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Hsu B, Wang C, Lai Y, Kuo C, Lin Y. Association of endothelial dysfunction and peripheral arterial disease with sarcopenia in chronic kidney disease. J Cachexia Sarcopenia Muscle 2024; 15:1199-1208. [PMID: 38644163 PMCID: PMC11154745 DOI: 10.1002/jcsm.13471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 12/21/2023] [Accepted: 03/19/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Endothelial dysfunction and peripheral arterial disease (PAD), which disturb skeletal muscle microperfusion, are highly prevalent in patients with chronic kidney disease (CKD). We evaluated the association of endothelial dysfunction and PAD with sarcopenia in patients with non-dialysis CKD. METHODS This cross-sectional study included 420 patients with stages 3-5 non-dialysis CKD aged 69.0 ± 11.8 years. Skeletal muscle index (skeletal muscle mass/height2), handgrip strength, 6-m gait speed and strength of hip flexion and knee extension were measured. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019. Endothelial dysfunction and PAD were assessed using the vascular reactivity index (VRI) and ankle-brachial index (ABI), respectively. A VRI < 1.0 was classified as poor endothelial function, and an ABI < 0.9 was defined as PAD. Additionally, endothelial and inflammatory biomarkers, including intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), asymmetric dimethylarginine, endothelin-1 (ET-1) and interleukin-6, were measured in a subgroup of 262 patients. RESULTS Among the participants, 103 (24.5%) were classified as having sarcopenia. Compared with patients without sarcopenia, those with sarcopenia had significantly lower ABI (1.04 ± 0.16 vs. 1.08 ± 0.15, P = 0.028 for the right ABI; 1.01 ± 0.16 vs. 1.06 ± 0.16, P = 0.002 for the left ABI) and VRI (0.83 ± 0.57 vs. 1.08 ± 0.56, P < 0.001) and had higher serum levels of ICAM-1 (P < 0.001), VCAM-1 (P = 0.003) and ET-1 (P = 0.037). Multivariate logistic regression revealed that, beyond age and body mass index, the average ABI (odds ratio [OR]: 0.81/0.1 increase; 95% confidence interval [CI]: 0.67-0.98; P = 0.032) and VRI (OR: 0.93/0.1 increase; 95% CI: 0.88-0.98; P = 0.010) were independently associated with sarcopenia. Among the endothelial biomarkers measured, ICAM-1 (OR: 2.47/1-SD increase; 95% CI: 1.62-3.75) and VCAM-1 (OR: 1.91/1-SD increase; 95% CI: 1.27-2.87) were independent predictors of sarcopenia. Group stratification based on the cut-offs of VRI and ABI showed that those with both poor VRI and ABI had the greatest risk for sarcopenia (OR: 4.22; 95% CI: 1.69-10.49), compared with those with normal VRI and ABI. CONCLUSIONS Endothelial dysfunction and PAD are independently associated with sarcopenia in patients with stages 3-5 CKD, suggesting the dominant role of vascular dysfunction in sarcopenia.
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Affiliation(s)
- Bang‐Gee Hsu
- Division of NephrologyHualien Tzu Chi Hospital, Buddhist Tzu Chi Medical FoundationHualienTaiwan
- School of MedicineTzu Chi UniversityHualienTaiwan
| | - Chih‐Hsien Wang
- Division of NephrologyHualien Tzu Chi Hospital, Buddhist Tzu Chi Medical FoundationHualienTaiwan
- School of MedicineTzu Chi UniversityHualienTaiwan
| | - Yu‐Hsien Lai
- Division of NephrologyHualien Tzu Chi Hospital, Buddhist Tzu Chi Medical FoundationHualienTaiwan
- School of MedicineTzu Chi UniversityHualienTaiwan
| | - Chiu‐Huang Kuo
- Division of NephrologyHualien Tzu Chi Hospital, Buddhist Tzu Chi Medical FoundationHualienTaiwan
- School of Post‐baccalaureate Chinese MedicineTzu Chi UniversityHualienTaiwan
| | - Yu‐Li Lin
- Division of NephrologyHualien Tzu Chi Hospital, Buddhist Tzu Chi Medical FoundationHualienTaiwan
- School of MedicineTzu Chi UniversityHualienTaiwan
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Deppen JN, Ginn SC, Tang EO, Wang L, Brockman ML, Levit RD. Alginate-Encapsulated Mesenchymal Stromal Cells Improve Hind Limb Ischemia in a Translational Swine Model. J Am Heart Assoc 2024; 13:e029880. [PMID: 38639336 PMCID: PMC11179867 DOI: 10.1161/jaha.123.029880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/01/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Cellular therapies have been investigated to improve blood flow and prevent amputation in peripheral artery disease with limited efficacy in clinical trials. Alginate-encapsulated mesenchymal stromal cells (eMSCs) demonstrated improved retention and survival and promoted vascular generation in murine hind limb ischemia through their secretome, but large animal evaluation is necessary for human applicability. We sought to determine the efficacy of eMSCs for peripheral artery disease-induced limb ischemia through assessment in our durable swine hind limb ischemia model. METHODS AND RESULTS Autologous bone marrow eMSCs or empty alginate capsules were intramuscularly injected 2 weeks post-hind limb ischemia establishment (N=4/group). Improvements were quantified for 4 weeks through walkway gait analysis, contrast angiography, blood pressures, fluorescent microsphere perfusion, and muscle morphology and histology. Capsules remained intact with mesenchymal stromal cells retained for 4 weeks. Adenosine-induced perfusion deficits and muscle atrophy in ischemic limbs were significantly improved by eMSCs versus empty capsules (mean±SD, 1.07±0.19 versus 0.41±0.16, P=0.002 for perfusion ratios and 2.79±0.12 versus 1.90±0.62 g/kg, P=0.029 for ischemic muscle mass). Force- and temporal-associated walkway parameters normalized (ratio, 0.63±0.35 at week 3 versus 1.02±0.19 preligation; P=0.17), and compensatory footfall patterning was diminished in eMSC-administered swine (12.58±8.46% versus 34.85±15.26%; P=0.043). Delivery of eMSCs was associated with trending benefits in collateralization, local neovascularization, and muscle fibrosis. Hypoxia-cultured porcine mesenchymal stromal cells secreted vascular endothelial growth factor and tissue inhibitor of metalloproteinase 2. CONCLUSIONS This study demonstrates the promise of the mesenchymal stromal cell secretome at improving peripheral artery disease outcomes and the potential for this novel swine model to serve as a component of the preclinical pipeline for advanced therapies.
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Affiliation(s)
- Juline N. Deppen
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGA
- Division of CardiologyEmory University School of MedicineAtlantaGA
| | - Sydney C. Ginn
- Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaGA
- Division of CardiologyEmory University School of MedicineAtlantaGA
| | - Erica O. Tang
- Division of CardiologyEmory University School of MedicineAtlantaGA
| | - Lanfang Wang
- Division of CardiologyEmory University School of MedicineAtlantaGA
| | | | - Rebecca D. Levit
- Division of CardiologyEmory University School of MedicineAtlantaGA
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Elsaid NMH, Peters DC, Galiana G, Sinusas AJ. Clinical physiology: the crucial role of MRI in evaluation of peripheral artery disease. Am J Physiol Heart Circ Physiol 2024; 326:H1304-H1323. [PMID: 38517227 DOI: 10.1152/ajpheart.00533.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 03/23/2024]
Abstract
Peripheral artery disease (PAD) is a common vascular disease that primarily affects the lower limbs and is defined by the constriction or blockage of peripheral arteries and may involve microvascular dysfunction and tissue injury. Patients with diabetes have more prominent disease of microcirculation and develop peripheral neuropathy, autonomic dysfunction, and medial vascular calcification. Early and accurate diagnosis of PAD and disease characterization are essential for personalized management and therapy planning. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and multiplanar imaging capabilities and is useful as a noninvasive imaging tool in the comprehensive physiological assessment of PAD. This review provides an overview of the current state of the art of MRI in the evaluation and characterization of PAD, including an analysis of the many applicable MR imaging techniques, describing the advantages and disadvantages of each approach. We also present recent developments, future clinical applications, and future MRI directions in assessing PAD. The development of new MR imaging technologies and applications in preclinical models with translation to clinical research holds considerable potential for improving the understanding of the pathophysiology of PAD and clinical applications for improving diagnostic precision, risk stratification, and treatment outcomes in patients with PAD.
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Affiliation(s)
- Nahla M H Elsaid
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Gigi Galiana
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
| | - Albert J Sinusas
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, United States
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, United States
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States
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4
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Bradley CE, Fletcher E, Wilkinson T, Ring A, Ferrer L, Miserlis D, Pacher P, Koutakis P. Mitochondrial fatty acid beta-oxidation: a possible therapeutic target for skeletal muscle lipotoxicity in peripheral artery disease myopathy. EXCLI JOURNAL 2024; 23:523-533. [PMID: 38741727 PMCID: PMC11089102 DOI: 10.17179/excli2024-7004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/10/2024] [Indexed: 05/16/2024]
Abstract
Peripheral artery disease (PAD) is an atherosclerotic disease impacting over 200 million individuals and the prevalence increases with age. PAD occurs when plaque builds up within the peripheral arteries, leading to reduced blood flow and oxygen supply to the outer extremities. Individuals who experience PAD suffer from ischemia, which is typically accompanied by significant damage to skeletal muscles. Additionally, this tissue damage affects mitochondria, causing them to become dysregulated and dysfunctional, resulting in decreased metabolic rates. As there is no known cure for PAD, researchers are exploring potential therapeutic targets by examining coexisting cardiovascular conditions and metabolic risk factors, such as the aging process. Among these comorbidities, type-two diabetes mellitus and obesity are particularly common in PAD cases. These conditions, along with aging itself, are associated with an elevated accumulation of ectopic lipids within skeletal muscles, similar to what is observed in PAD. Researchers have attempted to reduce excess lipid accumulation by increasing the rate of fatty acid beta oxidation. Manipulating acetyl coenzyme A carboxylase 2, a key regulatory protein of fatty acid beta oxidation, has been the primary focus of such research. When acetyl coenzyme A carboxylase 2 is inhibited, it interrupts the conversion of acetyl-CoA into malonyl-CoA, resulting in an increase in the rate of fatty acid beta oxidation. By utilizing samples from PAD patients and applying the pharmacological strategies developed for acetyl coenzyme A carboxylase 2 in diabetes and obesity to PAD, a potential new therapeutic avenue may emerge, offering hope for improved quality of life for individuals suffering from PAD.
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Affiliation(s)
- Cassandra E. Bradley
- Department of Biology, Baylor University, One Bear Place #97388, Waco, TX 76798, USA
| | - Emma Fletcher
- Department of Biology, Baylor University, One Bear Place #97388, Waco, TX 76798, USA
| | - Trevor Wilkinson
- Department of Biology, Baylor University, One Bear Place #97388, Waco, TX 76798, USA
| | - Andrew Ring
- Department of Biology, Baylor University, One Bear Place #97388, Waco, TX 76798, USA
| | - Lucas Ferrer
- Department of Surgery, University of Texas at Austin Dell Medical School, 1601 Trinity St, Room 6708A, Austin, TX 78712, USA
| | - Dimitrios Miserlis
- Department of Surgery, University of Texas at Austin Dell Medical School, 1601 Trinity St, Room 6708A, Austin, TX 78712, USA
| | - Pal Pacher
- National Institutes of Health, Bethesda, MD, USA
| | - Panagiotis Koutakis
- Department of Biology, Baylor University, One Bear Place #97388, Waco, TX 76798, USA
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5
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Gu J, Huang W, Duanmu Z, Zhuang R, Yang X. Cuproptosis and copper deficiency in ischemic vascular injury and repair. Apoptosis 2024:10.1007/s10495-024-01969-y. [PMID: 38649508 DOI: 10.1007/s10495-024-01969-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 04/25/2024]
Abstract
Ischemic vascular diseases are on the rise globally, including ischemic heart diseases, ischemic cerebrovascular diseases, and ischemic peripheral arterial diseases, posing a significant threat to life. Copper is an essential element in various biological processes, copper deficiency can reduce blood vessel elasticity and increase platelet aggregation, thereby increasing the risk of ischemic vascular disease; however, excess copper ions can lead to cytotoxicity, trigger cell death, and ultimately result in vascular injury through several signaling pathways. Herein, we review the role of cuproptosis and copper deficiency implicated in ischemic injury and repair including myocardial, cerebral, and limb ischemia. We conclude with a perspective on the therapeutic opportunities and future challenges of copper biology in understanding the pathogenesis of ischemic vascular disease states.
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Affiliation(s)
- Jiayi Gu
- Department of Neurology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Huang
- Department of Neurology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Duanmu
- School of Instrument Science and Opto-Electronics Engineering of Beijing Information Science and Technology University, Beijing, China
| | - Rulin Zhuang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
| | - Xilan Yang
- Department of General Practice, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Speichinger F, Gratl A, Raude B, Schawe L, Carstens J, Hering NA, Greiner A, Pesta D, Frese JP. Mitochondrial respiration in peripheral arterial disease depends on stage severity. J Cell Mol Med 2024; 28:e18126. [PMID: 38534092 DOI: 10.1111/jcmm.18126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/17/2023] [Accepted: 01/05/2024] [Indexed: 03/28/2024] Open
Abstract
Peripheral arterial disease (PAD) is an increasing cause of morbidity and its severity is graded based on clinical manifestation. To investigate the influence of the different stages on myopathy of ischemic muscle we analysed severity-dependent effects of mitochondrial respiration in PAD. Eighteen patients with severe PAD, defined as chronic limb-threatening ischemia, 47 patients with intermittent claudication (IC) and 22 non-ischemic controls were analysed. High-resolution respirometry (HRR) was performed on muscle biopsies of gastrocnemius and vastus lateralis muscle of patients in different PAD stages to investigate different respiratory states. Results from HRR are given as median and interquartile range and were normalized to citrate synthase activity (CSA), a marker for mitochondrial content. In order to account for inter-individual differences between patients and controls, we calculated the ratio of O₂-flux in gastrocnemius muscle over vastus muscle ('GV ratio'). CSA of the gastrocnemius muscle as a proxy for mitochondrial content was significantly lower in critical ischemia compared to controls. Mitochondrial respiration normalized to CSA was higher in IC compared to controls. Likewise, the GV ratio was significantly higher in IC compared to control. Mitochondrial respiration and CSA of PAD patients showed stage-dependent modifications with greater changes in the mild PAD stage group (IC).
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Affiliation(s)
- Fiona Speichinger
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of General and Visceral Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Alexandra Gratl
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ben Raude
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Larissa Schawe
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Carstens
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nina A Hering
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of General and Visceral Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Greiner
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Pesta
- Institute of Aerospace Medicine, German Aerospace Center (DLR), Cologne, Germany
- Centre for Endocrinology, Diabetes and Preventive Medicine (CEDP), University Hospital Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany
| | - Jan Paul Frese
- Department of Vascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
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7
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Palzkill VR, Tan J, Tice AL, Ferriera LF, Ryan TE. A 6-minute Limb Function Assessment for Therapeutic Testing in Experimental Peripheral Artery Disease Models. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.21.586197. [PMID: 38585832 PMCID: PMC10996543 DOI: 10.1101/2024.03.21.586197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Background The translation of promising therapies from pre-clinical models of hindlimb ischemia (HLI) to patients with peripheral artery disease (PAD) has been inadequate. While this failure is multifactorial, primary outcome measures in preclinical HLI models and clinical trials involving patients with PAD are not aligned well. For example, laser Doppler perfusion recovery measured under resting conditions is the most used outcome in HLI studies, whereas clinical trials involving patients with PAD primarily assess walking performance. Here, we sought to develop a 6-min limb function test for preclinical HLI models that assess muscular performance and hemodynamics congruently. Methods We developed an in situ 6-min limb function test that involves repeated isotonic (shortening) contractions performed against a submaximal load. Continuous measurement of muscle blood flow was performed using laser Doppler flowmetry. Quantification of muscle power, work, and perfusion are obtained across the test. To assess the efficacy of this test, we performed HLI via femoral artery ligation on several mouse strains: C57BL6J, BALBc/J, and MCK-PGC1α (muscle-specific overexpression of PGC1α). Additional experiments were performed using an exercise intervention (voluntary wheel running) following HLI. Results The 6-min limb function test was successful at detecting differences in limb function of C57BL6/J and BALBc/J mice subjected to HLI with effect sizes superior to laser Doppler perfusion recovery. C57BL6/J mice randomized to exercise therapy following HLI had smaller decline in muscle power, greater hyperemia, and performed more work across the 6-min limb function test compared to non-exercise controls with HLI. Mice with muscle-specific overexpression of PGC1α had no differences in perfusion recovery in resting conditions, but exhibited greater capillary density, increased muscle mass and absolute force levels, and performed more work across the 6-min limb function test compared to their wildtype littermates without the transgene. Conclusion These results demonstrate the efficacy of the 6-min limb function test to detect differences in the response to HLI across several interventions including where traditional perfusion recovery, capillary density, and muscle strength measures were unable to detect therapeutic differences.
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Affiliation(s)
- Victoria R. Palzkill
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Jianna Tan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | | | - Leonardo F. Ferriera
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- The Myology Institute, The University of Florida, Gainesville, FL, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Terence E. Ryan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- The Myology Institute, The University of Florida, Gainesville, FL, USA
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8
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Träger AP, Günther JS, Raming R, Paulus LP, Lang W, Meyer A, Kempf J, Caranovic M, Li Y, Wagner AL, Tan L, Danko V, Trollmann R, Woelfle J, Klett D, Neurath MF, Regensburger AP, Eckstein M, Uter W, Uder M, Herrmann Y, Waldner MJ, Knieling F, Rother U. Hybrid ultrasound and single wavelength optoacoustic imaging reveals muscle degeneration in peripheral artery disease. PHOTOACOUSTICS 2024; 35:100579. [PMID: 38312805 PMCID: PMC10835356 DOI: 10.1016/j.pacs.2023.100579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/18/2023] [Accepted: 11/29/2023] [Indexed: 02/06/2024]
Abstract
Peripheral arterial disease (PAD) leads to chronic vascular occlusion and results in end organ damage in critically perfused limbs. There are currently no clinical methods available to determine the muscular damage induced by chronic mal-perfusion. This monocentric prospective cross-sectional study investigated n = 193 adults, healthy to severe PAD, in order to quantify the degree of calf muscle degeneration caused by PAD using a non-invasive hybrid ultrasound and single wavelength optoacoustic imaging (US/SWL-OAI) approach. While US provides morphologic information, SWL-OAI visualizes the absorption of pulsed laser light and the resulting sound waves from molecules undergoing thermoelastic expansion. US/SWL-OAI was compared to multispectral data, clinical disease severity, angiographic findings, phantom experiments, and histological examinations from calf muscle biopsies. We were able to show that synergistic use of US/SWL-OAI is most likely to map clinical degeneration of the muscle and progressive PAD.
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Affiliation(s)
- Anna P. Träger
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
- Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
| | - Josefine S. Günther
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
- Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
| | - Roman Raming
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Lars-Philip Paulus
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
| | - Alexander Meyer
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
| | - Julius Kempf
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
- Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
| | - Milenko Caranovic
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
- Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
| | - Yi Li
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
- Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
| | - Alexandra L. Wagner
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Lina Tan
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Vera Danko
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Regina Trollmann
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Joachim Woelfle
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Daniel Klett
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, D-91054 Erlangen, Germany
| | - Markus F. Neurath
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, D-91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), University Hospital Erlangen, Ulmenweg 18, D-91054 Erlangen, Germany
- Erlangen Graduate School in Advanced Optical Technologies (SAOT), Friedrich-Alexander-Universität Erlangen-Nürnberg, Paul-Gordan-Straße 6, D-91052 Erlangen, Germany
| | - Adrian P. Regensburger
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Markus Eckstein
- Department of Pathology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstrasse 8-10, D-91054 Erlangen, Germany
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürrnberg (FAU), Waldstraße 6, D-91054 Erlangen, Germany
| | - Michael Uder
- Institute of Radiology, University Hospital Erlangen, Friedrich-Alexander, Universität Erlangen-Nürnberg (FAU), Maximiliansplatz 1, D-91054 Erlangen, Germany
| | - Yvonne Herrmann
- Department of Pediatric Cardiology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Maximilian J. Waldner
- Department of Medicine 1, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, D-91054 Erlangen, Germany
- Deutsches Zentrum für Immuntherapie (DZI), University Hospital Erlangen, Ulmenweg 18, D-91054 Erlangen, Germany
- Erlangen Graduate School in Advanced Optical Technologies (SAOT), Friedrich-Alexander-Universität Erlangen-Nürnberg, Paul-Gordan-Straße 6, D-91052 Erlangen, Germany
| | - Ferdinand Knieling
- Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nuremberg (FAU), Loschgestraße 15, D-91054 Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Krankenhausstraße 12, D-91054 Erlangen, Germany
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Koyama Y, Migita S, Shimodai-Yamada S, Suzuki M, Uto K, Okumura Y, Ohura N, Hao H. Pathology of Critical Limb Ischemia; Comparison of Plaque Characteristics Between Anterior and Posterior Tibial Arteries. J Atheroscler Thromb 2023; 30:1893-1904. [PMID: 37331812 DOI: 10.5551/jat.64259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023] Open
Abstract
AIMS Though the number of patients with peripheral arterial disease (PAD) and critical limb ischemia (CLI) is increasing, few histopathological studies of PAD, particularly that involving below-the-knee arteries, has been reported. We analyzed the pathology of anterior tibial artery (ATA) and posterior tibial artery (PTA) specimens obtained from patients who underwent lower extremity amputation due to CLIMethods: Dissected ATAs and PTAs were subjected to ex-vivo soft X-ray radiography, followed by pathological examination using 860 histological sections. This protocol was approved by the Ethics Review Board of Nihon University Itabashi Hospital (RK-190910-01) and Kyorin University Hospital (R02-179). RESULTS The calcified area distribution was significantly larger in PTAs than in ATAs on soft X-ray radiographic images (ATAs, 48.3% ±19.2 versus PTAs, 61.6% ±23.9; p<0.001). Eccentric plaque with necrotic core and macrophage infiltration were more prominent in ATAs than in PTAs (eccentric plaque: ATAs, 63.7% versus PTAs, 49.1%; p<0.0001, macrophage: ATAs, 0.29% [0.095 - 1.1%] versus PTAs, 0.12% [0.029 - 0.36%]; p<0.001), histopathologically. Thromboembolic lesions were more frequently identified in PTAs than in ATAs (ATAs, 11.1% versus PTAs 15.8%; p<0.05). Moreover, post-balloon injury pathology differed between ATAs and PTAs. CONCLUSIONS Histological features differed strikingly between ATAs and PTAs obtained from CLI patients. Clarifying the pathological features of CLI would contribute to establishing therapeutic strategies for PAD, particularly disease involving below-the knee-arteries.
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Affiliation(s)
- Yutaka Koyama
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Suguru Migita
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Sayaka Shimodai-Yamada
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
| | - Mayumi Suzuki
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
| | - Kenta Uto
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University School of Medicine
| | - Hiroyuki Hao
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine
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10
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Pass CG, Palzkill V, Tan J, Kim K, Thome T, Yang Q, Fazzone B, Robinson ST, O’Malley KA, Yue F, Scali ST, Berceli SA, Ryan TE. Single-Nuclei RNA-Sequencing of the Gastrocnemius Muscle in Peripheral Artery Disease. Circ Res 2023; 133:791-809. [PMID: 37823262 PMCID: PMC10599805 DOI: 10.1161/circresaha.123.323161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Lower extremity peripheral artery disease (PAD) is a growing epidemic with limited effective treatment options. Here, we provide a single-nuclei atlas of PAD limb muscle to facilitate a better understanding of the composition of cells and transcriptional differences that comprise the diseased limb muscle. METHODS We obtained gastrocnemius muscle specimens from 20 patients with PAD and 12 non-PAD controls. Nuclei were isolated and single-nuclei RNA-sequencing was performed. The composition of nuclei was characterized by iterative clustering via principal component analysis, differential expression analysis, and the use of known marker genes. Bioinformatics analysis was performed to determine differences in gene expression between PAD and non-PAD nuclei, as well as subsequent analysis of intercellular signaling networks. Additional histological analyses of muscle specimens accompany the single-nuclei RNA-sequencing atlas. RESULTS Single-nuclei RNA-sequencing analysis indicated a fiber type shift with patients with PAD having fewer type I (slow/oxidative) and more type II (fast/glycolytic) myonuclei compared with non-PAD, which was confirmed using immunostaining of muscle specimens. Myonuclei from PAD displayed global upregulation of genes involved in stress response, autophagy, hypoxia, and atrophy. Subclustering of myonuclei also identified populations that were unique to PAD muscle characterized by metabolic dysregulation. PAD muscles also displayed unique transcriptional profiles and increased diversity of transcriptomes in muscle stem cells, regenerating myonuclei, and fibro-adipogenic progenitor cells. Analysis of intercellular communication networks revealed fibro-adipogenic progenitors as a major signaling hub in PAD muscle, as well as deficiencies in angiogenic and bone morphogenetic protein signaling which may contribute to poor limb function in PAD. CONCLUSIONS This reference single-nuclei RNA-sequencing atlas provides a comprehensive analysis of the cell composition, transcriptional signature, and intercellular communication pathways that are altered in the PAD condition.
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Affiliation(s)
- Caroline G. Pass
- Department of Applied Physiology and Kinesiology (C.G.P., V.P., J.T., K.K., T.T., Q.Y., T.E.R.), The University of Florida, Gainesville
| | - Victoria Palzkill
- Department of Applied Physiology and Kinesiology (C.G.P., V.P., J.T., K.K., T.T., Q.Y., T.E.R.), The University of Florida, Gainesville
| | - Jianna Tan
- Department of Applied Physiology and Kinesiology (C.G.P., V.P., J.T., K.K., T.T., Q.Y., T.E.R.), The University of Florida, Gainesville
| | - Kyoungrae Kim
- Department of Applied Physiology and Kinesiology (C.G.P., V.P., J.T., K.K., T.T., Q.Y., T.E.R.), The University of Florida, Gainesville
| | - Trace Thome
- Department of Applied Physiology and Kinesiology (C.G.P., V.P., J.T., K.K., T.T., Q.Y., T.E.R.), The University of Florida, Gainesville
| | - Qingping Yang
- Department of Applied Physiology and Kinesiology (C.G.P., V.P., J.T., K.K., T.T., Q.Y., T.E.R.), The University of Florida, Gainesville
| | - Brian Fazzone
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy (B.F., S.T.R., K.A.O., S.T.S., S.A.B.), The University of Florida, Gainesville
- Malcom Randall VA Medical Center, Gainesville, FL (B.F., S.T.R., K.A.O., S.T.S., S.A.B.)
| | - Scott T. Robinson
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy (B.F., S.T.R., K.A.O., S.T.S., S.A.B.), The University of Florida, Gainesville
- Malcom Randall VA Medical Center, Gainesville, FL (B.F., S.T.R., K.A.O., S.T.S., S.A.B.)
| | - Kerri A. O’Malley
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy (B.F., S.T.R., K.A.O., S.T.S., S.A.B.), The University of Florida, Gainesville
- Malcom Randall VA Medical Center, Gainesville, FL (B.F., S.T.R., K.A.O., S.T.S., S.A.B.)
| | - Feng Yue
- Department of Animal Sciences (F.Y.), The University of Florida, Gainesville
- Myology Institute (F.Y., T.E.R.), The University of Florida, Gainesville
| | - Salvatore T. Scali
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy (B.F., S.T.R., K.A.O., S.T.S., S.A.B.), The University of Florida, Gainesville
- Malcom Randall VA Medical Center, Gainesville, FL (B.F., S.T.R., K.A.O., S.T.S., S.A.B.)
| | - Scott A. Berceli
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy (B.F., S.T.R., K.A.O., S.T.S., S.A.B.), The University of Florida, Gainesville
- Malcom Randall VA Medical Center, Gainesville, FL (B.F., S.T.R., K.A.O., S.T.S., S.A.B.)
| | - Terence E. Ryan
- Department of Applied Physiology and Kinesiology (C.G.P., V.P., J.T., K.K., T.T., Q.Y., T.E.R.), The University of Florida, Gainesville
- Center for Exercise Science (T.E.R.), The University of Florida, Gainesville
- Myology Institute (F.Y., T.E.R.), The University of Florida, Gainesville
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11
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Kumar A, Narkar VA. Nuclear receptors as potential therapeutic targets in peripheral arterial disease and related myopathy. FEBS J 2023; 290:4596-4613. [PMID: 35942640 PMCID: PMC9908775 DOI: 10.1111/febs.16593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 12/31/2022]
Abstract
Peripheral arterial disease (PAD) is a prevalent cardiovascular complication of limb vascular insufficiency, causing ischemic injury, mitochondrial metabolic damage and functional impairment in the skeletal muscle, and ultimately leading to immobility and mortality. While potential therapies have been mostly focussed on revascularization, none of the currently available pharmacological treatments are fully effective in PAD, often leading to amputations, particularly in chronic metabolic diseases. One major limitation of focussed angiogenesis and revascularization as a therapeutic strategy is a limited effect on metabolic restoration and muscle regeneration in the affected limb. Therefore, additional preclinical investigations are needed to discover novel treatment options for PAD preferably targeting multiple aspects of muscle recovery. In this review, we propose nuclear receptors expressed in the skeletal muscle as potential candidates for ischemic muscle repair in PAD. We review classic steroid and orphan receptors that have been reported to be involved in the regulation of paracrine muscle angiogenesis, oxidative metabolism, mitochondrial biogenesis and muscle regeneration, and discuss how these receptors could be critical for recovery from ischemic muscle damage. Furthermore, we identify existing gaps in our understanding of nuclear receptor signalling in the skeletal muscle and propose future areas of research that could be instrumental in exploring nuclear receptors as therapeutic candidates for treating PAD.
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Affiliation(s)
- Ashok Kumar
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX 77204
| | - Vihang A. Narkar
- Brown Foundation Institute of Molecular Medicine, UTHealth McGovern Medical School, Houston, TX, 77030
- University of Texas MD Anderson and UTHealth Graduate School of Biomedical Sciences, Houston, TX, 77030
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12
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Sopariwala DH, Rios AS, Saley A, Kumar A, Narkar VA. Estrogen-Related Receptor Gamma Gene Therapy Promotes Therapeutic Angiogenesis and Muscle Recovery in Preclinical Model of PAD. J Am Heart Assoc 2023; 12:e028880. [PMID: 37548153 PMCID: PMC10492941 DOI: 10.1161/jaha.122.028880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/30/2023] [Indexed: 08/08/2023]
Abstract
Background Peripheral arterial disease and critical limb ischemia are cardiovascular complications associated with vascular insufficiency, oxidative metabolic dysfunction, and myopathy in the limbs. Estrogen-related receptor gamma (ERRγ) has emerged as a dual regulator of paracrine angiogenesis and oxidative metabolism through transgenic mouse studies. Here our objective was to investigate whether postischemic intramuscular targeting of ERRγ via gene therapy promotes ischemic recovery in a preclinical model of peripheral arterial disease/critical limb ischemia. Methods and Results Adeno-associated virus 9 (AAV9) Esrrg gene delivery vector was developed and first tested via intramuscular injection in murine skeletal muscle. AAV9-Esrrg robustly increased ERRγ protein expression, induced angiogenic and oxidative genes, and boosted capillary density and succinate dehydrogenase oxidative metabolic activity in skeletal muscles of C57Bl/6J mice. Next, hindlimb ischemia was induced via unilateral femoral vessel ligation in mice, followed by intramuscular AAV9-Esrrg (or AAV9-green fluorescent protein) gene delivery 24 hours after injury. ERRγ overexpression increased ischemic neoangiogenesis and markers of endothelial activation, and significantly improved ischemic revascularization measured using laser Doppler flowmetry. Moreover, ERRγ overexpression restored succinate dehydrogenase oxidative metabolic capacity in ischemic muscle, which correlated with increased mitochondrial respiratory complex protein expression. Most importantly, myofiber size to number quantification revealed that AAV9-Esrrg restores myofibrillar size and mitigates ischemia-induced myopathy. Conclusions These results demonstrate that intramuscular AAV9-Esrrg delivery rescues ischemic pathology after hindlimb ischemia, underscoring that Esrrg gene therapy or pharmacological activation could be a promising strategy for the management of peripheral arterial disease/critical limb ischemia.
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Affiliation(s)
- Danesh H. Sopariwala
- Brown Foundation Institute of Molecular MedicineMcGovern Medical School at The University of Texas Health Science Center (UTHealth)HoustonTXUSA
| | - Andrea S. Rios
- Brown Foundation Institute of Molecular MedicineMcGovern Medical School at The University of Texas Health Science Center (UTHealth)HoustonTXUSA
| | - Addison Saley
- Department of BiosciencesRice UniversityHoustonTXUSA
| | - Ashok Kumar
- Department of Pharmacological and Pharmaceutical SciencesUniversity of HoustonTXUSA
| | - Vihang A. Narkar
- Brown Foundation Institute of Molecular MedicineMcGovern Medical School at The University of Texas Health Science Center (UTHealth)HoustonTXUSA
- Graduate School of Biomedical Sciences at UTHealthHoustonTXUSA
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13
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Palzkill VR, Tan J, Yang Q, Morcos J, Laitano O, Ryan TE. Activation of the Aryl Hydrocarbon Receptor in Endothelial Cells Impairs Ischemic Angiogenesis in Chronic Kidney Disease. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.24.550410. [PMID: 37546909 PMCID: PMC10401998 DOI: 10.1101/2023.07.24.550410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Rationale Chronic kidney disease (CKD) is a strong risk factor for peripheral artery disease (PAD) that is associated with worsened clinical outcomes. CKD leads to accumulation of tryptophan metabolites that associate with adverse limb events in PAD and are ligands of the aryl hydrocarbon receptor (AHR) which may regulate ischemic angiogenesis. Objectives To test if endothelial cell-specific deletion of the AHR (AHRecKO) alters ischemic angiogenesis and limb function in mice with CKD subjected to femoral artery ligation. Findings Male AHRecKO mice with CKD displayed better limb perfusion recovery and enhanced ischemic angiogenesis compared to wildtype mice with CKD. However, the improved limb perfusion did not result in better muscle performance. In contrast to male mice, deletion of the AHR in female mice with CKD had no impact on perfusion recovery or angiogenesis. Using primary endothelial cells from male and female mice, treatment with indoxyl sulfate uncovered sex-dependent differences in AHR activating potential and RNA sequencing revealed wide ranging sex-differences in angiogenic signaling pathways. Conclusion Endothelium-specific deletion of the AHR improved ischemic angiogenesis in male, but not female, mice with CKD. There are sex-dependent differences in Ahr activating potential within endothelial cells that are independent of sex hormones.
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Affiliation(s)
- Victoria R. Palzkill
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Jianna Tan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Qingping Yang
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Juliana Morcos
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
| | - Orlando Laitano
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- The Myology Institute, The University of Florida, Gainesville, FL, USA
| | - Terence E. Ryan
- Department of Applied Physiology and Kinesiology, The University of Florida, Gainesville, FL, USA
- Center for Exercise Science, The University of Florida, Gainesville, FL, USA
- The Myology Institute, The University of Florida, Gainesville, FL, USA
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14
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Ferrucci L, Candia J, Ubaida-Mohien C, Lyaskov A, Banskota N, Leeuwenburgh C, Wohlgemuth S, Guralnik JM, Kaileh M, Zhang D, Sufit R, De S, Gorospe M, Munk R, Peterson CA, McDermott MM. Transcriptomic and Proteomic of Gastrocnemius Muscle in Peripheral Artery Disease. Circ Res 2023; 132:1428-1443. [PMID: 37154037 PMCID: PMC10213145 DOI: 10.1161/circresaha.122.322325] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/17/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Few effective therapies exist to improve lower extremity muscle pathology and mobility loss due to peripheral artery disease (PAD), in part because mechanisms associated with functional impairment remain unclear. METHODS To better understand mechanisms of muscle impairment in PAD, we performed in-depth transcriptomic and proteomic analyses on gastrocnemius muscle biopsies from 31 PAD participants (mean age, 69.9 years) and 29 age- and sex-matched non-PAD controls (mean age, 70.0 years) free of diabetes or limb-threatening ischemia. RESULTS Transcriptomic and proteomic analyses suggested activation of hypoxia-compensatory mechanisms in PAD muscle, including inflammation, fibrosis, apoptosis, angiogenesis, unfolded protein response, and nerve and muscle repair. Stoichiometric proportions of mitochondrial respiratory proteins were aberrant in PAD compared to non-PAD, suggesting that respiratory proteins not in complete functional units are not removed by mitophagy, likely contributing to abnormal mitochondrial activity. Supporting this hypothesis, greater mitochondrial respiratory protein abundance was significantly associated with greater complex II and complex IV respiratory activity in non-PAD but not in PAD. Rate-limiting glycolytic enzymes, such as hexokinase and pyruvate kinase, were less abundant in muscle of people with PAD compared with non-PAD participants, suggesting diminished glucose metabolism. CONCLUSIONS In PAD muscle, hypoxia induces accumulation of mitochondria respiratory proteins, reduced activity of rate-limiting glycolytic enzymes, and an enhanced integrated stress response that modulates protein translation. These mechanisms may serve as targets for disease modification.
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Affiliation(s)
- Luigi Ferrucci
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | - Julián Candia
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | | | - Alexey Lyaskov
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | - Nirad Banskota
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | - Christiaan Leeuwenburgh
- University of Florida, Institute on Aging, Department of Physiology and Aging, Gainesville, FL, USA
| | - Stephanie Wohlgemuth
- University of Florida, Institute on Aging, Department of Physiology and Aging, Gainesville, FL, USA
| | - Jack M. Guralnik
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD, USA
| | - Mary Kaileh
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | - Dongxue Zhang
- Northwestern University Feinberg School of Medicine, Department of Neurology, Chicago, IL, USA
| | - Robert Sufit
- Northwestern University Feinberg School of Medicine, Department of Neurology, Chicago, IL, USA
| | - Supriyo De
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | - Myriam Gorospe
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | - Rachel Munk
- National Institute on Aging, Intramural Research Program, Baltimore, MD, USA
| | - Charlotte A. Peterson
- Center for Muscle Biology. College of Health Sciences, University of Kentucky, Lexington, KY, USA
| | - Mary M. McDermott
- Northwestern University Feinberg School of Medicine, Department of Medicine, Chicago, IL, USA
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15
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SenthilKumar G, Gutierrez-Huerta CA, Freed JK, Beyer AM, Fancher IS, LeBlanc AJ. New developments in translational microcirculatory research. Am J Physiol Heart Circ Physiol 2022; 323:H1167-H1175. [PMID: 36306213 PMCID: PMC9678417 DOI: 10.1152/ajpheart.00566.2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 01/28/2023]
Abstract
Microvascular disease plays a critical role in systemic end-organ dysfunction, and treatment of microvascular pathologies may greatly reduce cardiovascular morbidity and mortality. The Call for Papers collection: New Developments in Translational Microcirculatory Research highlights key advances in our understanding of the role of microvessels in the development of chronic diseases as well as therapeutic strategies to enhance microvascular function. This Mini Review provides a concise summary of these advances and draws from other relevant research to provide the most up-to-date information on the influence of cutaneous, cerebrovascular, coronary, and peripheral microcirculation on the pathophysiology of obesity, hypertension, cardiovascular aging, peripheral artery disease, and cognitive impairment. In addition to these disease- and location-dependent research articles, this Call for Papers includes state-of-the-art reviews on coronary endothelial function and assessment of microvascular health in different organ systems, with an additional focus on establishing rigor and new advances in clinical trial design. These articles, combined with original research evaluating cellular, exosomal, pharmaceutical, exercise, heat, and dietary interventional therapies, establish the groundwork for translating microcirculatory research from bench to bedside. Although numerous studies in this collection are focused on human microcirculation, most used robust preclinical models to probe mechanisms of pathophysiology and interventional benefits. Future work focused on translating these findings to humans are necessary for finding clinical strategies to prevent and treat microvascular dysfunction.
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Affiliation(s)
- Gopika SenthilKumar
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cristhian A Gutierrez-Huerta
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Julie K Freed
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andreas M Beyer
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ibra S Fancher
- Department of Kinesiology and Applied Physiology, College of Health Sciences, University of Delaware, Newark, Delaware
| | - Amanda Jo LeBlanc
- Department of Cardiovascular and Thoracic Surgery, School of Medicine, University of Louisville, Louisville, Kentucky
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky
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16
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Murrow JR, Brizendine JT, Young HJ, Rathbun S, Nilsson KR, McCully KK. Work during treadmill rehabilitation correlates with clinical benefit and muscle mitochondrial improvements in claudication. Vasc Med 2022; 27:585-586. [PMID: 36205229 DOI: 10.1177/1358863x221122529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Jonathan R Murrow
- Department of Medicine, Augusta University - University of Georgia Medical Partnership, Athens, GA, USA
| | - Jared T Brizendine
- Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Hui-Ju Young
- School of Health Professions, University of Alabama Birmingham, Birmingham, AB, USA
| | - Stephen Rathbun
- College of Education (Kinesiology), University of Georgia, Athens, GA, USA
| | - Kent R Nilsson
- Department of Medicine, Augusta University - University of Georgia Medical Partnership, Athens, GA, USA
| | - Kevin K McCully
- College of Education (Kinesiology), University of Georgia, Athens, GA, USA
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17
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Park SY, Pekas EJ, Anderson CP, Kambis TN, Mishra PK, Schieber MN, Wooden TK, Thompson JR, Kim KS, Pipinos II. Impaired microcirculatory function, mitochondrial respiration, and oxygen utilization in skeletal muscle of claudicating patients with peripheral artery disease. Am J Physiol Heart Circ Physiol 2022; 322:H867-H879. [PMID: 35333113 PMCID: PMC9018007 DOI: 10.1152/ajpheart.00690.2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/08/2022] [Accepted: 03/22/2022] [Indexed: 11/22/2022]
Abstract
Peripheral artery disease (PAD) is an atherosclerotic disease that impairs blood flow and muscle function in the lower limbs. A skeletal muscle myopathy characterized by mitochondrial dysfunction and oxidative damage is present in PAD; however, the underlying mechanisms are not well established. We investigated the impact of chronic ischemia on skeletal muscle microcirculatory function and its association with leg skeletal muscle mitochondrial function and oxygen delivery and utilization capacity in PAD. Gastrocnemius samples and arterioles were harvested from patients with PAD (n = 10) and age-matched controls (Con, n = 11). Endothelium-dependent and independent vasodilation was assessed in response to flow (30 μL·min-1), acetylcholine, and sodium nitroprusside (SNP). Skeletal muscle mitochondrial respiration was quantified by high-resolution respirometry, microvascular oxygen delivery, and utilization capacity (tissue oxygenation index, TOI) were assessed by near-infrared spectroscopy. Vasodilation was attenuated in PAD (P < 0.05) in response to acetylcholine (Con: 71.1 ± 11.1%, PAD: 45.7 ± 18.1%) and flow (Con: 46.6 ± 20.1%, PAD: 29.3 ± 10.5%) but not SNP (P = 0.30). Complex I + II state 3 respiration (P < 0.01) and TOI recovery rate were impaired in PAD (P < 0.05). Both flow and acetylcholine-mediated vasodilation were positively associated with complex I + II state 3 respiration (r = 0.5 and r = 0.5, respectively, P < 0.05). Flow-mediated vasodilation and complex I + II state 3 respiration were positively associated with TOI recovery rate (r = 0.8 and r = 0.7, respectively, P < 0.05). These findings suggest that chronic ischemia attenuates skeletal muscle arteriole endothelial function, which may be a key mediator for mitochondrial and microcirculatory dysfunction in the PAD leg skeletal muscle. Targeting microvascular dysfunction may be an effective strategy to prevent and/or reverse disease progression in PAD.NEW & NOTEWORTHY Ex vivo skeletal muscle arteriole endothelial function is impaired in claudicating patients with PAD, and this is associated with attenuated skeletal muscle mitochondrial respiration. In vivo skeletal muscle oxygen delivery and utilization capacity is compromised in PAD, and this may be due to microcirculatory and mitochondrial dysfunction. These results suggest that targeting skeletal muscle arteriole function may lead to improvements in skeletal muscle mitochondrial respiration and oxygen delivery and utilization capacity in claudicating patients with PAD.
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Affiliation(s)
- Song-Young Park
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska
| | - Elizabeth J Pekas
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska
| | - Cody P Anderson
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska
| | - Tyler N Kambis
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Paras K Mishra
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Molly N Schieber
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - TeSean K Wooden
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, Nebraska
| | - Jonathan R Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kyung Soo Kim
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
- Department of Surgery and Veterans Affairs Research Service, Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Iraklis I Pipinos
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska
- Department of Surgery and Veterans Affairs Research Service, Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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Implantation of Hypoxia-Induced Mesenchymal Stem Cell Advances Therapeutic Angiogenesis. Stem Cells Int 2022; 2022:6795274. [PMID: 35355589 PMCID: PMC8958070 DOI: 10.1155/2022/6795274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 12/13/2022] Open
Abstract
Hypoxia preconditioning enhances the paracrine abilities of mesenchymal stem cells (MSCs) for vascular regeneration and tissue healing. Implantation of hypoxia-induced mesenchymal stem cells (hi-MSCs) may further improve limb perfusion in a murine model of hindlimb ischemia. This study is aimed at determining whether implantation of hi-MSCs is an effective modality for improving outcomes of treatment of ischemic artery diseases. We evaluated the effects of human bone marrow-derived MSC implantation on limb blood flow in an ischemic hindlimb model. hi-MSCs were prepared by cell culture under 1% oxygen for 24 hours prior to implantation. A total of 1 × 105 MSCs and hi-MSCs and phosphate-buffered saline (PBS) were intramuscularly implanted into ischemic muscles at 36 hours after surgery. Restoration of blood flow and muscle perfusion was evaluated by laser Doppler perfusion imaging. Blood perfusion recovery, enhanced vessel densities, and improvement of function of the ischemia limb were significantly greater in the hi-MSC group than in the MSC or PBS group. Immunochemistry revealed that hi-MSCs had higher expression levels of hypoxia-inducible factor-1 alpha and vascular endothelial growth factor A than those in MSCs. In addition, an endothelial cell-inducing medium showed high expression levels of vascular endothelial growth factor, platelet endothelial cell adhesion molecule-1, and von Willebrand factor in hi-MSCs compared to those in MSCs. These findings suggest that pretreatment of MSCs with a hypoxia condition and implantation of hi-MSCs advances neovascularization capability with enhanced therapeutic angiogenic effects in a murine hindlimb ischemia model.
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Manfredini F, Traina L, Gasbarro V, Straudi S, Caruso L, Fabbian F, Zamboni P, Manfredini R, Lamberti N. Structured pain-free exercise progressively improves ankle-brachial index and walking ability in patients with claudication and compressible arteries: an observational study. Intern Emerg Med 2022; 17:439-449. [PMID: 34499318 PMCID: PMC8964614 DOI: 10.1007/s11739-021-02827-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/04/2021] [Indexed: 01/18/2023]
Abstract
In patients with peripheral artery disease (PAD), supervised exercise at near-moderate pain improves walking ability but not ankle-brachial index (ABI) values. In a retrospective observational study, we determined vascular and functional effects of a 6-month structured pain-free exercise program in patients with claudication and compressible vessels. Four-hundred and fifty-nine consecutive patients were studied. Segmental limb pressures were measured and ABI calculated during circa-monthly hospital visits. The 6-min (6MWD) and the pain-free walking distance (PFWD) during the 6-min walking test were determined. Two daily 8-min sessions of slow-moderate in-home walking at increasing metronome-paced speed were prescribed. After excluding patients with unmeasurable ABI or incompletion of the program, 239 patients were studied. Safe and satisfactory (88%) execution of the prescribed training sessions was reported. During the visits, bilateral ABI improved (+ 0.07; p < 0.001) as well as the segmental pressures in the more impaired limb, with changes already significant after 5 weeks of slow walking. Both systolic and diastolic blood pressure decreased overtime (F = 46.52; p < 0.001; F = 5.52; p < 0.001, respectively). 6MWD and PFWD improved (41[0‒73]m p < 0.001 and 107[42‒190]m p < 0.001, respectively) with associated decrease of walking heart rate (F = 15.91; p < 0.001) and Physiological Cost Index (F = 235.93; p < 0.001). The variations of most parameters at different visits correlated to the training load calculated. In a regression model, the PFWD variations directly correlated with rate sessions completed, training load and ABI change and inversely with the baseline value (R2 = 0.27; p < 0.001). In the PAD population studied, moderate pain-free exercise improved ABI with associated progressive functional and cardiovascular changes occurring regardless of subjects characteristics.
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Affiliation(s)
- Fabio Manfredini
- Department of Neuroscience and Rehabilitation, University of Ferrara, Via Luigi Borsari 46, 44121, Ferrara, Italy
- Unit of Physical and Rehabilitation Medicine, University Hospital of Ferrara, Ferrara, Italy
| | - Luca Traina
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Vincenzo Gasbarro
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Ferrara, Italy
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Sofia Straudi
- Unit of Physical and Rehabilitation Medicine, University Hospital of Ferrara, Ferrara, Italy
| | - Lorenzo Caruso
- Unit of Physical and Rehabilitation Medicine, University Hospital of Ferrara, Ferrara, Italy
| | - Fabio Fabbian
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Paolo Zamboni
- Vascular Diseases Center, University Hospital of Ferrara, Ferrara, Italy
| | | | - Nicola Lamberti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Via Luigi Borsari 46, 44121, Ferrara, Italy.
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Mohamad Yusoff F, Kajikawa M, Yamaji T, Takaeko Y, Hashimoto Y, Mizobuchi A, Han Y, Kishimoto S, Maruhashi T, Nakashima A, Higashi Y. Low-intensity pulsed ultrasound decreases major amputation in patients with critical limb ischemia: 5-year follow-up study. PLoS One 2021; 16:e0256504. [PMID: 34411183 PMCID: PMC8376014 DOI: 10.1371/journal.pone.0256504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/06/2021] [Indexed: 11/18/2022] Open
Abstract
Various therapeutic strategies for angiogenesis are performed to improve symptoms in patients with critical limb ischemia (CLI). Pre-clinical studies have shown that low-intensity pulsed ultrasound (LIPUS) exposure induces angiogenesis. LIPUS may be a new stratergy for treatment of CLI. The purpose of this pilot trial was to evaluate outcomes in patients with CLI who were treated with LIPUS. Fourteen patients with CLI, who were not candidates for angioplasty or surgical revascularization, were enrolled in this study. Historical control data were obtained from the Hiroshima University PAD database. The primary endpoints were major amputation and death. The outcomes were compared in 16 lower limbs of the 14 patients with CLI who were treated with LIPUS and in 14 lower limbs of 14 patients with CLI as historical controls. All patients were followed for after 5 years after treatment with LIPUS. The mean duration of LIPUS exposure in the LIPUS group was 381± 283 days. During the 5-year follow-up periods, there were 3 major amputations and 7 deaths in the LIPUS group and there were 14 major amputations and 7 deaths in the historical control group. The overall amputation-free survival rate was significantly higher in patients who were treated with LIPUS than in historical controls. There was no significant difference between overall mortality-free survival rates in the LIPUS group and historical control group. LIPUS is a noninvasive option for therapeutic angiogenesis with the potential to reduce the incidence of major amputations in patients with CLI.
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Affiliation(s)
- Farina Mohamad Yusoff
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Masato Kajikawa
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Takayuki Yamaji
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Yuji Takaeko
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Yu Hashimoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Aya Mizobuchi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yiming Han
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Shinji Kishimoto
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Ayumu Nakashima
- Department of Stem Cell Biology and Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
- * E-mail:
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21
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de Souza P, Perfete C. The Paradox of Exercise Intensity in Preventing Cardiovascular Events in Peripheral Arterial Occlusive Disease. Arq Bras Cardiol 2021; 117:317-318. [PMID: 34495226 PMCID: PMC8395792 DOI: 10.36660/abc.20210595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Pablo de Souza
- Clínica CardiosportFlorianópolisSCBrasilClínica Cardiosport, Florianópolis SC - Brasil.
- Instituto de Cardiologia de Santa CatarinaSão JoséSCBrasilInstituto de Cardiologia de Santa Catarina (ICSC), São José SC - Brasil.
| | - Cássio Perfete
- Clínica CardiosportFlorianópolisSCBrasilClínica Cardiosport, Florianópolis SC - Brasil.
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