Circulation. 2000;101:e33-e35
(Circulation. 2000;101:e33.)
© 2000 American Heart Association, Inc.
Circulation Electronic Pages |
Angiotensin-Converting Enzyme Tissue Activity in the Diffuse In-Stent Restenotic Plaque
Flavio Ribichini, MD;
Francesco Pugno, MD;
Valeria Ferrero, MD;
Gianni Bussolati, MD, FRCPath;
Germano Melissano, MD;
Roberto Chiesa, MD;
Carlo Di Mario, MD;
Antonio Colombo, MD
From the Cardiac Catheterization Laboratory and Division of Cardiology
(F.R., V.F.) and the Laboratory of Human Pathology (F.P.), Ospedale Santa
Croce, Cuneo; the Department of Biomedical Science, Università di
Torino (G.B.); and the Department of Vascular Surgery, Ospedale San Raffaele
(G.M., R.C.) and Cardiac Catheterization Laboratory, Centro Cuore
ColumbusOspedale San Raffaele (C.D.M., A.C.), Milano, Italy.
Correspondence to Flavio Ribichini, MD, Laboratorio di Emodinamica, Ospedale Santa Croce, Via Michele Copino 26, 12100 Cuneo, Italy. E-mail emodinamica{at}scroce.sanitacn.it
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Introduction
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We present the
6-month anatomic, histological, and immunohistochemical
(IHC)
images of a diffuse and aggressive type of in-stent
restenosis
of a popliteal artery of a patient homozygous for
the D (deletion)
allele of the ACE gene (Figures 1

, 2

, and 3

).

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Figure 2. Hematoxylin-eosin microscopy of the
arterial wall after removal of the metallic struts of the
stent. Right, Muscularis of media of arterial wall. Around
wire is a "wire cuffing" composed of inflammatory and
spindle-shaped cells. Left, Core of restenotic plaque shows
spindle-shaped cells and neovessels.
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A detailed description of the histological changes of
the arterial wall with time after coronary stenting
in humans was published recently.1 These findings have
confirmed that the ultrasound-detected "neointima"
observed >1 month after implantation is composed primarily of smooth
muscle cells (SMCs) and a proteoglycan-rich matrix. In the first weeks
after stenting, the metallic struts associate with inflammatory
cells, local thrombus formation, and "dedifferentiated"
-actinnegative spindle-shaped cells. Later,
multinucleated giant cells and
-actinpositive spindle-shaped cells
are observed in a more differentiated fibrocellular
lesion.1 2 ACE increases up to 100-fold during the
transformation of monocytes to macrophages, and most of the
dedifferentiated SMCs (
-actinnegative cells) stain for
ACE.3 However, ACE activity is thought to be limited only
to the first 2 months of the reparative process that follows
postballoon injury.
Our samples reproduce the histological findings
reported in 2 previous studies,1 2 but in contrast to the
results of Ohishi et al3 obtained from postballoon
restenotic samples, IHC staining for ACE was seen even 6 months
after stent implantation. In fact, the spindle-shaped cells observed in
the most external part of the restenotic plaque (close to the
wire) stained for ACE in our sample (Figure 3A
).
The data presented suggest that the transition of the
stent-induced inflammatory process, rich in ACE-positive cells, into a
fibrocellular lesion composed of differentiated SMCs is not a
time-determined sequence. Rather, it might be an ongoing process,
evolving from peripheral areas (close to the wire) to
central areas and ultimately leading to progressive lumen occlusion in
patients with enhanced ACE activity. This is consistent with
clinical studies that advocate a role of ACE in restenosis of
coronary stents.4
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Footnotes
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The editor of Images in Cardiovascular Medicine is Hugh A. McAllister,
Jr, MD, Chief, Department of Pathology, St Lukes Episcopal
Hospital and Texas Heart Institute, and Clinical Professor of
Pathology, University of Texas Medical School and Baylor College
of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Lukes Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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References
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Neointimal tissue response at sites of coronary
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Ohishi M, Ueda M, Rakugi H, Okamura A, Naruko T,
Becker AE, Hiwada K, Kamitani A, Kamide K, Higaki J, Ogihara Y.
Upregulation of angiotensin-converting enzyme during the
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Ribichini F, Steffenino G, Dellavalle A, Matullo G,
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Plasma activity and insertion/deletion polymorphism of
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Circulation. 1998;97:147154.[Abstract/Free Full Text]
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