Blood Flow Characteristics and Tissue Nutrition in Apparently Ischaemic Feet

Blood flow in the apparently ischaemic feet of patients with atherosclerotic peripheral vascular disease was only weakly pulsatile but the volume of the resting total foot blood flow was higher than normal. No biochemical evidence of overall regional ischaemia or tissue anoxia was found to explain the aetiology of chronic nutritional skin lesions in these clinically ischaemic feet. The physiological effectiveness of a regional blood flow ultimately depends on its ability to perfuse the tissues, and in this respect it is suggested that pulse and pressure are more important than mere volume. It is further suggested that ischaemic or anoxic nutritional skin lesions develop in the presence of localized tissue perfusion failure and not from any overall regional blood flow insufficiency.     

Hypoxic preconditioning‐induced autophagy enhances survival of engrafted endothelial progenitor cells in ischaemic limb

Recent clinical studies have suggested that endothelial progenitor cells (EPCs) transplantation provides a modest benefit for treatment of the ischaemic diseases such as limb ischaemia. However, cell‐based therapies have been limited by poor survival of the engrafted cells. This investigation was designed to establish optimal hypoxia preconditioning and evaluate effects of hypoxic preconditioning‐induced autophagy on survival of the engrafted EPCs. Autophagy of CD34⁺VEGFR‐2⁺ EPCs isolated from rat bone marrow increased after treatment with 1% O₂. The number of the apoptotic cells in the hypoxic cells increased significantly after autophagy was inhibited with 3‐methyladenine. According to balance of autophagy and apoptosis, treatment with 1% O₂ for 2 hrs was determined as optimal preconditioning for EPC transplantation. To examine survival of the hypoxic cells, the cells were implanted into the ischaemic pouch of the abdominal wall in rats. The number of the survived cells was greater in the hypoxic group. After the cells loaded with fibrin were transplanted with intramuscular injection, blood perfusion, arteriogenesis and angiogenesis in the ischaemic hindlimb were analysed with laser Doppler‐based perfusion measurement, angiogram and the density of the microvessels in histological sections, respectively. Repair of the ischaemic tissue was improved significantly in the hypoxic preconditioning group. Loading the cells with fibrin has cytoprotective effect on survival of the engrafted cells. These results suggest that activation of autophagy with hypoxic preconditioning is an optimizing strategy for EPC therapy of limb ischaemia.     

Shear induced collateral artery growth modulated by endoglin but not by ALK1

Transforming growth factor-beta (TGF-β) stimulates both ischaemia induced angiogenesis and shear stress induced arteriogenesis by signalling through different receptors. How these receptors are involved in both these processes of blood flow recovery is not entirely clear. In this study the role of TGF-β receptors 1 and endoglin is assessed in neovascularization in mice. Unilateral femoral artery ligation was performed in mice heterozygous for either endoglin or ALK1 and in littermate controls. Compared with littermate controls, blood flow recovery, monitored by laser Doppler perfusion imaging, was significantly hampered by maximal 40% in endoglin heterozygous mice and by maximal 49% in ALK1 heterozygous mice. Collateral artery size was significantly reduced in endoglin heterozygous mice compared with controls but not in ALK1 heterozygous mice. Capillary density in ischaemic calf muscles was unaffected, but capillaries from endoglin and ALK1 heterozygous mice were significantly larger when compared with controls. To provide mechanistic evidence for the differential role of endoglin and ALK1 in shear induced or ischaemia induced neovascularization, murine endothelial cells were exposed to shear stress in vitro. This induced increased levels of endoglin mRNA but not ALK1. In this study it is demonstrated that both endoglin and ALK1 facilitate blood flow recovery. Importantly, endoglin contributes to both shear induced collateral artery growth and to ischaemia induced angiogenesis, whereas ALK1 is only involved in ischaemia induced angiogenesis.     

Further evidence for a role of endothelin-1 (ET-1) in critical limb ischaemia

Critical limb ischaemia (CLI), due to atherosclerotic arterial occlusion, affects over 20,000 people per year in the United Kingdom with many facing lower limb amputation and early death. A role for endothelin-1 (ET-1) in atherosclerosis is well-established and increased circulating and tissue levels of this peptide have been detected in patients with CLI. ET-1 and its receptors were identified in atherosclerotic popliteal arteries obtained from CLI patients undergoing lower limb amputation. In addition, plasma ET-1 levels were compared with those of non-ischaemic controls. ET-1 was associated with regions of atherosclerotic plaque, particularly in regions with high macrophage content. This peptide was also associated with endothelial cells lining the main vessel lumen as well as adventitial microvessels. ET_A and ET_B receptors were located within regions of plaque, adventitial microvessels and perivascular nerves. There was a statistically significant increase (P < 0.001) in plasma ET-1 in CLI patients when compared with controls. These results reveal sources of ET-1 in atherosclerotic popliteal arteries that potentially contribute to increased circulating levels of this peptide. Identification of variable receptor distributions in ischaemic tissue suggests a therapeutic potential of selective receptor targeting in patients with CLI.     

Post-ischaemic administration of hyperosmolar mannitol enhances erythrocyte trapping in outer medullary vasculature in the rat kidney.

Mannitol is widely used as a therapeutic agent in the management of acute renal failure. We sought to determine whether mannitol influences the trapping of red blood cells (RBCs) in renal microvasculature, as measured from the distribution of 51Cr-labelled RBCs, in the rat kidney after ischaemia. The results indicate that administration of hyperosmolar mannitol after an ischaemic insult increases RBC trapping in the outer renal medulla in a dose-dependent manner. This was found to occur even though parameters of nephron function were unaffected or even improved.     

Inducible Nitric Oxide Production and Expression of Transforming Growth Factor-β1 in Serum and CSF after Cerebral Ischaemic Stroke in Man

A residual blood supply to the ischaemic brain is a crucial determinant for tissue survival. Early changes in the vascular network and subsequent angiogenesis may be mediated by short-lived molecules like nitric oxide (NO) or growth factors such as transforming growth factor-beta1 (TGF-beta1). Although TGF-beta1 can inhibit NO production, this interaction has not been studied after ischaemia in humans. Serum samples were taken from patients at 24 h and 6 months and cerebrospinal fluid (CSF) samples at 24 h and 1 week later for possible correlation between the two factors. Tissue expression of TGF-beta1 and of the inducible isoform of NO synthase (NOS2) was assessed by immunohistochemistry. CSF levels of NO2-/NO3- as well as total (active + latent) TGF-beta1 were higher in stroke patients as compared to controls 24 h after the stroke. Both NO2-/NO3- and TGF-beta1 were lower 6 months after the stroke compared to 24 h. Levels of NO2-/NO3- correlated with levels of TGF-beta1 within the time points (P = 0.041, Kendall correlation coefficient). There was a strong staining for NOS2 in brain tissue sections in neurones, reactive astrocytes, infiltrating white blood cells, and endothelial cells of larger microvessels. TGF-beta1 expression was mainly limited to neurones and reactive astrocytes. These findings suggest that the interaction between TGF-beta1 and NOS2 might be important for angiogenesis after cerebral ischaemia and may indicate that TGF-beta1 is upregulated as a negative feedback response to elevated levels of NO.     

Foot Skin Ischaemia in Atherosclerotic Peripheral Vascular Disease

Hyperbaric oxygen and the vasodilating effect of tolazoline hydrochloride were used to investigate atherosclerotic ischaemia of the skin of the foot. Ischaemic feet were divided into two subgroups each with a foot blood flow significantly higher than normal and significantly different from each other. The high blood flow in the ischaemic feet appears to have been an attempt to meet a tissue oxygen need. In some instances this need seems to have been satisfied but without obvious benefit to the ischaemic or anoxic skin. It is suggested that a local rather than a regional blood flow insufficiency is the cause of skin lesions in peripheral vascular disease.     

Effects of an analogue of thyrotrophin-releasing hormone, RX77368, on infarct size and cerebral blood flow in focal cerebral ischaemia in the rat

Effects of a stable analogue of thyrotrophin-releasing hormone, RX77368, on cerebral blood flow and infarct size have been studied in an acute model of cerebral ischaemia in the rat. Two hours after electrocoagulation of the left middle cerebral artery (MCA), the mean area of ischaemia (+/- SEM), determined histochemically, was 11.5 +/- 2.2% of a single hemisphere and blood flow, determined using radiolabelled microspheres, was reduced by 40% in the left forebrain (p less than 0.001 compared with sham-operated animals). Administration of RX77368 (50 micrograms/kg, intracerebroventricularly) within 10 min of arterial occlusion caused a significant (p less than 0.01) reduction in mean lesion size to 3.7 +/- 1.8% and stimulation of blood flow to the left ischaemic forebrain (60% above saline treated). Peripheral administration of RX77368 (1 mg/kg intraperitoneally) also significantly stimulated blood flow to the ischaemic forebrain and caused an apparent decrease in frequency of large infarcted areas of brain tissue, although mean lesion size was not significantly affected. These findings indicate that RX77368 ameliorates tissue damage in acute focal cerebral ischaemia. Such effects may be related to stimulation of cerebral blood flow.     

Effect of restricted blood flow on exercise-induced hormone changes in healthy men

To test the influence of the accumulation of metabolites on exercise-induced hormone responses, plasma concentrations of cortisol, growth hormone (GH), insulin, testosterone, thyrotropin (TSH), free thyroxine (fT₄) and triiodothyronine (T₃) were compared during exercise performed under normal conditions (control) and under conditions of restricted blood flow of exercising leg muscles (ischaemia) in nine healthy young men. Blood supply was reduced by 15%–20% by the application of 50 mmHg external pressure over the exercising leg. During 45-min cycling exercise during ischaemia the increase in GH concentration was twice as large as under normal conditions. Despite the below-threshold exercise intensity for activation of the pituitary-adrenocortical system under normal exercise conditions ischaemic exercise elicited cortisol and T₃ responses (concentration increases of 83% and 9.5%, respectively). Ischaemic exercise attenuated the decrease of plasma insulin concentration found under normal conditions. The concentrations of testosterone, TSH and fT₄ were not changed significantly during exercise performed in either condition. The results support the suggested essential role of muscle metaboreceptors in the control of hormone responses during muscle activity. Accepted: 6 November 1997     

Effect of a transitory ischaemia on the structure-linked latency of rat liver acid phosphatase and beta-galactosidase.

The structure-linked latency of acid phosphatase and beta-galactosidase was studied in rat liver lobes made ischaemic for 1 or 2 h and then recirculated with blood for increasing periods. Free activity of acid phosphatase and unsedimentable activity of beta-galactosidase are increased in homogenates of ischaemic livers. When ischaemia had been maintained for 1 h, the recovery of normal latency for both enzymes was observed 1 h after re-establishment of the blood flow. After a 2 h period of ischaemia, unmasked activity markedly decreases during the first 1 h after restoration of blood flow; after that, a large and irreversible secondary rise takes place. Chlorpromazine, injected 30 min before or just after induction of ischaemia, extensively prevents the latency decrease occurring during restoration of blood flow. Modifications of the hydrolase distribution pattern obtained after differential centrifugation are in agreement with the latency changes. These results suggest that a 2 h ischaemia causes an alteration of the liver lysosomes that is largely reversible and that restoration of blood flow induces an irreversible alteration of these organelles. Chlorpromazine treatment prevents the irreversible lesion from taking place.     

Focal cerebral ischaemia induces corticotropin releasing factor (CRF) vascular immunoreactivity in rat occluded hemisphere

Corticotropin-releasing factor (CRF) induces the dilatation of cerebral blood vessels and increases cerebral blood flow (CBF). CRF receptor antagonists reduce ischaemic damage in the rat. In the present study, the expression of CRF around cerebral vessels has been investigated in the rat. No CRF immunoreactivity was identified around pial or intracerebral vessels in the absence of cerebral ischaemia. Four hours after middle cerebral artery occlusion (MCAo), intensely CRF-positive blood vessels were evident on the ischaemic cortical surface and in the peri-infarct and infarct zone. Increased CRF immunoreactivity was also detected in swollen axons in subcortical white matter, caudate nucleus and lateral olfactory tract of the ipsilateral hemisphere, consistent with the failure of axonal transport. These data provide morphologic support for a role of CRF in the pathophysiology of cerebral ischaemia.     

Acid‐sensing ion channel 1a is involved in ischaemia/reperfusion induced kidney injury by increasing renal epithelia cell apoptosis

Acidic microenvironment is commonly observed in ischaemic tissue. In the kidney, extracellular pH dropped from 7.4 to 6.5 within 10 minutes initiation of ischaemia. Acid‐sensing ion channels (ASICs) can be activated by pH drops from 7.4 to 7.0 or lower and permeates to Ca²⁺entrance. Thus, activation of ASIC1a can mediate the intracellular Ca²⁺ accumulation and play crucial roles in apoptosis of cells. However, the role of ASICs in renal ischaemic injury is unclear. The aim of the present study was to test the hypothesis that ischaemia increases renal epithelia cell apoptosis through ASIC1a‐mediated calcium entry. The results show that ASIC1a distributed in the proximal tubule with higher level in the renal tubule ischaemic injury both in vivo and in vitro. In vivo, Injection of ASIC1a inhibitor PcTx‐1 previous to ischaemia/reperfusion (I/R) operation attenuated renal ischaemic injury. In vitro, HK‐2 cells were pre‐treated with PcTx‐1 before hypoxia, the intracellular concentration of Ca²⁺, mitochondrial transmembrane potential (?ψm) and apoptosis was measured. Blocking ASIC1a attenuated I/R induced Ca²⁺ overflow, loss of ?ψm and apoptosis in HK‐2 cells. The results revealed that ASIC1a localized in the proximal tubular and contributed to I/R induced kidney injury. Consequently, targeting the ASIC1a may prove to be a novel strategy for AKI patients.     

MicroRNA let‐7g possesses a therapeutic potential for peripheral artery disease

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis and conveys a significant health burden globally. Critical limb ischaemia encompasses the most severe consequence of PAD. Our previous studies indicate that microRNA let‐7g prevents atherosclerosis and improves endothelial functions. This study aimed to investigate whether and how let‐7g therapy may improve blood flow to ischaemic limbs. The present study shows that let‐7g has multiple pro‐angiogenic effects on mouse ischaemic limb model and could be a potential therapeutic agent for PAD. Mice receiving intramuscular injection of let‐7g had more neovascularization, better local perfusion and increased recruitment of endothelial progenitor cells after hindlimb ischaemia. The therapeutic effects of let‐7g's on angiogenesis are mediated by multiple regulatory machinery. First, let‐7g increased expression of vascular endothelial growth factor‐A (VEGF‐A) and VEGF receptor‐2 (VEGFR‐2) through targeting their upstream regulators HIF‐3α and TP53. In addition, let‐7g affected the splicing factor SC35 which subsequently enhanced the alternative splicing of VEGF‐A from the anti‐angiogenic isoform VEGF‐A_165b towards the pro‐angiogenic isoform VEGF‐A_164a. The pleiotropic effects of let‐7g on angiogenesis imply that let‐7g may possess a therapeutic potential in ischaemic diseases.     

Results of the treatment of peripheral arterial diseases with PGE1

PGE1 (Prostin VR by Upjohn) was administered in the form of intra-arterial infusion to the patients with ischaemic disease of the limbs. The investigations aimed at collecting additional data contributing to the elaboration of optimal administration of the drug, its dosage and objective assessment of the obtained results. The obtained results have shown that the therapeutic efficiency of PGE1 depends on the advancement of ischaemia. Favourable clinical result was achieved in 45% of the patients manifested by the decrease of pain and healing rate. Such an effect persisted 2-7 months. An increase in serum total proteins and fibrinogen fraction and a decrease in platelet aggregation was seen during the PGE1 infusion. Skin temperature measurements and radioisotope examination with perfusion scintigraphy have shown an increase in blood flow in both muscles and other tissues in the treated patients. The obtained results confirmed a value of intra-arterial PGE1 infusion in the treatment of ischaemic limb diseases.     

Ischaemia alters the effects of cardiomyocyte‐derived extracellular vesicles on macrophage activation

Myocardial ischaemia is associated with an exacerbated inflammatory response, as well as with a deregulation of intercellular communication systems. Macrophages have been implicated in the maintenance of heart homeostasis and in the progression and resolution of the ischaemic injury. Nevertheless, the mechanisms underlying the crosstalk between cardiomyocytes and macrophages remain largely underexplored. Extracellular vesicles (EVs) have emerged as key players of cell‐cell communication in cardiac health and disease. Hence, the main objective of this study was to characterize the impact of cardiomyocyte‐derived EVs upon macrophage activation. Results obtained demonstrate that EVs released by H9c2 cells induced a pro‐inflammatory profile in macrophages, via p38MAPK activation and increased expression of iNOS, IL‐1β and IL‐6, being these effects less pronounced with ischaemic EVs. EVs derived from neonatal cardiomyocytes, maintained either in control or ischaemia, induced a similar pattern of p38MAPK activation, expression of iNOS, IL‐1β, IL‐6, IL‐10 and TNFα. Importantly, adhesion of macrophages to fibronectin was enhanced by EVs released by cardiomyocytes under ischaemia, whereas phagocytic capacity and adhesion to cardiomyocytes were higher in macrophages incubated with control EVs. Additionally, serum‐circulating EVs isolated from human controls or acute myocardial infarction patients induce macrophage activation. According to our model, in basal conditions, cardiomyocyte‐derived EVs maintain a macrophage profile that ensure heart homeostasis, whereas during ischaemia, this crosstalk is affected, likely impacting healing and post‐infarction remodelling.     

Subarachnoid haemorrhage: older patients have low cerebral blood flow.

Daily estimations of hemispheral cerebral blood flow using the xenon-133 inhalation technique was made in 116 patients during the first three weeks after subarachnoid haemorrhage. The patients'' cerebral perfusion on average remained less than the normal perfusion expected for their age (based on a single estimation of cerebral blood flow in 67 volunteers). On each separate day after subarachnoid haemorrhage cerebral blood flow was inversely related to the patient''s age. Older patients seem especially at risk of developing cerebral ischaemia after subarachnoid haemorrhage. The clinical outcome was more often unfavourable in older patients--that is, in those who tended to have the lowest cerebral blood flow. Present results support the view that episodes of low cerebral blood flow lead to a poor outcome after subarachnoid haemorrhage. Because of the risk of inducing cerebral ischaemia great care should be exercised by physicians administering hypotensive drugs to older patients after subarachnoid haemorrhage.     

A Novel CXCR4 antagonist enhances angiogenesis via modifying the ischaemic tissue environment

Endothelial progenitor cells (EPCs) play a capital role in angiogenesis via directly participating in neo‐vessel formation and secreting pro‐angiogenic factors. Stromal cell‐derived factor 1 (SDF‐1) and its receptor CXCR4 play a critical role in the retention and quiescence of EPCs within its niche in the bone marrow. Disturbing the interaction between SDF‐1 and CXCR4 is an effective strategy for EPC mobilization. We developed a novel CXCR4 antagonist P2G, a mutant protein of SDF‐1β with high antagonistic activity against CXCR4 and high potency in enhancing ischaemic angiogenesis and blood perfusion. However, its direct effects on ischaemic tissue remain largely unknown. In this study, P2G was found to possess a robust capability to promote EPC infiltration and incorporation in neo‐vessels, enhance the expression and function of pro‐angiogenic factors, such as SDF‐1, vascular endothelial growth factor and matrix metalloprotein‐9, and activate cell signals involved in angiogenesis, such as proliferating cell nuclear antigen, protein kinase B (Akt), extracellular regulated protein kinases and mammalian target of rapamycin, in ischaemic tissue. Moreover, P2G can attenuate fibrotic remodelling to facilitate the recovery of ischaemic tissue. The capability of P2G in direct augmenting ischaemic environment for angiogenesis suggests that it is a potential candidate for the therapy of ischaemia diseases.     

Enhancement of angiogenic and vasculogenic potential of endothelial progenitor cells by haptoglobin

Endothelial progenitor cells (EPCs) were transfected with the haptoglobin (Hp) gene to investigate the effect of Hp on cell function. Hp potentiated the gene expression of various pro-angiogenic factors in the EPCs. The Hp-modified EPCs also increased in vitro tube formation on Matrigel compared with control cells. In hindlimb ischaemia models, Hp-EPCs showed a greater ability for improving blood perfusion and recovery from ischaemic injury. These results indicate that Hp improves EPC function in neovasculogenesis, which suggests that ex vivo modification of EPCs with the Hp gene can be applied to the treatment of vascular damage.     

Characterisation and validation of a new murine model of global ischaemia-reperfusion injury

A specially designed Langendorff apparatus was constructed to allow perfusion of the isolated mouse heart. Hearts were randomised into groups to receive differing periods of global (zero flow) ischaemia or continuous perfusion (controls). During reperfusion, recovery of baseline force was recorded and perfusate collected for LDH assay (U/L/g wet weight). After 30 min reperfusion, hearts were stained with tetrazolium and planimetry performed to measure infarct size. Dose-response relationships were demonstrated for all 3 end-points against duration of ischaemic insult. Functional recovery and enzyme leakage correlated well with infarct size (r = 0.77, p < 0.001 and r = 0.73, p < 0.001 respectively). Transgenic mice may now be used to study the effect of specific phenotypic changes on the pathogenesis of ischaemia-reperfusion injury using a reliable and reproducible technique.