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Martinez de Lizarrondo S, Gakuba C, Herbig BA, Repessé Y, Ali C, Denis CV, Lenting PJ, Touzé E, Diamond SL, Vivien D, Gauberti M. Potent Thrombolytic Effect of N-Acetylcysteine on Arterial Thrombi. Circulation 2017; 136:646-660. [PMID: 28487393 DOI: 10.1161/circulationaha.117.027290] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/26/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Platelet cross-linking during arterial thrombosis involves von Willebrand Factor (VWF) multimers. Therefore, proteolysis of VWF appears promising to disaggregate platelet-rich thrombi and restore vessel patency in acute thrombotic disorders such as ischemic stroke, acute coronary syndrome, or acute limb ischemia. N-Acetylcysteine (NAC, a clinically approved mucolytic drug) can reduce intrachain disulfide bonds in large polymeric proteins. In the present study, we postulated that NAC might cleave the VWF multimers inside occlusive thrombi, thereby leading to their dissolution and arterial recanalization. METHODS Experimental models of thrombotic stroke induced by either intra-arterial thrombin injection or ferric chloride application followed by measurement of cerebral blood flow using a combination of laser Doppler flowmetry and MRI were performed to uncover the effects of NAC on arterial thrombi. To investigate the effect of NAC on larger vessels, we also performed ferric chloride-induced carotid artery thrombosis. In vitro experiments were performed to study the molecular bases of NAC thrombolytic effect, including platelet aggregometry, platelet-rich thrombi lysis assays, thromboelastography (ROTEM), and high-shear VWF string formation using microfluidic devices. We also investigated the putative prohemorrhagic effect of NAC in a mouse model of intracranial hemorrhage induced by in situ collagenase type VII injection. RESULTS We demonstrated that intravenous NAC administration promotes lysis of arterial thrombi that are resistant to conventional approaches such as recombinant tissue-type plasminogen activator, direct thrombin inhibitors, and antiplatelet treatments. Through in vitro and in vivo experiments, we provide evidence that the molecular target underlying the thrombolytic effects of NAC is principally the VWF that cross-link platelets in arterial thrombi. Coadministration of NAC and a nonpeptidic GpIIb/IIIa inhibitor further improved its thrombolytic efficacy, essentially by accelerating thrombus dissolution and preventing rethrombosis. Thus, in a new large-vessel thromboembolic stroke model in mice, this cotreatment significantly improved ischemic lesion size and neurological outcome. It is important to note that NAC did not worsen hemorrhagic stroke outcome, suggesting that it exerts thrombolytic effects without significantly impairing normal hemostasis. CONCLUSIONS We provide evidence that NAC is an effective and safe alternative to currently available antithrombotic agents to restore vessel patency after arterial occlusion.
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Affiliation(s)
- Sara Martinez de Lizarrondo
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Clément Gakuba
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Bradley A Herbig
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Yohann Repessé
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Carine Ali
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Cécile V Denis
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Peter J Lenting
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Emmanuel Touzé
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Scott L Diamond
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Denis Vivien
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.)
| | - Maxime Gauberti
- From Normandie Univ, UNICAEN, INSERM, INSERM UMR-S U1237, Physiopathology and Imaging of Neurological Disorders (PhIND), Cyceron, Caen, France (S.M.d.L., C.G., Y.R., C.A., E.T., D.V., M.G.); CHU de Caen, Department of Anesthesiology and Critical Care Medicine, CHU de Caen Côte de Nacre, France (C.G.); Institute for Medicine and Engineering, Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia (B.A.H., S.L.D.); Laboratoire d'Hématologie, CHU de Caen, France (Y.R.); Institut National de la Santé et de la Recherche Médicale, UMR_S 1176, Univ. Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France (C.V.D., P.J.L.); CHU Caen, Neurology Department, CHU de Caen Côte de Nacre, France (E.T.); CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, France (D.V.); and CHU Caen, Department of Diagnostic Imaging and Interventional Radiology, CHU de Caen Côte de Nacre, France (M.G.).
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