Insufficient arterial driving pressure turns hypoxic microvascular remodeling into a catastrophe
Authors: Korpisalo P , Tarvainen S , Wirth G , Juusola G , Happonen K , Frimodig C , Hytonen J , Taavitsainen J , Greco D , Knuuti J , Hartikainen J , Laitinen T , Yla-Herttuala S , Hakovirta H , Makinen K 
Published: November 2023

The tissue microvasculature is known to remodel in response to ischemia. However, the benefit or harm of this process is not completely understood and may limit also the potential of taking control of ischemic diseases that remain the leading cause of death worldwide. In a series of clinical and preclinical studies, we have thus dissected the biological relevance and the pathomechanistic role of hypoxic microvascular remodeling in critical limb threatening ischemia (CLTI).

High-resolution contrast enhanced ultrasound was used in 50 patients with severe CLTI scheduled for immediate revascularization to study ischemic muscle microvascular blood flow. Immunohistological analyses were performed for amputation muscle samples from a set of 40 CLTI patients to analyze microvascular changes with respect to the level of myofiber atrophy. Furthermore, the amputation muscle samples were used to find 3 paired samples from 20 patients representing microvascular transformation along worsening of ischemic muscle damage, and used for RNA sequencing to analyze mechanisms of microvascular transformation. Additionally, animal models for acute ischemia in C57Bl-mice (n=42) and hypercholesterolemic LDLR-/-ApoB100/100 mice (n=61) and chronic CLTI-like ischemia model in cholesterol-fed NZW rabbits (n=24) with AdVEGF-A or AdLacZ control gene transfer were employed to study: 1) the natural course of microvascular changes leading to efficient muscle regeneration; 2) the effect of reduced arterial driving pressure on muscle regeneration; and 3) the effect of reduced arterial driving pressure and microvascular transformation on muscle regeneration, respectively.

Decreased capillary transit time (P&lt;0.01) and a gradual arterialization of capillaries along worsening of ischemic tissue damage (P&lt;0.001) were observed in CLTI muscle. CLTI muscle RNA sequencing further suggested that the capillary arterialization process is an orchestration of different growth factors, cell types and even physical forces in the hypoxic muscle. Furthermore, animal models of acute and chronic limb ischemia display post-ischemic capillary enlargement (P&lt;0.05) as a primary microvascular modification that facilitates collateral maturation but under decreased arterial driving pressure can turn from a good intention to aggravating ischemic damage.

These results depict a critical role for the microvasculature in determining ischemic muscle outcome after an initial arterial occlusion in CLTI. Hypoxic microvascular remodeling, according to this data, initially has a good purpose but can also cause harm given enough time and the wrong environment. Moreover, these results offer understanding to the differential natural recoveries of experimental animals and human patients from an ischemic exposure – information that is essential for designing better treatments for ischemic diseases.