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UCSF Vascular Symposium 2014

Peter J. Pappas, M.D.Clinical Professor of Surgery

Chairman, Department of SurgeryThe Brooklyn Hospital

Brooklyn, N.Y.

Pathophysiology and VenousUlcer Healing

Topics

• Macrovascular disease

– Varicose Vein Formation

• Microvascular disease

– Skin damage and venous ulcer formation

Anatomy of Vessel Wall Macrovascular Disease: Varicose Veins

• Genetic

– Primary Disease

• Acquired

– Deep venous thromboses

– Extrinsic Compression

• Environmental– Age, sex and race

– Pregnancy and female hormones

– Diet, bowel habits

– Occupation

– Height, weight and posture

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Primary and Deep Venous Thrombosis

• Primary disease has an unknown etiology

– Responsible for 70% of all reflux cases

– Genetics with environmental factors, such as multiple pregnancies, cause vein wall architecture changes

• DVTs cause of reflux and vein wall and valvular damage in up to 30%.

– Thrombosis causes vein valve destruction and vein wall inflammation leading to reflux and or outflow obstruction. (i.e. post-phlebitic syndrome)

Causes of disease progression and varix formation

Two Hit Theory

• Valve damage leading to reflux and venous hypertension

• Vein wall damage and contractile abnormalities

Valve Damage

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Normal Venous Valve

H.F. Janssen, Ph.D. Texas Tech University Health Sc ience Center, Lubbock, Texas.Thanks to Joe Caprini for the movie clip

Damaged Venous Valve

Thanks to Joe Caprini for the movie clip

Damaged Venous Valve

H.F. Janssen, Ph.D. Texas Tech University Health Sc ience Center, Lubbock, Texas.Thanks to Joe Caprini for the movie clip.

Vein Wall DamageAnd Contractile

Dysfunction

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Longititudinal view of normal vein architectureInflammatory Stimulus

P-selectin; PSGL-1; E-selectin; ESL-1 Interactions

Leukocytes; Platelets; Endothelium

PSGL-1 PSGL-1 ESL-1

P-selectin

P-sel; PSGL-1

Tissue Factor =TF

Platelet (PLT)

PSGL-1

MonocyteMonocyte

MonocyteMonocyte

MonocyteMonocyte

End

oth

eliu

m

Fibrin Deposition & Thrombus Amplification

Activation of Extrinsic Pathway

Red Blood Cells (RBC)

Fibrin Strands

11

MPs

Cell

MPs

MPsPLT

TF

E-sel; ESL-1

Injury

ns

GL-1 ESL-1

Neutrophil

T)

Neutrophil

PL

Neutrophil

LTPL

E-seL 1P-sel; PSGL-L-1

Binding

E-selectin

Mechanism of clot induced vein wall injury

Courtesy ofTom Wakefield

Vacuolated Smooth Muscle Cells of Varicose Vein Specimen With Collagen Invasion of Media

Transverse view of Collagen Fibers In Media Of Varicose Vein

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Vein wallThickening Secondary to Clot inducedInflammationOver time

Courtesy ofPeter Henke

Raffetto JD et al J Vasc Surg 2010;51:962-71.

Vein wall and luminal damage

Genetic Factors

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Cornu-Thenard et al. J Dermatol Surg Oncol 1994;20:318-326.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Positive-Positive 90% 90%Positive-Negative 25% 62%Negative-Negative 20% 20%

Males Females

Microvascular Disease

Venous Hypertension: Microvascular Disease CVI Dermal Microcirculation

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RBCs

PMN

Capillary Endothelium

CVI Dermal Microcirculation

PericapillaryCuff

MigratingMacrophages

FibroblastPostcapillary

Venule Lymphatic

CVI Dermal Microcirculation

Results: Immunohistochemistry Of CVI Skin For TGF-β1 and Vimentin

Results: Immunohistochemistry For TGF-β1

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Leukocytes with TGF-ß1 Granules Leukocyte Diapedesis

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TGF-ß1 Release TGF-ß1 Release

TGF-ß1 stimulated fibroblasts differentiate into myofibroblasts.

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Injury Stimulus causes cytokine releaseAnd RAS activation with possible

Senescence development and MMPSynthesis

RAS Activation RAS Activation

Normal wound healing process

Impaired venous ulcer healing process

Gel contraction of LC fibroblasts due to pCMV-Ras transfection

0

20

40

60

80

100

TGFpCMV-Ras TGF+pCMV-RasControl pCMV-β

LC 2LC 4LC 6

NC***

*** ***

***(#) **

***

*p<0.05, **p<0.01, ***p<0.001, #: N.S. between NC & LC6

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Active MMP-1,2 and TIMP-1

NS MM

P-1NS M

MP-2

NS TIM

P-1C2

MM

P-1C2

MM

P-2C2

TIMP-1

C3 M

MP-1

C3 M

MP-2

C3 TIM

P-1C4

MM

P-1C4

MM

P-2C4

TIMP-1

C5 M

MP-1

C5 M

MP-2

C5 TIM

P-1C6

MM

P-1C6

MM

P-2C6

TIMP-1

0.0

0.5

1.0

1.5

2.0�MMP-1 and TIMP-1 vs MMP-2 (p≤0.01)

�

� �

�

NS

C2

C3

C4

C5

C6

CVI class

rati

o of

nor

mal

ized

ban

d in

tens

itie

sCompression modalities

Unna BootMulti layer Bandage

MMP Levels in Healthy vs Ulcer Tissue Before and After Compression Therapy

MMP-8 (#, †, ‡) MMP-9 (#,†,‡)Significance of Data:

# = p< 0.05 Healthy v. Before Tx, † = p< 0.05 Health y v. After Tx, ‡ = p< 0.05 Before Tx v. After Tx

pg/µ

g to

tal p

rote

in

0

200

400

600

800

1000

1200

HealthyBefore TxAfter Tx

Venous Ulcer Interleukins

0

2

4

6

8

10

12

14

16

normal tissue ulcer before Rx ulcer after Rx

Il-8

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

norm al before after

IL12p40

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

normal before After

Il-1b

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Venous Ulcer Interleukins

TNF-alpha

00.0020.0040.006

0.0080.01

0.012

0.0140.0160.0180.02

Normal Before After

IFN-gamma

0

0.05

0.1

0.15

0.2

0.25

0.3

normal before after

TGF-beta

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

healthy before after

TGF-beta

• Elisa in 14 patients

Healthy vs before 0.05

Healthy vs after 0.008

Before vs after 0.03P values

Compression and Compliance

Mayberry et al. Surgery 1991; 81:575-581.

Conclusions

• Two hit theory for varicose vein formation

– Valve damage secondary to genetic and acquired conditions.

– Vein wall thickening and contractile abnormalities

• Microvascular Disease

– Venous hypertension causes chronic inflammatory damage leading to venous ulceration and poor wound healing.