9
Atherosclerosis, 90 (1991) 9-21 0 1991 Elsevier Scientific Publishers Ireland, Ltd. All rights reserved 0021-9150/91/$03.50 ADONIS 002191509100159A
ATHERO 04688
Pathological and angiographic regression of coronary atherosclerosis by LDL-apheresis in a patient with familial hypercholesterolemia Nobuhiko Koga
’ and
Yasushi Iwata 2
’Department of Cardiology. Koga Hospital, Kurume City 830 (Japan), ’ Kyushu Kosei Nenkin Hospital, Kitakyushu City 806 (Japan) (Received 2 November, 1990) (Revised, received 25 April and 24 May, 1991) (Accepted 28 May, 1991)
Summary We present the case of a 42-year-old male with familial hypercholesterolemia (FH) who had received long-term low-density lipoprotein (LDLI-apheresis before death occurred, presumably from an arrhythmia. He had been treated with double filtration plasmapheresis (DFPP) for 4 years and selective LDL adsorbent plasmapheresis (LAPP) for 2 years and 7 months. During the period of treatment (6 years and 7 months) he had received a total of 129 sessions of LDL-apheresis. Serum total cholesterol of the patient before the treatment was 638 mg/dl and during the treatment, the time-averaged values ranged from 336 mg/dl to 411 mg/dl for the first 4 years (with DFPP) and from 257 mg/dl to 364 mg/dl for the sequential 2 years and 7 months (with LAPP). Coronary angiograms were analysed for 13 segments of the coronary arteries using a digitized processing system. Analysis documented regression by identifying a reduction in percent stenosis from 34% to 20% in the proximal left circumflex artery (LCX), from 78% to 61% in the proximal right coronary artery (RCA), and from 92% to 72% in the middle RCA. In the other 10 segments analysed no significant regression and no progression were observed. The autopsy findings of the step-wise serial sections of the native coronary arteries did not record the formation of new and/or typical atheroma. In addition, a thickened intima, and an eccentric thickened wall lesion rich in collagen fiber were observed, although an accumulation of foam cells in the thickened wall lesions was found in some segments. This observation suggested scarring of the atheromatous plaque. We confirmed that LDL-apheresis performed over a period of 6 years and 7 months induced angiographic regressionof coronary atherosclerosis in the patient with FH, and found that most of the atherosclerotic lesions were changed pathologically into sclerotic lesions rich in collagen fiber.
Key words: Regression; Coronary atherosclerosis;
Correspondence to: Nobuhiko Koga, M.D., Department of Cardiology, Koga Hospital, 106 Tenjin-cho, Kurume City 830, Japan. Fax: 0942-37-3793.
Familial hypercholesterolemia;
LDL-apheresis
10 Introduction
Recently, LDL-apheresis has been widely accepted as a therapeutic measure for individuals with severe familial hypercholesterolemia (FH). The goal of this therapy is to remove the increased LDL-cholesterol and prevent the emergence and/or progression of coronary heart disease which is the major cause of death in FH. The efficacy of LDL-apheresis therapy in combination with lipid-lowering drugs has been reported [l-31, with angiographic documentation of the prevention and/or regression of coronary atherosclerosis. However, to date no report has documented the efficacy of treatment on arterial lesions both angiographically and pathologically. We used long-term treatment of LDL-apheresis in one patient with FH, and subsequently identified regression of stenotic lesions by serial angiography and noted the pathological change of atherosclerotic lesions into sclerotic lesions rich in collagen fiber, which also suggests pathological regression of atherosclerosis. Methods
Case history The patient, a 42-year-old Japanese male was working in a paint-coating factory. His parents are cousins, and both his mother and younger brother suffer from familial hypercholesterolemia. The younger brother (heterozygous FH) presented with angina pectoris and xanthoma, and he also has been receiving LDL-apheresis therapy. The patient developed xanthoma on his elbow at 6 years of age. The xanthoma gradually increased and at 13 years of age he developed xanthomata on his hands, buttocks, and Achilles’ tendons. At 30 years of age, he began to experience precordial oppressive sensations and dyspnea on effort, and his general condition was deteriorating. At 36 years of age (in 19821, he was diagnosed with hyperlipoproteinemia type IIa (serum total cholesterol, 638 mg/dl; triglyceride, 71 mg/dl) along with unstable angina and a left ventricular aneurysm. The patient also had previously suffered a myocardial infarction. LDL-receptor activity was studied by cultured skin fi-
broblasts 141.The studies showed that the receptor binding, internalization, and degradation of r2’I-LDL were 11 ng/mg of cell protein, 108 ng/mg of cell protein, and 198 ng/bhr/mg of cell protein, respectively, and also they were 38, 29, and 32% of normal control in each experiment. We diagnosed him to be a heterozygote, although LDL-receptor activity was determined to be intermediate between those of homozygous and heterozygous FH patients. He then started to receive DFPP and subsequent LAPP therapy. The severe symptoms of angina pectoris soon disappeared, although symptoms of chronic heart failure such as exertional dyspnea and shortness of breath remained. At 37 years of age (8 months after the start of LDL-apheresis), the patient underwent coronary artery bypass grafting (CABG) of 5 coronary arteries; the left anterior descending artery (LAD), the 1st diagonal artery, 1st marginal/2nd marginal arteries of the LCX, and the distal RCA combined with the left ventricular aneurysmectomy. After CABG was performed, the symptoms of angina pectoris disappeared completely and the heart failure symptoms diminished sufficiently which enabled the patient to enjoy daily life. The xanthomata on the elbows, buttocks, hands, and Achilles’ tendons were significantly reduced after LDL-apheresis therapy. In 1989, while the patient was helping with moving house, he died suddenly, presumably due to ventricular fibrillation at 42 years of age. Upon physical examination, he was well-developed (height 182 cm, weight 71 kg). Blood pressure was 120/60 mm Hg. We observed tendon xanthomata primarily in the Achilles’ tendons, and subcutaneous xanthomata on the elbows, knees, buttocks, and hands. There was no bruit over both carotid arteries, abdominal aorta or both femoral arteries. A systolic ejection murmur of grade 3/6 intensity was heard in the aortic area radiating to the apex. The murmurs ended before the second heart sound, which split normally with respiration. Electrocardiogram before CABG showed normal sinus rhythm, left axis deviation, left atria1 overload, abnormal Q wave in III and aV,, poor R wave progression in V,-V,, T wave inversion in II, III aV,, V,, V,, high voltage, and monofocal premature ventricular contraction (PVC). It later
1
IN SERUM
LIPIDS,
AND LIPOPROTEIN
CHOLESTEROL
a h ’ d ’
o A B C D E F G H
22.9 20.9 21.7 14.7 15.3 15.7 14.0 14.8
35 9 21 11 9 11 5 28
ment
No. of treat_
nil 1000 nil nil 1000 1000 1000 1000
(mg) a
Drug
No.
nil nil nil nil nil 10 10 20
nil nil nil nil nil nil 27 27 34 9 17 9 9 9 5 25
(mg) b (g) ’ Of samples
(/days)
value. = TC - (HDL - C + TG/5).
(days)
Interval period
Probucol. Pravastatin. Cholestyramine. Time-averaged LDL-cholesterol
Baseline DFPP DFPP DFPP LAPP LAPP LAPP LAPP LAPP
LDLapheresis
LEVELS
638 459+52 381i28 459k53 478+53 35lk46 363+39 386+46 338+38
_ 237+63 405k45 192k12 336+30 247k28 411k47 143k37 364+40 109+30 265+34 91k16 277+25 130+ 8 294+32 91+12 257+27
_ 595 394+47 335+35 409k46 405&60 294+41 303k31 332+39 278f34
Before
’
203+64 166&11 216k26 97+38 74k24 58+16 93k 4 55+12
_
After
LDL-cholesterol
After
d
Time averaging
Before
plasmapheresis;
Total cholesterol
DFPP: double filtration plasmapheresis; LAPP: selective LDL adsorbent level between the apheresis therapy. Values are mean f SD.
CHANGES
TABLE
_ 350+47 294+27 365k41 302+48 218+30 224k23 245+27 205k25
’
calculation
38+10 23+ 28+ 44k 24+ 24k 25k 26k
29
Before
7 5 7 7 3 6 3
23k4 16+3 21+3 37+5 24k6 25+2 25k5 26+2
_
After
HDL-cholesterol
_ 35i8 22+6 26k4 41+6 22+2 24+3 25+5 26+2
d
is given in Methods,
71 102+23 117+21 112+26 138+31 163+2l 157k41 144+31 172+33
Before
Triglyceride d
_ 55flO 95&19 55+ 8 102+17 54+ 9 loo&-21 42klO 103+21 54510 129+15 54+17 119k24 55k14 114+21 60+13 132+22
_
After
which gives a time-averaged
12 began to show atria1 fibrillation and PVC, frequently after CABG. PVC was monofocal at the beginning, but later increased in frequency and became multifocal. Marked left ventricular enlargement (cardiothoracic ratio 65%) and pulmonary venous congestion were observed on the chest roentgenogram. After CABG, the cardiothoracic ratio decreased to 62% and the pulmonary venous congestion improved slightly. On a series of ultrasonographic studies after the operation, the left ventricular aneurysm became smaller but the left ventricular diastolic dimension remained 70 mm at almost the same size as before the operation. The left ventricular ejection fraction was less than 30%.
column (Kanegafuchi Chemical Industry Co., Ltd., Osaka Japan) [9-121 packed with dextran sulfate cellulose bead adsorbent was used. Four liters of plasma were processed in DFPP every 3 weeks and 7 liters of plasma were processed in LAPP every 2 weeks. The patient received a total of 129 sessions (DFPP; 65 and LAPP; 64) of treatment during the treatment period of 6 years and 7 months in combination with the lipidlowering drugs probucol, pravastatin, and cholestyramine. Laboratory examinations
Total cholesterol (TC), triglyceride (TG), and high density lipoprotein cholesterol (HDL-C) were measured immediately each pre- and posttreatment. TC was also measured enzymatically [13] with a cholesterol C-AR11 assay kit (Wake Junyaku, Tokyo, Japan). TG was measured enzymatically [14] with a TG GII-AR assay kit (Wako Junyaku, Tokyo, Japan). HDL-C was measured using the dextran sulfate/ magnesium method [ 151 with the HDL-C 2 assay kit (Daiichi Kagaku, Tokyo, Japan). Low density lipoprotein cholesterol (LDL-C) was calculated by the Friedewald formula [16]. The time-averaged values (integral mean val-
LDL-apheresis
Two variations of the DFPP method [5--81 and the LAPP method [9-121 were employed as LDL-apheresis. In DFPP, APOSH (Asahi Medical Co., Ltd., Tokyo, Japan) or PS05 (Toray Medical Co., Ltd., Tokyo, Japan) was used as the 1st filter for plasma separation, and Evaflux 4A (Kuraray, Co., Ltd., Osaka, Japan) as the 2nd filter. In LAPP, FS05 (Kanegafuchi Chemical Industry Co., Ltd., Osaka, Japan) was used as the 1st filter, and for selective LDL adsorption the LA40 or LA15
Cholestyramine 279 every day Pravastatin 10 20mg every days Probucol IOOOmgevery day
;.....
:...,____r? I
6 1985
C 1986
L_
____
H. ..__.post
DEFG 1987
1988
1989
1990 (year)
Clinical Course Fig. 1. Clinical course and serum total cholesterol levels. Time-averaged value of TC is shown by solid line, mean value of TC of the pretreatment by upper dotted line and that of posttreatment by lower dotted line. Course divided into 8 periods of A-H according to the combination with medication.
13
w so 00
.r a 70 5 ‘60 8 Es0 1 c 40 5 g 30 P 20 10
Fig. 2. Chronological improvements of 3 stenotic segments of coronary atherosclerotic lesion via a serial angiography. A: middle segment of right coronary artery; B: proximal segment of right coronary artery; C: proximal segment of left circumflex artery.
ues) of TC, LDL-C, TG, and HDL-C were calculated as follows: in the case of TC, the value determined by integration calculus is based on the hypothesis that the TC level after LDLapheresis rebounds linearly to the same level as the subsequent pre-treatment level after 10 days. The formula is integral mean value of TC = (bc + 5a - 5b)/c where a = post-TC level, b = pre-TC level of subsequent procedure, and c = days between each procedure. Coronary angiography
Coronary angiography (CAG) was performed at a total of 6 sessions and during one session. Along with CAG percutaneous transluminal
Fig. 3. The left circumflex artery which showed the angiographic regression obtained by the treatment of LDL-apheresis. Left: the proximal lesion of the left circumflex artery showed 34% stenosis (Sept. 1983). Right: the arrow shows the improvements in stenosis from 34 to 20% (Oct. 1988).
14 coronary angioplasty (PTCA) was also performed. The first CAG was performed in August 1983 (8 months after the start of LDL-apheresis and before CABG), the 2nd 1 month after the first one (2 month after CABG), the 3rd in September 1984, the 4th in December 1986, the 5th along with PTCA in RCA and the proximal anastomosis site of RCA bypass vein graft in January 1988, and the 6th in October 1988. Evaluation of coronary angiograms
The evaluation of coronary stenosis was done using a digitized processing system (Mypron I system, Kontron Instruments). The analyses were performed in a blind fashion by experienced technicians under the supervision of skilled coronary angiographers. Measurements were made in a
single projection that displayed the most severe stenosis, and the serial measurements used for evaluation were made using the same projection for accurate comparison. As a rule, we selected the projection that showed the coronary segment in the plane (as closely as possible) perpendicular to the axis of the x-ray beam. To assess the variation in our method, we performed reevaluation for 23 random coronary arterial sites after 1 month. The mean of change was -0.8%, and the standard deviation (1 SD) was 3.7%. A significant change in coronary stenosis was defined as change in at least 11.2% of 3SD. We omitted from these calculations those lesions which were completely occluded or which suffered influence from bypass surgery. Preparation of histological specimens and staining
Serial step-sections of all of the coronary arteries including vein bypass graft bed were prepared at 3 mm intervals. Masson’s trichrome resorcine Fuchsin staining (Gordon stain) was carried out for histopathological examinations of the sections. The pathological observation was performed using light microscopy. Results Changes in serum lipids, and lipoprotein cholesterol levels
Fig. 4. In the middle portion of LAD, thickened intima and an eccentric thickened wall lesion rich in collagen fiber suggesting scarring of atheromatous plaque was seen. These findings were often seen in other native coronary arteries (x58). L: lumen, C: proliferation of collagen fibers.
The changes in serum total cholesterol level by the treatment of two methods of LDL-apheresis (DFPP and LAPP) combined with various lipidlowering drugs such as probucol, pravastatin and cholestyramine are shown in Table 1 and Fig. 1. The entire therapeutic course of the patient, 6 years and 7 months, was divided into 8 periods marked in Fig. 1 A-H. As shown in Table 1, the TC level decreased from 638 mg/dl at baseline to a time-averaged value of 405 mg/dl by DFPP (A). The administration of probucol (1000 mg/day) induced further decrease of the time averaged TC value, from 405 to 336 mg/dl (B). When the administration of probucol was discontinued, the TC value returned to the same level as that in period A (0 The acute lowering effect of TC, as determined by the difference between pre- and postprocedure values was more dramatic by LAPP
15
Fig. 5. Superficial foam cell accumulation (F) was seen in the proximal LCX. These findings were also seen in some other sites of native coronary arteries (X 71).
(D) than DFPP (in period A, Cl. As seen with DFPP, the administration of probucol in combination with LAPP was effective in further lowering TC (E). The addition of cholestyramine and pravastatin did not further induce a decrease in time averaged TC value (F, G, H). However, maximum doses of the 3 drugs in combination with LAPP produced the lowest time averaged TC level. Therefore, we maintained maximum therapy with the 3 drugs in combination of probucol, pravastatin and cholestyramine, and LAPP. No adverse reactions to the drugs were observed. The influence of DFPP and LAPP procedures in combination with lipid lowering drugs on serum LDL-C, HDL-C and TG levels is also shown in Table 1. Serial coronary angiographic findings
Cineangiography before CABG (8 months after starting LDL-apheresis therapy) revealed high grade stenosis in the proximal (78%) and middle (92%) RCA. A total occlusion just distal from the branching portion of the huge acute marginal artery in the distal RCA was observed. In the left coronary artery, there were 25% and 99% steno-
sis in the proximal and far proximal portions of the LAD, subtotal occlusion in the 1st diagonal artery, and 34% stenosis in the proximal LCX. In the 1st and 2nd marginal arteries of the LCX, there were high grade stenotic lesions. Left ventriculogram showed marked left ventricular dilatation, diffuse hypokinesis and inferoapical aneurysm. The left ventricular ejection fraction was 26%. The aortogram showed an irregular contour and slight narrowing in the aortic root, with no systolic pressure gradient between the left ventricle and aorta. We measured 13 evaluable segments using computer analysis (Mypron I system, Kontron Instruments) and observed significant improvement in the stenosis in 3 of the 13 segments after CABG (Fig. 2). At the 5th CAG (4 years and 4 months later), percent stenosis was reduced from 78 to 61% in the proximal, from 92 to 72% in the middle segment of the RCA, and from 34 to 20% in the proximal LCX. The two angiograms of the proximal LCX are shown in Fig. 3. When the 5th angiography was performed on January 20, 1988, a high grade stenosis in the proximal anastomosis sites of RCA graft was found and PTCA was
17
Fig. 7. In the PTCA
site of proximal
RCA,
intimal
and medial disruption, layered head) were seen f x 73).
performed successfully. Simultaneously, PTCA was also performed in both proximal and middle site of the RCA and the lesion was dilated from 61 to 46% in the proximal lesion, and from 72 to 32% in the middle. These lesions maintained dilatation satisfactorily for 10 months. The lesions in the 10 segments remained unchanged. The final CAG confirmed patency in the 5 bypass grafts without appearance of new lesions.
thickened
intima
(I), and calcification
(at row
rotic lesions. There was a thickened intima and an eccentric thickened wall lesion rich in collagen fiber which suggests a scarring of atheromatous plaque (Fig. 4). Accumulation of foam cells was observed in only a few sites (Fig. 5). In the proximal site of the LCX where angiographic regression was documented, circumferential thickened intima and a large eccentric thickened wall lesion with deficit in the media were observed. The eccentric thickened wall lesion was rich in collagen fiber and there was a small necrotic center surrounded by foam cells (Fig. 6a, b). Together with the angiographic documentation, these pathological findings reveal the process of the scarring of atheromatous plaque, which
Pathological findings of coronary arteries and vein bypass grafts
In the native coronary arteries, we observed sclerotic lesions without new or typical atheroma in the arterial wall and a few typical atheroscle-
Pig. 6. (aI The specimen corresponding to the angiographic regression site of proximal left circumflex artery. The color light microscopy was prepared by Masson’s Trichrome resorcin Fuchin staining. Collagen fiber was stained blue, elastic fiber black, and smooth muscle brown. There was diffuse intimal thickening and eccentric thickened wall lesion (I) rich in collagen fiber (X 20). L: lumen; (b) Magnified pattern of the eccentric thickened wall lesion of (a). We can see the accumulation of foam cells (F) around the small necrotic center in the eccentric thickened wall lesion. Improvement of stenosis of this site was confirmed by serial angiography. We consider that this pattern is the process of the disappearance of atheroma ( X 76). F: foam cells; * Dense collagen fibers.
18 nest of the vein graft, and in some sites accumulation of foam cells was observed (Fig. IO). Discussion
Fig. 8. In the near PTCA site of middle segment of RCA, injimal proliferation, and foam cell accumulation (F) in all of the arterial wall were seen. The severity of accumulation of foam cellshere was highest of all other sites of the native coronary arteries (X 143).
also suggests regression. At two sites, the proximal and middle segments of the RCA, PTCA was carried out. Intimal and medial disruption, layered intima, intimal thickening, and calcification were found in the proximal site (Fig. 7). In the middle site we observed almost the same findings as in the proximal site but no calcification was observed. Thickened intima with accumulation of foam cells was also found near the PTCA site of the middle RCA (Fig. 8). In the proximal anastomosis lesion of the RCA vein bypass graft which simultaneously received PTCA, there were atheroma, accumulation of foam cells, intimal disruption, and plaque proliferation (Fig. 9). Intimal proliferation was seen in
There have been several reports presenting angiographic regression of coronary atherosclerosis obtained by LDL-apheresis with lipid-lowering drugs for FH [1,3,17,20]. However, the histopathological improvement that might occur in arterial walls by these therapies has been obscure. In our patient the serial coronary angiograms showed definite regression in 3 out of 13 segments evaluated, and no change in the other 10 segments. For advanced coronary atherosclerosis characterized as severe stenosis alternative procedures such as PTCA and CABG may be necessary due to the fact that the regression of coronary atherosclerosis induced by LDL-apheresis combined with drug therapy, takes a longer period of time to occur. However, it was obvious that the LDL-apheresis therapy can induce the regression of both severe atherosclerotic lesions and mild to moderate atherosclerotic lesions containing segments after PTCA (Fig. 2). Clinical improvement was considered to be achieved by not only angiographic reduction of stenosis but also histopathological improvement of stenotic lesions. We observed pathologically that the condensation of thin and loose fibrous cap and the concomittant disappearance of atheromatous plaque was induced by the LDLapheresis therapy (Fig. 6a, b). In most native coronary artery walls, we observed atypical atherosclerotic changes without atheroma and eccentric thickened wall lesions rich in collagen fiber both suggesting scarring of the atheromatous plaque. It was further suggested that formation of eccentric, thickened wall lesions rich in collagen fiber prevents the atheromatous plaque from tearing off which could cause acute coronary events. We can conclude that, clinicopathologically speaking, cholesterol-lowering therapy can bring about “true” regression of coronary atherosclerosis. One should, however, consider the limitations of estimating regression by angiographic examinations and focus more on the histological changes
19
Fig. 9. In the proximal
anastomosis
site of the RCA vein bypass graft which received
(F), intimal
Fig. 10. In the proximal
disruption
anastomosis
(arrow
heads)
site of diagonal
and plaque
proliferation
PTCA.
atheroma
(A), foam
c:ell accumul ation
were seen ( x 24).
vein bypass graft. foam cell accumulation
(F) was seen
( x 2.1).
20
of the arterial wall. Even if widening of the stenotic lumen caliber is not available, one can expect improvement in the atherosclerotic lesions, which means that the development of methodologies to detect the qualitative alteration of vessel lesions is very important. To discuss the efficacy of the lipid-lowering therapy, it is important to clarify how much and how long one should lower serum cholesterol to prevent progression and induce regression. Our regimen for the patient lowered TC from 638 mg/dl at baseline to a time-averaged value of 257 mg/dl by initiating treatment with DFPP and LAPP for 6 years and 7 months (Table 1, Fig. 1). The results of pathological studies showed regression in most of the native arteries, although atheroma remained in the proximal anastomosis site of bypass vein graft. In the sites of PTCA and some sites of native artery or bypass graft, we observed the accumulation of foam cells. This fact might suggest that the cholesterol lowering level which we applied was insufficient to prevent atherosclerosis completely, especially for vein bypass graft. Selective systems for LDL-removal such as anti-LDL antibody agarose gel [18], HELP (Heparin-mediated extracorporeal LDL: fibrinogen precipitation) system [19], and LDL adsorption by dextran sulphate cellulose columns are available. Furthermore, more effective drugs such as pravastatin (eptastatinl, simvastatin, and lovastatin for cholesterol lowering can be used in combination with these methods [20-231. In our patient, we succeeded in inducing both angiographic and histologic regression of coronary atherosclerosis by treatment with LDL-apheresis. Acknowledgments
We would like to acknowledge the expert help received while treating this patient. In particular, we would like to thank Professor N. Kimura and Professor H. Toshima (Third Dept. Int. Med., Kurume Univ.), Drs. T. Fujino, S. Kanaya (First Dept. Int. Med., Kyushu Univ.), T. Matsuguchi (Aso Iizuka Hospital), T. Yamashita (Kanegafuchi Chemical Ind. Co., Ltd.,), T. Sato, K. Kohchi, Mr. T. Nagano, Mr. T. Nishimura, and Mr. T. Hashizume (Koga Hospital) for their help. We
appreciate the determination of LDL-receptor activity by Drs. H. Mabuchi, H. Fujita, K. Kajinami (Second Int. Med. Kanazawa Univ.). We are grateful to Akiko Sanada for secretarial assistance. References 1 Thompson,
2
3
4
5
6
I
8
9
10
G.R., Myant, N.B. Kilpatrick, D.. Oakley, CM.. Raphael, M.J. and Steiner, R.E., Assessment of long-term plasma exchange for familial hypercholesterolemia. Br. Heart J., 43 (1980) 680. Stein, E.A., Adolph, R., Rice, V., Glueck, C.J. and Spitz. H.B., Nonprogression of coronary artery atherosclerosis in homozygous familial hypercholesterolemia after 31 months of repetitive plasma exchange, Clin. Cardiol., 9 (1986) 115. Hombach, V., Borberg, H., Gadzkowski, A.. Oette, K. and Stoffel, W., Regression der Koronarsklerose bei familiarer Hypercholesterinamie IIa durch spezifische LDL-apherese, Dtsch. med. Wschr., III (1986) 1709. Haba, T., Mabuchi, H., Yoshimura, A.. Watanabe. A.. Wakasugi, T., Tatami, R., Ueda, K.. Ueda. R., Kametani. T., Koizumi, J., Miyamoto, S., Takeda, R. and Takeshita. H., Effects of ML236B (compactin) on sterol synthesis and low density lipoprotein receptor activities in fihroblasts of patients with homozygous familial hypercholesterolemia, J. Clin. Invest., 67 (1981) 1532. Agishi, T.. Kaneko, I, Hasuo, Y.. Hayasaka. Y.. Sanada, T.. Ota, K.. Amemiya, H., Sugino, N., Abe, M.. Ono, T.. Kawai, S. and Yamane, T., Double filtration plasmaphersis, Trans. Am. Sot. Artif. Intern. Organs, 26 (1980) 46. Koga, N., Nomura, G.. Yamagata. Y.. Takada. S.. Nishimura, T., Sanada, A., Kanaya, S. and Fujuno. T.. Double-filtration plasmapheresis in the treatment of two cases of homozygous familial hypercholesterolemia, In: Oda, T. (Ed.), Therapeutic Plasmapheresis (III). Schattauer, Stuttgart-New York, 1983, pp. 113. Mabuchi, H.. Michishita, I., Sakai, T., Sakai. Y.. Watanabe, A., Wakasugi, T. and Takeda. R.. Treatment of homozygous patients with familial hypercholesterolemia by double-filtration plasmapheresis, Atherosclerosis, 61 (1986) 135. Sasaki, H., Koga, N., Maw, P.R., Moriyama, A. and Nomura, G.. Reverse rinse of the second filter in double filtration plasmapheresis: when to rinse and influence on removal of cholesterol., In: Oda, T., Shiokawa. Y. and Inoue, N. (Eds.), Therapeutic Plasmapheresis (VI). ISA0 Press, Cleveland, OH, 1987, p. 343. Yokoyama, S., Hayashi, R., Kikkawa, T., Tani, N.. Takada. S., Hatanaka, D. and Yamamoto. A., Specific sorbent of apolipoprotein B-containing lipoproteins for plasmapheresis: characterizaton and experimental use in hypercholesterolemic rabbits, Arteriosclerosis, 4 (I 984) 276. Yokoyama, S., Hayashi, R., Satani, M. and Yamamoto, A.. Selective removal of low density lipoprotein by plasmapheresis in familial hypercholesterolemia, Arteriosclerosis. 5 (1985) 613.
21 11 Koga, N., Sasaki, H., Nishimura, T., Maw, P.R., Nishida, H. and Nomura, G., Adsorbent rinse in LDL-apheresis, ASAIO Abstr.. 16 (1987) 48. 12 Mabuchi, H., Michishita I., Takeda, M. and Fujita H., A new low density lipoprotein apheresis system using two dextran sulfate cellulose columms in an automated column regenerating unit (LDL continuous apheresis), Atherosclerosis, 68 (1987) 19. 13 Richmond. W., Preparation and properties of a cholesterol oxidase from nocardia sp. and its application to the enzymatic assay of total cholesterol in serum, Clin. Chem.. 19 (1973) 1350. 14 Tamaoku, K., Ueno, K., Akiura, K. and Ohkura Y., New water soluble hydrogen donors for the enzymatic photometric determination of hydrogen peroxide. II. N-Ethyl-N(2-hydroxy-3sulfopropylJaniline derivatives, Chem. Pharm. Bull., 30 (1982) 2492. 15 Warnick, G.R., Nguyen, T. and Albers, A.A., Comparison of improved precipitation methods for quantification of high-density lipoprotein cholesterol, Clin. Chem., 31(1985) 217. 16 Friedewald. W.T., Levy, RI. and Friedrickson, D.S.. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparation ultracentrifuge, Clin. Chem., 18 (1972) 499. 17 Klein, J.M., Drobinski, G., Brukert, E., Dairout, F., Thomas, D. and De Gennest, J.L., Results of serial coronary angiography in patients with homozygous familial hypercholesterolemia, European Heart Journal, 9 (1988). 1067.
18 Stoffel, W., Borberg, H. and Greve, V.. Application of specific extracorporeal removal of low density lipoprotein in familial hypercholesterolemia, Lancet, ii (1981) 1005. 19 Armstrong, V.W. and Seidel, D., The HELP system: a novel technique for the extracorporeal treatment of familial hypercholesterolemia; In: Schlierf. G. and Marl, H. (Eds.), Expanding Horizons in Atherosclerosis Research, Springer, Heidelberg, 1987, p. 34.5. 20 Thompson, G.R., Barbir, M., Okabayashi, K., Trayner, I. and Larkin, S., Plasmapheresis in familial hypercholesterolemia, Arteriosclerosis, 9 (1989) Suppl. 1, 152. 21 Mabuchi, H.. Fujita, H., Michishita, I. Takeda, M., Kajinami, K., Koizumi, J., Takeda, R.. Tekegoshi. T., Wakasugi, T., Ueda, K., Miyamoto, S., Watanabe, A. and Oota, M.. Effect of CS-514 (eptastatin), an inhibitor of 3-hydroxy-3-methylglutaryyl-coenzyme A (HMG-CoA) reductase, on serum lipid and apolipoprotein levels in heterozygous familial hypercholesterolemic patients treated by low density lipoprotein (LDL)-apheresis, Atherosclerosis, 72 (1988) 183. 22 Riesen, W.F., Descoeudres, C.. Mordasini, R. and Girod, M.A., Selektive Elimination atherogener Lipoproteine mit Dextrasulfat-Cellulose’; Schw. Med. Woch, 119 (1989) 55. 23 Thiery, J., Walli, A.K., Janning, G. and Seidel. D., Lowdensity lipoprotein plasmapheresis with and without lovastatin in the treatment of the homozygous form of familial hypercholesterolaemia, Eur. J. Pediatr., 149 (1990) 716.
Atherosclerosis, 90 (1991) 9-21 0 1991 Elsevier Scientific Publishers Ireland, Ltd. All rights reserved 0021-9150/91/$03.50 ADONIS 002191509100159A
ATHERO 04688
Pathological and angiographic regression of coronary atherosclerosis by LDL-apheresis in a patient with familial hypercholesterolemia Nobuhiko Koga
’ and
Yasushi Iwata 2
’Department of Cardiology. Koga Hospital, Kurume City 830 (Japan), ’ Kyushu Kosei Nenkin Hospital, Kitakyushu City 806 (Japan) (Received 2 November, 1990) (Revised, received 25 April and 24 May, 1991) (Accepted 28 May, 1991)
Summary We present the case of a 42-year-old male with familial hypercholesterolemia (FH) who had received long-term low-density lipoprotein (LDLI-apheresis before death occurred, presumably from an arrhythmia. He had been treated with double filtration plasmapheresis (DFPP) for 4 years and selective LDL adsorbent plasmapheresis (LAPP) for 2 years and 7 months. During the period of treatment (6 years and 7 months) he had received a total of 129 sessions of LDL-apheresis. Serum total cholesterol of the patient before the treatment was 638 mg/dl and during the treatment, the time-averaged values ranged from 336 mg/dl to 411 mg/dl for the first 4 years (with DFPP) and from 257 mg/dl to 364 mg/dl for the sequential 2 years and 7 months (with LAPP). Coronary angiograms were analysed for 13 segments of the coronary arteries using a digitized processing system. Analysis documented regression by identifying a reduction in percent stenosis from 34% to 20% in the proximal left circumflex artery (LCX), from 78% to 61% in the proximal right coronary artery (RCA), and from 92% to 72% in the middle RCA. In the other 10 segments analysed no significant regression and no progression were observed. The autopsy findings of the step-wise serial sections of the native coronary arteries did not record the formation of new and/or typical atheroma. In addition, a thickened intima, and an eccentric thickened wall lesion rich in collagen fiber were observed, although an accumulation of foam cells in the thickened wall lesions was found in some segments. This observation suggested scarring of the atheromatous plaque. We confirmed that LDL-apheresis performed over a period of 6 years and 7 months induced angiographic regressionof coronary atherosclerosis in the patient with FH, and found that most of the atherosclerotic lesions were changed pathologically into sclerotic lesions rich in collagen fiber.
Key words: Regression; Coronary atherosclerosis;
Correspondence to: Nobuhiko Koga, M.D., Department of Cardiology, Koga Hospital, 106 Tenjin-cho, Kurume City 830, Japan. Fax: 0942-37-3793.
Familial hypercholesterolemia;
LDL-apheresis
10 Introduction
Recently, LDL-apheresis has been widely accepted as a therapeutic measure for individuals with severe familial hypercholesterolemia (FH). The goal of this therapy is to remove the increased LDL-cholesterol and prevent the emergence and/or progression of coronary heart disease which is the major cause of death in FH. The efficacy of LDL-apheresis therapy in combination with lipid-lowering drugs has been reported [l-31, with angiographic documentation of the prevention and/or regression of coronary atherosclerosis. However, to date no report has documented the efficacy of treatment on arterial lesions both angiographically and pathologically. We used long-term treatment of LDL-apheresis in one patient with FH, and subsequently identified regression of stenotic lesions by serial angiography and noted the pathological change of atherosclerotic lesions into sclerotic lesions rich in collagen fiber, which also suggests pathological regression of atherosclerosis. Methods
Case history The patient, a 42-year-old Japanese male was working in a paint-coating factory. His parents are cousins, and both his mother and younger brother suffer from familial hypercholesterolemia. The younger brother (heterozygous FH) presented with angina pectoris and xanthoma, and he also has been receiving LDL-apheresis therapy. The patient developed xanthoma on his elbow at 6 years of age. The xanthoma gradually increased and at 13 years of age he developed xanthomata on his hands, buttocks, and Achilles’ tendons. At 30 years of age, he began to experience precordial oppressive sensations and dyspnea on effort, and his general condition was deteriorating. At 36 years of age (in 19821, he was diagnosed with hyperlipoproteinemia type IIa (serum total cholesterol, 638 mg/dl; triglyceride, 71 mg/dl) along with unstable angina and a left ventricular aneurysm. The patient also had previously suffered a myocardial infarction. LDL-receptor activity was studied by cultured skin fi-
broblasts 141.The studies showed that the receptor binding, internalization, and degradation of r2’I-LDL were 11 ng/mg of cell protein, 108 ng/mg of cell protein, and 198 ng/bhr/mg of cell protein, respectively, and also they were 38, 29, and 32% of normal control in each experiment. We diagnosed him to be a heterozygote, although LDL-receptor activity was determined to be intermediate between those of homozygous and heterozygous FH patients. He then started to receive DFPP and subsequent LAPP therapy. The severe symptoms of angina pectoris soon disappeared, although symptoms of chronic heart failure such as exertional dyspnea and shortness of breath remained. At 37 years of age (8 months after the start of LDL-apheresis), the patient underwent coronary artery bypass grafting (CABG) of 5 coronary arteries; the left anterior descending artery (LAD), the 1st diagonal artery, 1st marginal/2nd marginal arteries of the LCX, and the distal RCA combined with the left ventricular aneurysmectomy. After CABG was performed, the symptoms of angina pectoris disappeared completely and the heart failure symptoms diminished sufficiently which enabled the patient to enjoy daily life. The xanthomata on the elbows, buttocks, hands, and Achilles’ tendons were significantly reduced after LDL-apheresis therapy. In 1989, while the patient was helping with moving house, he died suddenly, presumably due to ventricular fibrillation at 42 years of age. Upon physical examination, he was well-developed (height 182 cm, weight 71 kg). Blood pressure was 120/60 mm Hg. We observed tendon xanthomata primarily in the Achilles’ tendons, and subcutaneous xanthomata on the elbows, knees, buttocks, and hands. There was no bruit over both carotid arteries, abdominal aorta or both femoral arteries. A systolic ejection murmur of grade 3/6 intensity was heard in the aortic area radiating to the apex. The murmurs ended before the second heart sound, which split normally with respiration. Electrocardiogram before CABG showed normal sinus rhythm, left axis deviation, left atria1 overload, abnormal Q wave in III and aV,, poor R wave progression in V,-V,, T wave inversion in II, III aV,, V,, V,, high voltage, and monofocal premature ventricular contraction (PVC). It later
1
IN SERUM
LIPIDS,
AND LIPOPROTEIN
CHOLESTEROL
a h ’ d ’
o A B C D E F G H
22.9 20.9 21.7 14.7 15.3 15.7 14.0 14.8
35 9 21 11 9 11 5 28
ment
No. of treat_
nil 1000 nil nil 1000 1000 1000 1000
(mg) a
Drug
No.
nil nil nil nil nil 10 10 20
nil nil nil nil nil nil 27 27 34 9 17 9 9 9 5 25
(mg) b (g) ’ Of samples
(/days)
value. = TC - (HDL - C + TG/5).
(days)
Interval period
Probucol. Pravastatin. Cholestyramine. Time-averaged LDL-cholesterol
Baseline DFPP DFPP DFPP LAPP LAPP LAPP LAPP LAPP
LDLapheresis
LEVELS
638 459+52 381i28 459k53 478+53 35lk46 363+39 386+46 338+38
_ 237+63 405k45 192k12 336+30 247k28 411k47 143k37 364+40 109+30 265+34 91k16 277+25 130+ 8 294+32 91+12 257+27
_ 595 394+47 335+35 409k46 405&60 294+41 303k31 332+39 278f34
Before
’
203+64 166&11 216k26 97+38 74k24 58+16 93k 4 55+12
_
After
LDL-cholesterol
After
d
Time averaging
Before
plasmapheresis;
Total cholesterol
DFPP: double filtration plasmapheresis; LAPP: selective LDL adsorbent level between the apheresis therapy. Values are mean f SD.
CHANGES
TABLE
_ 350+47 294+27 365k41 302+48 218+30 224k23 245+27 205k25
’
calculation
38+10 23+ 28+ 44k 24+ 24k 25k 26k
29
Before
7 5 7 7 3 6 3
23k4 16+3 21+3 37+5 24k6 25+2 25k5 26+2
_
After
HDL-cholesterol
_ 35i8 22+6 26k4 41+6 22+2 24+3 25+5 26+2
d
is given in Methods,
71 102+23 117+21 112+26 138+31 163+2l 157k41 144+31 172+33
Before
Triglyceride d
_ 55flO 95&19 55+ 8 102+17 54+ 9 loo&-21 42klO 103+21 54510 129+15 54+17 119k24 55k14 114+21 60+13 132+22
_
After
which gives a time-averaged
12 began to show atria1 fibrillation and PVC, frequently after CABG. PVC was monofocal at the beginning, but later increased in frequency and became multifocal. Marked left ventricular enlargement (cardiothoracic ratio 65%) and pulmonary venous congestion were observed on the chest roentgenogram. After CABG, the cardiothoracic ratio decreased to 62% and the pulmonary venous congestion improved slightly. On a series of ultrasonographic studies after the operation, the left ventricular aneurysm became smaller but the left ventricular diastolic dimension remained 70 mm at almost the same size as before the operation. The left ventricular ejection fraction was less than 30%.
column (Kanegafuchi Chemical Industry Co., Ltd., Osaka Japan) [9-121 packed with dextran sulfate cellulose bead adsorbent was used. Four liters of plasma were processed in DFPP every 3 weeks and 7 liters of plasma were processed in LAPP every 2 weeks. The patient received a total of 129 sessions (DFPP; 65 and LAPP; 64) of treatment during the treatment period of 6 years and 7 months in combination with the lipidlowering drugs probucol, pravastatin, and cholestyramine. Laboratory examinations
Total cholesterol (TC), triglyceride (TG), and high density lipoprotein cholesterol (HDL-C) were measured immediately each pre- and posttreatment. TC was also measured enzymatically [13] with a cholesterol C-AR11 assay kit (Wake Junyaku, Tokyo, Japan). TG was measured enzymatically [14] with a TG GII-AR assay kit (Wako Junyaku, Tokyo, Japan). HDL-C was measured using the dextran sulfate/ magnesium method [ 151 with the HDL-C 2 assay kit (Daiichi Kagaku, Tokyo, Japan). Low density lipoprotein cholesterol (LDL-C) was calculated by the Friedewald formula [16]. The time-averaged values (integral mean val-
LDL-apheresis
Two variations of the DFPP method [5--81 and the LAPP method [9-121 were employed as LDL-apheresis. In DFPP, APOSH (Asahi Medical Co., Ltd., Tokyo, Japan) or PS05 (Toray Medical Co., Ltd., Tokyo, Japan) was used as the 1st filter for plasma separation, and Evaflux 4A (Kuraray, Co., Ltd., Osaka, Japan) as the 2nd filter. In LAPP, FS05 (Kanegafuchi Chemical Industry Co., Ltd., Osaka, Japan) was used as the 1st filter, and for selective LDL adsorption the LA40 or LA15
Cholestyramine 279 every day Pravastatin 10 20mg every days Probucol IOOOmgevery day
;.....
:...,____r? I
6 1985
C 1986
L_
____
H. ..__.post
DEFG 1987
1988
1989
1990 (year)
Clinical Course Fig. 1. Clinical course and serum total cholesterol levels. Time-averaged value of TC is shown by solid line, mean value of TC of the pretreatment by upper dotted line and that of posttreatment by lower dotted line. Course divided into 8 periods of A-H according to the combination with medication.
13
w so 00
.r a 70 5 ‘60 8 Es0 1 c 40 5 g 30 P 20 10
Fig. 2. Chronological improvements of 3 stenotic segments of coronary atherosclerotic lesion via a serial angiography. A: middle segment of right coronary artery; B: proximal segment of right coronary artery; C: proximal segment of left circumflex artery.
ues) of TC, LDL-C, TG, and HDL-C were calculated as follows: in the case of TC, the value determined by integration calculus is based on the hypothesis that the TC level after LDLapheresis rebounds linearly to the same level as the subsequent pre-treatment level after 10 days. The formula is integral mean value of TC = (bc + 5a - 5b)/c where a = post-TC level, b = pre-TC level of subsequent procedure, and c = days between each procedure. Coronary angiography
Coronary angiography (CAG) was performed at a total of 6 sessions and during one session. Along with CAG percutaneous transluminal
Fig. 3. The left circumflex artery which showed the angiographic regression obtained by the treatment of LDL-apheresis. Left: the proximal lesion of the left circumflex artery showed 34% stenosis (Sept. 1983). Right: the arrow shows the improvements in stenosis from 34 to 20% (Oct. 1988).
14 coronary angioplasty (PTCA) was also performed. The first CAG was performed in August 1983 (8 months after the start of LDL-apheresis and before CABG), the 2nd 1 month after the first one (2 month after CABG), the 3rd in September 1984, the 4th in December 1986, the 5th along with PTCA in RCA and the proximal anastomosis site of RCA bypass vein graft in January 1988, and the 6th in October 1988. Evaluation of coronary angiograms
The evaluation of coronary stenosis was done using a digitized processing system (Mypron I system, Kontron Instruments). The analyses were performed in a blind fashion by experienced technicians under the supervision of skilled coronary angiographers. Measurements were made in a
single projection that displayed the most severe stenosis, and the serial measurements used for evaluation were made using the same projection for accurate comparison. As a rule, we selected the projection that showed the coronary segment in the plane (as closely as possible) perpendicular to the axis of the x-ray beam. To assess the variation in our method, we performed reevaluation for 23 random coronary arterial sites after 1 month. The mean of change was -0.8%, and the standard deviation (1 SD) was 3.7%. A significant change in coronary stenosis was defined as change in at least 11.2% of 3SD. We omitted from these calculations those lesions which were completely occluded or which suffered influence from bypass surgery. Preparation of histological specimens and staining
Serial step-sections of all of the coronary arteries including vein bypass graft bed were prepared at 3 mm intervals. Masson’s trichrome resorcine Fuchsin staining (Gordon stain) was carried out for histopathological examinations of the sections. The pathological observation was performed using light microscopy. Results Changes in serum lipids, and lipoprotein cholesterol levels
Fig. 4. In the middle portion of LAD, thickened intima and an eccentric thickened wall lesion rich in collagen fiber suggesting scarring of atheromatous plaque was seen. These findings were often seen in other native coronary arteries (x58). L: lumen, C: proliferation of collagen fibers.
The changes in serum total cholesterol level by the treatment of two methods of LDL-apheresis (DFPP and LAPP) combined with various lipidlowering drugs such as probucol, pravastatin and cholestyramine are shown in Table 1 and Fig. 1. The entire therapeutic course of the patient, 6 years and 7 months, was divided into 8 periods marked in Fig. 1 A-H. As shown in Table 1, the TC level decreased from 638 mg/dl at baseline to a time-averaged value of 405 mg/dl by DFPP (A). The administration of probucol (1000 mg/day) induced further decrease of the time averaged TC value, from 405 to 336 mg/dl (B). When the administration of probucol was discontinued, the TC value returned to the same level as that in period A (0 The acute lowering effect of TC, as determined by the difference between pre- and postprocedure values was more dramatic by LAPP
15
Fig. 5. Superficial foam cell accumulation (F) was seen in the proximal LCX. These findings were also seen in some other sites of native coronary arteries (X 71).
(D) than DFPP (in period A, Cl. As seen with DFPP, the administration of probucol in combination with LAPP was effective in further lowering TC (E). The addition of cholestyramine and pravastatin did not further induce a decrease in time averaged TC value (F, G, H). However, maximum doses of the 3 drugs in combination with LAPP produced the lowest time averaged TC level. Therefore, we maintained maximum therapy with the 3 drugs in combination of probucol, pravastatin and cholestyramine, and LAPP. No adverse reactions to the drugs were observed. The influence of DFPP and LAPP procedures in combination with lipid lowering drugs on serum LDL-C, HDL-C and TG levels is also shown in Table 1. Serial coronary angiographic findings
Cineangiography before CABG (8 months after starting LDL-apheresis therapy) revealed high grade stenosis in the proximal (78%) and middle (92%) RCA. A total occlusion just distal from the branching portion of the huge acute marginal artery in the distal RCA was observed. In the left coronary artery, there were 25% and 99% steno-
sis in the proximal and far proximal portions of the LAD, subtotal occlusion in the 1st diagonal artery, and 34% stenosis in the proximal LCX. In the 1st and 2nd marginal arteries of the LCX, there were high grade stenotic lesions. Left ventriculogram showed marked left ventricular dilatation, diffuse hypokinesis and inferoapical aneurysm. The left ventricular ejection fraction was 26%. The aortogram showed an irregular contour and slight narrowing in the aortic root, with no systolic pressure gradient between the left ventricle and aorta. We measured 13 evaluable segments using computer analysis (Mypron I system, Kontron Instruments) and observed significant improvement in the stenosis in 3 of the 13 segments after CABG (Fig. 2). At the 5th CAG (4 years and 4 months later), percent stenosis was reduced from 78 to 61% in the proximal, from 92 to 72% in the middle segment of the RCA, and from 34 to 20% in the proximal LCX. The two angiograms of the proximal LCX are shown in Fig. 3. When the 5th angiography was performed on January 20, 1988, a high grade stenosis in the proximal anastomosis sites of RCA graft was found and PTCA was
17
Fig. 7. In the PTCA
site of proximal
RCA,
intimal
and medial disruption, layered head) were seen f x 73).
performed successfully. Simultaneously, PTCA was also performed in both proximal and middle site of the RCA and the lesion was dilated from 61 to 46% in the proximal lesion, and from 72 to 32% in the middle. These lesions maintained dilatation satisfactorily for 10 months. The lesions in the 10 segments remained unchanged. The final CAG confirmed patency in the 5 bypass grafts without appearance of new lesions.
thickened
intima
(I), and calcification
(at row
rotic lesions. There was a thickened intima and an eccentric thickened wall lesion rich in collagen fiber which suggests a scarring of atheromatous plaque (Fig. 4). Accumulation of foam cells was observed in only a few sites (Fig. 5). In the proximal site of the LCX where angiographic regression was documented, circumferential thickened intima and a large eccentric thickened wall lesion with deficit in the media were observed. The eccentric thickened wall lesion was rich in collagen fiber and there was a small necrotic center surrounded by foam cells (Fig. 6a, b). Together with the angiographic documentation, these pathological findings reveal the process of the scarring of atheromatous plaque, which
Pathological findings of coronary arteries and vein bypass grafts
In the native coronary arteries, we observed sclerotic lesions without new or typical atheroma in the arterial wall and a few typical atheroscle-
Pig. 6. (aI The specimen corresponding to the angiographic regression site of proximal left circumflex artery. The color light microscopy was prepared by Masson’s Trichrome resorcin Fuchin staining. Collagen fiber was stained blue, elastic fiber black, and smooth muscle brown. There was diffuse intimal thickening and eccentric thickened wall lesion (I) rich in collagen fiber (X 20). L: lumen; (b) Magnified pattern of the eccentric thickened wall lesion of (a). We can see the accumulation of foam cells (F) around the small necrotic center in the eccentric thickened wall lesion. Improvement of stenosis of this site was confirmed by serial angiography. We consider that this pattern is the process of the disappearance of atheroma ( X 76). F: foam cells; * Dense collagen fibers.
18 nest of the vein graft, and in some sites accumulation of foam cells was observed (Fig. IO). Discussion
Fig. 8. In the near PTCA site of middle segment of RCA, injimal proliferation, and foam cell accumulation (F) in all of the arterial wall were seen. The severity of accumulation of foam cellshere was highest of all other sites of the native coronary arteries (X 143).
also suggests regression. At two sites, the proximal and middle segments of the RCA, PTCA was carried out. Intimal and medial disruption, layered intima, intimal thickening, and calcification were found in the proximal site (Fig. 7). In the middle site we observed almost the same findings as in the proximal site but no calcification was observed. Thickened intima with accumulation of foam cells was also found near the PTCA site of the middle RCA (Fig. 8). In the proximal anastomosis lesion of the RCA vein bypass graft which simultaneously received PTCA, there were atheroma, accumulation of foam cells, intimal disruption, and plaque proliferation (Fig. 9). Intimal proliferation was seen in
There have been several reports presenting angiographic regression of coronary atherosclerosis obtained by LDL-apheresis with lipid-lowering drugs for FH [1,3,17,20]. However, the histopathological improvement that might occur in arterial walls by these therapies has been obscure. In our patient the serial coronary angiograms showed definite regression in 3 out of 13 segments evaluated, and no change in the other 10 segments. For advanced coronary atherosclerosis characterized as severe stenosis alternative procedures such as PTCA and CABG may be necessary due to the fact that the regression of coronary atherosclerosis induced by LDL-apheresis combined with drug therapy, takes a longer period of time to occur. However, it was obvious that the LDL-apheresis therapy can induce the regression of both severe atherosclerotic lesions and mild to moderate atherosclerotic lesions containing segments after PTCA (Fig. 2). Clinical improvement was considered to be achieved by not only angiographic reduction of stenosis but also histopathological improvement of stenotic lesions. We observed pathologically that the condensation of thin and loose fibrous cap and the concomittant disappearance of atheromatous plaque was induced by the LDLapheresis therapy (Fig. 6a, b). In most native coronary artery walls, we observed atypical atherosclerotic changes without atheroma and eccentric thickened wall lesions rich in collagen fiber both suggesting scarring of the atheromatous plaque. It was further suggested that formation of eccentric, thickened wall lesions rich in collagen fiber prevents the atheromatous plaque from tearing off which could cause acute coronary events. We can conclude that, clinicopathologically speaking, cholesterol-lowering therapy can bring about “true” regression of coronary atherosclerosis. One should, however, consider the limitations of estimating regression by angiographic examinations and focus more on the histological changes
19
Fig. 9. In the proximal
anastomosis
site of the RCA vein bypass graft which received
(F), intimal
Fig. 10. In the proximal
disruption
anastomosis
(arrow
heads)
site of diagonal
and plaque
proliferation
PTCA.
atheroma
(A), foam
c:ell accumul ation
were seen ( x 24).
vein bypass graft. foam cell accumulation
(F) was seen
( x 2.1).
20
of the arterial wall. Even if widening of the stenotic lumen caliber is not available, one can expect improvement in the atherosclerotic lesions, which means that the development of methodologies to detect the qualitative alteration of vessel lesions is very important. To discuss the efficacy of the lipid-lowering therapy, it is important to clarify how much and how long one should lower serum cholesterol to prevent progression and induce regression. Our regimen for the patient lowered TC from 638 mg/dl at baseline to a time-averaged value of 257 mg/dl by initiating treatment with DFPP and LAPP for 6 years and 7 months (Table 1, Fig. 1). The results of pathological studies showed regression in most of the native arteries, although atheroma remained in the proximal anastomosis site of bypass vein graft. In the sites of PTCA and some sites of native artery or bypass graft, we observed the accumulation of foam cells. This fact might suggest that the cholesterol lowering level which we applied was insufficient to prevent atherosclerosis completely, especially for vein bypass graft. Selective systems for LDL-removal such as anti-LDL antibody agarose gel [18], HELP (Heparin-mediated extracorporeal LDL: fibrinogen precipitation) system [19], and LDL adsorption by dextran sulphate cellulose columns are available. Furthermore, more effective drugs such as pravastatin (eptastatinl, simvastatin, and lovastatin for cholesterol lowering can be used in combination with these methods [20-231. In our patient, we succeeded in inducing both angiographic and histologic regression of coronary atherosclerosis by treatment with LDL-apheresis. Acknowledgments
We would like to acknowledge the expert help received while treating this patient. In particular, we would like to thank Professor N. Kimura and Professor H. Toshima (Third Dept. Int. Med., Kurume Univ.), Drs. T. Fujino, S. Kanaya (First Dept. Int. Med., Kyushu Univ.), T. Matsuguchi (Aso Iizuka Hospital), T. Yamashita (Kanegafuchi Chemical Ind. Co., Ltd.,), T. Sato, K. Kohchi, Mr. T. Nagano, Mr. T. Nishimura, and Mr. T. Hashizume (Koga Hospital) for their help. We
appreciate the determination of LDL-receptor activity by Drs. H. Mabuchi, H. Fujita, K. Kajinami (Second Int. Med. Kanazawa Univ.). We are grateful to Akiko Sanada for secretarial assistance. References 1 Thompson,
2
3
4
5
6
I
8
9
10
G.R., Myant, N.B. Kilpatrick, D.. Oakley, CM.. Raphael, M.J. and Steiner, R.E., Assessment of long-term plasma exchange for familial hypercholesterolemia. Br. Heart J., 43 (1980) 680. Stein, E.A., Adolph, R., Rice, V., Glueck, C.J. and Spitz. H.B., Nonprogression of coronary artery atherosclerosis in homozygous familial hypercholesterolemia after 31 months of repetitive plasma exchange, Clin. Cardiol., 9 (1986) 115. Hombach, V., Borberg, H., Gadzkowski, A.. Oette, K. and Stoffel, W., Regression der Koronarsklerose bei familiarer Hypercholesterinamie IIa durch spezifische LDL-apherese, Dtsch. med. Wschr., III (1986) 1709. Haba, T., Mabuchi, H., Yoshimura, A.. Watanabe. A.. Wakasugi, T., Tatami, R., Ueda, K.. Ueda. R., Kametani. T., Koizumi, J., Miyamoto, S., Takeda, R. and Takeshita. H., Effects of ML236B (compactin) on sterol synthesis and low density lipoprotein receptor activities in fihroblasts of patients with homozygous familial hypercholesterolemia, J. Clin. Invest., 67 (1981) 1532. Agishi, T.. Kaneko, I, Hasuo, Y.. Hayasaka. Y.. Sanada, T.. Ota, K.. Amemiya, H., Sugino, N., Abe, M.. Ono, T.. Kawai, S. and Yamane, T., Double filtration plasmaphersis, Trans. Am. Sot. Artif. Intern. Organs, 26 (1980) 46. Koga, N., Nomura, G.. Yamagata. Y.. Takada. S.. Nishimura, T., Sanada, A., Kanaya, S. and Fujuno. T.. Double-filtration plasmapheresis in the treatment of two cases of homozygous familial hypercholesterolemia, In: Oda, T. (Ed.), Therapeutic Plasmapheresis (III). Schattauer, Stuttgart-New York, 1983, pp. 113. Mabuchi, H.. Michishita, I., Sakai, T., Sakai. Y.. Watanabe, A., Wakasugi, T. and Takeda. R.. Treatment of homozygous patients with familial hypercholesterolemia by double-filtration plasmapheresis, Atherosclerosis, 61 (1986) 135. Sasaki, H., Koga, N., Maw, P.R., Moriyama, A. and Nomura, G.. Reverse rinse of the second filter in double filtration plasmapheresis: when to rinse and influence on removal of cholesterol., In: Oda, T., Shiokawa. Y. and Inoue, N. (Eds.), Therapeutic Plasmapheresis (VI). ISA0 Press, Cleveland, OH, 1987, p. 343. Yokoyama, S., Hayashi, R., Kikkawa, T., Tani, N.. Takada. S., Hatanaka, D. and Yamamoto. A., Specific sorbent of apolipoprotein B-containing lipoproteins for plasmapheresis: characterizaton and experimental use in hypercholesterolemic rabbits, Arteriosclerosis, 4 (I 984) 276. Yokoyama, S., Hayashi, R., Satani, M. and Yamamoto, A.. Selective removal of low density lipoprotein by plasmapheresis in familial hypercholesterolemia, Arteriosclerosis. 5 (1985) 613.
21 11 Koga, N., Sasaki, H., Nishimura, T., Maw, P.R., Nishida, H. and Nomura, G., Adsorbent rinse in LDL-apheresis, ASAIO Abstr.. 16 (1987) 48. 12 Mabuchi, H., Michishita I., Takeda, M. and Fujita H., A new low density lipoprotein apheresis system using two dextran sulfate cellulose columms in an automated column regenerating unit (LDL continuous apheresis), Atherosclerosis, 68 (1987) 19. 13 Richmond. W., Preparation and properties of a cholesterol oxidase from nocardia sp. and its application to the enzymatic assay of total cholesterol in serum, Clin. Chem.. 19 (1973) 1350. 14 Tamaoku, K., Ueno, K., Akiura, K. and Ohkura Y., New water soluble hydrogen donors for the enzymatic photometric determination of hydrogen peroxide. II. N-Ethyl-N(2-hydroxy-3sulfopropylJaniline derivatives, Chem. Pharm. Bull., 30 (1982) 2492. 15 Warnick, G.R., Nguyen, T. and Albers, A.A., Comparison of improved precipitation methods for quantification of high-density lipoprotein cholesterol, Clin. Chem., 31(1985) 217. 16 Friedewald. W.T., Levy, RI. and Friedrickson, D.S.. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparation ultracentrifuge, Clin. Chem., 18 (1972) 499. 17 Klein, J.M., Drobinski, G., Brukert, E., Dairout, F., Thomas, D. and De Gennest, J.L., Results of serial coronary angiography in patients with homozygous familial hypercholesterolemia, European Heart Journal, 9 (1988). 1067.
18 Stoffel, W., Borberg, H. and Greve, V.. Application of specific extracorporeal removal of low density lipoprotein in familial hypercholesterolemia, Lancet, ii (1981) 1005. 19 Armstrong, V.W. and Seidel, D., The HELP system: a novel technique for the extracorporeal treatment of familial hypercholesterolemia; In: Schlierf. G. and Marl, H. (Eds.), Expanding Horizons in Atherosclerosis Research, Springer, Heidelberg, 1987, p. 34.5. 20 Thompson, G.R., Barbir, M., Okabayashi, K., Trayner, I. and Larkin, S., Plasmapheresis in familial hypercholesterolemia, Arteriosclerosis, 9 (1989) Suppl. 1, 152. 21 Mabuchi, H.. Fujita, H., Michishita, I. Takeda, M., Kajinami, K., Koizumi, J., Takeda, R.. Tekegoshi. T., Wakasugi, T., Ueda, K., Miyamoto, S., Watanabe, A. and Oota, M.. Effect of CS-514 (eptastatin), an inhibitor of 3-hydroxy-3-methylglutaryyl-coenzyme A (HMG-CoA) reductase, on serum lipid and apolipoprotein levels in heterozygous familial hypercholesterolemic patients treated by low density lipoprotein (LDL)-apheresis, Atherosclerosis, 72 (1988) 183. 22 Riesen, W.F., Descoeudres, C.. Mordasini, R. and Girod, M.A., Selektive Elimination atherogener Lipoproteine mit Dextrasulfat-Cellulose’; Schw. Med. Woch, 119 (1989) 55. 23 Thiery, J., Walli, A.K., Janning, G. and Seidel. D., Lowdensity lipoprotein plasmapheresis with and without lovastatin in the treatment of the homozygous form of familial hypercholesterolaemia, Eur. J. Pediatr., 149 (1990) 716.
