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Introdução: A reestenose pós tratamento endovascular de lesões ateroscleróticas em artérias periféricas é a principal desvantagem desta técnica minimamente invasiva. A inflamação vascular após angioplastia com balão e/ou implante de stent desempenha um papel importante na proliferação de células do músculo liso vascular e posterior crescimento de uma neoíntima, e vários marcadores inflamatórios têm sido referidos como potenciais preditores dessa complicação, porém os fatores que contribuem para a estenose intra-stent no segmento vascular periférico não foram completamente elucidados. Recentemente, tem-se sugerido que a superfície revestida de stents recobertos possa impedir a reestenose de forma mais eficaz do que os stents convencionais. Objetivo: Avaliar o papel do sistema calicreína-cinina (SCC), do óxido nítrico (NO) e das metaloproteinases (MMP), mediadores inflamatórios importantes e que contribuem ativamente para a reparação de tecidos, no processo de reestenose arterial devido a hiperplasia intimal, pós angioplastia com stent recoberto no segmento fêmoro-poplíteo, com a intenção de contribuir com novas medidas terapêuticas. Método: Foi realizado um estudo prospectivo envolvendo 27 pacientes submetidos à angioplastia com stent revestido no segmento fêmoro-poplíteo, selecionados no Ambulatório de Cirurgia Vascular e Endovascular do HCFMRP/USP. Foram estudados os seguintes marcadores: sistema calicreína-cininas - com quantificação dos substratos (cininogênio de alto e baixo peso molecular - CAPM / CBPM) e da atividade das enzimas (calicreína plasmática e tecidual e cininase II); a determinação dos níveis de nitrito e nitratos para a avaliação de óxido nítrico; dosagem das MMPs 2 e 9 e dos níveis circulantes de seus inibidores (inibidores teciduais das metaloproteinases - TIMPs [1 e 2]). Amostras de sangue foram coletadas antes do implante do stent, 24 horas e seis meses após o procedimento. Foi realizado ultrasson Doppler após seis meses, e, na presença de alterações, realizada angiografia para comprovação da presença de reestenose. Resultados: Quatro (14,8%) dos vinte sete pacientes estudados desenvolveram reestenose (>= 50%) em seis meses. Esses pacientes tiveram níveis significativamente mais baixos de CAPM (24h, P <0,05) e de CBPM (antes - P <0,05; 24 horas P <0,01; 6 meses P <0,05); níveis mais baixos de TIMP 2 ( seis meses P<0,05) comparados ao grupo sem reestenose. As atividades da calicreína plasmática e tecidual, da cininase II, NO e MMPs tiveram comportamento semelhante entre os pacientes com e sem reestenose. Conclusão: As taxas de reestenose foram baixas com o uso de stents revestidos no segmento fêmoro-poplíteo comparativamente aos índices publicados de stents não revestidos. Os pacientes que desenvolveram reestenose mostraram níveis reduzidos de cininogênios e de TIMP-2 (seis meses após a angioplastia). Por outro lado, não foi possível demonstrar a participação do óxido nítrico e das metaloproteinases no processo de reestenose / Background: Restenosis after endovascular treatment of atherosclerotic lesions in the peripheral circulation is the major drawback of this minimally invasive technique. Vascular inflammation after balloon angioplasty or stent implantation plays an important role in smooth muscle cells proliferation and subsequent neointima growth, and various inflammatory markers have been reported as potential predictors of this complication, but the factors that contribute to the in-stent stenosis in peripheral vascular segment have not been fully elucidated. Recently, it has been suggested that the coated surface of stents grafts can prevent restenosis more effectively than conventional stents. Objective: The aim of this study was to evaluate the role of the kallikrein-kinin system (KKS), nitric oxide (NO) and metalloproteinases (MMPs), wich are important inflammatory mediators and actively contribute to tissue repair, in the process of arterial restenosis due to intimal hyperplasia, with the aim of developing new interventions. Method: Single-center prospective study with 27 patients with peripheral artery disease (PAD) requiring percutaneous transluminal angioplasty (PTA) and stenting, in the femoropopliteal segment, using coated stents grafts, was performed. The following markers were studied: kallikreinkinin system using the quantification of proteins (high and low weight Molecular kininogen HMWK / LMWK), verification of enzyme activity (tissue kallikrein, plasma kallikrein and kininase II), determination of nitrite and nitrates levels for evaluation of nitric oxide, MMPs 2 and 9 circulating levels and their inhibitors (tissue inhibitors of metalloproteinases [TIMPs 1 and 2]). Serum samples were collected before stent implantation, 24 h and six months after the procedure. Doppler ultrasound was performed after six months, and in the presence of any changes, an angiography was performed to prove the presence of restenosis. Results: Four (14,8%) of the treated patients developed restenosis (>50%) within 6 months. These patients had significantly lower levels of HMWK (24 hours, P < .05), LMWK (before - P < .05; 24 hours - P < .01; 6 months - P < .05) and lower levels of TIMP 2 (6 months < .05) compered to no restenosis group. The activities of plasma and tissue kallikrein, kininase II, NO and MMP had similar behavior among patients with and without restenosis. Conclusion: Restenosis rates were low with the use of coated stents in the femoropopliteal segment compared to published bare metal stents results. Patients with restenosis showed reduced levels of kininogens and TIMP-2 (six months after angioplasty) in patients who developed restenosis. Moreover, it was not possible to demonstrate the involvement of nitric oxide and metalloproteinases in the restenosis process

Introdução: A reestenose pós tratamento endovascular de lesões ateroscleróticas em artérias periféricas é a principal desvantagem desta técnica minimamente invasiva. A inflamação vascular após angioplastia com balão e/ou implante de stent desempenha um papel importante na proliferação de células do músculo liso vascular e posterior crescimento de uma neoíntima, e vários marcadores inflamatórios têm sido referidos como potenciais preditores dessa complicação, porém os fatores que contribuem para a estenose intra-stent no segmento vascular periférico não foram completamente elucidados. Recentemente, tem-se sugerido que a superfície revestida de stents recobertos possa impedir a reestenose de forma mais eficaz do que os stents convencionais. Objetivo: Avaliar o papel do sistema calicreína-cinina (SCC), do óxido nítrico (NO) e das metaloproteinases (MMP), mediadores inflamatórios importantes e que contribuem ativamente para a reparação de tecidos, no processo de reestenose arterial devido a hiperplasia intimal, pós angioplastia com stent recoberto no segmento fêmoro-poplíteo, com a intenção de contribuir com novas medidas terapêuticas. Método: Foi realizado um estudo prospectivo envolvendo 27 pacientes submetidos à angioplastia com stent revestido no segmento fêmoro-poplíteo, selecionados no Ambulatório de Cirurgia Vascular e Endovascular do HCFMRP/USP. Foram estudados os seguintes marcadores: sistema calicreína-cininas - com quantificação dos substratos (cininogênio de alto e baixo peso molecular - CAPM / CBPM) e da atividade das enzimas (calicreína plasmática e tecidual e cininase II); a determinação dos níveis de nitrito e nitratos para a avaliação de óxido nítrico; dosagem das MMPs 2 e 9 e dos níveis circulantes de seus inibidores (inibidores teciduais das metaloproteinases - TIMPs [1 e 2]). Amostras de sangue foram coletadas antes do implante do stent, 24 horas e seis meses após o procedimento. Foi realizado ultrasson Doppler após seis meses, e, na presença de alterações, realizada angiografia para comprovação da presença de reestenose. Resultados: Quatro (14,8%) dos vinte sete pacientes estudados desenvolveram reestenose (>= 50%) em seis meses. Esses pacientes tiveram níveis significativamente mais baixos de CAPM (24h, P <0,05) e de CBPM (antes - P <0,05; 24 horas P <0,01; 6 meses P <0,05); níveis mais baixos de TIMP 2 ( seis meses P<0,05) comparados ao grupo sem reestenose. As atividades da calicreína plasmática e tecidual, da cininase II, NO e MMPs tiveram comportamento semelhante entre os pacientes com e sem reestenose. Conclusão: As taxas de reestenose foram baixas com o uso de stents revestidos no segmento fêmoro-poplíteo comparativamente aos índices publicados de stents não revestidos. Os pacientes que desenvolveram reestenose mostraram níveis reduzidos de cininogênios e de TIMP-2 (seis meses após a angioplastia). Por outro lado, não foi possível demonstrar a participação do óxido nítrico e das metaloproteinases no processo de reestenose / Background: Restenosis after endovascular treatment of atherosclerotic lesions in the peripheral circulation is the major drawback of this minimally invasive technique. Vascular inflammation after balloon angioplasty or stent implantation plays an important role in smooth muscle cells proliferation and subsequent neointima growth, and various inflammatory markers have been reported as potential predictors of this complication, but the factors that contribute to the in-stent stenosis in peripheral vascular segment have not been fully elucidated. Recently, it has been suggested that the coated surface of stents grafts can prevent restenosis more effectively than conventional stents. Objective: The aim of this study was to evaluate the role of the kallikrein-kinin system (KKS), nitric oxide (NO) and metalloproteinases (MMPs), wich are important inflammatory mediators and actively contribute to tissue repair, in the process of arterial restenosis due to intimal hyperplasia, with the aim of developing new interventions. Method: Single-center prospective study with 27 patients with peripheral artery disease (PAD) requiring percutaneous transluminal angioplasty (PTA) and stenting, in the femoropopliteal segment, using coated stents grafts, was performed. The following markers were studied: kallikreinkinin system using the quantification of proteins (high and low weight Molecular kininogen HMWK / LMWK), verification of enzyme activity (tissue kallikrein, plasma kallikrein and kininase II), determination of nitrite and nitrates levels for evaluation of nitric oxide, MMPs 2 and 9 circulating levels and their inhibitors (tissue inhibitors of metalloproteinases [TIMPs 1 and 2]). Serum samples were collected before stent implantation, 24 h and six months after the procedure. Doppler ultrasound was performed after six months, and in the presence of any changes, an angiography was performed to prove the presence of restenosis. Results: Four (14,8%) of the treated patients developed restenosis (>50%) within 6 months. These patients had significantly lower levels of HMWK (24 hours, P < .05), LMWK (before - P < .05; 24 hours - P < .01; 6 months - P < .05) and lower levels of TIMP 2 (6 months < .05) compered to no restenosis group. The activities of plasma and tissue kallikrein, kininase II, NO and MMP had similar behavior among patients with and without restenosis. Conclusion: Restenosis rates were low with the use of coated stents in the femoropopliteal segment compared to published bare metal stents results. Patients with restenosis showed reduced levels of kininogens and TIMP-2 (six months after angioplasty) in patients who developed restenosis. Moreover, it was not possible to demonstrate the involvement of nitric oxide and metalloproteinases in the restenosis process

Intimal hyperplasia (IH) is characteristic of a cell population increase within the innermost layer of the arterial wall. It is hypothesized that extracellular matrix vascular remodeling secondary vascular injury is dependent upon the Th17 subset of the CD4+ lymphocytes. Male C57BL/6J and FVB/NJ murine strains underwent complete left common carotid artery ligation for periods of 14 and 28 days. A therapeutic simvastatin model was carried out in the FVB/NJ strain and involved a daily subcutaneous injection regimen of 40 mg/kg/mouse beginning 72 hours prior to and daily following a 14 day carotid ligation period. Histological and RT-PCR analysis was carried out with harvested carotid artery samples. The FVB/NJ 14 day and 28 day histological stains of the left common carotid artery following ligation injury developed evident structured and disassembled intimal hyperplasia, respectively. A gene array demonstrated dramatic expression of immune and cytokine transcription markers particularly in the FVB/NJ strain at both ligation time points. IL-17 and IL-6 transcriptional gene expression was upregulated greater than 20-fold in the FVB/NJ 28 day injury model. IL-17 transcription was significantly expressed by a change of 50.06 ± 0.19 (p = 0.004) in this strain at 28 days versus the control. Lastly, the simvastatin treatment model was found to exacerbate the immune response to ligation injury. These results revealed that the immune system elicits a role in the vascular remodeling that potentiates intimal hyperplasia.

Introdução: Um dos fatores mais comuns de falha do procedimento das angioplastias vasculares periféricas é a estenose recorrente (reestenose). A inflamação vascular após angioplastia e implante de stent desempenha papel importante na proliferação de células do músculo liso vascular e posterior crescimento de neoíntima hipertrófica. Diversos estudos têm sugerido que a superfície dos stents, quando impregnada com determinadas moléculas, pode limitar a reestenose de forma eficaz. O carbono diamante, polímero de hidrocarboneto amorfo, pode ser usado para essa finalidade, reduzindo liberação de íons metálicos e a trombogenicidade. Diversos mediadores têm sido implicados na resposta inflamatória vascular, como o sistema calicreína-cinina (SCC), as citocinas, proteína C reativa (PCR) e o óxido nítrico (NO). Portanto, estudos clínicos específicos correlacionando o implante do stent aos níveis séricos destes possíveis marcadores podem contribuir no entendimento desse processo. Objetivo: Estudar a perviedade do dispositivo e a evolução clínica de doentes submetidos a angioplastia com stents impregandos de carbono no território vascular periférico, assim como o comportamento de mediadores séricos envolvidos nas fases mais precoces do processo inflamatório pós angioplastia. População e Método: Estudo prospectivo envolvendo 32 pacientes submetidos à angioplastia com stent no segmento ilíacofêmoro-poplíteo, selecionados no Ambulatório de Cirurgia Vascular e Endovascular do HCFMRP/USP. Foram tratadas lesões estenosantes ou oclusivas com angioplastia e colocação de stents de nitinol, com superfície impregnada de carbono (Carbostent®). Foram estudados os seguintes marcadores: SCC - com quantificação dos substratos (cininogênio de alto e baixo peso molecular - CAPM / CBPM) e das enzimas calicreína plasmática e tecidual, além da quantificação da cininase II; a determinação dos níveis de nitrito e nitratos para a avaliação de óxido nítrico; dosagem sérica de PCR e citocinas (IL-1 beta, IL-6, IL-8, IL-10, TNF-alfa e TGFbeta). Também foi realizado a dosagem dos leucócitos. Amostras séricas foram coletadas antes, 24 horas e 6 meses após o implante do stent. Os pacientes foram seguidos por um ano, para avaliação da perviedade nesse período. Resultados: Dos 27 pacientes que completaram seis meses de estudo, houve apenas uma reestenose (3,7%) e nenhuma oclusão (96,3% de perviedade). No período de um ano, quatro pacientes perderam seguimento e todos os 23 doentes avaliados, mantiveram a perviedade dos stents, com exceção do paciente no qual houve reestenose no tempo seis meses. Houve redução significativa das concentrações das citocinas inflamatórias (IL-1 beta, IL-6, IL-8 e TNF-?) no tempo 24 horas e seis meses quando comparado com o pré-procedimento (p<0,05); exceto a IL-8 no tempo 24 horas. As citocinas anti-inflamatórias (IL10 e TGF-beta) comportaram-se de maneira antagônica, com elevação do TGF-beta no tempo 24 horas e elevação, tanto do TGF-beta quanto da IL-10, no tempo 6 meses versus pré-tratamento e 6 meses versus 24 horas (P<0,05). A PCR apresentou queda no tempo seis meses em relação ao tempo 24h (p<0,05). Os níveis de NO não se alteraram entre os tempos; os de leucócitos elevaram-se no tempo 24 horas e reduziram-se no tempo seis meses em relação ao tempo 24 horas (p<0,05). Conclusão: No presente estudo a taxa de reestenose precoce foi de 3,7% nos primeiros 6 meses e 5% em 12 meses de seguimento. O comportamento dos marcadores inflamatórios evidenciou sua correlação direta com o processo de angioplastia e implante de carbostent, em especial o SCC, as citocinas, PCR e os leucócitos. Contudo, não foi possível relacionar a variação dos seus níveis séricos com o processo de reestenose. / Background: One of the most common factors of failure of the peripheral vascular angioplasty procedure is recurrent stenosis (restenosis). Vascular inflammation following angioplasty and stent implantation plays an important role in vascular smooth muscle cell proliferation and subsequent hypertrophic neointimal growth. Several studies have suggested that the surface of stents, when impregnated with certain molecules, can limit restenosis effectively. Diamond carbon, amorphous hydrocarbon polymer, can be used for this purpose, reducing release of metal ions and thrombogenicity. Several mediators have been implicated in the vascular inflammatory response, such as the kallikrein-kinin system (SCC), cytokines, C-reactive protein (CRP) and nitric oxide (NO). Therefore, specific clinical studies correlating stent implantation with serum levels of these possible markers may contribute to the understanding of this process. Objective: To study the patency of the device and the clinical evolution of patients undergoing angioplasty with carbon-impregnated stents in the peripheral vascular territory, as well as the behavior of serum mediators involved in the earlier stages of the inflammatory process after angioplasty. Population and Method: Prospective study involving 32 patients submitted to angioplasty with stent in the iliac-femoro-popliteal segment, selected at the HCFMRP / USP Outpatient Vascular and Endovascular Outpatient Clinic. Stenosis or occlusive lesions were treated with angioplasty and placement of nitinol stents with a carbon impregnated surface (Carbostent®). The following markers were studied: SCC - with quantification of substrates (high and low molecular weight cincinogens - HMWC / LMWC) and plasma and tissue kallikrein enzymes, besides quantification of kininase II; determination of nitrite and nitrate levels for the evaluation of nitric oxide; serum levels of CRP and cytokines (IL-1 beta, IL-6, IL-8, IL-10, TNF-a and TGF-b). Leucocytes were also dosed. Serum samples were collected before, 24 hours and 6 months after stent implantation. The patients were followed for one year to assess the patency in this period. Results: Of the 27 patients who completed six months of study, there was only one restenosis (3.7%) and no occlusion (96.3% of patency). In one year, four patients lost follow-up and all 23 patients evaluated, maintained stent patency, with the exception of the patient who had restenosis over time for six months. There was a significant reduction in the concentrations of inflammatory cytokines (IL-1 b, IL-6, IL-8 and TNF-a) in the time 24 hours and six months when compared with the pre-procedure (p <0.05); except for IL-8 in the 24 hour time. Anti-inflammatory cytokines (IL10 and TGF-b) behaved in an antagonistic manner, with TGF-b elevation in the 24 hour time and elevation of both TGF-b and IL-10, at 6 months versus pre- treatment and 6 months versus 24 hours (P <0.05). CRP showed a decrease in time six months in relation to time 24h (p <0.05). NO levels did not change between the times; the leukocytes increased in time 24 hours and reduced in time six months in relation to time 24 hours (p <0.05). Conclusion: In the present study, the rate of early restenosis was 3.7% in the first 6 months and 5% in 12 months of follow-up. The behavior of the inflammatory markers showed its direct correlation with the angioplasty and carbostent implantation process, especially SCC, cytokines, CRP and leukocytes. However, it was not possible to relate the variation of their serum levels to the restenosis process.

O objetivo do presente trabalho foi avaliar a morfologia e a ultraestrutura da hiperplasia intimal arterial decorrente de um modelo de estenose aórtica experimental, através da inserção de um pino de acrílico no orifício da artéria renal esquerda. Realizamos um estudo morfológico e ultraestrutural em 64 ratos Wistar, machos, com peso médio de 250 g, divididos em 4 subgrupos de acordo com o dia da eutanásia (1, 7, 15 e 30 dias de pós-operatório). O segmento da aorta envolvendo o pino foi retirado e estudado com diferentes protocolos para: microscopia óptica de alta resolução, microscopia eletrônica de transmissão e de varredura. Uma trombose se formou ao redor do pino 24 horas após a cirurgia, mostrando sinais de organização com 7 dias. Com 15 dias, uma hiperplasia intimal adjacente à base do pino foi visualizada. Esta alteração permaneceu com 30 dias de pós-operatório. Este espessamento era caracterizado principalmente por células musculares lisas provenientes da camada muscular média. A obstrução gera alterações hemodinâmicas locais com repercussão sobre as células endoteliais localizadas próximas à base do pino. Esses achados são discutidos. / Objective: To study the light and electron microscopy of intimal hyperplasia induced by experimental aortic stenosis after insertion of a plug into the aorta through the left renal artery. Methods: Sixty-four Wistar male rats, weighing an average of 250g, were allocated into two groups: group control, sham-operated, and group experimental, operated. The animals were killed on days 1, 7, 15, and 30 after surgery. The fragments of aorta implicating the plug were excised and studied using high resolution light microcopy and transmission and scanning electron microscopy. Results and Conclusions: A thrombus was observed around the plug 24 hours after surgery, organized at day 7. An intimal hyperplasia could be observed closed to the basis of the plug 15 and 30 days after surgery. The intimal thickening detected was mainly composed of smooth muscle cells migrated from the medial layer of the aorta intermixed with extracellular matrix. Moreover, the endothelial cells around the plug lost their orientation. Theses findings are discussed.

Cardiovascular diseases (CVD) remain the most common cause of death in the United States. Additionally, peripheral artery disease affects thousands of people each year. A major underlying cause of these diseases is the occlusion of the coronary or peripheral arteries due to arteriosclerosis. To overcome this, a number of vascular interventions have been developed including angioplasty, stenting, endarterectomies and bypass grafts. Although all of these methods are capable of restoring blood flow to the distal organ after occlusion, they are all plagued by unacceptably high restenosis rates. While the biological reactions that occur as a result of each of these methods differ, the initiating factor of both the primary atherosclerosis and subsequent failure of vascular interventions appears to be intimal hyperplasia (IH). Intimal hyperplasia is most simply defined as the expansion of multiple layers of cells internally to the internal elastic lamina of the blood vessel. This excessive cellular growth leads to arterial stenosis, plaque formation and inflammatory reactions. Despite extensive research the underlying factors that cause IH remain unclear. A quantity of research to date has implicated endothelial cell mechanosensation as the mechanism by which IH is initiated with evidence positively correlating wall shear stress with IH. Others, however, have demonstrated that changes in the stresses applied to the wall in vitro can modulate IH independent of hemodynamic shear stress. Thus, relations between wall tensile stress and IH in vivo may shed light on the underlying mechanisms of IH. Since noninvasive measurement of wall tensile stress in vivo is difficult, it is most feasible to measure oscillatory wall strain which is intimately related to wall tensile stress through the mechanical properties of the arterial wall. In this dissertation, we hypothesize that reductions in oscillatory wall strain precede the formation of intimal hyperplasia in a murine model. To test our hypothesis, we first developed a novel, high spatial and temporal resolution method to measure oscillatory wall strains in the murine common carotid artery. We validated this method both in vitro using an arterial phantom and in vivo using a murine model of abdominal aortic aneurysms. To assess relationships between strain and IH, we applied our strain measurement technique to a recently developed mouse model of IH. In this model, a suture is used to create a focal stenosis and reduce flow through the common carotid artery by 85%; resulting in proximal IH formation. Using this approach, we identified a relationship between oscillatory strain reductions and IH. Subsequent analysis demonstrated that early reductions in mechanical strain just 4 days after focal stenosis creation correlate with IH formation nearly 1 month later. Since IH is not expected to form by day 4 in this model, we went on to assess changes in gross vascular morphology at day 4. We discovered that, although strains are significantly reduced by day 4, no significant IH can be observed, suggesting that changes in wall structure are resulting in strain reductions. At day 4 post-op, we observed cellular proliferation and leukocyte recruitment to the wall without intimal hyperplasia. These studies suggest that early reductions in mechanical strain may be an important predictor of IH formation. Clinically, this relation could be important for the development of novel techniques for predicting IH formation before it becomes hemodynamically significant.

血管內膜的進行性增厚是動脈粥樣硬化的重要標誌，並最終導致閉塞性血管病。血管內膜增生的一個主要因素是血管中膜的平滑肌細胞遷移至內膜層並增殖。大量研究證實，在動脈粥樣硬化的發生發展中，過量產生的活性氧簇（ROS）參與了血管壁的增厚。M型瞬時受體電位通道亞家族的成員TRPM2在血管平滑肌細胞中有表達，它能被ROS激活並對Ca²⁺通透，但其在血管平滑肌中的功能以及與心血管疾病的聯繫尚未見報道。 / 本論文著眼於探討TRPM2在鼠和人血管內膜增生中的作用。用血管外周套管法建立在體齧齒類動脈內膜增生模型。套管放置2周後，大鼠股動脈可見明顯的內膜增厚。免疫染色顯示新生內膜及其鄰近中膜區域內有大量增殖細胞核抗原陽性細胞，提示在增生的動脈中，細胞週期活動增強。動脈內膜和中膜内二氫乙錠螢光信號顯著增強，提示了ROS的過量生成。免疫染色和免疫印跡法均顯示，套管損傷導致TRPM2表達上調。免疫螢光雙標TRPM2與α-平滑肌肌動蛋白顯示內膜區域有大量TRPM2陽性的平滑肌細胞。與正常股動脈中膜平滑肌細胞相比，次黃嘌呤和黃嘌呤氧化酶在套管損傷的動脈來源的新生內膜平滑肌細胞中引起更大幅度的細胞內鈣離子濃度升高，而TRPM2抑制性抗體TM2E3預處理可消除這種差異。套管放置3周可引起小鼠頸動脈新生內膜形成，並伴隨著TRPM2表達上調。敲除TRPM2基因可顯著抑制內膜增生。取冠狀動脈搭橋術後殘餘的大隱靜脈，離體培養2周誘導內膜增生。免疫螢光雙標TRPM2與α-平滑肌肌動蛋白顯示新生內膜內含有大量TRPM2陽性的平滑肌細胞。TM2E3和另一TRPM2抑制劑2-氨乙氧基二苯酯硼酸處理均可有效降低內膜的增生。培養齧齒類主動脈平滑肌細胞，用劃痕試驗和MTT法檢測TRPM2阻斷劑和TRPM2基因敲除對過氧化氫誘導的細胞遷移和增殖的影響。結果顯示，暴露於過氧化氫48小時，細胞的遷移和增殖均明顯加快。TM2E3和2-氨乙氧基二苯酯硼酸處理有效抑制過氧化氫誘導的大鼠主動脈平滑肌細胞遷移和增殖；類似地，TRPM2基因敲除可顯著抑制過氧化氫誘導的小鼠主動脈平滑肌細胞遷移和增殖。 / 以上結果表明，血管內膜增生伴隨著TRPM2表達的上調；TRPM2參與了血管內膜增生以及血管平滑肌細胞的遷移、增殖；抑制TRPM2可能是對抗血管內膜增厚的潛在治療手段。 / A hallmark in atherosclerosis is progressive intimal thickening, which leads to occlusive vascular diseases. A causation of neointimal hyperplasia is the migration of medial smooth muscle cells (SMCs) to the intima where they proliferate. It is well recognized that excessive production of reactive oxide species (ROS) contributes to vascular wall thickening during arteriosclerotic development. TRPM2, a member of the melastatin-like transient receptor potential channel subfamily, is a Ca²⁺-permeable cation channel activated by ROS and is expressed in vascular smooth muscle cells (VSMCs). The functional properties of TRPM2 in vascular smooth muscle remain to be identified and an association between TRPM2 and cardiovascular diseases has not been reported. / In the present study, I investigated the involvement of TRPM2 in rodent and human neointimal hyperplasia. In vivo neointimal hyperplasia in rodent arteries was induced by perivascular cuff placement. After the cuff placement for 2 weeks, rat femoral arteries showed distinct intimal thickening. Immunostaining showed a great number of PCNA-positive proliferating cells in the neointima and its adjacent media region, indicating the enhanced cell cycle activity in the hyperplasic arteries. Dihydroethidium signal was markedly increased in the neointima and media of the cuffed arteries, suggesting that ROS is over-produced. Interestingly, both immunostaining and immunoblot showed that cuff-injury also led to an up-regulated expression of TRPM2. Double immunofluorescent labeling of TRPM2 and α-smooth muscle actin showed a large amount of TRPM2-positive SMCs in the neointimal region. Compared with the normal medial SMCs isolated from non-cuffed arteries, the neointimal SMCs from cuff-injured arteries displayed a greater [Ca²⁺] rise in response to hypoxanthine-xanthine oxidase, which was inhibited by pre-treatment with a TRPM2-specific blocking antibody TM2E3. In mouse carotid arteries, cuff placement for 3 weeks caused clear neointimal formation, accompanied by up-regulated expression of TRPM2. Trpm2 disruption dramatically reduced the neointimal growth. Human saphenous vein samples obtained during CABG surgery were organ-cultured for 2 weeks to allow growth of neointima. Double immunofluorescent labeling of TRPM2 and α-smooth muscle actin showed that the neointima contained numerous TRPM2-positive SMCs. Neointimal hyperplasia in the veins was effectively suppressed by in vitro treatment with TM2E3 or a chemical blocker 2-aminoethoxydiphenyl borate. Furthermore, the effect of TRPM2 blockers and Trpm2 disruption on hydrogen peroxide-induced migration and proliferation of cultured rodent aortic SMCs were evaluated by scratch wound healing assay and MTT assay, respectively. It was found that exposure to hydrogen peroxide for 48 hour substantially enhanced the migration and proliferation of rodent aortic SMCs. In rat aortic SMCs, both TM2E3 and 2-aminoethoxydiphenyl borate significantly inhibited the hydrogen peroxide-induced cell migration and proliferation. The hydrogen peroxide-induced cell migration and proliferation of SMCs was also reduced in Trpm2 knockout mice. / Taking together, these results provide strong evidences that in vivo neointimal hyperplasia is accompanied by an up-regulated expression of TRPM2 and that TRPM2 plays a key role in neointimal hyperplasia, VSMCs migration and proliferation. Blocking TRPM2 can be a potential therapeutic approach for protecting blood vessels against intimal thickening. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Ru, Xiaochen. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 125-151). / Abstracts also in Chinese. / Declaration of Originality --- p.i / Abstract --- p.ii / 論文摘要 --- p.iv / Acknowledgements --- p.vi / Abbreviations and Units --- p.vii / Table of Content --- p.x / List of Figures --- p.xvi / List of Tables --- p.xviii / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Neointimal hyperplasia --- p.1 / Chapter 1.1.1 --- Definition of neointimal hyperplasia --- p.2 / Chapter 1.1.2 --- Medical significance of coronary neointimal hyperplasia --- p.3 / Chapter 1.1.3 --- Pathogenesis of neointimal hyperplasia --- p.5 / Chapter 1.1.3.1 --- “Response to injury“ hypothesis --- p.6 / Chapter 1.1.3.2 --- Role of VSMCs --- p.7 / Chapter 1.1.3.2.1 --- VSMC phenotypic switch --- p.7 / Chapter 1.1.3.2.2 --- Ca²⁺ channel modulation in VSMCs --- p.8 / Chapter 1.1.3.2.3 --- VSMC migration --- p.9 / Chapter 1.1.3.2.4 --- VSMC proliferation --- p.10 / Chapter 1.1.3.2.5 --- Extracellular matrix production by VSMCs --- p.11 / Chapter 1.1.3.3 --- Endothelial dysfunction --- p.11 / Chapter 1.1.3.4 --- Platelet adhesion --- p.12 / Chapter 1.1.3.5 --- Inflammation --- p.13 / Chapter 1.1.4 --- Role of ROS in neointimal hyperplasia --- p.14 / Chapter 1.1.4.1 --- Types of ROS --- p.15 / Chapter 1.1.4.1.1 --- Superoxide anion --- p.16 / Chapter 1.1.4.1.2 --- Hydroxyl radical --- p.16 / Chapter 1.1.4.1.3 --- Hydrogen peroxide --- p.16 / Chapter 1.1.4.1.4 --- Nitric oxide --- p.17 / Chapter 1.1.4.2 --- Sources of ROS in vessel wall --- p.17 / Chapter 1.1.4.3 --- ROS signaling in endothelial cells --- p.19 / Chapter 1.1.4.4 --- ROS signaling in VSMCs --- p.20 / Chapter 1.1.4.5 --- ROS and atherosclerosis --- p.21 / Chapter 1.1.5 --- Current therapeutic approaches to neointimal hyperplasia --- p.23 / Chapter 1.1.5.1 --- Pharmacological approaches --- p.23 / Chapter 1.1.5.2 --- Technical Approaches --- p.25 / Chapter 1.2 --- Transient receptor potential melastatin 2 (TRPM2) channel --- p.27 / Chapter 1.2.1 --- TRP Channels --- p.27 / Chapter 1.2.2 --- TRPM2 structure and expression --- p.29 / Chapter 1.2.2.1 --- Structure --- p.29 / Chapter 1.2.2.2 --- Alternative splicing isoforms --- p.30 / Chapter 1.2.2.3 --- Expression pattern --- p.32 / Chapter 1.2.3 --- TRPM2 channel properties --- p.32 / Chapter 1.2.4 --- TRPM2 activators and inhibitors --- p.32 / Chapter 1.2.4.1 --- Activators --- p.33 / Chapter 1.2.4.1.1 --- ADPR --- p.33 / Chapter 1.2.4.1.2 --- NAD, cADPR and NAADP --- p.33 / Chapter 1.2.4.1.3 --- H₂O₂ and oxidative stress --- p.34 / Chapter 1.2.4.1.4 --- Ca²⁺ --- p.34 / Chapter 1.2.4.1.5 --- Other regulators --- p.35 / Chapter 1.2.4.2 --- Inhibitors --- p.35 / Chapter 1.2.5 --- Biological relevance of TRPM2 --- p.36 / Chapter 1.2.5.1 --- TRPM2 in insulin release --- p.36 / Chapter 1.2.5.2 --- TRPM2 in inflammation --- p.36 / Chapter 1.2.5.3 --- TRPM2 in cell death --- p.37 / Chapter 1.2.5.4 --- TRPM2-mediated lysosomal Ca²⁺ release --- p.38 / Chapter 1.2.5.5 --- TRPM2 and cardiovascular diseases --- p.39 / Chapter Chapter 2 --- Objectives of the Present Study --- p.40 / Chapter Chapter 3 --- Materials and Methods --- p.42 / Chapter 3.1 --- Materials --- p.42 / Chapter 3.1.1 --- Chemicals --- p.42 / Chapter 3.1.2 --- Media, supplements and other reagents for cell/tissue culture --- p.44 / Chapter 3.1.3 --- Antibodies --- p.45 / Chapter 3.1.4 --- Solutions --- p.46 / Chapter 3.1.4.1 --- Solutions for immunohistochemical and immunocytochemical staining --- p.46 / Chapter 3.1.4.2 --- solutions for immunoblotting --- p.47 / Chapter 3.1.4.3 --- Solutions for Genotyping --- p.49 / Chapter 3.1.4.4 --- Solutions for hematoxylin and eosin (HE) staining --- p.50 / Chapter 3.1.4.5 --- Solutions for [Ca²⁺]i measurement --- p.51 / Chapter 3.1.4.6 --- Solutions for IgG purification --- p.51 / Chapter 3.1.5 --- Animals --- p.51 / Chapter 3.1.5.1 --- Rat --- p.51 / Chapter 3.1.5.2 --- Trpm2 knockout mice --- p.52 / Chapter 3.1.5.3 --- Rabbit --- p.52 / Chapter 3.1.5.4 --- Ethics --- p.52 / Chapter 3.1.6 --- Human Tissue --- p.52 / Chapter 3.2 --- Methods --- p.54 / Chapter 3.2.1 --- Rodent models of neointimal hyperplasia --- p.54 / Chapter 3.2.1.1 --- Cuff-induced vascular injury in rat femoral artery --- p.54 / Chapter 3.2.1.2 --- Cuff-induced vascular injury in mouse carotid artery --- p.54 / Chapter 3.2.2 --- Genotyping for Trpm2 knockout mice --- p.55 / Chapter 3.2.2.1 --- Genomic DNA extraction from tail --- p.55 / Chapter 3.2.2.2 --- Polymerase Chain Reaction (PCR) --- p.55 / Chapter 3.2.2.3 --- Agarose gel electrophoresis of DNA --- p.56 / Chapter 3.2.3 --- Human saphenous vein culture and treatment --- p.56 / Chapter 3.2.4 --- Generation of anti-TRPM2 antibody, TRPM2-specific blocking antibody TM2E3 and preimmune IgG --- p.57 / Chapter 3.2.5 --- Histological analysis and immunohistochemistry --- p.58 / Chapter 3.2.6 --- Western blotting --- p.59 / Chapter 3.2.7 --- Detection of ROS production by dihydroethidium fluorescence --- p.60 / Chapter 3.2.8 --- Isolation of rodent neointimal and medial smooth muscle cells --- p.60 / Chapter 3.2.9 --- Culture of rodent aortic smooth muscle cells --- p.61 / Chapter 3.2.9.1 --- Cell culture --- p.61 / Chapter 3.2.9.2 --- Cell identification --- p.61 / Chapter 3.2.10 --- [Ca²⁺]i measurement --- p.62 / Chapter 3.2.11 --- Cell proliferation assay --- p.63 / Chapter 3.2.12 --- Cell migration assay --- p.63 / Chapter 3.2.13 --- Statistical analysis --- p.64 / Chapter Chapter 4 --- ROS over-production and TRPM2 up-regulation in cuff-induced rodent neointimal hyperplasia --- p.65 / Chapter 4.1 --- Introduction --- p.65 / Chapter 4.2 --- Materials and Methods --- p.66 / Chapter 4.2.1 --- Cuff-induced vascular injury in rat femoral artery --- p.66 / Chapter 4.2.2 --- Preparation of anti-TRPM2 antibody, TM2E3 and preimmune IgG --- p.66 / Chapter 4.2.3 --- Histological analysis and immunohistochemistry --- p.66 / Chapter 4.2.4 --- Western blotting --- p.67 / Chapter 4.2.5 --- Detection of ROS production --- p.67 / Chapter 4.2.6 --- Isolation of rat neointimal and medial smooth muscle cells --- p.68 / Chapter 4.2.7 --- [Ca²⁺]i measurement --- p.68 / Chapter 4.2.8 --- Statistical analysis --- p.68 / Chapter 4.3 --- Results --- p.69 / Chapter 4.3.1 --- Cuff-induced neointimal hyperplasia in rat femoral arteries --- p.69 / Chapter 4.3.2 --- ROS over-production in neointimal region of cuff-injured rat femoral arteries --- p.69 / Chapter 4.3.3 --- TRPM2 up-regulation in neointimal region of cuff-injured rat femoral arteries --- p.69 / Chapter 4.3.4 --- Enhanced [Ca²⁺]i response to HX-XO in rat neointimal smooth muscle cells --- p.70 / Chapter 4.4 --- Discussion --- p.81 / Chapter Chapter 5 --- TRPM2 contributes to human and rodent neointimal hyperplasia --- p.86 / Chapter 5.1 --- Introduction --- p.86 / Chapter 5.2 --- Materials and Methods --- p.87 / Chapter 5.2.1 --- Cuff-induced vascular injury in mouse carotid artery --- p.87 / Chapter 5.2.2 --- Genotyping for Trpm2 knockout mice --- p.87 / Chapter 5.2.3 --- Organ culture of human saphenous vein --- p.87 / Chapter 5.2.4 --- Preparation of anti-TRPM2 antibody, TM2E3 and preimmune IgG --- p.88 / Chapter 5.2.5 --- Histological analysis and immunohistochemistry --- p.88 / Chapter 5.2.6 --- Western blotting --- p.88 / Chapter 5.2.7 --- Isolation of mouse neointimal and medial smooth muscle cells --- p.89 / Chapter 5.2.8 --- [Ca²⁺]i measurement --- p.89 / Chapter 5.2.9 --- Statistical analysis --- p.90 / Chapter 5.3 --- Results --- p.90 / Chapter 5.3.1 --- Cuff-induced neointimal hyperplasia was reduced in Trpm2 knockout mice --- p.90 / Chapter 5.3.2 --- [Ca²⁺]i response to HX-XO in mouse neointimal smooth muscle cells --- p.90 / Chapter 5.3.3 --- Inhibiting TRPM2 reduced the neointimal hyperplasia in in vitro cultured human saphenous vein --- p.91 / Chapter 5.4 --- Discussion --- p.99 / Chapter Chapter 6 --- Role of TRPM2 in H₂O₂-stimulated migration and proliferation of vascular smooth muscle cells --- p.103 / Chapter 6.1 --- Introduction --- p.103 / Chapter 6.2 --- Materials and Methods --- p.104 / Chapter 6.2.1 --- Culture of rodent aortic smooth muscle cells --- p.104 / Chapter 6.2.2 --- Immunocytochemistry --- p.104 / Chapter 6.2.3 --- Genotyping for Trpm2 knockout mice --- p.104 / Chapter 6.2.4 --- Preparation of anti-TRPM2 antibody, TM2E3 and preimmune IgG --- p.104 / Chapter 6.2.5 --- [Ca²⁺]i measurement --- p.105 / Chapter 6.2.6 --- Cell proliferation assay --- p.105 / Chapter 6.2.7 --- Western blotting --- p.105 / Chapter 6.2.8 --- Cell migration assay --- p.106 / Chapter 6.2.9 --- Statistical analysis --- p.106 / Chapter 6.3 --- Results --- p.106 / Chapter 6.3.1 --- H₂O₂-induced [Ca²⁺]i rises in rodent aortic smooth muscle cells --- p.106 / Chapter 6.3.2 --- Role of TRPM2 in H₂O₂-stimulated smooth muscle cell proliferation --- p.107 / Chapter 6.3.3 --- Role of TRPM2 in H₂O₂-stimulated smooth muscle cell migration --- p.108 / Chapter 6.4 --- Discussion --- p.118 / Chapter Chapter 7 --- General Conclusion and Future Work --- p.121 / Chapter 7.1 --- Concluding remarks --- p.121 / Chapter 7.2 --- Future work --- p.123 / Chapter 7.2.1 --- Specific downstream signaling pathway of TRPM2 that mediates ROS-induced VSMC proliferation and migration --- p.123 / Chapter 7.2.2 --- Involvement of TRPM2 in leukocyte infiltration and inflammation in vascular wall --- p.124 / References --- p.125 / List of Publications --- p.152

O objetivo do presente trabalho foi avaliar a morfologia e a ultraestrutura da hiperplasia intimal arterial decorrente de um modelo de estenose aórtica experimental, através da inserção de um pino de acrílico no orifício da artéria renal esquerda. Realizamos um estudo morfológico e ultraestrutural em 64 ratos Wistar, machos, com peso médio de 250 g, divididos em 4 subgrupos de acordo com o dia da eutanásia (1, 7, 15 e 30 dias de pós-operatório). O segmento da aorta envolvendo o pino foi retirado e estudado com diferentes protocolos para: microscopia óptica de alta resolução, microscopia eletrônica de transmissão e de varredura. Uma trombose se formou ao redor do pino 24 horas após a cirurgia, mostrando sinais de organização com 7 dias. Com 15 dias, uma hiperplasia intimal adjacente à base do pino foi visualizada. Esta alteração permaneceu com 30 dias de pós-operatório. Este espessamento era caracterizado principalmente por células musculares lisas provenientes da camada muscular média. A obstrução gera alterações hemodinâmicas locais com repercussão sobre as células endoteliais localizadas próximas à base do pino. Esses achados são discutidos. / Objective: To study the light and electron microscopy of intimal hyperplasia induced by experimental aortic stenosis after insertion of a plug into the aorta through the left renal artery. Methods: Sixty-four Wistar male rats, weighing an average of 250g, were allocated into two groups: group control, sham-operated, and group experimental, operated. The animals were killed on days 1, 7, 15, and 30 after surgery. The fragments of aorta implicating the plug were excised and studied using high resolution light microcopy and transmission and scanning electron microscopy. Results and Conclusions: A thrombus was observed around the plug 24 hours after surgery, organized at day 7. An intimal hyperplasia could be observed closed to the basis of the plug 15 and 30 days after surgery. The intimal thickening detected was mainly composed of smooth muscle cells migrated from the medial layer of the aorta intermixed with extracellular matrix. Moreover, the endothelial cells around the plug lost their orientation. Theses findings are discussed.

OBJETIVO: analisar, por meio de morfometria digital, a reação intimal presente na artéria carótida de suínos submetidos à angioplastia isoladamente e à angioplastia seguida de implante de stent de cromo - cobalto. MATERIAIS E MÉTODOS: em oito suínos sadios foi realizada a angioplastia isolada da artéria carótida comum (ACC) direita e angioplastia com implante de um stent de cromo – cobalto expansível por balão na artéria carótida comum esquerda. Após período de quatro semanas, os animais foram submetidos à eutanásia para a retirada de amostras de tecido arterial e preparo de lâminas histológicas divididas do seguinte modo: grupo 1, segmento médio da artéria carótida comum direita (angioplastia isolada); grupo 2, segmento médio da artéria carótida comum esquerda em localização “intra stent”. As imagens das lâminas foram digitalizadas e analisadas por programa de morfometria digital com cálculo da área luminal, área da camada íntima e área da camada média dos cortes histológicos. A análise estatística foi realizada através da média e desvio padrão das áreas em cada grupo, utilizando-se Teste t de Student. O valor de p<0,05 foi considerado significativo. RESULTADOS: na análise das médias das áreas obtidas, foi encontrada maior hiperplasia em resposta ao implante de stent e diferença estatisticamente significativa quando realizada a comparação entre a área do lúmen (5,841 x 106μm2 X 1,287 x 106μm2), da lâmina elástica interna (6,566 x 106μm2 X 1,287 x 106μm2) e lâmina elástica externa (9,832 x 106μm2 X 4,559 x 106μm2) dos dois grupos (ATP + STENT X ATP; medidas em micrômetros quadrados). Não se observou diferença significativa do ponto de vista estatístico quando se realizou a comparação entre as camadas médias dos dois grupos (3,266 x 106μm2 X 3,271 x 106μm2). CONCLUSÃO: o implante de stent de cromo-cobalto expansível por balão na ACC do suíno gerou um espessamento intimal maior do que aquele produzido apenas pela angioplastia, porém este não foi suficiente para afetar o lúmen arterial. / OBJECTIVE: to analyze, through digital morphometry, the intimal reaction in the carotid artery of pigs submitted to isolated angioplasty and angioplasty followed by implantation of cobalt-chromium stent. MATERIALS AND METHODS: eight healthy pigs had their common carotid artery (CCA) submitted to isolated angioplasty in the right side and angioplasty plus stenting in the left side. Four weeks latter, all animals were submitted to euthanasia for arterial tissue sampling and preparation of histological blades sorted as follows: group 1, middle segment of common right carotid artery (isolated angioplasty); group 2, middle segment of common left carotid artery (intra-stent). Blade images were scanned and analyzed through a digital morphometry program with calculation of luminal, intimal and media layers area in the histological sections. The statistical analysis was performed through mean values and standard deviations of the areas in each group, using the Student’s t-Test. The value of p<0.05 was considered significant. RESULTS: When compare to angioplasty alone, the stent group showed greater hyperplasia in response to implantation regarding the lumen area (5.841 x 106μm2 X 1.287 x 106μm2), the internal elastic lamina area (6.566 x 106μm2 X 1.287 x 106μm2) and the external elastic lamina area (9.832 x 106μm2 X 4.559 x 106μm2). No statistically significant difference was observed when comparing the media layers of both groups (3.266 x 106μm2 X 3.271 x 106μm2). CONCLUSION: angioplasty followed by the implantation of a cobalt-chromium balloon expandable stent in the CCA of the pig creates more intimal thickening than angioplasty alone. Nevertheless intimal thickening was not enough to affect the luminal area thanks to a positive elastic remodeling effect.