Deep venous thrombosis of the legs after strokes. Part I--incidence and predisposing factors.

Forty out of 76 patients (53%) who had suffered a cerebrovascular accident developed deep venous thrombosis of the paralysed leg, as detected with the 125I-fibrinogen technique. A further five also had thrombosis in the non-paralysed leg. A study of many predisposing risk factors provided no help either in elucidating the cause of venous thromboembolism or in identifying patients at risk of DVT as a complication of cerebrovascular accidents.     

Bacteroides gingivalis and Bacteroides intermedius recognize different sites on human fibrinogen.

Bacteroides (Porphyromonas) gingivalis and Bacteroides (Porphyromonas) intermedius have been implicated in the etiology of human periodontal diseases. These organisms are able to bind and degrade human fibrinogen, and these interactions may play a role in the pathogenesis of periodontal disease. In attempts to map the bacterial binding sites along the fibrinogen molecule, we have found that strains of B. gingivalis and B. intermedius, respectively, recognize spatially distant and distinct sites on the fibrinogen molecule. Isolated reduced and alkylated alpha-, beta-, and gamma-fibrinogen chains inhibited binding of 125I-fibrinogen to both Bacteroides species in a concentration-dependent manner. Plasmin fragments D and to some extent fragment E, however, produced a concentration-dependent inhibition of 125I-fibrinogen binding to B. intermedius strains but did not affect binding of 125I-fibrinogen to B. gingivalis strains. Radiolabeled fibrinogen chains and fragments were compared with 125I-fibrinogen with respect to specificity and reversibility of binding to bacteria. According to these criteria, gamma chain most closely resembled the native fibrinogen molecule in behavior toward B. gingivalis strains and fragments D most closely resembled fibrinogen in behavior toward B. intermedius strains. The ability of anti-human fibrinogen immunoglobulin G (IgG) to inhibit binding of 125I-fibrinogen to B. intermedius strains was greatly reduced by absorbing the IgG with fragments D. Absorbing the IgG with fragments D had no effect on the ability of the antibody to inhibit binding of 125I-fibrinogen to B. gingivalis strains. A purified staphylococcal fibrinogen-binding protein blocked binding of 125I-fibrinogen to B. intermedius strains but not to B. gingivalis strains.     

Diagnostic Accuracy in Venous Thrombosis

A group of 111 surgical patients at high risk of venous thrombosis were studied after operation by independent clinical assessment and with ¹²⁵I-fibrinogen to detect venous thrombosis. Almost half of the patients developed venous thrombosis. Of these, two-thirds were not suspected clinically despite careful scrutiny. In the patients in whom a clinical diagnosis of venous thrombosis was made this diagnosis was falsely positive in a quarter. More than half of all thrombotic episodes were detectable on the day after operation.The prevalence of venous thrombosis, together with the difficulty in diagnosing it, strongly supports the argument that a reduction in the incidence of pulmonary embolism must depend on widespread adoption of effective prophylaxis, especially in the large number of patients at high risk of venous thrombosis. Prophylactic trials must be objectively assessed, and it is in this field that the ¹²⁵I-fibrinogen technique probably has the most to offer.     

Human fibrinogen specifically binds hyaluronic acid

Fibrin and hyaluronic acid (HA) are macromolecules whose concentrations are elevated at the same time in the extracellular space of damaged tissues. We have investigated whether HA can bind to fibrinogen using solid phase and soluble assays. Purified human fibrinogen specifically bound to HA-Sepharose to a greater extent (greater than 5-fold) than did alpha 1-acid glycoprotein, DNaseI, ovalbumin, haptoglobin, or lysozyme. Fibrinogen did not bind to ethanolamine-Sepharose, a control chromatographic support. Treatment of HA-Sepharose containing bound 125I-fibrinogen with ovine testicular hyaluronidase released 44% of the 125I radioactivity, indicating that fibrinogen was specifically bound to HA. Moreover, 125I-fibrinogen bound to HA-Sepharose could be displaced by free HA but not by either of the monosaccharide components of this polymer, glucuronic acid, or N-acetylglucosamine. Chondroitin sulfate and polygalacturonic acid competed only weakly for bound 125I-fibrinogen. Bound 125I-fibrinogen was also not released by high concentrations of NaCl (up to 4 M), indicating that the interaction is not simply ionic. The apparent affinity of fibrinogen for HA covaried with the molecular weight of the HA. Small HA oligosaccharides (Mr = 3900) were only 50% as effective as larger HA (Mr = 8 X 10(5)) in eluting bound 125I-fibrinogen from HA-Sepharose. The optimal oligosaccharide size for displacement of bound 125I-fibrinogen was greater than or equal to 200 monosaccharides. Additionally, the amount of 125I-fibrinogen bound to HA-Sepharose was directly related to the size of the HA-amine linked to the affinity support. The affinity constant for fibrinogen binding to 125I-HA (approximately 150 monosaccharides) is estimated to be at least 2 X 10(7) M-1. These results demonstrate for the first time a specific, reversible binding between HA and fibrinogen.     

High molecular weight kininogen inhibits fibrinogen binding to cytoadhesins of neutrophils and platelets

Fibrinogen inhibited 125I-high molecular weight kininogen (HMWK) binding and displaced bound 125I-HMWK from neutrophils. Studies were performed to determine whether fibrinogen could bind to human neutrophils and to describe the HMWK-fibrinogen interaction on cellular surfaces. At 4 degrees C, the binding of 125I-fibrinogen to neutrophils reached a plateau by 30 min and did not decrease. At 23 and 37 degrees C, the amount of 125I-fibrinogen bound peaked by 4 min and then decreased over time because of proteolysis of fibrinogen by human neutrophil elastase (HNE). Zn++ (50 microM) was required for binding of 125I-fibrinogen to neutrophils at 4 degrees C and the addition of Ca++ (2 mM) increased the binding twofold. Excess unlabeled fibrinogen or HMWK completely inhibited binding of 125I-fibrinogen. Fibronectin degradation products (FNDP) partially inhibited binding, but prekallikrein and factor XII did not. The binding of 125I-fibrinogen at 4 degrees C was reversible with a 50-fold molar excess of fibrinogen or HMWK. Binding of 125I-fibrinogen, at a concentration range of 5-200 micrograms/ml of added radioligand, was saturable with an apparent Kd of 0.17 microM and 140,000 sites/cell. The binding of 125I-fibrinogen to neutrophils was not inhibited by the peptide RGDS derived from the alpha chain of fibrinogen or by the mAb 10E5 to the platelet glycoprotein IIb/IIIa heterodimer. Fibrinogen binding was inhibited by a gamma-chain peptide CYGHHLGGAKQAGDV and by mAb OKM1 but was not inhibited by OKM10, an mAb to a different domain of the adhesion glycoprotein Mac-1 (complement receptor type 3 [CR3]). HMWK binding to neutrophils was not inhibited by OKM1. These observations were consistent with a further finding that fibrinogen is a noncompetitive inhibitor of 125I-HMWK binding to neutrophils. Fibrinogen binding to ADP-stimulated platelets was increased twofold by Zn++ (50 microM) and was inhibited by HMWK. These studies indicate that fibrinogen specifically binds to the C3R receptor on the neutrophil surface through the carboxy terminal of the gamma-chain and that HMWK interferes with the binding of fibrinogen to integrins on both neutrophils and activated platelets.     

Reconstitution of the purified platelet fibrinogen receptor. Fibrinogen binding properties of the glycoprotein IIb-IIIa complex

Several lines of evidence indicate that the platelet membrane glycoprotein IIb-IIIa complex (GP IIb-IIIa) is necessary for the expression of platelet fibrinogen receptors. The purpose of the present study was to determine whether purified GP IIb-IIIa retains the properties of the fibrinogen receptor on platelets. Glycoprotein IIb-IIIa was incorporated by detergent dialysis into phospholipid vesicles composed of 30% phosphatidylcholine and 70% phosphatidylserine. 125I-Fibrinogen binding to the GP IIb-IIIa vesicles, as measured by filtration, had many of the characteristics of 125I-fibrinogen binding to whole platelets or isolated platelet plasma membranes: binding was specific, saturable, reversible, time dependent, and Ca2+ dependent. The apparent dissociation constant for 125I-fibrinogen binding to GP IIb-IIIa vesicles was 15 nM, and the maximal binding capacity was 0.1 mol of 125I-fibrinogen/mol of GP IIb-IIIa. 125I-Fibrinogen binding was inhibited by amino sugars, the GP IIb and/or IIIa monoclonal antibody 10E5, and the decapeptide from the carboxyl terminus of the fibrinogen gamma chain. Furthermore, little or no 125I-fibrinogen bound to phospholipid vesicles lacking protein or containing proteins other than GP IIb-IIIa (i.e. bacteriorhodopsin, apolipoprotein A-I, or glycophorin). Also, other 125I-labeled plasma proteins (transferrin, orosomucoid) did not bind to the GP IIb-IIIa vesicles. These results demonstrate that GP IIb-IIIa contains the platelet fibrinogen receptor.     

Prevention of Postoperative Deep Vein Thrombosis in Patients with Malignant Disease

We have used the ¹²⁵I-fibrinogen test to asses the value of an improved method of peroperative intermittent calf compression as a prophylactic measure against postoperative thrombosis. In a group of 99 patients over the age of 40 undergoing operations lasting more than 30 minutes the technique reduced the incidence of postoperative thrombosis by over 75%. In patients suffering from malignant disease, who are generally considered to be in the very high risk category, the reduction achieved was almost 90%.     

Criteria in Radioisotope Detection of Venous Thrombosis

Forty-one patients out of a larger series undergoing elective surgery were examined for the presence of venous thrombosis in the legs by means of the ¹²⁵I-fibrinogen technique. The radioisotope data were analysed by three different methods. The percentage uptake was calculated and, by the generally accepted difference of 15%, 22 patients had evidence of thrombosis. The statistical index, which takes account of the errors due to radioactivity counting inherent in the percentage uptake calculation, indicated thrombosis in 36 patients. The relative uptake index, which allows for the errors due to unequal distribution of radioactivity throughout the normal limb as well as the errors due to radioactivity counting, provided evidence of thrombosis in a total of 34 patients, compared with only 22 patients when assessed by the “15%” criterion.     

Characteristics of collagen-induced fibrinogen binding to human platelets

Polymerized type I calf skin collagen induced a time-dependent specific binding of 125I-fibrinogen to washed human platelets. Binding occurred more rapidly in a shaken rather than in an unstirred system. It was linear in the range 0.05-0.3 microM added fibrinogen and was saturated at higher fibrinogen concentrations (more than 0.8 microM). Scatchard analysis showed a single population of binding sites (16530 +/- 5410 per platelet) with a Kd = 0.53 +/- 0.23 microM. Collagen-induced 125I-fibrinogen binding to platelets was completely inhibited by ADP antagonists such as creatine phosphate/creatine phosphokinase and AMP, and partially inhibited by pretreatment of the platelets with aspirin. With both normal and aspirin-treated platelets a close correlation was observed between the amount of 125I-fibrinogen bound and the extent of dense granule secretion. Our results confirm that fibrinogen becomes bound to platelet surface receptors during collagen-induced platelet aggregation and suggest that secreted ADP is an essential cofactor in this process.     

Prevention of Postoperative Leg Vein Thrombosis by Electrical Muscle Stimulation. An Evaluation with 125I-Labelled Fibrinogen

In a prospective trial of preventing deep vein thrombosis electrical stimulation of the calf muscles of one leg was used in 110 patients undergoing major surgery. Deep vein thrombosis was detected by means of the ¹²⁵I-fibrinogen uptake test in nine of the stimulated legs and in 23 of the unstimulated legs. It is suggested that this technique, which is both simple and effective, should be used on all patients undergoing major surgery.     

125I-fibrin deposition in IgE-dependent immediate hypersensitivity reactions in mouse skin. Demonstration of the role of mast cells using genetically mast cell-deficient mice locally reconstituted with cultured mast cells

We investigated the clotting associated with IgE-dependent immediate hypersensitivity reactions in the mouse by injecting monoclonal mouse anti-dintrophenyl IgE antibodies i.d. and, the next day, administering 125I-guinea pig fibrinogen i.v. 10 to 30 min before i.v. antigen (2,4-dinitrophenylated human serum albumin) challenge. In normal mice, 2-hr passive cutaneous anaphylaxis (PCA) reactions were associated with substantial leakage of 125I-fibrinogen and deposition of 125I-fibrin. Thus, ears injected with IgE contained up to six times the total cpm of 125I and up to 30 times the cross-linked 125I-fibrin-associated cpm of 125I than did control ears. Several lines of evidence indicated that the 125I-fibrin deposition associated with the PCA reactions was dependent on the activity of mast cells: 1) Mast cell degranulation occurred at sites of PCA reactions. 2) Antigen-induced influx of 125I-fibrinogen and deposition of 125I-fibrin were virtually abolished by heating the IgE (56 degrees C, 1 hr) before i.d. injection. 3) Little or no IgE-dependent 125I-fibrinogen influx or 125I-fibrin deposition occurred in mast cell-deficient WBB6F1-W/Wv or WCB6F1-S1/S1d mice X 4) Adoptive transfer of cutaneous mast cell populations into WBB6F1-W/Wv mice (by each of three approaches: i.v. transplantation of normal bone marrow cells or local i.d. injection of cultured, growth factor-dependent mast cells 2 days or 9 to 10 wk before antigen challenge) conferred on the recipients the ability to express the 125I-fibrinogen influx and 125I-fibrin deposition associated with PCA reactions. These data demonstrate that 125I-fibrinogen influx and 125I-fibrin deposition occurs in association with PCA reactions in the mouse, and that the reaction is largely or entirely dependent on the function of cutaneous mast cells. The experiments also demonstrate the utility of a novel model system for the analysis of mast cell function in vivo: WBB6F1-W/Wv mice locally reconstituted with mast cells by the injection of mast cell populations generated in vitro.     

Evaluation of 125I-fibrinogen test for venous thrombosis in patients with hip fractures: comparison between isotope scanning and necropsy findings.

The results of 125I-fibrinogen leg scanning during life were compared with the findings at a detailed post-mortem dissection of the leg veins in 31 patients with hip fractures who died during the period of isotope scanning or within seven days of the last scan. Thigh scanning on the side of the hip fracture proved valueless, and criteria for the confident isotopic diagnosis of venous thrombosis in the uninjured thigh could not be determined. In the lower leg a difference in uptake of 20% or more that persisted for 24 hours between adjacent positions on one leg or between corresponding positions on the two legs was consistently associated with the presence of venous thrombosis at necropsy.     

Prevention of Early Postoperative Deep Vein Thrombosis by Passive Exercise of Leg during Surgery

A clinical trial assessed the effect of passive exercise of the lower limb during surgery on the incidence of early postoperative deep vein thrombosis. Thrombosis was diagnosed by means of the ¹²⁵I-fibrinogen uptake test. Passive exercise of the lower limb during the operation was achieved by using a motorized foot mover designed for use on supine subjects, and by pedalling only one leg each patient acted as his own control.In a sequential statistical analysis, 47 patients were required to reach the 5% level of significance. Thrombosis was detected in 11 control (unpedalled) legs alone, and in only one pedalled leg alone. Two patients developed thrombosis bilaterally. The investigation shows that the incidence of early thrombosis in legs which were exercised during surgery was reduced by 77%.     

Prevention of Early Postoperative Deep Vein Thrombosis by Intermittent Compression of the Leg during Surgery

A clinical trial is described in which the effect of intermittent compression of the lower limb during surgery on the incidence of early postoperative deep vein thrombosis was assessed. Deep vein thromboses were diagnosed by the ¹²⁵I-fibrinogen uptake test. Peroperative intermittent compression was achieved by means of an inflatable plastic splint coupled to a pneumatic controller. By compressing only one leg of each patient, each patient acted as his own control.With a sequential statistical analysis, 39 patients were required to pass the 5% level of significance. Eleven thrombi were detected in the control (uncompressed) legs and two occurred in the compressed legs; one of the latter was bilateral. The investigation shows that increasing the pulsatility of the venous flow in the leg is a potent prophylactic against postoperative deep vein thrombosis.     

Complement proteins C5b-9 initiate secretion of platelet storage granules without increased binding of fibrinogen or von Willebrand factor to newly expressed cell surface GPIIb-IIIa

The functional and conformational activation of cell surface glycoproteins IIb-IIIa (GPIIb-IIIa) was probed in platelets stimulated to secrete by complement proteins C5b-9. Gel-filtered human platelets exposed to the purified human C5b-9 proteins exhibited non-lytic secretory release of both alpha- and dense granule storage pools with only a small increase in total binding of 125I-fibrinogen (less than 3000 molecules/cell) to the cell surface. By contrast to ADP- or thrombin-activated platelets, increased 125I-fibrinogen bound to C5b-9 platelets was not inhibited by Arg-Gly-Asp-containing peptides, suggesting that the high affinity membrane receptor for fibrinogen is not expressed under these conditions. C5b-9-stimulated platelets also failed to bind 125I-von Willebrand factor (less than 1 ng/10(8) platelets), confirming that the adhesive protein receptor function of cell surface GPIIb-IIIa is not expressed in these cells. Although specific binding of 125I-fibrinogen or 125I-von Willebrand factor did not significantly increase after C5b-9 assembly, these proteins elicited de novo expression of the GPIIb-IIIa activation-associated epitope recognized by monoclonal antibody PAC-1, and binding of this antibody to C5b-9 platelets was fully competed by Arg-Gly-Asp-containing peptides. These data suggest that the metabolic events which trigger granule secretion after C5b-9 insertion into the plasma membrane cause cell surface GPIIb-IIIa to be expressed in an activation-associated but functionally incompetent conformation.     

Crossed immunoelectrophoresis of human platelet membranes. Effect of charge on association and dissociation of the glycoprotein GPIIb-GPIIIa membrane complex

The mechanism of association of the human platelet membrane GPIIb-GPIIIa-Ca2+ complex was studied by treating solubilized membranes with various enzymes and cationic peptides and by studying the binding of 45Ca2+ and 125I-fibrinogen before and after dissociation with EGTA and association with Ca2+. Neuraminidase shifted the complex cathodally (presumably due to cleavage of negatively charged domains), whereas trypsin had no such effect. The EGTA-dissociated complex was almost completely reassociated with neuraminidase or the cationic peptide, tetralysine. The monoclonal antibody 10E5, which specifically binds to the Ca2+-associated complex (not to its dissociated components), also bound to the neuraminidase-associated complex. Thus, Ca2+ is not necessary for the association of the complex. Neuraminidase treatment of washed intact platelets resulted in a cathodal shift of the membrane Triton X-100-extracted associated complex with no effect on its ability to dissociate in the presence of EGTA. Neuraminidase treatment of ADP-perturbed washed platelets also resulted in a cathodal shift of the associated complex; however, dissociation with EGTA was inhibited. Thus, critical neuraminidase-sensitive components of the complex (sialic acid residues) are not exposed on the surface of the platelet membrane of resting platelets, but do become accessible following platelet stimulation with ADP or membrane solubilization with Triton X-100. 45Ca2+ bound to the associated complex, to GPIIb of the dissociated complex (not to GPIIIa), to the Ca2+-reassociated complex, and to the neuraminidase-associated complex which had been dissociated with EGTA. Thus, neuraminidase-sensitive components of the solubilized membrane are not required for Ca2+ binding. 125I-fibrinogen bound to the associated complex (not the dissociated complex), to the Ca2+-reassociated complex, and to the neuraminidase-reassociated complex which had been dissociated with EGTA. Thus, Ca2+ is not necessary for 125I-fibrinogen binding to the major antigen complex.     

Optimal Electrical Stimulus for Prevention of Deep Vein Thrombosis

The most effective electrical stimulus to the calf muscles which prevents stasis in the soleal veins during operation was determined. This was subsequently used in a clinical trial and was shown to produce a 92% relative reduction in the incidence of deep vein thrombosis as determined by the ¹²⁵I-fibrinogen test.     

Interaction of heterologous fibrinogens with human platelet receptors.

The interaction of ADP-stimulated human platelets with human 125I-fibrinogen as well as with pig and bovine fibrinogens was analysed. It was found that the fibrinogens studied were bound to the same platelet receptors but the affinity of animal preparations was about half the value observed for human fibrinogen (in a homologous system).     

Tissue (type II) transglutaminase covalently incorporates itself, fibrinogen, or fibronectin into high molecular weight complexes on the extracellular surface of isolated hepatocytes. Use of 2-[(2-oxopropyl)thio] imidazolium derivatives as cellular transglutaminase inactivators.

Rabbit hepatocyte surface-expressed tissue (type II) transglutaminase is shown to act as a binding site for fibrinogen or fibronectin and to covalently incorporate these glycoproteins, in addition to itself, into extracellular high molecular weight complexes. This concept is supported by the observation that a nonpeptidyl, active site-directed transglutaminase inactivator (L683685) elicited concentration-dependent (0.1-10 microM) decreases in the calcium-dependent binding and covalent cross-linking of 125I-fibrinogen, 125I-fibronectin, or [14C]putrescine by hepatocyte suspensions. In corroboration with these findings, an antiserum against rabbit liver transglutaminase, which did not cross-react with rabbit factor XIII, elicited concentration-dependent decreases in the calcium-dependent binding and covalent cross-linking of 125I-fibrinogen or [14C]putrescine by hepatocyte suspensions. Western blots of sodium dodecyl sulfate/Triton-insoluble hepatocyte fractions conducted with this antiserum, with a polyclonal antiserum against human erythrocyte transglutaminase, or with a monoclonal antibody (CUB-7401) against guinea pig liver transglutaminase detected the 80-kDa tissue transglutaminase, as well as tissue transglutaminase-immunoreactive bands of higher molecular mass (range of 90 to greater than 200 kDa). The higher molecular weight species were preferentially incorporated, in a time- and calcium-dependent manner, into very high molecular weight complexes which did not enter the stacking gel. Incorporation of these tissue transglutaminase-containing bands into the high molecular weight complexes was inhibited by L683685, indicating that cross-linking by the enzyme was responsible for the assembly of the complexes of which tissue transglutaminase was itself a component. Cellular integrins did not mediate ligand binding under the experimental conditions, as evidenced by the failure of the Arg-Gly-Asp-Ser tetrapeptide or anti-integrin antibodies to inhibit binding or cross-linking of 125I-fibrinogen or 125I-fibronectin, in the presence or absence of transglutaminase inactivators.     

Identification of two structurally and functionally distinct sites on human platelet membrane glycoprotein IIb-IIIa using monoclonal antibodies

Platelet membrane glycoprotein IIb-IIIa exists as a calcium-dependent complex of two large peptides (designated IIb and IIIa) in Triton X-100 solutions, but it remains unknown if these peptides are subunits of one glycoprotein or are actually two individual glycoproteins in the intact platelet membrane. We used crossed immunoelectrophoresis to define the epitopes of two monoclonal antibodies to IIb-IIIa, then used these antibodies to study the structural and functional organization of IIb and IIIa in the platelet membrane. Human platelets solubilized in Triton X-100 were electrophoresed through an intermediate gel containing 125I-monoclonal IgG, then into an upper gel containing rabbit anti-human platelet antibodies. Our previously characterized antibody. Tab, and a new monoclonal antibody, T10, both bound to the immunoprecipitate corresponding to the IIb-IIIa complex. When platelets were electrophoresed after solubilization in 5 mM EDTA, 125I-Tab bound to the dissociated IIb polypeptide, but not to IIIa. In contrast, 125-I-T10 did not react with either IIb or IIIa. Thus, Tab recognizes a determinant on IIb, while T10 recognizes a determinant created only after the association of IIb and IIIa. Gel-filtered platelets from six normal donors bound 50,600 +/- 5,600 125I-T10 molecules/platelet and 47,800 +/- 11,200 125I-Tab molecules/platelet, consistent with IIb-IIIa being a heterodimer. 125I-T10 binding was identical in unactivated platelets and platelets stimulated with 10 microM ADP. However, platelets did not aggregate or bind 125I-fibrinogen until ADP was added. T10, but not Tab or nonimmune mouse antibody, inhibited ADP-induced platelet aggregation and 125I-fibrinogen binding. Our findings suggest that IIb and IIIa exist as subunits of a single membrane glycoprotein in unstimulated platelets. Fibrinogen binding appears to require not only the interaction of IIb and IIIa, but also some additional change occurring after platelet activation.