Rabbit ear model of injury-induced arterial smooth muscle cell proliferation. Kinetics, reproducibility, and implications

Murine Aortic Crush Injury: An Efficient In Vivo Model of Smooth Muscle Cell Proliferation and Endothelial Function

Arterial reconstruction, whether angioplasty or bypass surgery, involves iatrogenic trauma causing endothelial disruption and vascular smooth muscle cell (VSMC) proliferation. Common murine models study small vessels such as the carotid and femoral arteries. Herein we describe an in vivo system in which both VSMC proliferation and endothelial barrier function can be simultaneously assessed in a large vessel. We studied the infrarenal aortic response to injury in C57BL/6 mice. The aorta was injured from the left renal vein to the aortic bifurcation by 30 transmural crushes of 5-seconds duration with a cotton-tipped applicator. Morphological changes were assessed with conventional histology. Aorta wall thickness was measured from the luminal surface to the adventitia. EdU integration and counter staining with DAPI and alpha-actin was used to demonstrate VSMC proliferation. Activation of ERK1/2, a known moderator of intimal hyperplasia formation, was determined by Western Blot analysis. The effect of inflammation was determined by immunohistochemistry for B-cells, T-cells, and macrophages. En face sections of endothelium were visualized with scanning electron microscopy (SEM). Endothelial barrier function was determined with Evans Blue staining. Transmural injury resulted in aortic wall thickening. This injury induced VSMC proliferation, most prominently at 3 days after injury, and early activation of ERK1/2 and decreased p27^kip1 expression. Injury did not result in increased B-cells, T-cells, or macrophages infiltration in the vessel wall. Injury caused partial endothelial cell denudation and loss of cell-cell contact. Injury resulted in a significant loss of endothelial barrier function, which returned to baseline after seven days. The murine transmural blunt aortic injury model provides an efficient system to simultaneously study both VSMC proliferation and endothelial barrier function in a large vessel.

Penile revascularization--contemporary update

Contemporary therapies for erectile dysfunction are generally targeted towards older men and universally engage pharmacological and/or device related treatment options. Penile revascularization, using microvascular arterial bypass surgical techniques, is a non-pharmacological, non-device-related, and reconstructive surgical strategy for men with erectile dysfunction that was first described by Dr Vaclav Michal in 1973. Contemporary penile revascularization attempts to 'cure' pure arteriogenic erectile dysfunction in young men with arterial occlusive pathology in the distal internal pudendal, common penile or proximal cavernosal artery secondary to focal endothelial injury from blunt pelvic, perineal or penile trauma. A microvascular anastomosis is fashioned between the donor inferior epigastric and recipient dorsal penile artery. Increased perfusion pressure is theoretically communicated to the cavernosal artery via perforating branches from the dorsal artery. This article will review the history, indications and pathophysiology of blunt trauma-induced focal arterial occlusive disease in young men with erectile dysfunction, current surgical techniques utilized and results of surgery. Contemporary use of penile revascularization is a logical and wanted therapeutic option to attempt to reverse erectile dysfunction in young men who have sustained blunt pelvic, perineal or penile trauma.

Animal models of restenosis

Percutaneous transluminal coronary angioplasty is a widely used technique for recanalizing arteries that are occluded by atherosclerotic plaque, but its usefulness is limited by the occurrence ofrestenosis in a high proportion of patients. The development of new therapies for this currently intractable problem will be facilitated by the use of animal models of restenosis that are predictive of drug efficacy in humans. Two approaches for improving predictivity can be identified. In the first of these, the goal is to maximize the anatomical and procedural resemblance of the model to humans. The second approach seeks to maximize the pathophysiological and molecular biological resemblance of the model to humans. Tangible progress is being made toward the first goal, but lack of understanding of the basic biology of human restenosis is hampering progress toward the second.

Preclinical Models of Restenosis and Their Application in the Evaluation of Drug-Eluting Stent Systems

Coronary arterial disease (CAD) is the leading cause of death in the United States, the European Union, and Canada. Percutaneous coronary intervention (PCI) has revolutionized the treatment of CAD, and it is the advent of drug-eluting stent (DES) systems that has effectively allayed much of the challenge of restenosis that has plagued the success of PCI through its 30-year history. However, DES systems have not been a panacea: There yet remain the challenges associated with interventions involving bare metallic stents as well as newly arisen concerns related to the application of DES systems. To effectively address these novel and ongoing issues, animal models are relied on both to project the safety and efficacy of endovascular devices and to provide insight into the pathophysiology underlying the vascular response to injury and mechanisms of restenosis. In this review, preclinical models of restenosis are presented, and their application and limitation in the evaluation of device-based interventional technologies for the treatment of CAD are discussed.

Iododeoxyuridine uptake in proliferating smooth muscle cells in vitro

PURPOSE

Iododeoxyuridine (IUdR) is a halogenated pyrimidine recognized as the thymidine substitute in DNA. When labeled with iodine 125, IUdR can be used as a carrier to incorporate the isotope into DNA and target the dividing cells. The purpose of this study was to assess the maximum uptake of IUdR by proliferating smooth muscle cells (SMCs) in vitro to determine the optimal concentration to be administered in an in vivo experiment. The long-term goal is to use radioactive IUdR to inhibit SMC proliferation and recurrent stenosis of arteries after balloon angioplasty in vivo.

MATERIALS AND METHODS

Porcine vascular SMCs were cultured in 5% fetal bovine serum medium and stimulated to proliferate by adding a medium containing 10% fetal bovine serum and insulin. IUdR was added to the proliferating SMCs at concentrations of 5, 10, 20, 30, and 40 micro mol/L on days 1, 3, 5, and 7 of incubation. One group of cells--the control group--did not receive IUdR. The SMCs were harvested and double-stained with an anti-IUdR antibody and propidium iodide, and fluorescence-activated cell scanning was performed to determine the ratio of IUdR-labeled cells to the total cell population for each IUdR concentration and at each time point. The data were measured three times at each time point. The doubling times, growth curve, and cell density of the proliferating SMCs were investigated by using the Coulter particle counter and digital microscopy.

RESULTS

The percentage of proliferating SMCs that showed IUdR uptake increased from 1 to 5 days incubation with all concentrations of IUdR; the incorporation rate reached a peak value at day 5 and then decreased by day 7. IUdR uptake on day 5 was higher with concentrations of 10 and 20 micro mol/L. When compared with that of the control group, the doubling times increased with an increase in IUdR concentration, whereas the proliferating cell number and density decreased significantly by days 5 (P < .05) and 7 (P < .01).

CONCLUSIONS

IUdR uptake peaked on day 5, and the optimal concentration of IUdR for in vitro uptake in proliferating SMCs was 10-20 micro mol/L. IUdR inhibited the proliferation of the SMCs, and the inhibitory effect was related to the concentration.

Reduction of Tissue Hyperplasia with a Rhenium188 Mercaptoacetyltriglycine-3–filled Balloon: Preliminary Study in a Canine Urethral Model

PURPOSE

To evaluate the efficacy of beta-radiation therapy with rhenium-188 mercaptoacetyltriglycine-3 (MAG(3))-filled balloons to reduce tissue hyperplasia secondary to stent placement in 18 canine urethras.

MATERIALS AND METHODS

Eight dogs were treated with 188-Re MAG(3)-filled balloon dilation immediately after stent placement and were killed 4 weeks later (group I, n = 4) or 8 weeks later (group II, n = 4). Five dogs were treated with 188-Re MAG(3)-filled balloon dilation 2 weeks after stent placement and were killed 4 weeks after stent placement (group III). The remaining five dogs were treated with conventional balloon dilation immediately after stent placement and were killed 4 weeks later; these animals formed the control group (group IV). Retrograde urethrography (RUG) was performed during follow-up and three histologic parameters were investigated: the number of epithelial layers, papillary projection thickness, and degree of submucosal inflammatory cell infiltration. The areas inside and outside the ends of the stents were evaluated in each case after animal sacrifice. After testing statistical significance of data for RUG and histologic findings in the four study groups, the Mann-Whitney U test was used to compare groups I and II to determine delayed effects of irradiation, groups I and III to determine benefits of delayed irradiation, groups I and IV to determine efficacy of immediate irradiation for reducing tissue hyperplasia, and groups III and IV to determine efficacy of delayed irradiation for reducing tissue hyperplasia.

RESULTS

There were no significant differences in the four study groups on RUG before animal sacrifice. Between groups I and II, group II showed significantly lower mean values in five of six histologic comparisons. Between groups I and III, group III showed significantly lower mean values in only papillary projection thickness inside the stent ends. Between groups I and IV, group I showed significantly lower mean values in all three histologic parameters outside the stent ends. Between groups III and IV, group III showed significantly lower mean values in only two histologic parameters (papillary projection thickness in the in-stent area and inflammatory cell infiltration outside the stent edges).

CONCLUSION

beta-Irradiation with use of a 188-Re MAG(3)-filled balloon shows the potential to reduce tissue hyperplasia secondary to stent placement in a canine urethral model. Treatment with 188-Re MAG(3)-filled balloons at the time of stent placement shows not only favorable outcomes for reducing tissue hyperplasia but also improved delayed effects until 8 weeks.

Cytomegalovirus infection of rats increases the neointimal response to vascular injury without consistent evidence of direct infection of the vascular wall

BACKGROUND

Previous studies suggest that infection may play a role in restenosis and atherogenesis; cytomegalovirus (CMV) is one of the implicated pathogens. To determine a potential causal role of CMV in these disease processes, we assessed whether CMV infection increases the neointimal response to injury of the rat carotid artery.

METHODS AND RESULTS

Carotid injury was performed on 60 rats; immediately thereafter, 30 rats were infected with rat CMV, and the other 30 were mock-infected. Six weeks later, rats were euthanized, and the salivary glands, spleen, and carotid arteries were harvested. CMV infection was associated with significant exacerbation of the neointimal response to injury (neointimal to medial ratio 0.81+/-0. 59 versus 0.31+/-0.38 in CMV-infected versus control rats; P<0.0001). This occurred despite absence of infectious virus from vascular tissues and detection of CMV DNA by polymerase chain reaction in the injured artery only at day 3 after infection. Persistent distant infection, associated with systemic cytokine response, was evidenced by isolation of infectious virus from homogenates of both salivary glands and spleen and by higher serum levels of interleukin (IL)-2 and IL-4 (but not interferon-gamma and tumor necrosis factor-alpha) in infected versus noninfected rats.

CONCLUSIONS

CMV infection of immunocompetent adult rats increases the neointimal response to vascular injury, suggesting that CMV may play a causal role in atherosclerosis/restenosis. Importantly, this CMV-induced response occurs even without the presence of virus in the vascular wall, suggesting that inflammatory and immune responses to infection of nonvascular tissues may contribute to the vascular response to injury.

Photobinding of [gamma-(32)P] ATP gamma-benzophenone to the surface of a polyurethane membrane in the preparation of a beta-particle-emitting balloon catheter

PURPOSE

The goal of this study was to photochemically bind 5'-[gamma-(32)P]-azido-ATP gamma-benzophenone ((32)P-ATP-BPA) to a polyurethane surface. Expandable balloon catheters composed of (32)P-coated polyurethane have the potential for preventing restenosis following percutaneous transluminal coronary angioplasty.

METHODS

After extensive preparation and cleaning of polyurethane disks, 10 microL of the radioactive ATP-BPA reagent (specific activity = 9.4 Ci/mmol) was applied to the surface. After drying, the membrane disks were exposed ultraviolet radiation (254 nm; 6,000 microwatts/cm(2)) for up to 2 h and subsequently washed. The amount of (32)P bound to the membrane disks was determined by Cerenkov counting in a liquid scintillation counter. The effect of the labeling solution composition (solvent, presence of potassium or manganese ions, addition of surfactants, etc.) on photobinding efficiency was determined.

RESULTS

The efficiency of attaching the (32)P-ATP-BPA reagent to the polyurethane surfaces was markedly dependent upon the cleaning and pretreatment conditions. Following detailed washing and rinsing steps, a photobinding efficiency of 36.4+/-3.6% was obtained with 10 min UV exposure time using (32)P-ATP-BPA solutions that were 95/5 methanol/water by vol. Increasing the concentration of the (32)P-ATP-BPA reagent did not improve the photobinding efficiency; however, the total amount of (32)P bound to the disks was increased.

CONCLUSIONS

Photochemical methods can be employed to attach beta(-)-emitting radionuclides to polymers that are employed as balloon catheters. The preparation of the polymeric material (washing, rinsing, and drying) is critically important in maximizing the amount of (32)P-ATP-BPA that can be bound to the polymer.

The experimental animal models for assessing treatment of restenosis

Coronary restenosis after percutaneous interventions remains a major clinical problem. The assessment of therapies for the prevention of restenosis relies on the use of experimental models. This review describes the most frequently used animal models of coronary artery retenosis and the intraspecies differences among them, particularly in the extent and composition of the neointimal thickening. These differences in neointima formation should be considered in the interpretation of effective antiproliferative therapies before they are transferred into clinical trials.

External beam irradiation inhibits neointimal hyperplasia after injury-induced arterial smooth muscle cell proliferation

PURPOSE

Restenosis after catheter-based revascularization has been demonstrated to be primarily caused by smooth muscle cell proliferation. This study examines the effects of external beam irradiation on neointimal proliferation after external injury to the central artery of the rabbit ear.

METHODS AND MATERIALS

Thirty male New Zealand White rabbits were used in this study. Crush lesions were performed on each ear under general anesthesia and bilateral auricular nerve blockade. A single dose of 1200 cGy (n = 10), 1600 cGy (n = 10), or 2000 cGy (n = 10) gamma radiation was delivered to the left or right central artery of the ear 24 hours after injury; the contralateral central artery served as control. All rabbits were sacrificed after 21 days and the central arteries of both ears were fixed for morphometric measurements.

RESULTS

Mean (+/-SD) neointimal area was 0.062 +/- 0.005 mm2 (1200 cGy), 0.022 +/- 0.005 mm2 (1600 cGy), and 0.028 +/- 0.006 mm2 in irradiated arteries compared with 0.081 +/- 0.009 mm2 in the control group. Mean (+/-SD) luminal area was 0.049 +/- 0.004 mm2 (1200 cGy), 0.059 +/- 0.002 mm2 (1600 cGy), and 0.072 +/- 0.006 mm2 (2000 cGy) in irradiated arteries compared with 0.043 +/- 0.008 mm2 in the control group. The differences in neointimal and luminal area between control and irradiated arteries were significant (p < 0.05) for the 1600 and 2000 cGy group only.

CONCLUSION

We conclude that in this model, external beam X-ray irradiation was successful in reducing neointimal proliferation after injury of the central artery of the rabbit ear. Marked reductions in neointimal proliferation were demonstrated in vessels subject to 1600 and 2000 cGy radiation; a less prominent effect was noted for 1200 cGy. Whether this approach can be used successfully to inhibit restenosis in the clinical setting requires further investigation.

Mechanisms of neointima formation--lessons from experimental models

The lamina intima of an artery is the region between the endothelial cell surface and the internal elastic lamina, which forms the luminal margin of the media. In humans the intima of atherosclerosis-prone arteries becomes thicker due to accumulation of smooth muscle cells, which originate from the media. The introduction of percutaneous transluminal coronary angioplasty (PTCA) boosted scientific interest in intimal thickening, because restenosis remains an unresolved problem of this intervention. In order to unravel the mechanisms of intimal thickening there is a need for appropriate animal models. A brief overview of these models is given together with factors that control proliferation and/or migration. Despite intensive research on neointima formation, an effective therapy for restenosis has not emerged to date. This may be due to the fact that other processes, such as acute elastic recoil and chronic constrictive remodeling may contribute to lumen narrowing as well. Other limitations of neointima models are related to species and anatomical differences. Most studies are performed in arteries that are either lesion-free, or contain relatively mild plaques, in contrast to the complicated, stenotic lesions that are the substrate for human PTCA. Other differences are the severity of the injury and incorporation of a mural fibrin-rich thrombus. Nevertheless, studies based on superficial injury, like the frequently used balloon denudation model, are useful. There are similarities with angioplasty, such as endothelial cell damage and proliferation of medial and intimal smooth muscle cells. The use of techniques such as differential display, gene transfer and application of antisense oligonucleotides may provide new therapeutic approaches to reduce neointima formation.

Dose distribution for a 32P-impregnated coronary stent: comparison of theoretical calculations and measurements with radiochromic film

PURPOSE

Restenosis, caused by proliferation of smooth-muscle cells, limits the efficacy of catheter-based revascularization of coronary arteries. Irradiation has been shown to inhibit growth of smooth-muscle cells in vitro and to prevent restenosis in animal models following stent placement. An intraarterial source of 32P, a pure beta emitter with a half-life of 14.28 days and a 90% range in water of 3.6 mm, is almost ideal for irradiating just arterial wall without exposing any other part of the patient's heart or any other organs, while posing minimal hazards to medical personnel. Two types of previously developed coronary stent impregnated with 32P were investigated. This study aimed to calculate and measure the dose outside of two types of 32P-impregnated beta-emitting coronary stents under conditions closely simulating clinical use.

METHODS AND MATERIALS

The dose distributions in water surrounding these stents were calculated using a convolution method and measured by exposing radiochromic film in a solid-water phantom.

RESULTS

Experimental results were in excellent agreement with theoretical calculations.

CONCLUSIONS

Radiochromic dosimetry can be used to measure the dose distribution around a beta-emitting intraarterial stent at distances as small as 0.1 mm from the stent surface. A simple cylindrical shell model is adequate for calculating the dose at points farther than 0.5 mm from the stent surface.

Local delivery of heparin to balloon angioplasty sites with a new angiotherapy catheter: pharmacokinetics and effect on platelet deposition in the porcine model

The purpose of this study was to assess the efficacy of local heparin delivery to balloon angioplasty sites in an in vivo porcine model by using a newly designed angiotherapy catheter that allows for prolonged drug infusion while maintaining distal arterial perfusion. Protocols were designed to assess the safety of intracoronary drug delivery, the effect of infusion time and drug concentration on intramural heparin deposition, the distribution of heparin within the arterial wall, the histologic effects of local heparin delivery, the wash-out of intramurally deposited heparin, and the effect of heparin delivery on early platelet deposition following balloon injury in peripheral and coronary vessels. Local intracoronary delivery of heparin was well tolerated in all animals. Between 0.04 and 0.08% of infused heparin was intramurally deposited at the time of drug delivery, with longer infusion durations and higher concentrations of heparin resulting in greater intramural deposition. Autoradiography demonstrated homogenous distribution of heparin throughout the intima, media, and adventitia, with localization in the nuclei, cytoplasm, and extracellular space. Histologic analysis demonstrated no additional vessel trauma from local drug delivery beyond that seen with conventional angioplasty. Wash-out studies demonstrated a biexponential disappearance of intramurally deposited drug, with rapid release of heparin over the first 60 min and persistence of small amounts of drug for at least 7 d. Locally delivered heparin significantly attenuated the deposition of platelets in peripheral vessels, although a similar decrease in platelet deposition in the coronary arteries was not statistically significant. Local delivery of heparin directly to coronary angioplasty sites is possible with the use of a new angiotherapy catheter. Wash-out of heparin from the arterial wall is initially rapid, although drug is detectable for up to 1 wk following delivery. In porcine peripheral arteries, use of this technique significantly decreases early platelet deposition following balloon injury.

Expression of platelet-derived growth factor B-chain in neointimal smooth muscle cells of balloon injured rabbit femoral arteries

In order to obtain information about the developmental mechanisms of restenosis after angioplasty, we investigated an association between the expression of platelet-derived growth factors (PDGFs) and neointimal cell accumulation in rabbit femoral arteries subjected to balloon angioplasty. Northern analysis demonstrated that mRNA expression of PDGF B-chain (PDGF-B) increased markedly in the injured arteries, peaking at day 7 (sevenfold), and the transcripts remained augmented until day 21. Also transcripts of PDGF beta-receptor (PDGFR-beta) and alpha-receptor increased by 3- and 2.5-fold, respectively, but those of PDGF A-chain showed only a slight increase (1.5-fold). In situ hybridization and immunohistochemistry demonstrated the concordant expression of mRNA and protein for PDGF-B in the smooth muscle cells (SMCs) of injured vessels throughout the experiment. PDGF-B expression peaked in neointimal SMCs at day 7. In accordance with PDGF-B expression, cellular proliferation in neointima peaked at day 7, being followed by a dramatic increase of neointimal areas thereafter. Further, we demonstrated PDGFR-beta immunoreactivity in these neointimal cells with PDGF-B expression. Our data provide evidence that PDGF-B may stimulate vascular SMC proliferation and contribute to neointimal formation after angioplasty.

The antiproliferative activity of c-myb and c-myc antisense oligonucleotides in smooth muscle cells is caused by a nonantisense mechanism

Smooth muscle cell (SMC) proliferation is thought to play a major role in vascular restenosis after angioplasty and is a serious complication of the procedure. Developing antisense (AS) oligonucleotides as therapeutics is attractive because of the potentially high specificity of binding to their targets, and several investigators have reported inhibition of SMC proliferation in vitro and in vivo by using AS strategies. We report here the results of our experiments on vascular SMCs using AS oligonucleotides directed toward c-myb and c-myc. We found that significant inhibition of SMC proliferation occurred with these specific AS sequences but that this inhibition was clearly not via a hybridization-dependent AS mechanism. Rather, inhibition was due to the presence of four contiguous guanosine residues in the oligonucleotide sequence. This was demonstrated in vitro in primary cultures of SMCs and in arteries ex vivo. The ex vivo model developed here provides a rapid and effective system in which to screen potential oligonucleotide drugs for restenosis. We have further explored the sequence requirements of this non-AS effect and determined that phosphorothioate oligonucleotides containing at least two sets of three or four consecutive guanosine residues inhibit SMC proliferation in vitro and ex vivo. These results suggest that previous AS data obtained using these and similar, contiguous guanosine-containing AS sequences be reevaluated and that there may be an additional class of nucleic acid compounds that have potential as antirestenosis therapeutics.

Vascular gene therapy

Gene therapy is emerging as a new and exciting therapeutic modality for cardiovascular pathology. The work reported here was carried out in the National Heart, Lung and Blood Institute (NHLBI) in Bethesda, MD, USA, where genetically engineered endothelial cells were used to seed endovascular prostheses and cell adhesion to the prostheses was tested both in vitro and in vivo. Two catheter based systems were used to deliver genes to the arterial wall cells in vivo, employing retroviral and adenoviral vectors. Efficient gene transfer to vascular cells in vivo was achieved with adenoviral vectors.

The uptake and distribution of phosphorothioate oligonucleotides into vascular smooth muscle cells in vitro and in rabbit arteries

Oligonucleotides are a class of compounds with potential as therapeutics for a variety of clinical applications. Local delivery of oligonucleotides to the arterial wall is a challenging aspect of the development of these therapeutics for restenosis, and herein we report experiments characterizing the uptake and distribution of phosphorothiate oligonucleotides into vascular smooth muscle cells in primary cultures and in rabbit arteries. Primary cultures of smooth muscle cells incubated with rhodamine-oligonucleotides showed uptake only into cytoplasmic vesicles. No nuclear or cytosolic localization was detected. In normal arteries there was no visible tissue or cellular uptake of oligonucleotides after intralumenal administration. However, in balloon-injured arteries there was significant oligonucleotide uptake into the tissue with apparent cytoplasmic delivery to the medial smooth muscle cells, as evinced by intense staining of their nuclei with labeled oligonucleotides. Measurement of FITC-oligonucleotide in artery extracts showed significantly greater uptake in injured, compared with normal arteries. Light and electron microscopic studies demonstrated a correlation between the degree of damage and the amount of uptake. These results demonstrate that oligonucleotides penetrate easily into the arterial wall of balloon-injured arteries and accumulate in the medial smooth muscle cells-the target cells for antirestenosis therapeutics following balloon angioplasty.

Morphologic characteristics of lesion formation and time course of smooth muscle cell proliferation in a porcine proliferative restenosis model

OBJECTIVES

This study was performed to define the evolution of lesion morphology and its relation to thrombus formation and smooth muscle cell proliferation after experimental coronary stent placement.

BACKGROUND

Restenosis after percutaneous revascularization may develop because of thrombus accumulation and smooth muscle cell proliferation. In animal models of restenosis, thrombus may assume a significant role in neointimal formation by providing an absorbable matrix into which smooth muscle cells proliferate.

METHODS

Twenty-eight oversized stents were placed in the coronary arteries of 23 juvenile domestic pigs. The histologic degree of vessel injury, lesion morphometry and smooth muscle cell proliferation measured by immunolocalization with a monoclonal antibody to proliferating cell nuclear antigen (PCNA) were assessed at 24 h and 7, 14 and 28 days after stent placement.

RESULTS

The area of thrombus was minimal at 24 h ([mean +/- SE] 0.44 +/- 0.12 mm2). Neointimal area at 7 days (0.72 +/- 0.20 mm2) was similar to the area of thrombus, followed by a significant increase at 14 days (3.15 +/- 0.39 mm2) and 28 days (3.30 +/- 0.28 mm2) (p < 0.0036, 24 h and 7 days vs. 14 and 28 days). At 14 and 28 days, neointimal thickness correlated with the histologic degree of vessel injury (p < 0.003). In arteries with severe injury, the increase in neointimal thickness is accounted for by replacement of the damaged media. The smooth muscle cell proliferation index was 18.6 +/- 3.5% at 7 days compared with 9.6 +/- 1.3% by 14 days (p = 0.0247) and declined to 1.1 +/- 0.97% by 28 days (p < 0.008, 7 and 14 days vs. 28 days).

CONCLUSIONS

Early thrombus formation is minimal, and thrombus accounts for a small portion of subsequent neointimal formation. Smooth muscle cell proliferation and matrix formation are the major factors relating to neointimal formation in this proliferative model of restenosis. The evolution of neointimal formation after coronary stenting shows maximal smooth muscle cell proliferation at 7 days, with a decline to low levels by 28 days. Therefore, these data may be useful for developing effective therapies for restenosis.

In vivo suppression of injury-induced vascular smooth muscle cell accumulation using adenovirus-mediated transfer of the herpes simplex virus thymidine kinase gene

Restenosis, a process characterized in part by excessive smooth muscle cell (SMC) proliferation in areas of vascular injury, occurs in up to 50% of patients undergoing balloon angioplasty. In an effort to develop a treatment strategy for restenosis, we constructed a replication-deficient recombinant adenovirus (AdMLP.HSTK) containing the herpes simplex virus thymidine kinase gene (HSV tk). This viral gene product phosphorylates the prodrug ganciclovir to form a nucleoside analog that inhibits DNA synthesis. Cultured primary rat SMCs infected with AdMLP.HSTK were completely growth-inhibited by incubation in ganciclovir-containing medium. In addition, when only a portion of the SMC population received the HSV tk transgene, an inhibitory effect on neighboring SMCs was evident. Evaluation of this strategy in vivo using a rat carotid balloon injury model demonstrated that local infection of injured arteries with AdMLP.-HSTK followed by 2 weeks of systemic ganciclovir treatment significantly (P < 0.01) reduced injury-induced SMC accumulation. In contrast, there was no suppression of injury-induced SMC accumulation in animals infected with AdMLP.HSTK but not receiving ganciclovir or in those animals infected with a control adenovirus and either treated or not treated with ganciclovir. These results demonstrate the potential utility of adenovirus-mediated gene transfer for treatment of restenosis after balloon injury.

Localized intramural drug delivery during balloon angioplasty using hydrogel-coated balloons and pressure-augmented diffusion

OBJECTIVES

This study was designed to assess the feasibility of using hydrogel-coated balloons to deliver biologically active agents to the blood vessel wall.

BACKGROUND

The local intramural delivery of therapeutic agents during balloon angioplasty has been proposed as an adjunctive technique for preventing early intracoronary thrombosis and late restenosis.

METHODS

To assess the efficacy of delivery and depth of penetration in vitro, local delivery of horseradish peroxidase was performed in 40 porcine peripheral arteries, and delivery of fluoresceinated heparin was performed in 20 porcine peripheral arteries and 7 human atheromatous arteries. To determine the persistence of these agents in the vessel wall in vivo, horseradish peroxidase was delivered to 18 porcine peripheral arteries that were harvested at intervals of 45 min to 48 h. Fluoresceinated heparin was delivered to 22 porcine peripheral arteries, 14 with the use of a protective sleeve, harvested at intervals of 30 s to 24 h.

RESULTS

In vitro agent delivery was successful in all specimens. The depth of penetration of horseradish peroxidase was directly related to both balloon pressure (p < 0.04) and duration of inflation (p < 0.01). In vivo peroxidase staining was evident at 45 and 90 min but not thereafter. With the use of a protective sleeve, heparin was present in all arteries harvested at 30 s, with marked dissipation at 1 and 24 h. Without a sleeve, no fluorescein staining was detected in any artery. With both agents, delivery occurred consistently over broad regions of the vessel wall that were free of architectural disruption.

CONCLUSIONS

Hydrogel-coated balloons can deliver biologically active agents to the vessel wall without gross tissue disruption and may provide an atraumatic method for the local delivery of therapeutic agents during balloon angioplasty.

The basis of molecular strategies for treating coronary restenosis after angioplasty

Excessive smooth muscle cell proliferation significantly contributes to restenosis, which occurs in 25% to 50% of patients within 6 months of coronary angioplasty. Because successful treatment will probably depend on our acquiring a comprehensive knowledge of the molecular and cellular mechanisms involved, this report reviews 1) information relevant to the molecular and cellular mechanisms responsible for the smooth muscle cell(s) response to vascular injury, and 2) several molecular-based therapeutic strategies currently being explored as possible approaches to the control of restenosis, including recombinant DNA technology to target delivery of cytotoxic molecules to proliferating smooth muscle cell(s), antisense strategies to inhibit expression of gene products necessary for cell proliferation and gene therapy.

The restenosis paradigm revisited: an alternative proposal for cellular mechanisms

Coronary restenosis is a reparative response to arterial injury during angioplasty, and remains a major clinical problem. The reasons for treatment failures likely stem from our incomplete understanding of the cellular mechanisms in restenotic neointimal formation. Restenosis is thought to result from migration and replication of medial smooth muscle cells to form an obstructive neointima, a concept neither observed nor demonstrated in humans. An alternative hypothesis for restenosis is based on observations in the porcine coronary injury model. In this model, there are three cellular stages in neointimal formation: thrombotic (stage I), cellular recruitment (stage II) and proliferative (stage III). The thrombotic stage occurs early and consists of platelets, fibrin and red blood cells accumulating at the vessel injury site. In the recruitment stage, the mural thrombus itself develops an endothelium, followed by a mononuclear leukocytic infiltrate beginning on the lumen side of the vessel. In the proliferative stage, a "cap" of actin-positive cells forms on the lumen surface and progressively thickens. These cells do not arise from media at the injury site. Extracellular matrix secretion and additional recruitment likely add to neointimal volume during this phase. Thrombus assumes a major role in restonosis by providing an absorbable matrix into which smooth muscle cells proliferate. Further studies are needed to validate or modify this hypothesis.