for accomplishing these studies in embryonic systems.

Molecular and cellular characterization of baboon C-Raf as a target for antiproliferative effects of antisense oligonucleotides

C-Raf is a an essential member of the growth factor-ras pathway and a target for intervention strategies aimed at blocking cell proliferative responses. Excessive smooth muscle proliferation is considered one cause of the arterial closure in restenosis. Because of the similarity to the human cardiovascular system, a useful current animal model of the disease is a baboon model. As a foundation for animal studies employing antisense oligonucleotides, efforts were made to characterize the molecular and cellular biology of the baboon system. The nucleotide sequence of baboon c-raf cDNA was determined. Antisense phosphorothioate oligonucleotides specific to the 3'-UTR of c-raf mRNA from human and baboon were compared using primary baboon smooth muscle cells in culture. A particular human antisense oligonucleotide, referred to as ISIS 5132, was different by only 2 of 20 bases from the baboon sequence. The corresponding baboon antisense oligonucleotide ISIS 12959, however, was markedly more effective to inhibit c-raf mRNA, protein production, and DNA synthesis, and the results attest to the species specificity of the approach. After antisense treatment, c-raf mRNA levels dropped rapidly, whereas protein levels decreased with a half-life of roughly 24-48 hours, consistent with the antiproliferative effects. The data are discussed with regard to the profile of protein-protein interactions made by C-Raf and with the view that the baboon system closely parallels the human one at the signal transduction level. As this work progressed, a baboon cDNA homolog of a human c-raf-2 pseudogene was isolated, sequenced, and shown to be transcribed into mRNA.

Long-term clinical follow-up after successful repeat percutaneous intervention for stent restenosis

OBJECTIVES

This study evaluated the long-term clinical outcome of successful repeat percutaneous intervention after in-stent restenosis.

BACKGROUND

Recurrence of symptoms and angiographic restenosis after stent implantation are observed in 15% to 35% of cases. Repeat percutaneous treatment for in-stent restenosis has been shown to be safe, with high immediate success, but little is known about the long-term clinical outcome.

METHODS

Clinical follow-up (minimum 9 months) was obtained in a consecutive series of 124 patients (127 vessels) presenting with stent restenosis who were successfully treated with repeat percutaneous intervention.

RESULTS

Clinical follow-up was obtained in all 124 patients at a mean [+/-SD] of 27.4 +/- 14.7 months (range 9 to 66); a stress test was available in 88 patients (71%). Recurrence of clinical events occurred in 25 patients (20%) and included death from any cause in 2 patients (2%), target vessel revascularization in 14 (11%), myocardial infarction in 1 (1%) and positive stress test results or recurrence of symptoms (Canadian Cardiovascular Society class I to IV) treated medically in 8 (6%). Cumulative event-free survival at 12 and 24 months was 86.2% and 80.7%, respectively. Significant predictive factors of recurrence of clinical events were repeat intervention in saphenous vein grafts, multivessel disease, low ejection fraction and a < or = 3-month interval between stent implantation and repeat intervention.

CONCLUSIONS

In-stent balloon angioplasty for stent restenosis in native vessels seems to be an effective method in terms of a low long-term clinical event rate.

Endoluminal local delivery of PCNA/cdc2 antisense oligonucleotides by porous balloon catheter does not affect neointima formation or vessel size in the pig coronary artery model of postangioplasty restenosis

Localized delivery of antisense oligonucleotides directed against cell cycle regulatory proteins has been proposed as a means to prevent restenosis after angioplasty. To test whether single endoluminal delivery of a combination of proliferating cell nuclear antigen (PCNA) and cell-division cycle 2 kinase (cdc2) antisense might affect restenosis, we delivered 2 ml of lipid-complexed PCNA/cdc2 antisense oligomers (1.35 mg) to the coronary arteries of pigs after balloon overstretch angioplasty (AS group) and performed planimetric histomorphometry on arterial sections of the tissue, harvested at 4 wk. Compared with controls receiving 3'-5' reversed sequence oligomers (REV group), there were no differences in absolute intimal area (AS 1.36 +/- 0.08 mm2, REV 1.23 +/- 0.10 mm2, P = NS), intimal area normalized to extent of injury (AS 0.67 +/- 0.03, REV 0.77 +/- 0.10, P = NS), or vessel perimeter (AS 7.72 +/- 0.19 mm, REV 7.36 +/- 0.22 mm, P = NS). We conclude that single endoluminal delivery of antisense against key cell cycle regulatory proteins does not affect neointima formation or vessel size in this model of restenosis.

Gene therapy for vascular disease

Atherosclerosis is a degenerative process characterized by endothelial cell dysfunction, inflammatory cell adhesion and infiltration, and the accumulation of cellular and matrix elements leading to the formation of fibrocellular plaques. In the end stages, advanced occlusive plaques limit blood flow and oxygen delivery resulting in the well-known ischemic syndromes of the coronary, skeletal muscle, mesenteric, and cerebrovascular circulation. Moreover, sudden critical ischemic events may be precipitated by plaque disturbance, rupture, hemorrhage, and/or thrombosis. Traditional pharmacologic approaches have been effective in reducing serum cholesterol and controlling thrombosis but, in the main, have had little impact on the treatment of advanced lesions. The purpose of this review is to examine the current status of gene therapy for vascular proliferation, aberrant endothelial function, thrombosis, peripheral ischemia, and modification of the blood/biomaterial interface.

Gene therapy and vascular disease: potential applications in vascular surgery

Advances in molecular biology have generated methods that are used to enhance diagnosis and treatment of a variety of human diseases. More recently modification of gene expression in cells by gene transfer has been introduced as a new therapeutic modality. The targeting of vascular cells with this method is appealing not only for anatomical reasons, but also because endovascular techniques provide access to the vasculature and makes site-specific delivery possible. Over the past few years, gene transfer has been widely used to explore the pathophysiology of vascular diseases in experimental models and available data suggests that this method may eventually become a therapeutic alternative for vascular disorders such as restenosis, graft failure, and critical ischaemia. In the following we discuss the methodology of gene transfer, its tentative use in vascular diseases related to vascular surgery, and the problems associated with this new technology.

Restenosis: is there a pharmacologic fix in the pipeline?

One of the most frustrating aspects of restenosis is that it is the result of advances in medical care (there was no restenosis before the days of balloon angioplasty), yet it seems to be resistant to all that science has to offer. Still we believe there is reason to be optimistic. We are at last beginning to see some promise from clinical trials, and data being generated confirm some of the hypotheses previously generated from animal experiments. Thus the effects seen with the GP IIb/IIIa antibody 7E3 suggest that thrombosis may be as important in its long-term sequelae as it is for acute reocclusion. The jury is still out on whether antiproliferative approaches will be a therapeutic option, but local delivery paradigms using novel formulations delivered by catheter or impregnated in stents may allow the concept to be tested without the risk of systemic toxicity. Plans are also underway for gene therapy trials, although we may have to wait for better vector technology before taking these into the coronary bed. Perhaps we should move away from the "single pill" approach and accept that, like many infections, malignancies, or even heart failure, a multifaceted approach with combination therapy will provide the first glimmer of that brighter tomorrow.

Gene and other biological therapies for vascular diseases

Gene transfer and antisense therapy offer novel approaches to the study and treatment of vascular diseases. The localized nature of vascular diseases like restenosis has made the application of genetic material an attractive therapeutic option. Viral and nonviral vectors have been developed to facilitate the entry of foreign DNA or RNA into cells. Vector improvement and production, demonstration of vector safety and demonstration of therapeutic efficacy are among the main present challenges. Various strategies have already been shown to be successful in preventing restenosis in animal models and include: the transfer of the herpes simplex virus thymidine kinase associated with ganciclovir: transfection of the cell cycle regulatory genes encoding for the active form of retinoblastoma gene product (Rb) or the cyclin-dependent kinase inhibitor p21, and antisense therapy. Therapeutic angiogenesis using gene transfer is a new strategy for the treatment of severe limb ischemia. Transfection of DNA encoding for the vascular endothelial growth factor has resulted in increasing collateral flow in animal models of peripheral ischemia. This approach is currently being investigated in a clinical trial in patients with distal ischemia. Other potential targets for genetic treatment in cardiovascular diseases include thrombosis, extracellular matrix synthesis and lipid metabolism.

Sequence-independent inhibition of in vitro vascular smooth muscle cell proliferation, migration, and in vivo neointimal formation by phosphorothioate oligodeoxynucleotides

Phosphorothioate oligodeoxynucleotides (PS oligos) are antisense (sequence-specific) inhibitors of vascular smooth muscle cell (SMC) proliferation when targeted against different genes. Recently an aptameric G-quartet inhibitory effect of PS oligos has been demonstrated. To determine whether PS oligos manifest non-G-quartet, non-sequence-specific effects on human aortic SMC, we examined the effects of S-dC28, a 28-mer phosphorothioate cytidine homopolymer, on SMC proliferation induced by several SMC mitogens. S-dC28 significantly inhibited SMC proliferation induced by 10% FBS as well as the mitogens PDGF, bFGF, and EGF without cytotoxicity. Moreover, S-dC28 abrogated PDGF-induced in vitro migration in a modified micro-Boyden chamber. Furthermore, S-dC28 manifested in vivo antiproliferative effects in the rat carotid balloon injury model. S-dC28 suppressed neointimal cross-sectional area by 73% and the intima/media area ratio by 59%. Therefore, PS oligos exert potent non-G-quartet, non-sequence-specific effects on in vitro SMC proliferation and migration as well as in vivo neointimal formation.

A simple method for delivering morpholino antisense oligos into the cytoplasm of cells

We report a simple and effective means for delivering Morpholino antisense oligos into the cytosol of cultured anchorage-dependent animal cells. This method, referred to as scrape-loading, is carried out in a matter of seconds, uses a common inexpensive laboratory implement, and has minimal detrimental impact on the cells. Using this delivery method, a Morpholino oligo present at 0.1 microM and 1 microM in the extracellular medium inhibited its targeted genetic sequence within cultured Hela cells at levels of 56% and 85%, respectively. Lack of inhibition by two control Morpholino oligos at concentrations up to 3 microM indicates good sequence specificity by this structural type. Also described is a test system for simple, rapid, and sensitive quantitation of antisense activity in cultured cells.