Matrix Metalloproteinase-9 May Play a Role in Recanalization and Recurrence after Therapeutic Embolization of Aneurysms or Arteries

PURPOSE

Matrix metalloproteinase (MMP)-9 plays various roles in vascular healing and angiogenesis. This study was conducted to determine if MMP-9 is involved in healing or recanalization after therapeutic occlusion of arteries or aneurysms.

MATERIALS AND METHODS

Angiographic and pathologic changes were investigated in canine bilateral venous pouch carotid aneurysms embolized with gelatin sponges with or without previous endothelial denudation, a procedure that can prevent recanalization. To assess a potential role of MMP-9, messenger RNA (mRNA) and protein were compared in denuded and nondenuded aneurysms 4, 7, and 14 days after embolization. To assess if MMP-9 is essential to arterial recanalization, transmyocardial angiography and pathologic findings were compared 14 days after carotid occlusion with platinum coils in MMP-9-knockout and wild-type mice.

RESULTS

Denudation of the endothelial lining led to improved angiographic results at 3 weeks (P < .001). Neointimal closure of the aneurysm neck was more complete in denuded versus nondenuded aneurysms. Denudation was followed by a decrease in MMP-9 mRNA (86%, P < .05) and protein (30%, P < .05) 7 days after embolization and a decrease in von Willebrand factor compared with nondenuded aneurysms. MMP-9 immunostaining of axial sections from embolized aneurysms confirmed MMP-9-positive endothelialized clefts, which were absent in denuded aneurysms. Transmyocardial angiography and pathologic examination showed recanalization of one of nine coiled carotid arteries of MMP-9-knockout mice, compared with five of seven controls (P = .035).

CONCLUSIONS

MMP-9 may play a role in recanalization of arteries after coil occlusion and in recurrences after sponge embolization of aneurysms.

Effects of stenting the parent artery on aneurysm filling and gene expression of various potential factors involved in healing of experimental aneurysms

SUMMARY

Intracranial stents are increasingly used in the endovascular treatment of aneurysms, but very little is known regarding their effect on the cellular and molecular evolution of aneurysms. Bilateral venous pouch lateral wall carotid aneurysms were created in 20 dogs. All dogs then underwent angiography and balloon-expandable stenting of one aneurysm four to six weeks later. Fifteen dogs underwent aneurysm harvesting at one day (n=3), four days (n=4), seven days (n=3), and 14 days (n=5) for mRNA expression analysis, using axial sections taken from the aneurysm neck and fundus for RTPCR amplification of four cytokines or growth factors: TNF-a, TGF-b1, MCP-1, and PDGFBB; two adhesion molecules: VCAM-1 and PECAM-1; five matrix modifying agents; MMP- 2, 9, TIMPs 1, 3, 4, and two cellular markers: CD34 and a-SMA. Five other dogs, sacrificed at 12 weeks, were examined for extent of filling of the aneurysm neck with organized tissue and for neointima formation at the aneurysm ostium. Angiography was performed prior to sacrifice in all animals, and compared with initial studies. Eleven out of 20 stented aneurysms showed a favorable angiographic evolution, while none of the 20 nonstented aneurysms improved (p=0.001). Pathology showed partially occluded aneurysms, with neointima formation around the stent struts.Observed trends in mRNA expression, that stenting increased expression of genes involved in organization and neointima formation, agreed with experimental hypotheses, but differences between stented and non-stented aneurysms did not reach statistical significance. Parent vessel stenting was associated with angiographic improvement of aneurysm appearance. Modifications in mRNA expression patterns following stenting deserve further study to better establish potential molecular targets to promote aneurysm healing.

Endovascular Treatment with Platinum Coils. Recanalization is Associated with Early Increased von Willebrand Factor mRNA

SUMMARY

Recanalization after coil occlusion is a concern for long-term results of endovascular treatment. Knowledge of molecular events following coil occlusion and recanalization could help design specific strategies to promote permanent occlusion. Platinum coils were implanted into canine maxillary, vertebral or lingual arteries. Coil occlusion (treatment 1), routinely followed by recanalization was compared with two strategies to prevent recanalization: beta radiation using (32)P coils (treatment 2) and endothelial denudation, using an endovascular device, followed by coil occlusion (treatment 3). The evolution of initial complete occlusions was followed by angiography and pathology at three months. Levels of messenger RNA of vWF (von Willebrand factor), SMA (smooth muscle actin), CD14, CD31 (or PECAM-1: Platelet Endothelial Cell Adhesion Molecule-1), PDGFBB (platelet-derived growth factor), TGF-b1 (transforming growth factor), MCP-1 (macrophage chemoattractant protein), Angiopoietins, Metalloproteinases-9, 14 and inhibitors (TIMP- 2, 4) were followed by Reverse Transcription and Polymerase Chain Reaction (RT-PCR). Analyses were performed one, four, seven and 14 days after coiling, and levels of expression after the three treatments were compared using ANOVAs. Intact arteries treated with platinum coils routinely recanalize (100%), but arteries treated by denudation and coiling or with radioactive coils recanalize in only 17% and 4% respectively (P<.001). Recanalization was associated with increased levels of vWF mRNA at seven days, a finding that was not observed with denudation or radiation (P=.015). There was no other significant difference. Recanalization is associated with early vWF expression, perhaps reflecting the development of endothelialized channels through thrombus formed after coil occlusion.

Endovascular Treatment of Aneurysms: Gene Expression of Neointimal Cells Recruited on the Embolic Agent and Evolution with Recurrence in an Experimental Model

PURPOSE

The authors attempted to identify genes associated with healing or recurrence after embolization in an aneurysm model in which neointima formation at the neck varies according to flow zones. A better understanding of the relationship between blood flow, molecular events, and healing or recurrence may provide future avenues to improve results of endovascular treatment of aneurysms.

METHODS

Bilateral carotid venous pouch aneurysms were constructed in 36 dogs and embolized with gelatin sponges. Angiography and pathological studies were performed at T0 and/or 3 weeks (n=22). Angiographic results and neointima formation were scored using a qualitative index applied to the distal (inflow) and proximal (outflow) zones of the neck. In 14 animals, mRNA expression 1 to 14 days after embolization at the proximal or distal segment of the sponge was analyzed by RT-PCR, attempting to correlate flow zones, gene expression, and neointima formation.

RESULTS

Aneurysms recurred at 3 weeks, as shown by significantly worse angiographic scores as compared to T0 (P<.01). Neointimal scores differed at pathology, with a more complete neointima at the proximal as compared to the distal aspect of the sponge at 3 weeks (P=.027). Embolization was followed by migration of CD31+, CD14+, smooth muscle alpha-actin+ (SMA+) cells that progressively expressed metalloproteinases (MMP-9,-12,-14), but stable or lesser, retarded expression of inhibitors (TIMP1-4). Growth factors (PDGF-BB, TGF-beta1, TNF-alpha, MCP-1 and Ang-1) were expressed at increasing levels, maximal at 7 to 14 days. Differences between distal and proximal zones were limited to increased expression of MMP-2 proximally (P<.035).

CONCLUSION

Gene expression after embolization is compatible with patterns associated with neointima formation. The authors have not identified key factors involved in recurrence.

Recanalization of arterial thrombus, and inhibition with β-radiation in a new murine carotid occlusion model: mRNA expression of angiopoietins, metalloproteinases, and their inhibitors

BACKGROUND

Recanalization is an important physiologic phenomenon because it can efficiently reestablish circulation after thrombosis. We attempted to characterize molecular events related to recanalization or organization of arterial thrombus in a new murine model by studying genes reported to be involved in angiogenesis or neointima formation.

METHODS

Platinum coils, radioactive phosphorus 32 coils or not, were implanted in the carotid artery in mice to cause thrombotic occlusion. The outcome of the occlusion was followed up with transmyocardial angiography and pathologic analysis at 2, 6, or 15 days. Angiographic results were compared with the Pearson chi2 test. Messenger RNA expression of von Willebrand factor (vWF); smooth muscle alpha-actin (SMA+); platelet endothelial cell adhesion molecule-1 (PECAM-1); vascular endothelium cadherin (VE-Cad); endothelial nitric oxide synthase (eNOS); vascular cell adhesion molecule-1 (VCAM-1); tumor necrosis factor alpha (TNF-alpha); matrix metalloproteinase (MMP-9, MMP-12, and MMP-14), and tissue inhibitors of MMPs (TIMPs: TIMP-1, TIMP-2, TIMP-3, TIMP-4); angiopoietins (Ang-1, Ang-2); and receptors Tie-1 and Tie-2, were analyzed with reverse transcriptase polymerase chain reaction 2, 6, and 15 days after surgery. Levels of mRNA expression were compared with analysis of variance and the Student t test.

RESULTS

Carotid arteries implanted with nonradioactive 0.015-caliber coils were occluded in 84% of arteries on day 2, but in only 57% of arteries on day 15, which confirms that recanalization occurred in this model. Arteries implanted with 0.015-caliber 32P coils did not become recanalized, and 100% were occluded on day 15 (n = 13; P = .006). Recanalization was associated with endothelial-like cell-lined channels, whereas persistent occlusion was caused by complete filling of the lumen with conjunctive tissue. Coil occlusion, with or without recanalization, was followed by decreased expression of vWf, VE-Cad, eNOS, VCAM-1, MMP-2, TIMP-1, and TIMP-2; stable expression of PECAM-1, SMA+, and TIMP-3; and overexpression of Ang-1 and Ang-2, MMP-9, MMP-14, and TIMP-4. Statistically significant differences when arteries were implanted with 32P coils included decreased expression of TIMP-4 (P = .011) and increased expression of MMP-9 (P = .02).

CONCLUSION

Recanalization and organization of arterial thrombus is associated with expression of genes involved in angiogenesis and neointima formation. Recanalization can be prevented with beta-radiation, but molecular mechanisms remain to be refined.

CLINICAL RELEVANCE

A better understanding of molecular mechanisms involved in angiogenesis has permitted its regulation as a new option in treatment of various diseases. Inhibition of angiogenesis may help control diseases such as cancer, arthritis, or diabetes retinopathy. On the other hand, stimulation of angiogenesis may palliate conditions associated with insufficient blood supply, such as ischemic heart disease or critical limb ischemia. Yet little is known regarding recanalization (to be differentiated from thrombolysis), a cellular process that occurs concurrently with thrombus "organization." Recanalization is an important physiologic phenomenon because it can efficiently reestablish antegrade circulation after thrombosis both in veins and in arteries, and could be modulated for therapeutic purposes. Thus our efforts at better understanding of mechanisms involved in recanalization could be used, in addition to its promotion to recover flow after thrombotic occlusions, to prevent its occurrence after endovascular interventions designed to permanently occlude aneurysms.