Photodynamic therapy for the prevention of intimal hyperplasia in balloon-injured rabbit arteries

Photodynamic Therapy for Atherosclerosis: Past, Present, and Future

This review paper examines the evolution of photodynamic therapy (PDT) as a novel, minimally invasive strategy for treating atherosclerosis, a leading global health concern. Atherosclerosis is characterized by the accumulation of lipids and inflammation within arterial walls, leading to significant morbidity and mortality through cardiovascular diseases such as myocardial infarction and stroke. Traditional therapeutic approaches have primarily focused on modulating risk factors such as hypertension and hyperlipidemia, with emerging evidence highlighting the pivotal role of inflammation. PDT, leveraging a photosensitizer, specific-wavelength light, and oxygen, offers targeted treatment by inducing cell death in diseased tissues while sparing healthy ones. This specificity, combined with advancements in nanoparticle technology for improved delivery, positions PDT as a promising alternative to traditional interventions. The review explores the mechanistic basis of PDT, its efficacy in preclinical studies, and the potential for enhancing plaque stability and reducing macrophage density within plaques. It also addresses the need for further research to optimize treatment parameters, mitigate adverse effects, and validate long-term outcomes. By detailing past developments, current progress, and future directions, this paper aims to highlight PDT's potential in revolutionizing atherosclerosis treatment, bridging the gap from experimental research to clinical application.

Photodynamic Therapy and Cardiovascular Diseases

Cardiovascular diseases are the third most common cause of death in the world. The most common are heart attacks and stroke. Cardiovascular diseases are a global problem monitored by many centers, including the World Health Organization (WHO). Atherosclerosis is one aspect that significantly influences the development and management of cardiovascular diseases. Photodynamic therapy (PDT) is one of the therapeutic methods used for various types of inflammatory, cancerous and non-cancer diseases. Currently, it is not practiced very often in the field of cardiology. It is most often practiced and tested experimentally under in vitro experimental conditions. In clinical practice, the use of PDT is still rare. The aim of this review was to characterize the effectiveness of PDT in the treatment of cardiovascular diseases. Additionally, the most frequently used photosensitizers in cardiology are summarized.

Photodynamic Therapy for Atherosclerosis

Atherosclerosis, which currently contributes to 31% of deaths globally, is of critical cardiovascular concern. Current diagnostic tools and biomarkers are limited, emphasizing the need for early detection. Lifestyle modifications and medications form the basis of treatment, and emerging therapies such as photodynamic therapy are being developed. Photodynamic therapy involves a photosensitizer selectively targeting components of atherosclerotic plaques. When activated by specific light wavelengths, it induces localized oxidative stress aiming to stabilize plaques and reduce inflammation. The key advantage lies in its selective targeting, sparing healthy tissues. While preclinical studies are encouraging, ongoing research and clinical trials are crucial for optimizing protocols and ensuring long-term safety and efficacy. The potential combination with other therapies makes photodynamic therapy a versatile and promising avenue for addressing atherosclerosis and associated cardiovascular disease. The investigations underscore the possibility of utilizing photodynamic therapy as a valuable treatment choice for atherosclerosis. As advancements in research continue, photodynamic therapy might become more seamlessly incorporated into clinical approaches for managing atherosclerosis, providing a blend of efficacy and limited invasiveness.

Recent Advances for Dynamic-Based Therapy of Atherosclerosis

Atherosclerosis (AS) is a chronic inflammatory disease, which may lead to high morbidity and mortality. Currently, the clinical treatment strategy for AS is administering drugs and performing surgery. However, advanced therapy strategies are urgently required because of the deficient therapeutic effects of current managements. Increased number of energy conversion-based organic or inorganic materials has been used in cancer and other major disease treatments, bringing hope to patients with the development of nanomedicine and materials. These treatment strategies employ specific nanomaterials with specific own physiochemical properties (external stimuli: light or ultrasound) to promote foam cell apoptosis and cholesterol efflux. Based on the pathological characteristics of vulnerable plaques, energy conversion-based nano-therapy has attracted increasing attention in the field of anti-atherosclerosis. Therefore, this review focuses on recent advances in energy conversion-based treatments. In addition to summarizing the therapeutic effects of various techniques, the regulated pathological processes are highlighted. Finally, the challenges and prospects for further development of dynamic treatment for AS are discussed.

Applications of inorganic nanoparticles in the diagnosis and therapy of atherosclerosis

Atherosclerosis is a chronic progressive disease, which may result in serious clinical outcomes, such as acute heart events or stroke with high mortality. At present, the clinical problems of atherosclerosis mainly consist of the difficulty in confirming the plaques or identifying the stability of the plaques in the early phase and the shortage of valid treatments. Fortunately, with the development of nanotechnology, various inorganic nanoparticles with imaging enhancement and noninvasive therapy functions have been studied in the imaging and treatment of atherosclerosis, which has brought new hope to patients. This review focuses on the recent progress in the use of inorganic nanoparticles in the diagnosis and therapy of atherosclerosis, including the key processes in the development of atherosclerosis and the mainly involved cells, inorganic nanoparticle-based dual-mode imaging methods classified by the types of targeting cells, and inorganic nanoparticle-based therapeutic approaches, such as photothermal therapy (PTT), photodynamic therapy (PDT), sonodynamic therapy (SDT), drug delivery, gene therapy and imaging-guided therapy for atherosclerosis. Finally, this review discusses the challenges and directions of inorganic nanoparticles in potential clinical translation of anti-atherosclerosis in future. We believe this review will enable readers to systematically understand the progress of the inorganic nanoparticle-based imaging and therapy of atherosclerosis and therefore promote the further development of anti-atherosclerosis.

Porphyrin photosensitizers in photodynamic therapy and its applications

In 1841, the extraction of hematoporphyrin from dried blood by removing iron marked the birth of the photosensitizer. The last twenty years has witnessed extensive research in the application of photodynamic therapy (PDT) in tumor-bearing (or other diseases) animal models and patients. The period has seen development of photosensitizers from the first to the third generation, and their evolution from simple to more complex entities. This review focuses on porphyrin photosensitizers and their effect on tumors, mediated via several pathways involved in cell necrosis, apoptosis or autophagic cell death, and the preventive and therapeutic application of PDT against atherosclerosis.

Photodynamic therapy for the treatment of atherosclerotic plaque: Lost in translation?

Acute coronary syndrome is a life-threatening condition of utmost clinical importance, which, despite recent progress in the field, is still associated with high morbidity and mortality. Acute coronary syndrome results from a rupture or erosion of vulnerable atherosclerotic plaque with secondary platelet activation and thrombus formation, which leads to partial or complete luminal obstruction of a coronary artery. During the last decade, scientific evidence demonstrated that when an acute coronary event occurs, several nonculprit plaques are in a "vulnerable" state. Among the promising approaches, several investigations provided evidence of photodynamic therapy (PDT)-induced stabilization and regression of atherosclerotic plaque. Significant development of PDT strategies improved its therapeutic outcome. This review addresses PDT's pertinence and major problems/challenges toward its translation to a clinical reality.

Intra-Arterial Drug and Light Delivery for Photodynamic Therapy Using Visudyne®: Implication for Atherosclerotic Plaque Treatment

Photodynamic therapy (PDT), which is based on the activation of photosensitizers with light, can be used to reduce plaque burden. We hypothesized that intra-arterial photosensitizer administration and photo-activation will lead to high and rapid accumulation within the plaque with reduced systemic adverse effects. Thus, this "intra-arterial" PDT would be expected to have less side effects and due to the short time involved would be compatible with percutaneous coronary interventions.

AIM

We characterized the dose-dependent uptake and efficacy of intra-arterial PDT using Liposomal Verteporfin (Visudyne®), efficient for cancer-PDT but not tested before for PDT of atherosclerosis.

METHODS AND RESULTS

Visudyne® (100, 200, and 500 ng/ml) was perfused for 5-30 min in atherosclerotic aorta isolated from ApoE(-/-) mice. The fluorescence Intensity (FI) after 15 min of Visudyne® perfusion increased with doses of 100 (FI-5.5 ± 1.8), 200 (FI-31.9 ± 1.9) or 500 ng/ml (FI-42.9 ± 1.2). Visudyne® (500 ng/ml) uptake also increased with the administration time from 5 min (FI-9.8 ± 2.5) to 10 min (FI-23.3 ± 3.0) and 15 min (FI-42.9 ± 3.4) before reaching saturation at 30 min (FI-39.3 ± 2.4) contact. Intra-arterial PDT (Fluence: 100 and 200 J/cm(2), irradiance-334 mW/cm(2)) was applied immediately after Visudyne® perfusion (500 ng/ml for 15 min) using a cylindrical light diffuser coupled to a diode laser (690 nm). PDT led to an increase of ROS (Dihydroethidium; FI-6.9 ± 1.8, 25.3 ± 5.5, 43.4 ± 13.9) and apoptotic cells (TUNEL; 2.5 ± 1.6, 41.3 ± 15.3, 58.9 ± 6%), mainly plaque macrophages (immunostaining; 0.3 ± 0.2, 37.6 ± 6.4, 45.3 ± 5.4%) respectively without laser irradiation, or at 100 and 200 J/cm(2). Limited apoptosis was observed in the medial wall (0.5 ± 0.2, 8.5 ± 4.7, 15.3 ± 12.7%). Finally, Visudyne®-PDT was found to be associated with reduced vessel functionality (Myogram).

CONCLUSION

We demonstrated that sufficient accumulation of Visudyne® within plaque could be achieved in short-time and therefore validated the feasibility of local intravascular administration of photosensitizer. Intra-arterial Visudyne®-PDT preferentially affected plaque macrophages and may therefore alter the dynamic progression of plaque development.

A first trial in the clinical application of photodynamic therapy for the prevention of restenosis after coronary-stent placement

BACKGROUND AND OBJECTIVES

The aim of this clinical study was to evaluate the safety of local delivery of a photosensitizer followed by photodynamic therapy (PDT), to determine its effectiveness in reducing in-stent restenosis.

STUDY DESIGN/PATIENTS AND METHODS

Porfimer sodium was administered via a local delivery catheter to five coronary-stent implanted lesions followed by irradiation with a pulse laser. Coronary angiography (CAG) was performed at the baseline, after the procedure and at a 6-month follow-up.

RESULTS

By the 18-month clinical follow-up, no adverse events such as photodermatosis, or myocardial ischemia had occurred. At the follow-up, no coronary embolization, dissection, or aneurysmal dilatation was observed in the CAG. In-stent diameter stenosis, late loss, and loss index were 19.16+/-8.20%, 0.37+/-0.18 mm, and 0.19+/-0.12, respectively. No in-stent restenosis was observed.

CONCLUSIONS

This study suggests that PDT, with local delivery of Porfimer sodium, is safe and may be a feasible technique in preventing in-stent restenosis.

Platelet adhesion to photodynamic therapy-treated extracellular matrix proteins

Photodynamic therapy (PDT) produces reactive species that alter vascular wall biology and vessel wall proteins. In this study, we examined platelet adhesion to PDT-treated (photosensitizer = Photofrin; fluence 100 J/cm2; lambda = 630 nm) extracellular matrix (ECM), fibrinogen, von Willebrand factor (vWF) and collagen Types I and III, under flow conditions in a recirculating perfusion chamber. Platelet adhesion was quantified by image analysis. The effect of PDT on vWF was assessed by measuring the binding of domain-specific antibodies to treated vWF. PDT significantly decreased platelet adhesion to the ECM, fibrinogen and vWF. However, PDT of collagen resulted in significantly increased platelet adhesion, with large aggregate formation. PDT affected mostly the A1 (glycoprotein [GP]-Ib-binding site), A2 and A3 (collagen-binding site) domains of vWF but not the D'-D3 (factor VIII-binding site) and B-C1 (GP-IIb/IIIa-binding site) domains. In conclusion, PDT can alter the ECM, resulting in decreased platelet adhesion. However, vessels with high collagen content, such as veins and small arteries, may become increasingly prone to thrombosis. The results of this study may thus play a role in understanding the thrombogenic properties and mechanisms of vascular PDT.

Creation of a transrenal arteriovenous dialysis shunt: feasibility study in a swine model

PURPOSE

To investigate the feasibility of percutaneous renal artery and vein access for the creation of a transrenal arteriovenous hemodialysis graft.

MATERIALS AND METHODS

Renal-artery-to-ipsilateral-renal-vein conduits were constructed with use of entirely percutaneous techniques in seven swine. Renal artery and vein access was performed in six animals with use of a retrograde (inside-out) technique and in one animal with use of an antegrade (outside-in) technique. Modified 8-F sheaths were used in the first three animals and Wallgrafts were used in the final four animals to form the arterial and venous limbs of each shunt. The arterial and venous limbs were joined together by a subcutaneous segment of 6-mm reinforced polytetrafluoroethylene (PTFE) in five animals and by external conduits in two animals. Wallgrafts were deployed from the renal artery and vein into the segments of PTFE. The free ends of each conduit were tunneled and joined together to close the arteriovenous circuit. Post-shunt angiography was used in all animals to document successful shunt creation and demonstrate rapid arteriovenous shunting as a determinant of technical feasibility. Two of the seven animals received additional anticoagulation therapy and/or antiplatelet therapy to prevent shunt thrombosis during the follow-up period. The three initial animals were killed within 2 hours of shunt creation, and two of the remaining four animals returned for angiographic follow-up, one on day 2 and one on day 9. All animals underwent a complete necropsy to assess for potential complications including hemorrhage and vascular or bowel injury.

RESULTS

Retrograde renal arterial and venous access was successful in all six animals in which it was attempted. Five of six arterial accesses and four of six venous accesses traversed the peritoneum with two arterial accesses and one venous access penetrating a loop of large bowel. Antegrade access was performed and successfully accomplished in the final animal. Brisk arteriovenous shunting was demonstrated on completion angiography in all animals. Graft occlusion was present in the two animals that returned for follow-up and two animals died before follow-up as a result of graft leakage and subsequent hemorrhage. Minimal perinephric and intrarenal hemorrhage was demonstrated at necropsy after shunt insertion in the remaining five animals. Renal infarction was present in all kidneys used for transrenal access.

CONCLUSION

The transrenal approach for the creation of a percutaneous arteriovenous shunt is feasible after renal artery and vein access by either the retrograde or antegrade technique. Additional technical refinements of the procedure and the devices used will be necessary before follow-up studies are conducted.