Textbook of Interventional Cardiovascular Pharmacology - part 6 pdf

308 Utilization of antiproliferative and antimigratory compounds Figure 9 Inhibition of restenosis by paclitaxel in the rat carotid artery injury model. Paclitaxel inhibits the accumulation of smooth muscle cells 11 days after balloon catheter injury of rat carotid artery. Animals were treated with 2 mg/kg body weigh paclitaxel in vehicle (control animals were treated with vehicle alone) two hours after injury and daily for the next four days. Representative hematoxylin- and eosin-stained cross sections from ( AA ) uninjured, ( BB ) vehicle-treated, and ( CC ) paclitaxel-treated, injured rat carotid arteries. X240. Source : From Ref. 47. Clinical trials investigating stent- based delivery of paclitaxel A number of randomized clinical trials (RCTs) have investi- gated stent-based delivery of paclitaxel. These studies utilized a number of different delivery methods, including polymeric sleeves, nonpolymeric drug delivery and from drug-polymer coatings on stents. The Study to COmpare REstenosis rate between QueSt and QuaDDS-QP2 trial was designed to control neointimal proliferation through prolonged high-dose (800 µg) delivery of the paclitaxel derivative 7-hexanoyltaxol (QP2) via acrylate polymer membranes on the QuaDDS stent (Quanam Medical, Santa Clara, California, U.S.A.) (64). Despite a potential antirestenotic effect, enrollment in the trial was terminated early, due to an unacceptable safety profile, as seen by high rates of early stent thrombosis and MI. The very high doses of paclitaxel used in this study and the unknown vascular compatibility of the polymeric sleeve used for deliv- ery could be a few of the many reasons responsible for failure of the study. Data from the European EvaLuation of pacliTaxel ElUting Stent clinical trial, in which a Cook V-Flex Plus DES (Cook Incorporated, Bloomington, Indiana, U.S.A.) was coated with escalating doses of paclitaxel (0.2, 0.7, 1.4, and 2.7 µg/mm 2 ) applied directly to the abluminal surface of the stent, showed a binary restenosis rate of 3.1% in the paclitaxel-eluting stent group compared with 20.6% in the BMS group (65). In the Asian Paclitaxel-Eluting Stent Clinical Trial, patients were randomized to placebo (BMS) or one of two doses of pacli- taxel (1.3 or 3.1 µg/mm 2 ) on a Supra G ™ stent (Cook Incorporated, Bloomington, Indiana, U.S.A.) (66). These studies demonstrated a positive result using angiographic endpoints and were used as the basis for the larger Drug ELuting coronary stent systems in the treatment of patients with de noVo nativE coronaRy lesions (DELIVER I) study. However, no significant reduction in angiographic restenosis rate or target vessel failure (TVF) was seen in the DELIVER-I trial (67). Therefore, despite the improvement seen in angio- graphic parameters in the earlier clinical trials, delivery of paclitaxel via a nonpolymeric approach did not demonstrate a positive clinical benefit. This failure may have several causes, such as the loss of the drug to the systemic circulation before its deployment at the target site, as well as variability of the drug-release kinetics and dose delivered. The use of polymers to control the release of a drug is discussed in Chapter 22, “The Application of Controlled Drug Delivery Principles to the Development of Drug-Eluting Stents.” The TAXUS DES, which utilizes a polymeric delivery approach for paclitaxel, has been examined across multiple patient and lesion types in various clinical trials with successful results demonstrating its antirestenotic potential. These clinical data are described next. Clinical studies using the TAXUS Express ® paclitaxel-eluting stent The first study of the TAXUS paclitaxel-eluting stent in humans, TAXUS I, reported major adverse cardiac events at one-year follow-up at 3.2% for the TAXUS DES group versus 10.0% for the BMS control group (p = NS) (68). TAXUS I, now has data through four years and these bene- fits were maintained for the TAXUS group (Fig. 12). These data formed the basis of the most comprehensive RCT program of a DES to date, evolving to encompass higher patient numbers and higher-risk lesions and patients. Over 6200 patients have been enrolled in the clinical trial 1180 Chap25 3/14/07 11:34 AM Page 308 program and a number of peri- and post-approval registries have also been completed. The TAXUS II study compared slow-release (SR) and moderate-release (MR) formulations of the PES with BMS in patients with relatively noncomplex lesions (69,75). At three years, the TLR rate was 5.4% for the SR group and 3.7% for the MR group, compared with 15.7% for the combined control groups (p = 0.0001) (Fig. 12). TAXUS III was a single- arm, pilot study assessing the feasibility of implanting up to two PES for the treatment of ISR (70). The TAXUS IV pivotal study in the United States is the largest ongoing PES RCT designed to assess the safety and efficacy of the SR TAXUS Express™ DES for the treatment of de novo, coronary artery lesions (62, 63). In this study, TLR rates at three years were significantly lower with the TAXUS DES group than the BMS control group [6.9% vs. 18.6%, respectively (P Յ 0.0001); Fig. 12]. The remaining trials, TAXUS V and VI, incorporated higher- risk patients or patients with higher-risk lesions. TAXUS V expanded on the TAXUS IV pivotal study by including a higher proportion of diabetic patients (31%) as well as those with Antirestenotic agents incorporated into drug-eluting stents 309 Figure 10 ( See color plate .) Inhibition of restenosis by paclitaxel inhibits in a porcine coronary model. Photomicrographs demonstrating neointimal thickness in arteries 28 days after stent deployment. ( AA ) Uncoated (bare) stent without paclitaxel; ( BB ) chondroitin sulphate and gelatin-coated stent with paclitaxel; ( CC ) chondroitin-sulphate and gelatin stent containing 1.5 µg of paclitaxel; ( DD ) chondroitin-sulphate and gelatin stent containing 8.6 µg of paclitaxel; ( EE ) chondroitin-sulphate and gelatin stent containing 20.2 µg of paclitaxel; and ( FF ) chondroitin-sulphate and gelatin stent containing 42.0 µg of paclitaxel. Movat pentochrome stain; Scale bar represents 0.12 mm. Source : From Ref. 61. 1.5 1.0 0.5 0.0 010203040 Days after stenting Uncoated stent Poly(lactide-co-Σ-caprolactone)-coated stent Intimal area (mm 2 ) 50 60 * Poly(lactide-co-Σ-caprolactone)-coated paclitaxel-releasing stent ** Figure 11 ( See color plate .) Sustained reduction in neointimal hyperplasia in the rabbit iliac model. Source : From Ref. 107. TAXUS VI (MR) n= 1 yr 2yr 3yr 4yr 100 70 100 70 100 70 100 70 219 227 PES BMS PES BMS SR MR PES BMS BMS PES 662 652 131 135 270 31 30 TAXUS IV (SR) TAXUS II (SR/MR) TAXUS I (SR) Figure 12 ( See color plate .) Sustained freedom from target lesion revascularization in TAXUS clinical trials. Abbreviations : BMS, bare-metal stent; MR, moderate-release; PES, paclitaxel-eluting stent; SR, slow-release. Source : From Ref. 73. 1180 Chap25 3/14/07 11:34 AM Page 309 small or large vessels, and patients with long lesions requiring multiple overlapping stents (71). In this study, PES reduced the nine-month TLR rate from 15.7% for BMS-treated patients to 8.6% for TAXUS DES-treated patients (p = 0.0003). The TAXUS VI moderate release paclitaxel-eluting stent study comprised the longest mean lesion lengths and highest-risk patient population of any DES study to date, and currently has data for three years of follow-up. A total of 28% of the patients had long lesions with overlapping stents; the small vessel subpopulation was also 28% of the total patient population. Diabetic patients represented 20% of the study population. Even in this more challenging study population, two-year TLR rates were low in the PES group (9.7%) compared with the BMS control group (21.0%) (p = 0.0013) (68). Similar findings to those demonstrated in RCTs have been seen in postapproval registries (72,73), corroborating the findings of RCTs with “real-world” data. In addition, recent studies have demonstrated significant benefit by DES when used for the treatment of ISR, comparable with that seen with intracoronary radiation (71,74). These findings point to the potential utility of DES platforms in scenarios other than de novo lesions, emphasizing the need to continue to under- stand and assess this technology for unmet clinical needs. Conclusions Stent-based delivery of antirestenotic agents, now considered a major technological advance in the interventional cardiology area, was the first successful application of controlled drug delivery technology in the management of occlusive coronary artery disease. The success of DES in preventing coronary restenosis has opened doors to other potential indications suitable for local and regional drug delivery. Various pharma- cotherapeutic options and delivery modalities are being considered for a number of pathologies, such as vulnerable plaque, stroke, valvular heart disease, and congestive heart fail- ure (76). A thorough understanding of disease biology, drug pharmacology, and a delivery technology appropriate for the intended clinical application would be critical elements of a successful therapeutic strategy. Acknowledgments The authors would like to thank Cecilia Schott, PharmD, and Michael Eppihimer, PhD, for their assistance in the prepara- tion of this chapter. References 1 Investigators TBARIB. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators. N Engl J Med 1996; 335(4):217–225. 2 Serruys PW, Unger F, Sousa JE, et al. Comparison of coronary- artery bypass surgery and stenting for the treatment of multivessel disease. 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Metalloproteinase inhibi- tion by batimastat does not reduce neointimal thickening in stented atherosclerotic porcine femoral arteries. Cardiovasc Radiat Med 2003; 4(4):186–191. 105 Wu CH, Pan JS, Chang WC, Hung JS, Mao SJ. The molecu- lar mechanism of actinomycin D in preventing neointimal formation in rat carotid arteries after balloon injury. J Biomed Sci 2005; 12(3):503–512. 106 Suzuki T, Kopia G, Hayashi S, et al. Stent-based delivery of sirolimus reduces neointimal formation in a porcine coronary model. Circulation 2001; 104(10):1188–1193. References 313 1180 Chap25 3/14/07 11:34 AM Page 313 1180 Chap25 3/14/07 11:34 AM Page 314 Introduction The role of immune cells and inflammatory mediators in cardiovascular disease has been well documented. Atherosclerosis has been described as a chronic inflammatory syndrome, a systemic disorder characterized by focal lesions throughout the vasculature (1,2). Immune cells such as T-cells and macrophages are recruited to the vascular wall where they and their signaling molecules play important roles at all stages of lesion development including plaque initiation, progression, and rupture leading to thrombotic events (3,4). Compositionally, varying sections of the plaque may be engorged with soft, pliable lipid (cholesterol ester) and immune components such as foam-cell-like macrophages, typical of either newly formed or shoulder regions of mature lesions versus regions with more stable transformations comprised of proliferated smooth muscle cells (SMCs), fibrob- lasts, and matrix (5–7). With growth and maturation, remodeling occurs with thickening and breakdown of the architecture and function of the vascular wall, ultimately impinging on the size of the lumen and reducing blood flow. It is these larger lesions, those more easily identified by angiog- raphy, that are typically treated with interventional procedures. Attempts at treating stenotic vessels due to vascular plaque have included surgical interventions such as bypass and, since the late 1970s, angioplasty. Unfortunately, in nearly 30% to 40% of patients, these procedures failed leading to re-occlusion of the vessel within 6 to 12 months (8). Pathologically, this fail- ure has been ascribed to either an acute closure from stretching and recoil of the vessel or a more chronic biologi- cally mediated lumen loss. This longer-term failure, or restenosis, is due to a response to the mechanical disruption and endothelial denudation from the procedure and results from a cellular response to repair the injury. The major component of restenotic plaque is neointima, primarily misaligned, proliferated/migrated SMCs and fibroblasts, and matrix material appearing somewhat in disarray. Early attempts to treat restenosis focused on the local proliferative process, primarily SMC expansion, with numerous therapeu- tic agents and approaches investigated over more than two decades (9). Recently, a breakthrough has been achieved leading to a significant shift in therapeutic paradigm, initially by use of the Cypher sirolimus drug-eluting stent (DES). Sirolimus, an immune suppressant approved for use in patients undergoing kidney transplant, has pleotropic effects on cellular metabolism. Specifically, the compound appears to act as an inhibitor of cell cycle progression, and based on this, may combine the activi- ties required on the numerous mechanisms and cell types purported to participate in the restenotic process. Utilizing this approach, a clear improvement has occurred in outcomes, despite the reality that we really still do not completely under- stand the restenotic participants or mechanisms. This chapter focuses on percutaneous transluminal coro- nary angioplasty (PTCA), provides a summary of the underlying immune activities of the diseased vasculature, and focuses in part on the role of immune and inflammatory mediators in the restenotic process. In addition, the mecha- nism of action of sirolimus, the drug used in the first successful DES for reduction of restenosis will be highlighted. Finally, the potential role for immune mediators on the overall processes of atherosclerosis will be explored. Percutaneous transluminal coronary angioplasty Today, standard therapy for myocardial infarction or luminal narrowing includes thrombolytics, anticoagulants, and often interventional procedures such as PTCA. With its introduction 26 Anti-inflammatory drugs, sirolimus, and inhibition of target of rapamycin and its effect on vascular diseases Steven J. Adelman 1180 Chap26 3/14/07 11:35 AM Page 315 in the late 1970s, improvement was seen in the treatment of luminal narrowing from obstructive coronary artery disease or blockage due to myocardial infarction. The procedure involves placing a balloon-tipped catheter at the site of occlusion and disrupting and expanding the occluded vessel by inflating the balloon. Although initially successful at removal of the blockage and achieving luminal enlargement, the process also damages the blood vessel wall extensively including the loss of the endothelial lining. The ensuing response to this severe injury is often enhanced expression of cytokines and growth factors and, subsequently, a rapid reclosure or recoil, and/or a slow progressive re-occlusion or restenosis of the vessel. With the introduction of stents, metal-based cage/tube-like structures placed into the vessel lumen, a step toward improving outcomes was achieved. Coronary stents provide luminal scaffolding, eliminating elastic recoil which can occur rapidly following an interventional procedure. Unfortunately, although acute reclosure was reduced, neointimal hyperplasia was not, and in fact, the procedure lead to an increase in the prolifera- tive comportment of restenosis (10). As a consequence of PTCA, a neointima is formed within the vascular wall, typically including myointimal hyperplasia, proliferation and migration of SMCs and fibroblasts, connec- tive tissue matrix remodeling, and formation of thrombus. Restenosis, referring to the renarrowing of the vascular lumen following an intervention such as balloon angioplasty, is defined clinically as Ͼ50% loss of the initial luminal diameter gain following the interventional procedure and has affected anywhere from 30% to 40% of treated vessels. Restenosis: role of inflammation Initial attempts at treating or preventing restenosis focused primarily on inhibition of the proliferation of vascular SMCs (VSMCs). A series of agents successful at inhibition of SMC proliferation in vitro as well as in vivo in animal models such as carotid injury models in the rat failed to demonstrate bene- fit in the clinic. More recently, it has been shown in addition to effects on SMCs, that mechanical intervention also activates the recruitment and activation of immune cells. Cell signaling through cytokines, chemokines, and adhesion molecule expression results in the recruitment to the vascular wall of cells of many types, as well as their proliferation, migration, and/or maturation. As with atherosclerosis itself, recruitment of inflammatory cells is now recognized as an essential step in the pathogene- sis of neointima formation in humans (11,12). In various animal models, reduction of leukocyte recruitment by selec- tive blockade of adhesion molecules significantly reduced neointima formation and restenosis (13–16). Recent studies also concluded a role of pre-existing inflammation within the treated lesion itself and also, a correlation with systemic markers of inflammation. Interestingly and in addition, there are also current data suggesting a mobilization of hematopoeitic progenitor cells (HPC) contributing to restenosis, both from studies in mice and in humans (17). Activation of inflammation Following PTCA, responses within the vascular wall are typi- cal of a response to injury. Numerous studies in animals demonstrate that the inflammatory response is strongly related to degree of arterial injury, with balloon dilation damaging the endothelial lining and stimulating cytokine and adhesion molecule expression (12,18). A layer of platelets and fibrin forms at the injured site and circulating cells are recruited. P-selectin mediates the adhesion of activated platelets with monocytes and neutrophils and the rolling of leukocytes on the endothelium (14,15). This is the main pathophysiological process linking inflammation with throm- bosis after arterial wall injury. Leukocytes are recruited to the site of injury and NFkB is activated. Recent findings support a role for nuclear factor- kappa B (NFkB) as a key player in restenosis. NFkB, a central mediator of expression of inflammatory genes including cytokines and interleukins (ILs), is activated by degradation of its inhibitor IkB through the ubiquitin–proteasome system. This system regulates mediators of proliferation, inflamma- tion, and apoptosis that are fundamental mechanisms for the development of restenosis. In animal studies, blocking the proteasome system reduced intimal hyperplasia (19,20) showing that inflammation contributes significantly. Activation of cytokines enhances the migration of leukocytes across the platelet–fibrin layer into the tissue. Growth factors are released from platelets and leukocytes, and SMCs and fibrob- lasts proliferate and undergo a transformation to myofibroblasts 3 to 14 days after the intervention (11). With the release of growth factors, the initiation of the first phase (G1) of the cell cycle is activated, regulated by the assembly and phosphorylation of cyclin/cyclin-dependent kinase (CDK) complexes. Growth factors trigger signaling pathways that activate these CDK complexes. Studies using human arterial segments strongly support a role for inflammation in restenosis. Immediately following stent implantation, studies by Grewe et al. (21) demonstrate that a mural thrombus is formed, followed by invasion of SMCs, T-lymphocytes, and macrophages. Additional studies in atherectomy specimens following PTCA demonstrate an increase of monocyte chemoattractant protein-1 and speci- mens from restenotic lesions show an increased number of macrophages (22). These results indicate that local expres- sion of macrophage activity may be associated with the mechanisms of intimal hyperplasia. A correlation was found between stent strut penetration with inflammatory cell 316 Inhibition of target of rapamycin and its effect on vascular diseases 1180 Chap26 3/14/07 11:35 AM Page 316 density and neointimal thickness (23). Neointimal inflamma- tory cell content was 2.4-fold greater in segments with restenosis, and inflammation was associated with neoangio- genesis. Coronary stenting that is accompanied by medial damage or penetration of the stent into the lipid core induces increased arterial inflammation, which is associated with increased neointimal growth. Circulating markers of inflammation Similar to a growing body of evidence in studies of athero- sclerosis and cardiovascular disease, assessment of markers from blood samples has provided information regarding the role of inflammation after PTCA. Included among markers for atherosclerosis are C-reactive protein (CRP), IL-6, serum amyloid A (SAA), and even white blood cell (WBC) count. With respect to PTCA, many of these same markers provide insight. In studies by Serrano et al. (24) coronary sinus blood samples taken 15 minutes after angioplasty showed evidence of leukocyte and platelet activation with increased adhesion molecule expression on the surface of neutrophils and mono- cytes. Late lumen loss was correlated with the changes in IL-6 concentrations post-PTCA and MAC-1 activation in coronary sinus blood (25,26). Recent studies demonstrated that stent deployment is associated with an increase in CRP (27). Interestingly, CRP plasma levels were significantly higher and more prolonged in patients with restenosis compared with patients without restenosis. Similar findings were reported in a series of patients with stable angina who underwent PTCA (28). The association between the extent of vascular inflam- matory response with long-term outcome was even observed in patients with stable angina undergoing stent implantation (29). Finally, a recent study showed that the inflammatory response after stent implantation can be assessed by measuring the circulating monocytes in the peripheral blood. The maximum monocyte count after stent implantation showed a significant positive correlation with in- stent neointimal volume at six-month follow-up. In contrast, other fractions of WBCs were not correlated with in-stent neointima volume (30). These findings demonstrate that there is an inflammatory stimulus following PTCA, which needs to be assessed for the risk stratification for restenosis. Pre-existing inflammation The studies discussed earlier demonstrate that vascular injury caused by PTCA triggers inflammation. Importantly, however, at the time of stent implantation, the overall inflammatory status is not equivalent in all patients and, critically, in all atherosclerotic plaques. Therefore, PTCA in an already inflamed plaque may have significant impact on clinical and angiographic outcome. Studies in patients with unstable angina and elevated baseline CRP, SAA, and IL-6 values showed an enhanced inflammatory response to angioplasty. Pretreatment CRP level is an indepen- dent predictor for one-year major adverse cardiac events (MACE), including the need for re-intervention in patients not receiving statins. CRP levels were significantly higher in patients with recurrent angina compared with asymptomatic patients (31,32). Walter et al. (33) found that tertiles of CRP levels were independently associated with a higher risk of MACE and angiographic restenosis after stenting, and Buffon et al. (34) found that baseline CRP and SAA levels were independent predictors of clinical restenosis. Additionally, Patti et al. (35) found that preprocedural IL-1 receptor antagonist (IL-1Ra) plasma levels were an independent predictor of MACE during the follow-up period. Furthermore, the overall activation status of the immune system, estimated by the amount of IL-1 β produced by monocytes, had positive correlation with late lumen loss, while the expression of CD66 by granulocytes has shown to prevent luminal renarrowing (36). Finally, the concentration of macrophages was also reported to be an independent predictor for restenosis (23). The role of pre-existing inflammation in clinical outcome after stenting was also studied by measuring the temperature of the culprit lesion (37), a marker of inflammation. Patients with MACE had increased plaque temperature before the intervention. During a clinical follow-up of 18 months, the incidence of MACE in patients with increased temperature was higher compared with those without increased thermal heterogeneity. The adverse cardiac events were mainly due to restenosis at the culprit lesions. It appears that the overall and local inflammatory status at the time of PTCA plays a significant role in the development of restenosis. The current evidence arises from studies combining data from the clinical syndrome and peripheral markers of inflammation. For patients with unstable clinical syndromes and with increased levels of monocytes and CRP, there is strong evidence for increased risk of restenosis. The measurement of other inflammatory indices, such as SAA, IL-6, IL-1 β , IL-1Ra plasma levels, Lp(a), and fibrinogen, seems to provide additional information. Thus, overall, there is considerable evidence for an impor- tant role for inflammation contributing to the restenotic process. Sirolimus: molecular mechanism of action Sirolimus (rapamycin, Rapamune) is a naturally occurring macrocyclic lactone produced by Streptomyces hygroscopicus, a streptomycete isolated from a soil sample collected from Sirolimus: molecular mechanism of action 317 1180 Chap26 3/14/07 11:35 AM Page 317 [...]... Gelatinase B MMP-9 Stromelysins Stromelysin 1 MMP-3 Stromelysin 2 Stromelysin 3 Membrane-type (MT-MMPs) MT1-MMP MMP-10 MMP-11 MT2-MMP MT3-MMP MT4-MMP MT5-MMP MT6-MMP Nonclassified MMPs Matrilysins MMP-15 MMP- 16 MMP-17 MMP-24 MMP-25 Metalloelastase Unnamed Enamelysin Endometase MMP-14 MMP-7 MMP-12 MMP-19 MMP-20 MMP-23 MMP- 26 Collagen types III, IV, IX, and X, gelatin, fibronectin, laminins, tenascin-C, vitronectin... stenting 327 MMPI GM6001 was shown to reduce intimal cross-sectional area and collagen content by 40% in stented arteries (13) These data help support the rationale for the use of a batimastat-loaded stent to help reduce the restenotic response of the artery after stenting Batimastat: mode of action Batimastat, (4-N-Hydroxyamino )-2 R-isobutyl-3s-(thiopen-2ylthiomethyl)-succinyl-l-phenylalanin-n-methylamide,... IL-2 production, however, the antiproliferative effect of sirolimus results from the inhibition of the kinase TOR and regulation of the CDK inhibitor p27kip1 (60 62 ) The T-cell proliferative effects of sirolimus are not limited to inhibition of IL-2 or IL-4 mediated growth as it has also been found to inhibit intermediate or late-acting IL-12, IL-7, and IL-15, driven proliferation of activated T-cells,... mechanisms of immunosuppression by cyclosporine, FK5 06, and rapamycin Curr Opin Nephrol Hypertens 1995; 4 (6) :472–477 Sarbassov Dos D, Ali SM, Sabatini DM Growing roles for the mTOR pathway Curr Opin Cell Biol 2005; 17 (6) :5 96 60 3 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 Wullschleger S, Loewith R, Hall MN TOR signaling in growth and metabolism Cell 20 061 0; 124(3):471–484 Dann SG, Thomas G The amino... 1180 Chap27 3/24/07 3 36 Table 6 10:17 AM Page 3 36 Anti-migratory drugs and mechanisms of action Six-month clinical follow-up: comparison between BRILLIANT-EU and DISTINCT BRILLIANT-EU N ϭ 173 (%) Cardiac death Q-wave MI Non-Q-Wave TLR CABG Total MACE DISTINCT N ϭ 313 (%) P-value 1 0 2 14 1 18 1 1 1 11 3 17 NS NS NS NS NS NS Abbreviations: BRILLIANT-EU, batimastat (BB94) anti-restenosis trial utilizing... correlates with loss of calcineurin phosphatase activity Biochemistry 1992; 31( 16) :38 96 3901 Parsons JN, Wiederrecht GJ, Salowe S, et al Regulation of calcineurin phosphatase activity and interaction with the FK5 06. FK-5 06 binding protein complex J Biol Chem 1994; 269 (30):1 961 0–1 961 6 Flanagan WM, Corthesy B, Bram RJ, Crabtree GR Nuclear association of a T-cell transcription factor blocked by FK5 06 and cyclosporin... Follow-up RVD (mm) MLD (mm) %DS Late loss (mm) Loss index Binary restenosis rate (%) DISTINCT N ϭ 163 2.91 Ϯ 0.41 1.01 Ϯ 0.34 65 .20 Ϯ 10.70 N ϭ 163 2.99 Ϯ 0.39 2.50 Ϯ 0.45 16. 54 Ϯ 8.39 1.81 Ϯ 0.38 N ϭ 1 46 3.12 Ϯ 2. 96 1.81 Ϯ 0 .63 37 .65 Ϯ 20.20 0.88 Ϯ 0 .63 0.50 Ϯ 0.39 23 N ϭ 313 2.95 Ϯ 0.48 0.81 Ϯ 0.37 72.27 Ϯ 11.92 N ϭ 1 46 2.92 Ϯ 0.47 2.87 Ϯ 0.43 2.87 Ϯ 12.08 2.03 Ϯ 0.49 N ϭ 143 2.90 Ϯ 0.45 1.94 Ϯ 0 .67 ... switch on the expression of several angiogenic factors including VEGF, nitric oxide synthase, and PDGF by activating hypoxia inducible transcription factors (HIFs) (Table 1) HIF-1 is an ab-heterodimer that was first recognized as a DNA binding factor Both HIF-a and -b subunits exist as a series of isoforms encoded by distinct genetic loci Among three isoforms of HIF-a, HIF-1a and HIF-2a are more closely... al Twenty-eight-day efficacy and pharmacokinetics of the sirolimus-eluting stent Coron Artery Dis 2002; 13(3):183–188 Kipshidze NN, Tsapenko MV, Leon MB, Stone GW, Moses JW Update on drug-eluting coronary stents Expert Rev Cardiovasc Ther 2005; 3:953– 968 Fajadet J, Morice MC, Bode C, et al Maintenance of long-term clinical benefit with sirolimus-eluting coronary stents: three-year results of the RAVEL... spectrum of successfully treatable coronary conditions, particularly in high-risk patients and complex lesions In long-term follow-up of the RAVEL trial (73), clinical benefit with sirolimus-eluting coronary stents has been maintained Using cumulative one to three-year event-free survival rates, treatment with sirolimus-eluting stents was associated with a sustained clinical benefit and very low rates of . proMMP-2 MT2-MMP MMP-15 Activates proMMP-2 MT3-MMP MMP- 16 Activates proMMP-2 MT4-MMP MMP-17 Not known MT5-MMP MMP-24 Activates proMMP-2 MT6-MMP MMP-25 Not known Nonclassified MMPs Matrilysins MMP-7. found to inhibit IL- 2-dependent and -independent proliferation of B-cells in the mid-G1-phase of the cell cycle and to prevent cytokine- induced B-cell differentiation into antibody-producing cells, thereby. From Ref. 61 . 1.5 1.0 0.5 0.0 010203040 Days after stenting Uncoated stent Poly(lactide-co-Σ-caprolactone)-coated stent Intimal area (mm 2 ) 50 60 * Poly(lactide-co-Σ-caprolactone)-coated paclitaxel-releasing