Atherosclerotic plaque ruptures have been determined as the most common underlying cause of acute coronary syndromes and stroke. Currently, the standard of care for plaque rupture risk is based on the amount of luminal stenosis presented in a particular vessel; however, X-ray angiographic studies have shown that plaques at risk of rupture generally show <50% luminal narrowing. These findings explicate the need for other, more accurate methods of identifying problem lesions prior to the rupture event. Unfortunately, the study of thrombotic events and vulnerable plaque lesions in humans is difficult due to the spontaneity of rupture and the lengthy time course of disease progression. To further the understanding of plaque rupture risk in light of vulnerability detection, a rabbit model of atherothrombosis was used in conjunction with magnetic resonance imaging (MRI). MRI has been validated as a suitable imaging modality for in vivo, non-invasive detection of atherosclerosis and has provided quantitative predictors of plaques at risk of rupture. Additionally, the rabbit model has been shown, histologically, to present 6 of the 8 human plaque types classified by the American Heart Association. The first portion of this dissertation work focuses on using MRI to serially image rabbits undergoing the atherosclerotic protocol in order to assess rupture risk at the various time points. Previous work has determined that an increase in the vessel remodeling ratio (which hides a large plaque in the vessel wall) and contrast uptake (which indicates inflammation) are both characteristics of increased rupture risk. By obtaining these parameters at various time points in the disease progression, it was possible to determine when a certain plaque displays a heightened risk of rupture. The second portion of this work tested the efficacy of a pro-resolving molecule, lipoxin (an endogenous molecule), in reducing atherosclerotic disease state, specifically rupture with a luminal thrombus. Using chronic administration of this molecule in the same rabbit model of atherosclerosis yielded a faint reduction in atherosclerotic severity based on the parameters of decreased vessel lipid content and decreased thrombotic events presented in the treated group.

Plaque rupture with superimposed thrombosis is the primary cause of acute coronary syndromes of unstable angina, myocardial infarction and sudden death. Although intensive studies in the past decade have shed light on the mechanism that causes unstable atheroma, none has directly addressed the clinical observation that most myocardial infarction (MI) patients have moderate stenoses (less than 50%). Considering the important role the arterial wall compliance and pulsitile blood flow play in atheroma rupture, fluid-structure interaction (FSI) phenomenon has been of interest in recent studies. In this thesis, the impact is investigated numerically of coupled blood flow and structural dynamics on coronary plaque rupture. The objective is to determine a unique index that can be used to characterize plaque rupture potential. The FSI index, developed in this study for the first time derives from the theory of buckling of thin-walled cylinder subjected to radial pressure. Several FSI indices are first defined by normalizing the predicted hemodynamic endothelial shear stress by the structural stresses, specifically, by the maximum principal stress (giving the ratio ), and the Von Mises stress (giving the ratio ). The predicted at the location of maximum (i.e { }) denoted , is then chosen to characterize plaque rupture through systematic investigation of a variety of plaque characteristics and simulated patient conditions. The conditions investigated include varying stenosis levels ranging from 20% to 70%, blood pressure drop ranging from 3125 Pa/m to 9375 Pa/m, fibrous cap thickness ranging from to , lipid pool location ranging from the leading to the trailing edge of plaque, lipid pool volume relative to stenosis volume ranging from 24% to 80%, Calcium volume relative to stenosis volume ranging from 24% to 80% and arterial remodeling. The predicted varies with the stenosis severity and indicates that the plaques investigated are prone to rupture at approximately 40-45% stenosis levels. It predicts that high pressure significantly lowers the threshold stenosis rate for plaque rupture. In addition, the plaque potential to rupture increases for relatively thin fibrous cap, lipid core located near the leading plaque shoulder, and dramatically for relative lipid pool volume above 60%. However, calcium deposit has marginal effect on plaque rupture. Overall, the predicted results are consistent with clinical observations, indicating that the has the potential to characterize plaque rupture when properly established. In the appendix, the unsteady flow in a collapsible tube model of a diseased artery is solved analytically. The novelty of our approach is that the set of governing equations is reduced to a single integro-differential equation in the transient state. The equation was solved using the finite difference method to obtain the pressure and compliant wall behavior. The analytical approach is less computer-intensive than solving the full set of governing equations. The predicted membrane deflection is quite large at low inlet velocity, suggesting possible approach to breakdown in equilibrium. As the transmural pressure increases with wall deflection, bulges appear at the ends of the membrane indicating critical stage of stability, consistent with previous studies. An increase in wall thickness reduces the wall deflection and ultimately results in its collapse. The collapse is due to breakdown in the balance of wall governing equation. An increase in internal pressure is required to maintain membrane stability.

Coronary atherosclerotic plaque rupture is a critical event during atherosclerosis disease progression. Clinical consequences of atherosclerotic plaque rupture vary from asymptomatic to acute arterial thrombosis, yet the mechanisms underpinning such divergent biological response remain poorly understood. Novel biological signatures of plaque rupture will confer further insights into the dynamic responses triggered by plaque rupture event(s), and may provide alternative strategies for modulation of this prevalent disease. This thesis aims to investigate the events that accompany coronary plaque rupture and their relations to subsequent, downstream systemic effects. In a prospective clinical study of patients undergoing non-emergency percutaneous coronary intervention (PCI), stenting induced plaque disruption was used as a model of plaque rupture in vivo. Optical coherence tomography (OCT) imaging of the plaque lesion was performed prior to stenting, followed by serial blood sampling from targeted anatomical sites in reference to the plaque disruption event. Coronary plaque debris were also retrieved in a controlled manner. Analysis of candidate markers demonstrated a role of matrix metalloproteinase 9 (MMP9) in the systemic response to plaque disruption. Local and systemic elevations of MMP9 were observed promptly after plaque disruption. The systemic release of MMP9 was independent to the myocardial injury and systemic inflammation as a result of PCI. OCT analysis further suggested that plaque morphology may be a determining factor in the subsequent MMP9 release, as the disruption of lipid rich plaque(s) resulted in more acute elevation 'of ~1'MP9 when compared to disruption of non-lipid lesions. Changes of systemic MMP9 served as an index of response to the stent induced plaque disruption. Subjects with divergent MMP9 responses to the plaque disruption event were put forward for further comprehensive investigation during the discovery phase, using mass spectrometry techniques to investigate the lipidomic, metabolomics, and proteomic signatures of plaque disruption. Coronary atherosclerotic plaque disruption was associated with immediate changes in the plasma lipidomics and metabolomics profiles, which had distinct relations to the subsequent systemic MMP9 release. Coronary plaque debris provided a "catalogue" of proteins which could be acutely liberated into systemic circulation. Several such novel proteins were detected in circulation after plaque disruption, which triggered disparate responses in known canonical pathways. Evidence from this thesis implicates the role of liver X receptor / retinoic acid receptor pathway (LXR/RXR) as a key mediator to the divergent systemic responses after plaque disruption, and pinpoints a direction for future investigations.

PET imaging, using the bone tracer Na18F, allows the non-invasive location of atherosclerotic plaques that are at risk of rupture. However, the spatial resolution of PET is only 4-5 mm, limiting the mechanistic information this technique can provide. In this thesis, the use of fluorescence and Raman imaging to elucidate the mechanism of micro-calcification within atherosclerotic plaques has been investigated. A number of fluorescent probes to detect fluoride and calcium have been synthesised. One of the fluoride probes has been shown to be selective for fluoride however, the concentration of fluoride required to activate the probe is order of magnitudes higher than the amount of Na18F used for PET imaging making it problematic to use for future studies. On the other hand, a calcium probe has been shown to: selectively bind to hydroxyapatite (HAP); permit visualisation and quantification of HAP in both vascular and bone cell models; and effectively stain cultured aortic sections and whole mouse aorta for OPT imaging. Building on these preliminary data, fluorescence imaging and immunohistochemistry (IHC) imaging of both healthy and atherosclerotic tissue that were previously subjected to PET imaging, were successfully carried out showing the ability of the probe to detect HAP in human vascular tissue. IHC staining for Osteoprotegerin (OPG) and Osteopontin (OPN), two bone proteins recently detected in vascular tissue, showed the co-localization of OPG with the probe. Conversely, the OPN was shown to localize in areas surrounding high OPG and probe signal. To determine the exact composition of vascular calcification, Raman spectroscopy was also used. It is believed that the biosynthetic pathway to HAP passes through a series of transitional states; each of these has different structural characteristics which can be studied using Raman spectroscopy. In particular, HAP has a strong characteristic Raman peak at 960 cm-1. An increase in HAP concentration has been detected by Raman in both calcified cell models and aortic sections. When human vascular tissue was analysed, an additional peak at 973 cm-1 was present suggesting the presence of whitlockite (WTK) in this tissue as well as HAP.

La thrombose est souvent liée à la survenue d’une rupture de la plaque d’athérosclérose qui expose le tissu sous endothélial thrombogène aux plaquettes sanguines circulantes. L’un des problèmes actuels est l’identification des mécanismes qui sont à l’origine de la fracture. Nous avons testé l’hypothèse que la vasoconstriction, induite par le LTC4 ou le thromboxane A2 (TXA2), joue un rôle dans la rupture de plaques d’athérosclérose et dans la formation de l’athérothrombose. Dans ce travail nous avons adapté la technique classique de la microscopie électronique pour observer les ruptures survenues sur une plaque d’athérosclérose. Avec cette méthode, nous avons montré qu’une vasoconstriction peut engendrer des ruptures de plaques, mais seulement lorsque ces plaques sont fragilisées (dites ‘vulnérables’) soit par un régime riche en graisse ou après exposition de la souris à un lipopolysaccharide extrait de membranes bactériennes. Nous avons montré aussi que la plaque produit du TXA2, et que l’absence de son récepteur chez les souris apoE-/- déficientes en TP prévient la rupture des plaques vulnérabilisées. La vasoconstriction constitue donc un élément déterminant dans la rupture des plaques vulnérables. Les résultats de ce travail identifient le TXA2 comme étant une éventuelle cible thérapeutique pour prévenir les ruptures des plaques. D’autre part, les analyses par microscopie électronique à balayage de la thrombose in vivo, et les analyses en microscopie électronique en transmission (MET) de l’ultrastructure des plaquettes agrégées in vitro, ont montré que les plaquettes activées fusionnent entre elle permettant ainsi la cicatrisation de l’endothélium lésé. / Rupture of atherosclerotic plaques exposes sub-endothelial thrombogenic material to circulating platelets, frequently leads to thrombus formation. At present, the mechanisms behind plaque ruptures are not well understood. We studied the hypothesis that vasoconstriction induced by LTC4 or thromboxane A2 (TXA2) plays an important role in plaque rupture and formation of atherothombosis. We used scanning electron microscopy to study rupture of the plaque in detail. We were able to show that vasoconstriction leads to plaque rupture, but only after plaques have been vulnerabilized by high fat diet, or by exposure of mice to lipopolysaccharide extracted from bacterial membranes. We could also show that plaques produce TXA2. As consequence the absence of TP, a receptor for TXA2 in apoE-/- mice prevented rupture of vulnerable plaques. Vasoconstriction is hence a determining factor in the rupture of vulnerable plaques. Our work has identified TXA2 as a potential therapeutic target in preventing plaque rupture. Moreover, analysis of the thrombosis in vivo by scanning electron microscopy, and the in vitro study of the ultra structure of aggregated platelets by transmission electron microscopy, showed that activated platelets fuse together to heal the injured endothelium.

Rupture of atherosclerotic plaque is one of the primary causes of death due to cardiovascular disease. The factors directing plaque progression to instability are poorly understood. It is well-known that arteries respond to changes in mechanical stress by remodeling, and that remodeling is mediated by the inflammatory response. Studies have shown that both mechanical stress and markers of inflammation are increased in the fibrous cap and shoulder regions of plaque, where rupture most often occurs. In this study we hypothesized that there are spatial relationships between the local mechanical environment and expression of markers of inflammation in atherosclerosis, and that these relationships are plaque-progression dependent. To test these hypotheses, we analyzed cross-sections at intervals along the length of human coronary atherosclerotic arteries. For each cross-section, a heterogeneous finite element model was developed to determine the spatial distribution of stress. In addition, novel techniques for quantifying inflammatory markers at high spatial resolution were used to determine the distributions of inflammatory markers. The distributions of stress and five markers of inflammation activated NF-kB, macrophages, MMP-1, nitrotyrosine, and microvessels - were then compared to determine whether spatial relationships exists. We demonstrated that the probability of activated NF-kB expression increases monotonically with increasing stress in all stages of plaque progression. This indicates that the relationship between mechanical stress and NF-kB activation is a player throughout the disease process. We found that the relationship between mechanical stress and macrophages is highly dependent on the state of plaque progression. In intermediate stages of progression macrophages increase with moderate stress but drop off again at very high stresses, while in the advanced stage macrophages continue to increase monotonically with stress. We found that MMP1 increases with stress in stages of progression where active remodeling is occurring, but decreases with stress in mature stable plaque. We found no relationship between mechanical stress and nitrotyrosine expression or microvessels. Taken together, these results support the role of mechanical stress in instigating and maintaining the inflammatory response, and help explain how mechanical input is able to direct the complex biological changes involved in remodeling.