Rainer Zeitlin

Genes Involved in Systemic and Arterial Bed Dependent Atherosclerosis - Tampere Vascular Study

Background Atherosclerosis is a complex disease with hundreds of genes influencing its progression. In addition, the phenotype of the disease varies significantly depending on the arterial bed. Methodology/Principal Findings We characterized the genes generally involved in human advanced atherosclerotic (AHA type V–VI) plaques in carotid and femoral arteries as well as aortas from 24 subjects of Tampere Vascular study and compared the results to non-atherosclerotic internal thoracic arteries (n=6) using genome-wide expression array and QRT-PCR. In addition we determined genes that were typical for each arterial plaque studied. To gain a comprehensive insight into the pathologic processes in the plaques we also analyzed pathways and gene sets dysregulated in this disease using gene set enrichment analysis (GSEA). According to the selection criteria used (>3.0 fold change and p-value <0.05), 235 genes were up-regulated and 68 genes down-regulated in the carotid plaques, 242 genes up-regulated and 116 down-regulated in the femoral plaques and 256 genes up-regulated and 49 genes down-regulated in the aortic plaques. Nine genes were found to be specifically induced predominantly in aortic plaques, e.g., lactoferrin, and three genes in femoral plaques, e.g., chondroadherin, whereas no gene was found to be specific for carotid plaques. In pathway analysis, a total of 28 pathways or gene sets were found to be significantly dysregulated in atherosclerotic plaques (false discovery rate [FDR] <0.25). Conclusions This study describes comprehensively the gene expression changes that generally prevail in human atherosclerotic plaques. In addition, site specific genes induced only in femoral or aortic plaques were found, reflecting that atherosclerotic process has unique features in different vascular beds.

Long-term outcome of surgical revascularization of supraaortic vessels

The aim of this study was to evaluate long-term results of different surgical reconstructions of supraaortic vessels, particularly the subclavian and innominate arteries. It is a retrospective review of 33 years experience in a teaching hospital; 80 surgical revascularizations were performed in 76 patients who suffered occlusive disease of subclavian or innominate artery from 1965 to 1998. These included 38 bypass (BP) Operations (28 carotid-subclavian, 4 aorto-subclavian, 3 aorto-innominate, and 3 subclavian transpositions) and 42 endarterectomies (EA). All available patients (34) were reassessed clinically, and by triplex scanning. The mean clinical follow-up was 9 months (range 1 to 116 months) for all patients and for control-examined patients 158 months (range 6 to 346 months). Four patients were lost to follow-up. The perioperative mortality was 2.5% (BP, 0%; EA, 5%). The overall patency rate for both the BP and the EA procedures was 95% at 1 and 5 years; 91% at 10 years (BP, 89%; EA, 93%) and 89% (BP, 87%; EA, 90%) at 15 years. Most of the patients (84%) were satisfied with the clinical result in the long term. We conclude that surgical revascularization of supraaortic vessels is an infrequent procedure, and all surgical techniques give good and durable long-term outcome.RésuméLe but de cette étude a été d’évaluer les résultats à long terme de reconstruction chirurgicale des vaisseaux supra-aortiques, et en particulier des artères sous-ciavière (SC) et innommée (AI). Selon une revue rétrospective sur 33 ans dans un hôpital universitaire, on a réalisé 80 revascularisations chirurgicales chez 76 patients porteurs de maladie occlusive des artères sous-clavière ou innominée entre 1965 et 1998. Celles-ci comprenaient 38 pontages (P) (28 carotido-sous-claviers, quatre aorto-sous-claviers, trois aorto-innominés et trois transpositions sous-clavières) et 42 endartérectomies (EA). Tous les patients disponibles (n=34) ont été ré-évalués cliniquement, et par Duplex scanning. Le suivi clinique moyen a été de 9 mois (extrêmes 1–116 mois) pour tous les patients et 158 mois (extrêmes 6–346 mois) pour les patients au moment de l’examen de contrôle (1998). Quatre patients ont été perdus de vue. La mortalité périopératoire a été de 2.5% (P 0%, EA 5%). Le taux de perméabilité globale a été similaire pour les P et pour les EA: 95% à 1 an et à 5 ans pour les deux, 91% à 10 ans (P 89%, EA 93%) et de 89% (P 87%, EA 90%) à 15 ans. Après un suivi à long terme, on a constaté que la plupart des patients (84%) étaient satisfaits des résultats cliniques. Nous concluons que la revascularisation des vaisseaux supra-aortiques est un procédé peu fréquent, mais que toutes les techniques chirurgicales donnent de bons résultats durables à long terme.ResumenEvaluar los resultados tardíos de diferentes técnicas de reconstructión de a los vasos supraaórticos especialmente de las arterias subclavia (SCA) y tronco innominado (INA). Se efectúa, en un hospital universitario, un estudio retrospectivo de 33 años. Entre 1965 y 1998 se realizaron 80 operaciones revascularizadoras en 76 pacientes con enfermedad oclusiva de la SCA o del INA. 38 (BP) bypass derivativos (28 carotida-subclavia, 4 aorto-subclavia, 3 aorto-tronco innominado y 3 transposiciones subclavias) y 42 endoarteriectomías (EA). 34 pacientes pudieron ser reexaminados mediante escanografía helicoidal y estudio clínico. El seguimiento medio para todos los pacientes fue de 9 meses (rango 1–116 meses) y para los pacientes controlados y reexplorados de 158 meses (rango 6–346 meses). Durante el seguimiento se perdieron 4 pacientes. La mortalidad perioperatoria fue de 2.5% (BP 0%, EA 5%). La permeabilidad global tanto para los procedimientos de BP como de EA fue del 95% a los 1–5 años, del 91% a los 10 años (BP 89%, EA 93%) y del 89% a los 15 años (BP 87%, EA 90%). La mayoría de los pacientes se mostraron satisfechos con los resultados clínicos tardíos. Las intervenciones revascularizadoras de los troncos supraaórticos son raras, pero todos los procedimientos quirúrgicos proporcionan buenos y perdurables resultados.

ADAM8 and its single nucleotide polymorphism 2662 T/G are associated with advanced atherosclerosis and fatal myocardial infarction: Tampere vascular study

Objective. Previously, we scanned all 23,000 human genes for differential expression between normal and atherosclerotic tissues and found the involvement of ADAM8. Methods. We investigated the expression of ADAM8 mRNA and protein level in human atherosclerotic tissues and non-atherosclerotic internal thoracic arteries as well as the association of ADAM8 2662 T/G single nucleotide polymorphism (SNP) with the extent of coronary atherosclerosis and with the risk of fatal myocardial infarction. Results. ADAM8 mRNA was up-regulated in carotid, aortic, and femoral atherosclerotic plaques (n=24) when compared with non-atherosclerotic arteries. ADAM8 protein expression was increased in advanced atherosclerotic plaques as compared to control vessels wherein it was localized to macrophages and smooth muscle cells The G allele carriers of the ADAM8 2662 T/G SNP had significantly larger areas of fibrotic, calcified, and complicated plaques in coronary arteries (P=0.027, P=0.011, and P=0.011, respectively) and significantly higher occurrence of myocardial infarction (MI) (P=0.004) and fatal pre-hospital MI (P=0.003) than did the TT homozygotes. Conclusion. ADAM8 is a promising candidate to be involved in atherosclerosis, and its 2662 T/G allelic variant significantly associates with advanced atherosclerotic lesion areas and MI.

The Fate of AAA Patients Referred Electively to Vascular Surgical Unit

Background: The ideal treatment of abdominal aortic aneurysms (AAA) is to operate aneurysms likely to rupture, without exposing other cases to major surgery. The purpose here was to analyse retrospectively the management of AAA in a well-defined geographical region in the 1990s. Methods: 194 new vascular surgical outpatient consultations due to AAA were done to the regional vascular centre during the years 1990, 1992, 1994, 1996 and 1998. Data were collected from case records. Statistics Finland provided causes and dates of death. Results: The mean observed annual AAA incidence was 9.0 per 100 000 inhabitants and it rose significantly (33.3 %) during the study period. The duration of follow-up varied between 0 and 129 months. The 5/8-year cumulative mortality was 37.3/50.7 %. The most common causes of death were AAA-related (31.7 %), cardiac (29.1 %) or malignancy (19.0 %). Twenty-five patients with small AAA were referred to primary health care sector for further follow-up. There were no RAAA (ruptured AAA) deaths in this group. The cumulative 5/8-year mortality was 43.2/49.9 %. One hundred patients underwent an elective aneurysm repair with in-hospital mortality of 7.0 %. The cumulative 5/8-year mortality was 23.7/35.4 %. Twelve patients refused elective treatment. The cumulative 5/8-year mortality was 45.1/63.4 % and 5/7 deaths were due to RAAA. Twenty-three patients were unfit for elective repair. The cumulative 5/8-year mortality was 87.0 %/100 % and 5/20 deaths were caused by RAAA. The cumulative 5/8-year RAAA-rate in the patients with AAA more than 5.0 cm in diameter and outside elective aneurysm-repair (n = 23) was 51.9 %/100.0 %. Conclusion: The observed incidence of AAA increased during the 1990s. Half of the patients underwent an elective procedure. Patients unfit for surgery died mainly for other reasons than RAAA. Most patients with AAA over 5.5 cm not subjected to elective procedure, died of rupture.

Ten-Year Outcomes after Endovascular Aneurysm Repair (Evar) and Magnitude of Additional Procedures

Background and Aims: With any new technology complications are possible, and problems with first-generation aortic stentgrafts have been extensively reported. The long-term outcome of this patient population and the magnitude of additional secondary procedures are, however, less well covered. Materials and Methods: Between February 1997 and November 1999, 48 patients (44 men and 4 women; mean age 70 years; range 54–85) with AAA (average 57mm, range 40–90mm) were treated with a Vanguard® endoprosthesis. Stentgrafts were sized by CT and angiography-based measurements. Results were continuously assessed using contrast-enhanced CT before discharge, 1, 3, 6 and 12 months after the procedure and thereafter annually. Since 2001 plain abdominal X-rays have been performed annually. Results: The technical implant success rate was 100%. Median follow-up was 91 months (range 7.6–120 months). None of the patients was lost during this period. Hospital mortality was 0%. There were 25 subsequent deaths (52%), the most common cause being coronary artery disease. There were ten late conversions to open surgical repair, including three emergency operations: two due to rupture and one to thrombosis. EVAR-related complications were encountered in 43 patients (90%): 12 primary endoleaks (all type II), 36 late endoleaks (16 type I, 2 type II and 18 type III), 22 migrations, 25 row separations, 20 thromboses, one endotension and 3 ruptures of the AAA. Secondary procedures were required in 39 patients (81%): 1 re-endografting by aortoiliac bifurcated graft and 3 with a uni-iliac graft; 33 limb graft repairs were performed and 19 infrarenal cuffs were placed. There were 4 late embolizations and 4 attempts, and 6 thrombolyses, four of which were successful. Further, 9 femoro-femoral crossover by-pass and 2 axillo-femoral by-pass operations and 2 amputations were carried out during the follow-up. Only one patient was alive without complications. Conclusions: The impact of long-term follow-up of patients treated with the new technology was emphasized in this patient population. A careful surveillance protocol and active endovascular treatment of complications can yield acceptable results and low AAA rupture and aneurysm mortality rates, also with the first-generation endovascular graft. A new technology, however, may involve unpredictable problems which can magnify the workload and incur high costs over several years after the initial procedure.

Mitochondrial accumulations in nerve fibres of human sympathetic ganglia

SummaryThe fine structure of mitochondrial accumulations in axonal swellings of human sympathetic ganglia is described. A typical swelling contained, in addition to regularly organized mitochondria, bundles of neurofilaments and vesicles as well as large dense-cored vesicles and myelin figures. Synaptic contacts between axonal swellings with mitochondrial accumulations and ganglion cells were not found.A three-dimensional model of the mitochondrial accumulation based on serial sectioning is presented. The possible degenerative and regenerative features of these accumulations are discussed. It is possible that mitochondrial accumulations are functionally active energy producers rather than results of degenerative processes.

Differentially expressed genes and canonical pathway expression in human atherosclerotic plaques – Tampere Vascular Study

Cardiovascular diseases due to atherosclerosis are the leading cause of death globally. We aimed to investigate the potentially altered gene and pathway expression in advanced peripheral atherosclerotic plaques in comparison to healthy control arteries. Gene expression analysis was performed (Illumina HumanHT-12 version 3 Expression BeadChip) for 68 advanced atherosclerotic plaques (15 aortic, 29 carotid and 24 femoral plaques) and 28 controls (left internal thoracic artery (LITA)) from Tampere Vascular Study. Dysregulation of individual genes was compared to healthy controls and between plaques from different arterial beds and Ingenuity pathway analysis was conducted on genes with a fold change (FC) > ±1.5 and false discovery rate (FDR) < 0.05. 787 genes were significantly differentially expressed in atherosclerotic plaques. The most up-regulated genes were osteopontin and multiple MMPs, and the most down-regulated were cell death-inducing DFFA-like effector C and A (CIDEC, CIDEA) and apolipoprotein D (FC > 20). 156 pathways were differentially expressed in atherosclerotic plaques, mostly inflammation-related, especially related with leukocyte trafficking and signaling. In artery specific plaque analysis 50.4% of canonical pathways and 41.2% GO terms differentially expressed were in common for all three arterial beds. Our results confirm the inflammatory nature of advanced atherosclerosis and show novel pathway differences between different arterial beds.

The Profile of Leg Symptoms, Clinical Disability and Reflux in Legs with Previously Operated Varicose Disease

Purpose: It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease. Methods: A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed. Results: The site of superficial reflux was at the groin in 58 % (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11 % (unoperated short saphenous vein). In 58 % of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74 % of the legs, sensation of oedema in 64 %, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2–3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2–3) were significantly more frequent among complicated legs (CEAP clinical class C2–3: 22% versus CEAP clinical class C4–6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7 % versus severe reflux: 48 %; p < 0.005). Conclusions: Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.