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Simonneau G, Dorfmüller P, Guignabert C, Mercier O, Humbert M. Chronic thromboembolic pulmonary hypertension: the magic of pathophysiology. Ann Cardiothorac Surg 2022; 11:106-119. [PMID: 35433354 PMCID: PMC9012195 DOI: 10.21037/acs-2021-pte-10] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/26/2021] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and underdiagnosed complication of acute pulmonary embolism (APE). CTEPH is a common cause of pulmonary hypertension (PH) with distinct management strategy including pulmonary endarterectomy, balloon pulmonary angioplasty, long-term anticoagulation and PH drugs targeting endothelial cell dysfunction. Initially, PH in chronic thromboembolic pulmonary disease (CTEPD) was thought to be due exclusively to the intravascular obstruction of pulmonary arteries by unresolved fibrotic clots. However, it is now well accepted that pulmonary vascular remodelling can include significant pulmonary microvasculopathy, which plays a role in the development of CTEPH. The histological description and clinical consequences of CTEPH microvasculopathy are now better understood. These lesions may involve not only small muscular pulmonary arteries <500 µm, but also pulmonary capillaries and veins. In addition, enlargement and proliferation of systemic bronchial arteries as well as anastomoses between the systemic and pulmonary circulations contribute to the development of microvasculopathy. In this review, we discuss the recent advances in the understanding of the pathophysiology of CTEPH.
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Affiliation(s)
- Gérald Simonneau
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Referral Centre, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Department of Thoracic and Vascular Surgery, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Peter Dorfmüller
- Department of Pathology, University Hospital Giessen/Marburg, Giessen, Germany
- German Centre for Lung Research (DZL), Giessen, Germany
| | - Christophe Guignabert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Olaf Mercier
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Department of Thoracic and Vascular Surgery, Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Le Plessis-Robinson, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Assistance Publique Hôpitaux de Paris, Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension Referral Centre, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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2
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Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 279] [Impact Index Per Article: 93.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
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Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
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Henn D, Abu-Halima M, Wermke D, Falkner F, Thomas B, Köpple C, Ludwig N, Schulte M, Brockmann MA, Kim YJ, Sacks JM, Kneser U, Keller A, Meese E, Schmidt VJ. MicroRNA-regulated pathways of flow-stimulated angiogenesis and vascular remodeling in vivo. J Transl Med 2019; 17:22. [PMID: 30635008 PMCID: PMC6330440 DOI: 10.1186/s12967-019-1767-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/02/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Vascular shear stress promotes endothelial cell sprouting in vitro. The impact of hemodynamic forces on microRNA (miRNA) and gene expression within growing vascular networks in vivo, however, remain poorly investigated. Arteriovenous (AV) shunts are an established model for induction of neoangiogenesis in vivo and can serve as a tool for analysis of hemodynamic effects on miRNA and gene expression profiles over time. METHODS AV shunts were microsurgically created in rats and explanted on postoperative days 5, 10 and 15. Neoangiogenesis was confirmed by histologic analysis and micro-computed tomography. MiRNA and gene expression profiles were determined in tissue specimens from AV shunts by microarray analysis and quantitative real-time polymerase chain reaction and compared with sham-operated veins by bioinformatics analysis. Changes in protein expression within AV shunt endothelial cells were determined by immunohistochemistry. RESULTS Samples from AV shunts exhibited a strong overexpression of proangiogenic cytokines, oxygenation-associated genes (HIF1A, HMOX1), and angiopoetic growth factors. Significant inverse correlations of the expressions of miR-223-3p, miR-130b-3p, miR-19b-3p, miR-449a-5p, and miR-511-3p which were up-regulated in AV shunts, and miR-27b-3p, miR-10b-5p, let-7b-5p, and let-7c-5p, which were down-regulated in AV shunts, with their predicted interacting targets C-X-C chemokine receptor 2 (CXCR2), interleukin-1 alpha (IL1A), ephrin receptor kinase 2 (EPHA2), synaptojanin-2 binding protein (SYNJ2BP), forkhead box C1 (FOXC1) were present. CXCL2 and IL1A overexpression in AV shunt endothelium was confirmed at the protein level by immunohistochemistry. CONCLUSIONS Our data indicate that flow-stimulated angiogenesis is determined by an upregulation of cytokines, oxygenation associated genes and miRNA-dependent regulation of FOXC1, EPHA2 and SYNJ2BP.
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Affiliation(s)
- Dominic Henn
- Department of Hand, Plastic and Reconstructive Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Masood Abu-Halima
- Institute of Human Genetics, Saarland University, Homburg-Saar, Germany
| | - Dominik Wermke
- Institute of Clinical Bioinformatics, Saarland University, Saarbruecken, Germany
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Christoph Köpple
- Department of Hand, Plastic and Reconstructive Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Nicole Ludwig
- Institute of Human Genetics, Saarland University, Homburg-Saar, Germany
| | - Matthias Schulte
- Department of Hand, Plastic and Reconstructive Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Mainz, Germany
| | - Yoo-Jin Kim
- Institute of Pathology, Kaiserslautern, Germany
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Andreas Keller
- Institute of Clinical Bioinformatics, Saarland University, Saarbruecken, Germany
| | - Eckart Meese
- Institute of Human Genetics, Saarland University, Homburg-Saar, Germany
| | - Volker J Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, University of Heidelberg, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Str. 13, 67071, Ludwigshafen, Germany.
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Ghigna MR, Guignabert C, Montani D, Girerd B, Jaïs X, Savale L, Hervé P, Thomas de Montpréville V, Mercier O, Sitbon O, Soubrier F, Fadel E, Simonneau G, Humbert M, Dorfmüller P. BMPR2 mutation status influences bronchial vascular changes in pulmonary arterial hypertension. Eur Respir J 2016; 48:1668-1681. [PMID: 27811071 DOI: 10.1183/13993003.00464-2016] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 08/29/2016] [Indexed: 12/22/2022]
Abstract
The impact of bone morphogenetic protein receptor 2 (BMPR2) gene mutations on vascular remodelling in pulmonary arterial hypertension (PAH) is unknown. We sought to identify a histological profile of BMPR2 mutation carriers.Clinical data and lung histology from 44 PAH patients were subjected to systematic analysis and morphometry.Bronchial artery hypertrophy/dilatation and bronchial angiogenesis, as well as muscular remodelling of septal veins were significantly increased in PAH lungs carrying BMPR2 mutations. We found that patients displaying increased bronchial artery remodelling and bronchial microvessel density, irrespective of the mutation status, were more likely to suffer from severe haemoptysis. History of substantial haemoptysis (>50 mL) was significantly more frequent in BMPR2 mutation carriers. 43.5% of BMPR2 mutation carriers, as opposed to 9.5% of noncarriers, displayed singular large fibrovascular lesions, which appear to be closely related to the systemic lung vasculature.Our analysis provides evidence for the involvement of the pulmonary systemic circulation in BMPR2 mutation-related PAH. We show that BMPR2 mutation carriers are more prone to haemoptysis and that haemoptysis is closely correlated to bronchial arterial remodelling and angiogenesis; in turn, pronounced changes in the systemic vasculature correlate with increased pulmonary venous remodelling, creating a distinctive profile in PAH patients harbouring a BMPR2 mutation.
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Affiliation(s)
- Maria-Rosa Ghigna
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Dept of Pathology, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | - Christophe Guignabert
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David Montani
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Dept of Pulmonology, DHU Thorax Innovation, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Barbara Girerd
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Dept of Pulmonology, DHU Thorax Innovation, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Xavier Jaïs
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Dept of Pulmonology, DHU Thorax Innovation, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Laurent Savale
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Dept of Pulmonology, DHU Thorax Innovation, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Philippe Hervé
- Dept of Thoracic and Vascular Surgery, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Olaf Mercier
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Dept of Thoracic and Vascular Surgery, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Dept of Pulmonology, DHU Thorax Innovation, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Florent Soubrier
- AP-HP, Dept of Genetics, Pitié-Salpétrière Hospital, Université Pierre et Marie Curie, Paris, France
| | - Elie Fadel
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Dept of Thoracic and Vascular Surgery, Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | - Gérald Simonneau
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Dept of Pulmonology, DHU Thorax Innovation, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Marc Humbert
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France.,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Dept of Pulmonology, DHU Thorax Innovation, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Peter Dorfmüller
- INSERM UMR_S 999, LabEx LERMIT, Marie Lannelongue Hospital, Le Plessis-Robinson, France .,School of Medicine, Paris South University, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,Dept of Pathology, Marie Lannelongue Hospital, Le Plessis-Robinson, France
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Yunt ZX, Mohning MP, Barthel L, Kearns MT, Tuder RM, Hyde DM, Henson PM, Janssen WJ. Kinetics of the angiogenic response in lung endothelium following acute inflammatory injury with bleomycin. Exp Lung Res 2014; 40:415-25. [PMID: 25153689 DOI: 10.3109/01902148.2014.938202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE/AIM Angiogenesis is a central component of normal wound healing but it has not been fully characterized in lung repair following acute inflammatory injury. The current literature lacks vital information pertaining to the extent, timing, and location of this process. This information is necessary for examining mechanisms that drive normal lung repair in resolving acute inflammatory injury. The goal of our study was to formally characterize lung angiogenesis over a time course of bleomycin-induced lung injury. MATERIALS AND METHODS Female C57BL/6 mice age 8-12 weeks were treated with a single dose of intratracheal bleomycin. Total lung endothelial cells were quantified with flow cytometry 0, 7, 14, 21, and 28 days following bleomycin administration, and endothelial cell replication was assessed using bromodeoxyuridine (BrdU) incorporation. RESULTS Endothelial cell replication was maximal 14 days after bleomycin administration, while total lung endothelial cells peaked at day 21. Tissue analysis with stereology was performed to measure total lung vascular surface area in bleomycin at day 21 relative to controls and demonstrated a trend toward increased vasculature in the bleomycin group. CONCLUSIONS Angiogenesis begins shortly after injury in the bleomycin model and leads to an expansion in the lung endothelial cell population that peaks at day 21. This study offers the first longitudinal examination of angiogenesis following acute inflammatory lung injury induced by bleomycin. Information provided in this study will be vital for further investigating mechanisms of angiogenesis in both normal and abnormal lung repair.
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