Assessment and modulation of the lymphatic function throughout the onset and progression of atherosclerosis

Atherosclerosis is the principal cause of coronary artery disease (CAD), affecting large- and medium-sized arteries. It is a chronic inflammatory disease characterized by intimal plaques composed of inflammatory cells, smooth muscle cells, fibrous components and lipids. Cholesterol that accumulates within macrophages in peripheral tissues, like the arterial wall, whether from dietary or synthetic sources, promotes inflammatory responses and needs to be excreted with the help of the cholesterol acceptor high density lipoprotein (HDL). This specific process is termed macrophage reverse cholesterol transport (mRCT) and studies have demonstrated that lipid free apolipoprotein A-I (apoA-I) could be a key player in mRCT regulation, exuding different effects than HDL. More importantly, recently, the lymphatic system has been identified as a novel prerequisite player in the removal of cholesterol out of the atherosclerotic lesion (Martel et al., JCI 2013). It has been demonstrated that without functioning lymphatic vessels cholesterol mobilization from the plaque cannot be properly achieved and aggravates the disease.  The lymphatic network runs in parallel to the blood vasculature and is present in almost all the tissues of the body. It is a crucial player in maintaining fluid homeostasis, trafficking immune cells from the periphery to corresponding lymph nodes, as well as transporting lipids from the intestine to the circulation. The lymphatic system comprises the   initial and collecting lymphatic vessels (LVs), as well as lymph nodes, all with a specific anatomy and distinctive roles. Lymph, the clear fluid that circulates within LVs drains towards the bloodstream at the level of the subclavian vein. Platelets are responsible to regulate this blood/lymphatic vessel separation by forming a clog, upon the interaction of their C-type lectin-like receptor 2 (CLEC-2) with podoplanin, present on lymphatic endothelial cells. Platelet activity has also been shown to be required throughout life in order to maintain LV junction integrity.   Atherosclerosis is also characterized by increased cellular activation and apoptosis. Consequently, these cellular activities may result in the formation of submicron particles called extracellular vesicles (EVs) that have variable effects on the blood endothelium and subsequent plaque evolution. CAD has been associated with increased circulating EVs, and we suspect that these EVs might be involved in atherosclerosis-related lymphatic dysfunction.  Based on recent data collected during my master’s degree, there is evidence that enhancing lymphatic transport could limit atherosclerosis progression and favour plaque regression. We showed that lymphatic transport is impaired in young, atherosclerosis-prone mice, even before atherosclerosis onset. We believe it to be potentially associated with a defect in the lymphatic pumping capacity, and we suggest that enhancing VEGF-C/VEGFR-3 binding can abolish this specific defect. The global objective of this thesis was to pursue along this path and better delineate the role of the important lymphatic-specific growth factor, VEGF-C and the lipoprotein apoA-I, on collecting LVs function. Furthermore, a better understanding of lymph components, especially cellular releasants was deemed necessary. The first publication allowed us to show that when injected with VEGF-C 152s, before the administration of a pro-atherogenic regimen, Ldlr-/- mice were protected from excessive plaque formation and long-term, had a more stable plaque. The sustained contraction capacity of the collecting lymphatic vessels and the enhanced expression of VEGFR-3 and FOXC2 observed in these VEGF-C-152s treated mice contributed to the clearance of harmful components contained in peripheral tissues such as the macrophages and cholesterol.  The second publication showed that atherosclerotic Ldlr-/- mice treated with low-dose lipid-free apoA-I had enhanced lymphatic transport and abrogated collecting LV permeability possibly through modulation of platelet activity.  The third publication is the first ever to demonstrate the presence of extracellular vesicles of heterogeneous origins in the lymph of mice, and that their levels differ in atherosclerosis. Collectively, these studies confirm that lymphatic dysfunction is present before the onset of atherosclerosis, and particularly of interest, that this dysfunction is primarily associated with a defect in the collecting vessels, thereby limiting the lymph transport from peripheral tissues to the blood. Different treatments with growth factors and lipoproteins have the potential to modulate the lesion onset and progression through the enhancement of lymphatic function, while our findings regarding the presence of EVs in lymph represents their potential as biomarkers, but also a new venue to better understand lymphatic dysfunction.

Keyphrases: Atherosclerosis, Cholesterol, Lymphatic vessels, Lymphatic endothelial cells, Smooth muscle cells, Lipoproteins, Cellular transport, Inflammation, Extracellular vesicles, Platelets, Athérosclérose, Llipoprotéines, Inflammation