BACKGROUND: Sirtuin-1 (SirT1) is a NAD+-dependent deacetylase essential for maintaining the structure and function of the vasculature. Reduced SirT1 expression and activity has been correlated with the development of vascular diseases, mainly attributed to loss of SirT1’s anti-oxidant and anti-inflammatory beneficial effects. We previously found that deletion of vascular smooth muscle (VSM) SirT1 in mice is associated with increased matrix metalloproteinases (MMPs) and the subsequent development of aortic dissections or ruptures in response to the hypertensive peptide angiotensin II. Based on these previous findings, we hypothesize that loss of SirT1 activity is involved in the pathogenesis of AA. SirT1 is a stress response gene, its deacetylase activity can be impaired by excessive oxidative stress. We postulate that mutating three cysteine residues in SirT1’s catalytic domain can prevent its inactivation by oxidative insults and protect against AA and other vascular diseases. OBJECTIVES: assess the role of SirT1 in a genetic mouse model of Marfan Syndrome that develops AA; (2) Determine design and optimize an enzyme-based colorimetric ELISA to determine SirT1 activity in mouse VSM cells and aortas; (3) Produce an adeno-associated virus (AAV) expressing an oxidant-resistant triple mutant SirT1 in VSM cells that has the potential to mitigate the downstream outcomes derived from alterations in SirT1 activity, such as MMPs activation and development of AA in mgR-/- mice. METHODS: mgR-/- and littermate mgR+/+ (WT) mice aortas and VSM cells were cultured in conditioned medium and the activity of released MMPs was determined by in-gel zymography. For the development of the SirT1 activity assay, we designed a multi-step sandwich ELISA that captures a biotin- and FLAG-tagged acetylated p53 peptide, used as SirT1 deacetylase substrate. Amounts of acetylated and total p53 peptide were sequentially detected with antibodies and colorimetric substrates as index of SirT1 deacetylase activity. AAVs expressing a control or triple mutant SirT1 (3M) were produced in HEK293T cells; VSM cells were then infected with control or 3M AAV and SirT1 protein expression levels were measured by Western Blot. RESULTS: MMPs activity is increased in aortas and VSMC of mgR-/- mice; the first stage of optimization of the SirT1 activity assay successfully defined the assay conditions and experimental design, and it is ready to be optimized with mgR-/- cell and tissue samples; our novel control and SirT1 triple mutant AAVs were produced and successfully overexpressed in VSM cells. / 2024-03-14T00:00:00Z

Diseases of the aorta rank as the 20th leading cause of mortality in the US, contributing to 10,000 deaths annually. Thoracic aortic aneurysms are typically asymptomatic, often undetected until life-threatening aortic dissection or rupture occurs. Familial cases constitute one in five instances of thoracic aortic aneurysm and dissection (TAAD), with genetic causes being heterogeneous and known risk genes explaining only a small fraction of cases. We hypothesized that additional TAAD risk genes remain undiscovered. This thesis aims to investigate the genetic etiology of TAAD using genetic and genomic approaches. Our methodological approach included: 1) exome sequencing of DNA from TAAD patients with subsequent genomic analysis, integrating clinical data, and 2) single-cell RNA sequencing (scRNA-seq) of the developing (embryonic) mouse aorta. We sequenced 1650 DNA samples from 1429 TAAD patients and, after quality control, analyzed genomic data from 1278 unrelated TAAD patients of European ancestry. For controls, we used 145,103 unrelated individuals of European ancestry from the UK BioBank. We conducted a per-gene and per-domain burden analysis using a binomial test. To improve the power of detection of novel risk genes, we integrated case-control association of rare damaging variants with cell-type specific gene expression data from scRNA-seq of the ascending and descending aorta of 17 mouse embryos (harvested at the E15 stage) with the hypothesis that true risk genes are highly expressed early in development. Our analysis of known TAAD risk genes identified 52 pathogenic or likely pathogenic variants, explaining 4.1% of TAAD cases, and 75 variants of uncertain significance (5.9%). Next, two potential novel candidate genes emerged from the unbiased case-control analysis, which utilized AlphaFold domain-based annotation of protein structure: β-propeller domain of VPS8 (p = 8.8 × 10-9) and UTP11 (p = 3.9 × 10-8). scRNA-seq of the developing mouse aorta revealed significant cell-type-specific expression differences between the ascending and descending aorta, identifying five subtypes of vascular smooth muscle cells in the ascending aorta and four in the descending aorta. Differentially expressed genes between major aortic cell types were also identified. Both, VPS8 and UTP11 were found to expressed in all three major aortic cell types – vascular smooth muscle cells, fibroblasts, and endothelial cells. In conclusion, our case-control association analysis identified two promising candidate risk genes for TAAD (VPS8 and UTP11), warranting further investigation and confirmation in additional cohorts of patients with aortopathy.

<p>An abdominal aortic aneurysm (AAA), defined as a pathological expansion of the largest artery in the abdomen, is a relatively common disease that frequently leads to death if rupture occurs. Once diagnosed, clinicians often evaluate the rupture risk based on the maximum diameter of the aneurysm, a limited metric that is not accurate for all patients. In this study, we worked to provide additional distinguishing factors between growing and stable AAAs to aid in clinical rupture risk assessment. We utilized a relatively new murine model that uses surgical application of topical elastase to cause initial aortic expansion, and a lysyl oxidase inhibitor, β-aminopropionitrile (BAPN), in the drinking water to promote AAA growth. We further sought to develop and demonstrate applications of advanced imaging approaches, including four-dimensional ultrasound (4DUS), to obtain and evaluate alternative geometric and biomechanical parameters between 1) growing AAAs, 2) stable AAAs, and 3) non-aneurysmal control mice. Our study confirmed the reproducibility of the model and found reduced strain values, greater tortuosity, and decreased elastin health in mice with aneurysms. We also found expanding murine AAAs to have increased peak wall stress and surface area per length compared to stable aneurysms. The results from this work help provide a better understanding of the growth patterns associated with elastase-BAPN murine aneurysms and demonstrate the capabilities of high-frequency ultrasound. Eventually these data could help lay the groundwork for improving insight into clinical prediction of AAA expansion.</p>

Les anévrysmes de l'aorte abdominale (AAAs) sont des dilatations artérielles qui exposent le patient au décès par rupture. Ils sont caractérisés notamment par la perte de la monocouche de cellules endothéliales et son remplacement par un épais thrombus mural. Cependant, le lienentre l'accroissement du diamètre anévrysmal, la présence d'un thrombus et la perte en cellules endothéliales reste inexploré. Notre hypothèse est que la perte de l'endothélium contribue au développement des AAAs et que sa restauration par thérapie cellulaire permettrait de stabiliser les AAAs. In vivo, la réparation endothéliale implique le recrutement des cellules endothéliales adjacentes mais également des cellules progénitrices endothéliales (EPCs). Chez l'homme, le nombre et l’activité fonctionnelle des EPCs sont inversement corrélés aux facteurs de risque cardiovasculaire, et très peu de données sont disponibles sur l’activité fonctionnelle des EPCs issues de patients porteurs d'AAA. La présence du thrombus pourrait ainsi diminuer le nombre et les propriétés cicatricielles des EPCs issues de patients porteurs d'AAA. / Summary not transmitted

<p>The mortality of thoracic aortic diseases (mainly aneurysms and dissections) is high, even with surgical treatment. Epidemiology and long-term outcomes are incompletely investigated. Stroke is a major complication contributing to mortality, morbidity, and possibly to reduced quality of life. </p><p><i>Study I</i> Increasing incidence of thoracic aortic diseases 1987 – 2002 was demonstrated (n=14229). Annual number of operations increased eight-fold. Overall long-time survival was 92%, 77%, and 57% at 1, 5, and 10 years. Risk of operative and long-term mortality was reduced across time.</p><p><i>Study II</i> 2634 patients operated on the proximal thoracic aorta (Swedish Heart Surgery register) were examined. Aortic valve replacement, coronary revascularization, emergency operation, and age were independently associated with surgical death. Long-term mortality was similar for aneurysms and dissections. Operative mortality was reduced (13.7% vs 7.2%) for aneurysms but remained unchanged (22.3% vs 22.4%) for dissections across time.</p><p><i>Study III</i> 65 patients underwent selective antegrade cerebral perfusion (SACP) uni- or bilaterally. Stroke was significantly more common after unilateral SACP (29% vs 8%, p=0.045), confirmed by propensity score-matched analysis. Subclavian artery cannulation with Seldinger-technique entailed vascular complication in one case (1.5%).</p><p><i>Study IV</i> Near-infrared spectroscopy (NIRS) was used to monitor cerebral tissue saturation (rSO2) during SACP in 46 patients. Lower rSO2 were encountered (1) in patients suffering a stroke (2) with unilateral SACP, and (3) in the affected hemisphere of stroke victims. A decrease of rSO2 by 14 – 21% from baseline increased the risk of stroke significantly.</p><p><i>Study V</i> Quality of life (QoL) in 76 survivors of thoracic aortic surgery was examined with the SF-36 health questionnaire. Except for pain, QoL was reduced in all dimensions. QoL was not affected by acuity of operation. Tendencies of lower QoL after descending aortic operations, after major complications, and with persistent dysfunction were non-significant.</p>

The mortality of thoracic aortic diseases (mainly aneurysms and dissections) is high, even with surgical treatment. Epidemiology and long-term outcomes are incompletely investigated. Stroke is a major complication contributing to mortality, morbidity, and possibly to reduced quality of life. Study I Increasing incidence of thoracic aortic diseases 1987 – 2002 was demonstrated (n=14229). Annual number of operations increased eight-fold. Overall long-time survival was 92%, 77%, and 57% at 1, 5, and 10 years. Risk of operative and long-term mortality was reduced across time. Study II 2634 patients operated on the proximal thoracic aorta (Swedish Heart Surgery register) were examined. Aortic valve replacement, coronary revascularization, emergency operation, and age were independently associated with surgical death. Long-term mortality was similar for aneurysms and dissections. Operative mortality was reduced (13.7% vs 7.2%) for aneurysms but remained unchanged (22.3% vs 22.4%) for dissections across time. Study III 65 patients underwent selective antegrade cerebral perfusion (SACP) uni- or bilaterally. Stroke was significantly more common after unilateral SACP (29% vs 8%, p=0.045), confirmed by propensity score-matched analysis. Subclavian artery cannulation with Seldinger-technique entailed vascular complication in one case (1.5%). Study IV Near-infrared spectroscopy (NIRS) was used to monitor cerebral tissue saturation (rSO2) during SACP in 46 patients. Lower rSO2 were encountered (1) in patients suffering a stroke (2) with unilateral SACP, and (3) in the affected hemisphere of stroke victims. A decrease of rSO2 by 14 – 21% from baseline increased the risk of stroke significantly. Study V Quality of life (QoL) in 76 survivors of thoracic aortic surgery was examined with the SF-36 health questionnaire. Except for pain, QoL was reduced in all dimensions. QoL was not affected by acuity of operation. Tendencies of lower QoL after descending aortic operations, after major complications, and with persistent dysfunction were non-significant.

Les endoprothèses sont devenues une solution thérapeutique de choix pour les anévrismes aortiques. Même si leur bénéfice à long terme face à la chirurgie ouverte reste incertain, elles permettent de réduire la mortalité et les complications postopératoires précoces. Elles sont toutefois soumises à un certain nombre de contraintes anatomiques. Il y a encore quinze ans, elles étaient contre-indiquées dans le traitement des anévrismes débutant au niveau ou au-dessus des artères rénales, à savoir les anévrismes juxta et suprarénaux (AJSR) et les anévrismes thoraco-abdominaux (ATA). Le développement d'endoprothèses fenêtrées et/ou branchées (EPFB) a permis de proposer une solution endovasculaire à ces patients. Il s'agit d'endoprothèses munies d'orifices ou de branches latérales destinées à maintenir la perfusion des artères rénales et viscérales. Plusieurs études rétrospectives ont rapporté des résultats encourageants à court et moyen terme. Il s'agit néanmoins de techniques complexes, exposées à la survenue de problèmes techniques au niveau des artères cibles (rénales et viscérales) et des voies d'accès fémorales. Les résultats des EPFB nous semblent améliorables par une optimisation de la sélection des patients, par des innovations techniques apportées aux dispositifs implantables, ainsi que l'amélioration des techniques d'imagerie et de navigation endovasculaire. En raisons des délais de fabrication (> 6 semaines), les patients nécessitant un traitement rapide (anévrismes douloureux ou volumineux) échappent par ailleurs aux EPFB manufacturées.Les objectifs de cette thèse étaient: (1) d'évaluer dans notre expérience la fréquence et la nature des problèmes techniques peropératoires, et d'analyser leur impact sur les suites cliniques immédiates; (2) d'évaluer la faisabilité et les performances sur modèle in vitro de la navigation endovasculaire utilisant un système de navigation électromagnétique (StealthStation®, Medtronic); (3) d'évaluer la faisabilité et la sureté de la navigation robotique au cours de la mise en place d'une EPFB; (4) d'analyser les résultats à court terme des endoprothèses avec fenêtres créées à façon par le chirurgien pour des patients porteurs d'anévrismes complexes nécessitant un traitement rapide.Au cours de ce travail, nous avons tout d'abord montré qu'en début d'expérience (113 premiers patients), les problèmes techniques peropératoires n'étaient pas rares (30 % des patients) et que ceux-ci aboutissaient dans plus de la moitié des cas à des complications postopératoires. Ces problèmes techniques sont certes en partie évitables par l'amélioration de la sélection des patients et l'expertise de l'équipe soignante, mais nous pensons que le développement de nouveaux outils d'imagerie et de navigation pourrait également jouer un rôle clé. C'est sur ce dernier point que nous avons accentué nos recherches. Bien qu'une amélioration des performances techniques de la navigation électromagnétique soit nécessaire, nous avons pu montrer qu'elle permettait de fournir des informations complémentaires à la fluoroscopie, notamment lors des étapes de déploiement de l'endoprothèse et de cathétérisme des artères cibles. Plus que concurrente de la fluoroscopie, elle pourrait être utilisée de façon combinée dans le but de diminuer l'irradiation par les rayons X et d'améliorer les performances de la navigation. Nous avons également pu montrer les bénéfices potentiels de la navigation robotique lors de la mise en place d'endoprothèses branchées et ses limites actuelles pour assister de façon efficace les procédures fenêtrées. Enfin, dans une série limitée (n=11) de patients porteurs d'ATA, nous avons montré que l'utilisation d'endoprothèses avec fenêtres créées à façon par le chirurgien était à même de fournir des résultats précoces comparables (mortalité hospitalière : 9%, ischémie médullaire : 9%) à ceux des EPFB, et constituait une solution à considérer pour les patients nécessitant un traitement rapide. / Aortic stent grafts have gained widespread acceptance for the treatment of aortic aneurysms. When compared with open repair, they have been shown to reduce significantly postoperative mortality and complication rates. However, these benefits remain uncertain in the long-term and aortic stent grafts are still limited by anatomic restrictions. Fifteen years ago, patients with complex aneurysms such as juxtarenal, suprarenal and thoracoabdominal aneurysms were not eligible for endovascular repair. With the development of fenestrated and branched stent grafts (FBSG), it is now possible to offer an endovascular solution to these patients. FBSG contains holes (fenestrations) or lateral branches. Their purpose is to allow the proximal margin of the device to sit higher than standard infrarenal devices and allow uninterrupted blood flow to renal and visceral vessels. Retrospective studies have shown encouraging short-term and mid-term results. However, fenestrated/ branched stent grafting remains a complex procedure, associated with significant risks of technical problems such as target vessel loss and difficulties with iliac or femoral accesses. Results of FBSG could be further improved by optimizing patient selection, technical innovation to optimize currently available devices, and developments of new imaging and navigation tools. In addition, due to manufacturing delays (6-10 weeks), FBSG are not applicable to high-risk patients who need rapid treatment (painful or large aneurysms).The objectives of this thesis were: (1) to evaluate the incidence and define the nature of unexpected intraoperative adverse events and analyse their impact on the postoperative outcome; (2) to evaluate in vitro the feasibility and the performances of electromagnetic navigation using a new device (StealthStation®, Medtronic); (3) to evaluate the feasibility and safety of robotic navigation for target vessel cannulation; (4) to analyse short-term results of physician modified stent grafts for patients with complex aortic aneurysms needing rapid treatment.During this work, we showed that intraoperative adverse events were not rare (30% of the first 113 patients) during our early experience. They were responsible for postoperative complications in more than 50 % of cases. Optimal patient selection and increased experience of the medical staff may reduce the incidence of technical problems. However, we believe the development of new imaging modalities and navigation tools could play a key role to limit their occurrence. Although further developments are mandatory, the use of electromagnetic navigation as a complementary imaging modality, as tested with the StealthStation®, might be beneficial in terms of radiation exposure, cannulation performances, and accuracy in the positioning of FBSG. We also showed that robotic cannulation of renal and visceral vessels during complex endovascular aortic procedures is feasible and safe. In our experience, it was more effective for branches than for fenestrations. Finally, we used physician modified stent grafts in a limited series of eleven patients with thoracoabdominal aortic aneurysms. With a 9% in-hospital mortality rate and a 9% rate of spinal cord ischemia, they provided similar results to those of manufactured FBSG, suggesting they might be an option to consider for high-risk patients needing rapid treatment.

Indiana University-Purdue University Indianapolis (IUPUI) / Neurofibromatosis Type 1 (NF1) is a genetic disorder resulting from mutations in the NF1 tumor suppressor gene. Neurofibromin is the protein product of NF1 and functions as a negative regulator of Ras activity in both hematopoietic and vascular wall cells, which are critical for maintaining blood vessel homeostasis. NF1 patients are predisposed to chronic inflammation and premature cardiovascular disease, including development of large arterial aneurysms, which may result in sudden death secondary to their rupture. However, the molecular pathogenesis of NF1 aneurysm formation is completely unknown. Utilizing a novel model of Nf1 murine aneurysm formation, we demonstrate that heterozygous inactivation of Nf1 (Nf1+/-) results in enhanced aneurysm formation with myeloid cell infiltration and increased reactive oxygen species in the vessel wall. Using cell lineage-restricted transgenic mice, we show that loss of a single Nf1 allele in myeloid cells is sufficient to recapitulate the Nf1+/- aneurysm phenotype in vivo. Additionally, oral administration of simvastatin, a statin with antioxidant and anti-inflammatory effects, significantly reduced aneurysm formation in Nf1+/- mice. Finally, the antioxidant apocynin was administered orally and also resulted in a significant reduction of Nf1+/- aneurysms. These data provide genetic and pharmacologic evidence that neurofibromin-deficient myeloid cells are the central cellular triggers for aneurysm formation in a novel model of NF1 vascular disease, implicated oxidative stress as the key biochemical mechanisms of NF1 aneurysm formation and provide a potential therapeutic target for NF1 vasculopathy.