Hamamsy Yacoub - 2009 - Cellular and Molecular Mechanisms of Thoracic Aortic Aneurysms

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cellular and molecular mechanisms of thoracic aortic aneurysms

Ismail El-Hamamsyand Magdi H. Yacoub
abstract | Thoracic aortic aneurysms (TA A ) increase the risk of aortic dissection or rupture and represent an important source of morbidity and mortality. Inherited forms of the disease, including Marfan syndrome, have been recognized for a long time but were considered degenerative diseases characterized by cystic medial necrosis of the aortic wall. Improved definition of the structure and function of the normal aortic wall, coupled with the discovery of genetic mutations in key regulatory molecules, have contributed to a more detailed understanding of the pathophysiology of syndromic, familial and sporadic TAAs. We here review the cellular and molecular mechanisms involved in TA A formation and outline areas for future research.
El-Hamams I. & Yacoub, M. H. Nat. Rev. Cardiol. 6, 771786 (2009); published online 3 November 2009; doi:10.1038/nrcardio.2009.1 91 y,
Introduction
traditionally, abdominal aortic aneurysms have been linked to atherosclerosis and steady progress has been made in understanding pathophysiological mechanisms under lying these aneurysms. By contrast, thoracic aortic aneu rysms (ta ) a have been labeled as a degenerative disease, characterized by cystic medial necrosis of unknown etio logy.1 this paradigm changed abruptly in 1991 with the discovery of a specific genetic locus encoding fibrillin 1, which is responsible for marfan syndrome, a condition characterized by the development of taas.2 this discov ery was followed by unprecedented activity in the field, with a rapid accumulation of landmark breakthroughs using genetic, molecular, cellular and engineering tech niques. Coupled with the use of targeted animal models, these discoveries are generating a much more cohesive unde rst anding of t he p at hogenesi s of taas, wit h extremely promising potential for clinical applications. the aortic wall is a highly dynamic and tightly regu lated structure that performs sophisticated functions in a unique hemodynamic environment. regulation of aortic wall homeostasis involves active mechanisms and inter actions between its major structural components and specific regulatory pathways. thus, a thorough under standing of the developmental origins of the thoracic aorta, its sophisticated structure and function, as well as factors that regulate them is fundamental for elucidating the pathophysiological mechanisms of taas. we here review the rapidly accumulating knowledge relating to these areas. mechanical properties of the aortic root and ascending aorta have a direct influence on left ventricular work load and coronary blood flow.3,4 studies have shown that a semirigid conduit (such as one made from Dacron, invista, wichita, Ks, u a ) s originating from the heart significantly increases impedance, which translates into increased ventricular workload. 57 By contrast, intrinsic contractile properties, combined with the elastic recoil capacity of the ascending aorta optimize the shape and propagation of the pulse wave through the vasculature, an important determinant of the efficiency and distri bution of blood flow.8,9 active regulation of the size and shape of the aorta also has a direct effect on systemic blood volume and pressure. adequate function of the thoracic aorta is the result of a dynamic, tightly regulated and highly preserved microstructural organization of the aortic wall. all arterial walls have the same basic triple layer compositionintima, media and adventitia. these layers are separated from each other by two layers of thick elastic fibers, the internal and external elastic laminae. Depending on their location in the vascular tree, these layers vary considerably in thickness, composition and biological properties. the basic structural and functional unit in the aortic wall is the lamellar unit, first defined by wolinsky and
Harefield Heart Science
Aortic structure and function

the thoracic aorta performs several sophisticated func tions in addition to serving as a blood conduit origi
nating from the left ventricle. the unique shape and
competing interests The authors declare no competing interests.
Glagov.10 each lamellar unit is composed of a vascular smooth muscle cell (vsmC) sandwiched between two layers of elastin fibers, which contain microfibrils and proteoglycans that form the extracellular matrix (eCm; Figure 1). lamellar units are intercalated by collagen fibers. the lamellar unit has both tensile strength and elastic recoil properties, allowing the aorta to with stand high pressures and return to its initial diameter during diastole. the proximal conduction arteries have the highest number of elastic lamellae (5560 u in the ascending aorta). 10 although the composition, thick ness (~15 m) and tension (13 n/m) per lamellar unit is
Centre, The Magdi Yacoub Institute, Imperial College London, UK (i. El-Hamams y, M. H. yacoub). Correspondence: M. H. Yacoub, Harefield Heart Science Centre, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, UK m.yacoub@ imperial.ac.uk
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2009 Macmillan Publisher Limited. All rights reserved s
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Key points
Developmental variations between the thoracic and abdominal aorta result in differences in cellular responses to similar biological stimuli In addition to their structural role, the cells and proteins in the aortic wall have important regulatory functions that maintain homeostasis Dysfunction of one or more components of the cytoskeletonreceptor extracellular matrix complex can lead to structural and functional dysregulation of aortic wall properties The transforming growth factor 1 pathway is important in matrix regulation in health and disease, and increased activity is a key component of various forms of thoracic aortic aneurysms (TAAs) TAAs can be syndromic, familial nonsyndromic or sporadic, and are characterized by apoptosis and disarray of vascular smooth muscle cells, fragmentation of elastin, inflammatory infiltration, and upregulation of matrix metalloproteinases Therapeutic strategies that target specific molecular pathways have shown promising results in mitigating TAA progression, and further understanding of the pathogenic mechanisms offers great potential for developing additional therapies
players in aortic wall homeostasis (cells, collagen, elastin
Elastin
EC M VSMC
Elastin
Figure 1 | The lamellar unit. Electron micrograph of a single lamellar unit in the medial layer of the aortic wall showing a vSMC lying between two layers of elastin fibers and surrounded by ECM proteins containing microfibrils and proteoglycans. Lamellar units are intercalated by collagen bundles. The lamellar unit represents the basic structural and functional unit of the aortic wall. Abbreviations: ECM, extracellular matrix; vSMC, vascular smooth muscle cell.
remarkably constant between the thoracic and abdomi nal aorta across species, notable differences have been observed in humans. the number of lamellar units in the ascending aorta ranges from 5560 u and decreases to 2832 u in the abdominal aorta.10 medial thickness in the ascending aorta is regulated by changes in the number of lamellae; in comparison, changes in lamellar thickness affect medial thickness in the abdominal aorta.11 studies by wolinsky and Glagov also suggest that the abdominal media is completely avascular, whereas the outer layers of the thoracic media contain vasa vasorum, which originate from the adventitia.11 interaction between the cellular and extracellular com ponents in the wall matrix mediates the various func tions of the aorta. Dysregulation of one or more of these components can pave the way for ta a formation. in the following sections, we present an overview of the major
and microfibrils), as well the major regulatory pathways controlling aortic wall function in health and disease, fol lowed by a description of the main clinical presentations (syndromic, familial and sporadic), potential therapeutic strategies and future directions.
Key structural componentsof the aorta

VSMcs
the medial layer of the aorta is populated mainly by vsmCs, which are circumferentially aligned and inter spaced by thin layers of elastic fibers. vsmCs are not terminally dif ferentiated cellsthe y p oss ess b oth contractile and secretory properties and can alternate between quiescent, contractile or proliferative states.1215 Contractions of vsmCs depend on the interaction between smooth muscle actin and myosin heavy chain (mHC). actinmyosin complexes in the cyto plasm are linked directly to the cell membrane through anchoring proteins such as talin, vinculin, actinin and filamin a. Cell contraction, therefore, results in changes in cell shape, migration and alignment, all of which are important elements in aortic wall homeo stasis. in addition to their contractile capacity, vsmCs possess important secretory properties that ensure the synthesis and repair of various eCm components that regulate the structure of the vascular wall (collagen, elastin, fibrillin, fibulin). these synthetic properties respond to biochemical signaling such as transforming growth factor 1 (tGF1), or mechanical stimulation such as cellular strain. 16 importantly, vsmCs can inter act directly with the different eCm components through cellsurface integrin receptors, Gproteincoupled recep tors and the discoidin domain receptor family.1721 the fundamental unit of the cytoskeletoncell receptor eCm complex regulates the function of the aortic wall
(Figure 2). indeed, vsmCs can transform mechani cal stimuli into biological responses (also known as mechanotransduction), leading to intracellular responses (cytoskeletal rearrangement and stress fiber alignment) and extracellular changes (synthesis, alignment and repair of particular eCm components) that, in turn, can communicate directly with the cell.21,22 mutations involving c ytoskeletal proteins in the vsmCs are involve d in taa for mat ion, prob ably through loss of these direct feedback mechanisms that lead to loss of vsmC shape and alignment, and abnormal signaling and synthesis of eCm proteins. these changes lead to the characteristic histological findings observed in taas, including vsmC apoptosis and disarray, and elastin fragmentation. 23,24 two cytoskeletal gene muta tions have been linked to formation of nonsyndromic familial taas: smooth muscle cellspecific actin encoded by the ACTA2 gene on chromosome 10q2324,25 and mHC encoded by the MYH11 gene on chromosome 16p12.2 13.3 (table 1). 26,27 mutations in filamin a (an actinanchoring protein) have been associated with periventricular heterotopia and ehlersDanlos syndrome with aortic aneurysms. 28
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collagen
type i and type iii collagen are the most abundant colla gen fibers in the aortic wall.29 they are found in the media and adventitia, and provide tensile strength and overall rigidity to the aorta. type iv collagen is a component of the basement membrane of the tunica intima; endo thelial cells adhere to and communicate with this layer. in addition to its role in providing mechanical strength to the aortic wall, collagen has several distinct functional properties, including activation of intracellular signaling cascades that affect cellular adhesion and proliferation by binding to cellsurface receptors.30 moreover, collagen acts as a reservoir for soluble factors, such as interleukin 2, and regulates their local activity (Figure 3). 31 thus, mutations in genes encoding collagen fibers have direct structural and functional consequences that could contribute to ta a formation. mutations in the COL3A1 gene encod ing type ii i collagen are associated with vasculartype ehlersDanlos syndrome, an autosomaldominant disorder characterized by taas (table 1).
ECM regulation Cell alignment Adaptation of mechanics 1 2
ECM
Cytoplasm
Talin 3 4
Talin Vinculin
Nucleus
Elastin
elastin is the dominant eCm protein in the aortic wall, constituting up to 50% of the dry weight of the thoracic aorta.32 elastin is synthesized by vsmCs in the media in response to mechanical stimuli such as stretch or pressure, and confers compliance and recoil capacity to the aorta. in addition to its structural role, elastin has an active role in regulating the cellular components of the aortic wall; it can interact directly with vsmCs through integrin receptors and elastinbinding protein to modulate cytoskeletal actin organization and limit cell proliferation and migration. 13,33,34 elastin fragmentation is an almost ubiquitous finding in aneurysmal thoracic aortas but, in contrast to other eCm proteins, disruption of elastin signaling does not result in characterized by discrete stenosis in the aorta and other aneurysm forma tion or arterial dissection. arterial beds caused by subendothelial proliferation of instead, elastin abnormalities result in an vsmCs despite normal endothelial function and the uncontrolled fibrocellular proliferative state absence of inflammatory or oxidative stimuli.36,37 of vsmCs, which highlights the regulatory role of this protein on vsmC proliferation. Fibrillin mice deficient in elastin in addition to elastin and collagenthe major compo nents (Eln/) die soon after birth because of of the medial layermicrofibrils comprise a mosaic of severe occlu sive disease of the aorta, proteins in the eCm, and their structural and signal ing characterized by unregulated vsmC properties have essential roles in health and disease.38 we 35 proliferation and fibrous deposition. will focus on fibrillin and fibulin, which are two of the main similarly, lossoffunction mutations of one microfibrillar network components. Fibrillins are extracellular elastin allele result in supravalvular microfibrils that interact with various stenosis and williams syndrome, which is
Figure 2 | The cytoskeletonreceptorECM complex. vSMCs produce the various ECM components. In addition to their structural role, ECM proteins can directly interact with vSMCs by binding to cell-specific receptors (for example, integrins and G-protein-coupled receptors). The receptors are linked directly to the cytoskeleton on the intracellular side, thereby directly affecting cell contraction, shape, migration and proliferation. In turn, vSMCs can sense mechanical stresses through specific membrane receptors and translate these stimuli into biological signals that are transmitted to the ECM (mechanotransduction). Thus, disruption to one or more elements of the cytoskeletonreceptorECM complex can affect aortic wall homeostasis and result in changes in the structure and mechanical properties of the aorta, which is characterized histologically by vSMC disarray and elastin fragmentation. Identified mutations that affect the cellreceptorECM complex and lead to aneurysms occur in 1) the FBN1 gene, encoding fibrillin 1 (Marfan syndrome) 2 2) the COL3A1gene, encoding collagen III (EhlerDanlos ; syndrome);109 3) the ACTA2 gene, encoding cytoskeletal actin (TAA4);25 and 4) the MYH11 gene, encoding -myosin (TA A and patent ductus arteriosus).26 Abbreviations: ECM, extracellular matrix; vSMC, vascular smooth muscle cell.
eCm components such as elastin, collagen, fibronectin and vitronectin. Fibrillins 1 and 2, which are encoded by genes on chromosomes 15 and 5, respectively, are two isoforms that have been well described. Fibrillin 3 has been described but its role in vascular physiology remains unknown.39 Fibrillin 1 is a major structural component that contributes to the mechanical strength of the aortic wall and forms a lattice surrounding elastic fibers (the Youngs modulus of microfibrils is
estimated at 70 mPa, compared with 1 mPa for elastin).40 metabolically, fibril lin 1 has a crucial role in the sequestration and regulation of the activity of growth factors and other microfibrillar proteins in the eCm, such as tGF1 and bone morpho genic proteins (BmP; Figure 4). 41,42 Fibrillin 1 can also activate cell signaling pathways directly, by binding to integrin receptors through the rGD motifs on fibril lins. 4347 the precise effect of vsmC fibrillin inter actions remains unclear, but they are thought to provide positional signaling to the cells. Fibrillin 2 (along with fibrillin 1) is involved mainly in aortic morphogenesis during the fetal period,48 and becomes less prominent in aortic wall homeostasis thereafter. notably, vascular anomalies are not associated with fibrillin 2 mutations,

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Table 1 | Summary of the known syndromic and nonsyndromic familial forms of TAAs Taa classification chromosome gene Protein
Syndromic Marfan syndrome Marfan-like syndrome LoeysDietz syndrome EhlersDanlos syndrome BAvTA A syndrome Arterial tortuosity syndrome Turner syndrome Noonan syndrome 15q21.1 3p24 -25 3p24 -25 9q33 -34 2q24.3 -31 9q34 -35, others 20q13.1 45,X0 12q24.1 2p21 -22 12p12.1 Polycystic kidney disease Nonsyndromic TAAD1 FAA1 TAAD2 TAAD3 TAAD4 TAADpatent ductus arteriosus TAAD5 5q13 -14 11q23 -24 3p24 -25 15q24 -26 10q23 -24 16p12 -13 9q33 -34 Unidentified Unidentified TGFBR2 Unidentified ACTA2 MYH11 TGFBR1 Unidentified Unidentified TG F -R2 Unidentified Smooth muscle actin -MHC TG F -R1 Unidentified Unidentified Cell surface Unidentified Intracellular Intracellular Cell surface 130 131 83, 140 132 25 26, 27 125 16p13.3 4q21 -22 FBN1 TGFBR2 TGFBR2 , TGFBR1 COL3A1 NOTCH1 Unidentified SLC2A10 Unidentified PTPN11 SOS1 KRAS PKD1 PKD2 Fibrillin 1 TG F -R2 TG F -R2, TG F -R1 Type III collagen Notch 1 Unidentified GLUT10 Unidentified PTPN11 (SHP2) SOS1 G TPase K-Ras Unidentified Unidentified Polycystin 1 Polycystin 2 ECM Cell surface Cell surface ECM Intracellular Intracellular Unidentified Intracellular Cell membrane Cell membrane Cell membrane 123 2, 49, 99, 144, 148, 160162 107, 108 80, 81 81 109, 111 57, 112, 116 114, 115, 163 120, 121 118 122
location
references
Abbreviations: -MHC, -myosin heavy chain; ECM, extracellular matrix; GLUT10, glucose transporter type 10; Notch 1, neurogenic locus Notch homolog protein 1; PTN11, tyrosine-protein phosphatase non-receptor 11; SLC2A10, solute carrier family 2, facilitated glucose transporter member 10; SOS1, son of sevenless homolog 1; TAA, thoracic aortic aneurysm; TA AD, thoracic aortic aneurysms and dissections; T G F transforming growth factor ; TGF-R, -, transforming growth factor receptor.
suggesting that fibrillins have welldefined tissuespecific roles. 49 Fibrillin 1 mutations are associated with marfan syndrome, as discussed later (table 1).
Fibulin
as with other eCm proteins, fibulins are active metabolic regulators of aortic wall homeostasis. Fibulin 5 acts as a scaffold for the deposition of elastic fibers in the matrix and has an essential role in formation of the lamellar unit by linking elastin to vsmCs.50 mice that lack fibulin 5 expression demonstrate marked elastinopathy, character ized by aortic tortuosity, loose skin and emphysematous lungs. 51 Patients with fibulin 5 mutations present with the typical association of cutis laxa and lung emphysema (no aortic dilations have been described in humans). 52 Fibulin 4 has been linked to regulation of the struc tural integrity of the vascular wall through modulation of tGF1 activity. mice homozygous for a lowexpres sion allele of fibulin 4 show dilatation of the ascending aorta as well as aortic tortuosity and stiffening caused by disorganized elastic fiber deposition.53 these changes have
been linked to increased tGF1 activity (as shown by increased tGF1 expression and smad2 nuclear
translocation) and upregulation of matrix metallopro teinase (mm P) 9 expression.53 Fibulin 4 mutations in humans present predominantly as aortic and arterial aneurysms and tortuosity, as well as some skeletal fea tures such as joint hypermobility.54 However, unlike fibulin 5 mutations, skin features are rather mild and lung emphysema is not pronounced. Further work is required to fully elucidate the regulatory role of fibulins, inc luding in vascular morphogenesis.
Major regulato pathways ry

ontological regulation
most of the signals that are operational during morpho genesis continue to influence growth and adaptation in
postnatal life. thus, defining the developmental biology of the thoracic aorta has important implications for understanding normal and diseased aortic wall physio logy. During the early stages of embryonic development, migration and differentiation of cells from the neural crest give rise to the ascending aorta, the aortic valve and the ductus arteriosus. the abdominal aorta, on the other hand, is mainly composed of mesodermderived cells (Figure 5). 55,56 Formation of vsmCs further depends
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on local epithelialmesenchymal transformation (e t ), m a process regulated by specific molecular pathways, including the tGF1 and notch 1 signaling pathways.57 Differences in cell lineage translate into different cellu lar responses to similar stimuli. thus, vsmCs grown in culture show lineagedependent differences in growth and receptormediated transcriptional responses to tGF1. 58 Differences were also observed in proliferation and signal transduction pathways,59 integrin expression and 60 collagen interactions, and expression of matrix and cytoskeletal proteins.61 indeed, these various studies show that tGF1 stimulation of neuralcrestderived vsmCs resulted in a significant increase in Dna synthesis, cell proliferation, activation of the protein kinase C signal ing pathway and collagen production, whereas parallel stimulation of mesodermderived vsmCs did not have the same effect. these findings, combined with the struc tural differences between the thoracic and abdominal lamellar units, highlight the regional heterogeneity within the aorta and the singular properties of the thoracic aorta described earlier. these features of the thoracic aorta were originally demonstrated in a series of early studies looking at the role of the intrinsic properties of the aorta in disease initiation and progression.6264 atherosclerosis resistant ascending aortic segments were substituted with atherosclerosisprone abdominal aortic segments in dogs that were subsequently fed an atherogenic diet for 1 year. after this period, the atherosclerosisprone abdominal aortic segments developed severe atherosclerotic lesions, whereas the ascending aortic homograft in the abdomi nal position failed to develop intimal lesions, suggesting that intrinsic properties were at least as important as environmental factors that are thought to be operative in the pathogenesis of disease.
Collagen
1 Structural integrity
3 Sequestering soluble ECM cytokines 2
4 Interaction with ECM proteins
Activation of signaling cascades
Talin Vinculin
Figure 3 | Illustration of the roles of collagen fibers in the ECM. Collagen fibers provide 1) structural strength to the aortic wall and have the following additional functions: 2) direct interaction with vSMCs and activation of different intracellular signaling pathways; 3) reservoirs for soluble enzymes and cytokines in the ECM, thereby regulating their function; 4) interaction with other ECM proteins to regulate their function. Mutations in collagen fibers such as observed in type Iv Ehler Danlos syndrome can affect both the structure and the function of the aortic wall. Abbreviations: ECM, extracellular matrix; IL-2, interleukin 2; vSMC, vascular smooth muscle cell.
Fibrillin 1
Structural integrity
Aortic morphogenesis
Binding of various ECM proteins (LTBP, BMP, decorin)
Direct interaction with cell receptors
Fibrillin-1 mutations
Mechanical regulation
the thoracic aorta is exposed to a variety of mechani cal stresses during each cardiac cycle, including radial strain and wall shear stress from the flow of blood. these mechanical cues have a direct effect on structure and function of cells in the aortic wall, characterized by changes in cell alignment, migration, proliferation and synthesis. In vitro studies have shown the ability of cul tured vsmCs to respond to stretch by changing their proliferative rate and increasing collagen production.65 although aneurysmal aortic specimens show reduced collagen in areas of dilatation, this
Stiffening of the aortic wall
Increased T G F 1 activity
In ammation MMP upregulation
Elastolysis Cell disarray
could be attributed to
Figure 4 | The structural and functional effects of normal and mutant fibrillin 1 in the regulation of aortic wall homeostasis. In normal individuals, fibrillin 1 is an important structural component of the aortic wall, forming a lattice around elastic
fibers.40 Fibrillin 1 is also involved in aortic morphogenesis during the fetal period, in conjunction with fibrillin 2, 48 and has pivotal regulatory functions by sequestering cytokines and growth factors such as T G F -1 through binding to LTBP.41,42 Although its functional effect remains unknown, fibrillin 1 can interact
4547
even higher levels of concomitant proteolysis, a process mediated by mm Ps, which will be considered in more detail later in the review. the role of local mechanical stresses on the aorta have been specifically investigated by Della Corte et al., who showed a regional pattern of vsmC apoptosis in ascending aortas associated with bicuspid aortic valve (Bav) disease.23 vsmC apoptosis was significantly increased at the aortic convexity (the site of highest stresses), compared with other areas of the ascending aorta.23 these changes occurred in parallel with a similar regional heterogeneity in matrix protein
directly with integrin receptors on vSMCs.
Mutations in the fibrillin 1-encoding
gene lead to structural changes in the aorta, increased bioavailability and activity of T G F -1, chemotaxis, inflammation and expression of MMPs. 86,96,106,159 These changes result in elastin fragmentation, cell apoptosis and disarray. Abbreviations: BMP, bone morphogenic proteins; ECM, extracellular matrix; LTBP, latent T G F -1binding protein; MMP, matrix metalloproteinase; T G F -1, transforming growth factor 1; vSMC, vascular smooth muscle cell.
content and composition.66 these studies demonstrate the importance of the local mechanical environment and the role of activated mechanotransduction pathways

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collagen and elastin production. However, 71 the data now reveal a prominent opposing role of tGF1, leading to matrix degradation through increased production of plasminogen activators and release of mm Ps 2 and 9 in the matrix. 68,69 tGF1 is now recognized as a key com ponent in the pathogenesis of taas. in the eCm, the large latent complex (l C) containing tGF1 is bound l to the latent tGF1binding protein (ltBP), a large molecule that keeps tGF1 in an inactive state in the matrix (Figure 6). Fibrillin 1 acts as potent regulator of tGF1 bioavailability by binding to ltBP (Figure 6).42 activation of tGF1 depends either on the release of ltBP from the microfibrils, allowing cleavage of the laP tGF1 bond, or on direct cellsurface binding of the llC to integrins. tGF1 is present in normal aortic walls, but only a fraction of it is metabolically active.70 Consequently, the bioavailability of active tGF1 in the eCm is more dependent on protease activity than on de novo synthesis. reduced or mutated forms of fibrillin 1 stimulate release of sequestered tGF1 and an increase in its activity. in addition, fragments of fibrillin 1 (PF10), which can be found independently in the matrix in mutated forms of the protein, can directly cleave the ltBPlaP complex, releasing active tGF1, which in turn can activate the smad and the p38 mitogenactivated protein kinase (m PK) a pathways in vsmCs. other signals capable of cleaving laPtGF1 bonds include thrombospondin 1 (tsP1), in mediating cellular and matrix responses. according to laplaces law, transmural strain increases with increases in radial diameter. in practice, these changes are expected to become more pronounced as the aorta increases in size and therefore contribute to the observed vsmC apop tosis and disarray, as well as matrix protein degradation in taas. wall shear stress is the main mechanical stimulus for endothelial cells lining the aortic wall. shear stressthe frictional force per unit areais proportional to blood viscosity and volumetric flow rate, and inversely propor tional to the third power of the internal radius. the role of shear stress has been thoroughly studied, particularly as a factor contributing to the development of athero sclerosis in areas of low shear (curvatures or bifurca tions). although the ascending aorta is often perceived as a tubular structure with high shear stresses, as dila tation occurs, the pattern and magnitude of shear can vary significantly along its surface. these changes can translate into altered paracrine signaling from endo thelial cells to underlying vsmCs, leading to a change in proliferative, contractile or synthetic properties.
RCA
LCA LS CA
RS CA INN aAo
PT
dAo
Figure 5 | Developmental origin of cells populating the ascending aorta. Neural crest cells are LacZ-positive (blue). Notice the distribution of neural crest cells to the aortic root, aAo, INN, LCA and R CA. The LSCA and the dAo beyond the ductus arteriosus (which is also derived from neural crest cells) are not derived from the neural crest. Abbreviations: aAo, ascending aorta; dAo, descending aorta; INN, innominate artery; LCA, left carotid artery; LSCA,left subclavian artery; PT, pulmonary trunk; RC A,right carotid artery; RSCA, right subclavian artery. Permission obtained from The Company of Biologists
Jiang et al. Development 127, 16071616 (2000).
ltBPllC or
regulation through biochemical signaling

TG F -1 tGF1, a member of a large family of cytokines that includes activins and BmP, has a central role in cardiac an d vascular morphogenesis and in maintaining eCm homeostasis.67 initially, tGF1 was thought to con tribute solely to matrix synthesis through stimulation of
BmP1, changes in local pH and various proteases.41,7275 By contrast, emilin 1, a matrix glycoprotein, inhibits tGF1 signaling by binding to the tGF propeptide and preventing its maturation in the extracellular space.76 Emilin1knockout mice present with hypertension (an effect attributed to increased tGF1 activity) 76 and show alterations in cell morphology and elastic fibers in the aortic wall.77 the role of emilin 1 in the pathogenesis of human taas remains to be defined. once active tGF1 is free in the matrix, it binds to tGF receptor (tGFr) 2, which in turn recruits and activates tGFr1, inducing a signaling cascade of intra cellular signaling protein phosphorylation, starting with receptorassociated smads (smads 2 and 3 or rsmad) that associate with a cosmad (smad4), translocating to the nucleus and inducing specific gene activators or repressors (Figure 6). alternative tGF1 signaling path ways have also been proposed,
including direct stimula tion of tGFr2 without tGFr1 activation, activation of tGFr1 without smad signaling, smad2/3 signaling in the absence of smad4 involvement and activation of smads 2 and 3 by other signaling mediators in response to tGF1.78,79 these alternative pathways help to explain the formation of taas in individuals with mutations in tGFr1 and tGFr2, which paradoxically show histological signs of tGF1 overactivity.8083 mutations in tGF receptors have been linked to several condi tions leading to taas, including the loeysDietz syn drome (lDs) 81 and a familial nonsyndromic form of ta (ta 2; table 1). 83 a a
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MMPs mm Ps and their tissue inhibitors (timPs) constitute a series of zinccontaining enzymes capable of matrix degradation, remodeling and processing of eCm proteins and adhesion molecules. 84,85 mm Ps can be produced by many cell types, including resident cells (vsmCs and fibroblasts) and inflammatory cells (neutrophils and macrophages), in response to inflammation, oxida tive stresses, matrix degradation products or increased tGF1 activity.69,86 mm Ps cause eCm degradation mainly through direct proteolysis of its structural com ponents, whereas tim Ps are endogen ous inhibitors that act directly by binding to and inactivating mm Ps. the local balance between mm Ps and tim Ps determines the overall effect on aortic wall matrix composition. the main regulatory step of mm P expression and activity occurs at the transcriptional level (a notable exception is mm P2). Factors such as members of the m PK pathway and the nuclear factor B a (nFB) signaling pathway can regulate mm P transcription.85 Posttranscriptional and posttranslational controls have also been identified in the regulation of mm P activity.87 the metabolic activity of mm Ps in the matrix is mitigated through sequestra tion by eCm proteins, as well as direct binding to tim Ps, thus preventing excessive matrix degradation. matrix proteolysis is one of the hallmarks of taas. various studies have examined the mm P profile in explanted thoracic aortas from patients with syndro mic, familial or sporadic taas. whereas healthy aortic tissue shows little expression of mm Ps, increas ed mm P expression is consistently obs er ved in ta a specimens.85,8890 these studies show marked hetero geneity in mm P expression profiles between different taa etiologies, possibly suggesting different mecha nistic pathways. nevertheless, an accurate description of diseasespecific changes remains difficult because of a lack of uniformity between study protocols: aortic har vesting sites var y between studies, resulting in regional variations in mm P expression along the circum ference; taa diameters at the time of harvest are vari able; mm P expression rather than activity is usually examined and few studies have focused specifically on syndromic or familial forms of taas (with
TSP1 FBN fragments MMPs LLC
Emilin 1 Inactive T G F 1 T G F LAP LTBP Fibrillin 1 T G F TG F
ECM Matrix proteolysis
Active T G F 1
MMP2
TGF
TGF
MMP9
R2
R1
R2
R2 P R1 P
Smad2/3
P SLC Smad2/3
Cytoplasm
P Smad2/3
Nucleus
the exception of those associated with marfan syndrome and Bavs). However, several important elements are apparent. taas associated with Bavs are characterized by an increase in mm P2 expression. 8994 mm P9 expression was inconsis tently increased in Bavtaas, 91,94,95 possibly reflecting spatiotemporal heterogeneity between studied samples. ikonomidis et al. performed a complete analysis of protease expression in this patient population, further showing that mm P14 activity is decreased in Bav aortas (mm P14 is an activator of mm P2). 93 the authors also showed changes in mm P expression according to aortic size.93 mm P2 expression is increased in Bavtaas ranging from 46 cm, along with a decrease in mm P3 and mm P14 expression. this expression profile is followed by a decrease in tim P1 expression once Bavtaas
Figure 6 | The role of T G F in TA A formation. T G F is -1 -1 normally maintained in an inactive state in the ECM by binding to the LAP, which in turn binds to the LTBP, forming the LLC. This complex interacts with ECM components including fibrillin 1 through LTBP, stabilizing T G F in an -1 inactive state. this represents the main step in regulating its activity. various proteases, TSP1, FBN fragments and changes in pH can cleave the LA P T G-1 or the LTBPLLCbonds, thus F releasing active T G F -1 in the matrix. The traditional T G F -1 signaling pathway requires binding to T G F -R2, recruitment of T G F -R1 and a series of Smad protein phosphorylations leading to nuclear translocation of the Smad2Smad3 complex and specific gene activation or repression. Increased T G F activity leads to matrix -1 proteolysis through release of proteases including MMP2 and MMP9. In addition, mutations in TGFBR 1and TGFBR2 result in increased T G F activity. Alternative T G F -1 -1 signaling pathways such as direct stimulation of T G F -R2 without T G F -R1 activation have been proposed. Abbreviations: ECM, extracellular matrix; FBN, fibrillin 1; LAP, latency- associated peptide; LLC, large latent complex; LTBP, large latent T G F --binding protein; MMP, matrix metalloproteinase; T G F -1, transforming growth factor 1; TG F -R, transforming growth factor receptor; TSP1, thrombospondin 1.
exceed 6 cm in diameter. By contrast, for taas associ ated with tricuspid aortic valves, an initial decrease in timP2 expression (<4 cm in diameter) is followed by a late increase in mm P7 expression (>6 cm). a gene array study on taa samples from patients with bicuspid or tricuspid aortic valves showed down regulation of metallothioneins in taas, compared with controls, and reduced metallothionein production by cultured vsmCs from diseased aortas.95 the precise role of metallothioneins is not yet fully understood but they are thought to affect mm P expression in the aortic wall, which might represent an important mechanism of mm P activity regulation. Finally, few studies have examined changes in protease expression in patients with marfan syndrome. ikonomidis et al. showed that mmP14 and timP2 were increased in taas associated with marfan syndrome, compared with agematched nonmarfan syndrome taas. 89 a recent analysis of taas from a

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taas consistently show the presence of inflammatory and immune cells (CD3 +, CD45 + and CD68 + cells), par ticularly in the adventitia, along with an increase in the density of the vasa vasorum and local endothelial activa tion (as observed in Figure 8). 24,98,99 no studies have yet linked 5lipoxygenase activity or other specific inflam matory pathways with taa formation but further work is warranted, given its promising therapeutic implications. in addition to inflammatory pathways, oxidative stress has long been implicated in the pathogenesis of abdomi nal aneurysms. However, the link between oxidative stress and taa formation remains to be firmly established, particularly in sporadic cases of the disease. reactive oxygen species can increase the expression and activity of mm Ps, as well as induce vsmC apoptosis, resulting in aortic wall weakening and elastolysis. a study of abdomi nal aortic aneurysms has demonstrated the central role of cyclophilin a (a chaperone protein that binds cyclosporin and is abundantly expressed in vsmCs) in disease patho genesis. 100 mice deficient for the cyclophilin a protein were completely protected from aneurysm formation, highlighting its central role in mediating matrix degra dation. 100 in a separate study, inhibition of the stress activated protein kinase Jun aminoterminal kinase (JnK) in two mouse models of abdominal aneurysms resulted in prevention of aortic dilatation and medial thinning, and preservation of aortic wall architecture.101 expression of mm Ps 2 and 9 was also decreased.101 these studies underscore the need for further research into the pathogenesis of sporadic taas, with a on inflammatory and oxidative pathways. adventitia expressed 5lipoxygenase and mediated their negative effects mainly through activation of endothelial cells lining the vasa vasorum and release of mm P2 in the aortic wall (Figure 7). 97 Crossing 5lipoxygenasenull mice with apoe/ mice resulted in a significant reduction in aneur ysm for mation, emphasizi ng its crucial role in degenerative aneurysms. interestingly, histological analyses of aortic wall specimens from patients with familial or sporadic
Endothelial cell
Blood vessel lumen
Macrophage Elastin Smooth muscle cell
Intima
Media
Macrophage 6 5-LO CysLT1 R LTD 4 1 2 MIP1 5-LO ECM-degrading factors (e.g. MMP2) 5 Adventitia
3 CysLT2R LTD4
4 MIP2
Aneurysm granuloma T cells
Monocyte
Endothelial cells of vasa vasorum
Figure 7 | The outside-in theory showing the role of the 5-LO pathway in the formation of aortic aneurysms. LTD4 stimulates the production of MIP1 by macrophages in an autocrine fashion (1), leading to recruitment of T-cells in the adventitia (2). LTD4 also stimulates production of MIP2 by endothelial cells in the vasa vasorum (3), which leads to leukocyte recruitment in the adventitia (4). Cells accumulating in a 5-LO-dependenttissue can release proteases such as MMP2 (5), which cause matrix degradation. Abbreviations: 5-LO, 5-lipoxygenase; LTD4, leukotriene D4; MIP, macrophage inflammatory protein; MMP, matrix metalloproteinase. Permission obtained from Nature Publishing Group Zhao et al. Nat. Med. 10, 966973 (2004).
particular focus mouse model of marfan syndrome shows an increase in mm P2 and mm P9 expression and a timedependent increase in the mm P2:timP2 ratio, compared with normal controls. 96
inflammation and oxidative stress

Histological analysis of taas often shows the presence of inflammatory cells in the adventitia and media of the aortic wall. this phenomenon suggests that inflammatory pathways might play an important part in the regulation of aortic wall physiology. an interesting new paradigm in the understanding of isolated aneurysms has been proposed, suggesting an outsidein theory of aneurysm formation, with the adventitia as the epicenter of patho genesis of the disease.97 in that study, Zhao et al. showed that macrophagedependent inflammation in the adven titia has a direct role in the pathogenesis of aortic aneu rysms (albeit abdominal aneurysms).97 macrophages and CD3 + cells in the
Clinical classificationof TAAs

taas are classified as syndromic, familial or sporadic. this clinical classification has facilitated the identifica tion of a large number of genes responsible for syndro mic forms of taas and some of the genes associated with familial taas. Classification of taas has also been useful in elucidating the underlying mechanisms. However, there are still several gaps in our knowledge, particularly in rela tion to the exact mechanisms of different manifestations or complications of the disease in individual patients.
various body systems. taas are a main feature of some syndromes, namely marfan syndrome, loeysDietz and ehlerDanlos syndrome. in other cases, such as Bav syndrome and turner syndrome, taas are a possible manifestation. Marfan syndrome marfan syndrome is an autosomaldominant, multi system disorder with manifestations typically involving the cardiovascular, skeletal and ocular systems. Diagnosis is based on a specific set of criteria that take into account all potentially involved systems.102 marfan syndrome
Syndromic Taas
syndromic taas are defined as aneurysms that occur in conjunction with a range of associated anomalies affecting
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SMA Elastin CD45 CD68 N FB
Figure 8 | Typical immunohistochemical findings in an explanted aortic wall of a patient who underwent surgery for a nonfamilial TA A, compared with a normal aortic wall obtained from a transplant recipient with a normal aorta. Typical findings include vSMC disarray, elastin fragmentation and increased inflammatory infiltration (particularly in the adventitia) characterized by the presence of CD45+ (leukocytes), CD68+ (macrophages)and NFB+ cells. Abbreviations: NFB, nuclear factor B; SMA, smooth muscle actin; TAA, thoracic aortic aneurysm; vSMC, vascular smooth muscle cell.
results from mutations in the fibrillin 1 gene located on chromosome 15q1531. since the first mutation in this gene was described in 1991,2 more than 1,000 different (mostly missense) mutations have been identified.103 the decrease in structural fibrillin 1 was originally thought to result directly in weakening of the aortic wall, leading to aneurysm formation. However, analyses in newborn mice with fibrillin 1 mutations showed abnormal sep tation of the distal alveoli, suggesting that the develop mental problems result from altered cell behavior during morphogenesis.104 the changes observed were attributed to a marked increase in tGF1 activity and signaling, highlighting the crucial role of fibrillin 1 in regulating the tGF1 pathway. increased tGF1 activity and products of fibrillin 1 degradation together lead to the observed histological findings in aortas of patients with marfan syndrome, including increased mm P signaling, elastin fragmentation, vsmC apoptosis, macrophage chemot axis and inflammation.41,86,106 tGF1 activity also explains the associated manifestations in marfan syndrome, such as bone overgrowth and mitral valve anomalies, which result from active changes in cell function. 105 treatment of mutant mice with systemic tGF1neutralizing anti bodies reversed the pulmonary parenchymal changes in vivo,104 as well as the mitral valve anomalies.105 a second locus linked to chromosome 3p2425 has been identified and a marfanlike syndrome described.107 this locus is associated with the gene encoding tGFr2.82,108 Controversy persists as to whether these
individuals have pure marfan syndrome, as they presented with some atypical features such as cervical spine instability, patent ductus arteriosus and cardiac septal defects.80 uncertainty also remains as to how well these patients were evaluated for features of loeysDietz syndrome, such as the skin and uvula abnormalities, as mutations in TGFBR1 and
TGFBR2 genes have been associated with this syndrome, as well as a familial form of nonsyndromic taas (ta 2), a as will be discussed later. of note, mutations in the fibrillin 2 gene have not been linked to vascular diseases. LoeysDietzsyndrome loeysDietz syndrome is an autosomaldominant disorder characterized by taas, arterial aneurysms and dissection, craniosynostosis, bifid uvula, cleft palate and thin, trans lucent skin.81 Patients with this syndrome present with aortic dissection at a young age and with aortic diameters less than 5 cm. mutations in TGFBR1 and TGFBR2 have been linked to the syndrome. most mutations are mis sense mutations that commonly affect an intracellular
kinase domain on the receptor, reducing receptor signal ing activity in response to tGF1. Paradoxically, cells obtained from the aortic wall of patients with loeysDietz syndrome have increased collagen, connective tissue growth factor and increased nuclear phosphorylation of smad2, indicating that tGF1 activity is increased. 80,81 thus, the same putative mechanism of increased tGF1 activity invoked in marfan syndrome is also at play in loeysDiet z syndrome, highlighting the central role of increased and dysregulated tGF1 signaling in aneu rysm formation. to date, the precise mechanisms for increased tGF1 signaling remain poorly understood as mutations in the kinase domain are expected to reduce signal transduction. alternative signaling pathways are probably activated but have not yet been clearly defined. o verall, there are no apparent differences in the clinical presentation between patients with TGFBR1 or TGFBR2 mutations.80 the median age for occurrence of a first major vascular event in loeysDietz syndrome is 30 years. the natural history of the disorder differs con siderably from that of other connective tissue disorders,

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with a median survival of patients with loeysDietz syn drome of 37 years,80 compared with 48 years and 70 years for patients with type iv ehlerDanlos syndrome109 and actively treated mFs,110 respectively. treatment with angiotensinreceptor blockers (a Bs), which counteract the r effects of excessive tGF1 signaling, is of benefit to patients with marfan syndrome, and is likely to benefit patient with loeys Dietz syndrome but studies have yet to confirm whether a B treatment will be r successful in this condition. EhlersDanlossyndrome vascular ehlersDanlos syndrome (type iv) is an auto somaldominant disorder that manifests with arterial aneurysms, rupture and dissection, as well as thin, trans lucent skin and easy bruising.109 Diagnosis is confirmed by demonstration of abnormal production of type iii pro collagen by cultured fibroblasts or by genetic screening.109 type iv ehlersDanlos syndrome results from mutations in the COL3A1 gene, which encodes type iii collagen.109,111 more than 70 different mutations have been identified in patients with the disease. Given the extreme friability and fragility of aortic tissue, patients with type iv ehlerDanlos syndrome are at a greater risk of adverse outcomes follow ing vascular surgery than are patients with other connective tissue disorders. median survival of patients with vascular ehlersDanlos syndrome is estimated to be 48 years.109 BAV syndrome Bav disease is the most common cardiovascular mal formation in humans (1 2%). in addition to bicuspid valve abnormalitites, Bav syndrome can manifest with various left heart lesions such as hypoplastic left hearts, arch hypo plasia and aortic coarctation.112 taas affect about 40% of patients with Bavs and are thought to be associated with increased risk of dissection and rupture. 113 the finding that firstdegree relatives of patients with Bavs have a 32% incidence of aortic root dilatation, despite having normal tricuspid valves, 114 supports the notion that Bav and taa can occur independently in individuals from Bav families. a study of 13 families of probands present ing with combined Bav and ta a strongly suggests that Bavtaa syndrome follows an autosomaldominant p attern of inheritance.115 no specific mutation has yet been associated with the combined Bavtaa phenotype although evidence now suggests that NOTCH1 mutations might be involved in a subset of patients with combined Bav and ta .116 this a observation is interesting, consider ing the role of notch 1 signaling in valvular and vascular morphogenesis, particularly in guiding neural crest cell migration and e t.57 m increased tGF1 activity might also contribute to aneurysm formation in patients with Bavs, as suggested by a study showing increased tGF1 expression and nuclear translocation of smad2.117 Turner syndrome turner syndrome is characterized by a 45,Xo aneuploid chromosomal constitution. its phenotypic characteristics
include short stature, gonadal disgenesis, web neck and widely spaced nipples. associated cardiovascular anoma lies include Bav, coarctation of the aorta, hypertension and taas, which are present in almost 40% of patients with turner syndrome.118 little is known about the pathological features of aortas from patients with the syndrome. Arterial tortuosity syndrome we have previously encountered individual cases of arte rial tortuosity associated with thoracic aneurysms and areas of arterial narrowing.119 arterial tortuosity syn drome has been described as an autosomalrecessive dis order characterized by tortuosity, elongation, stenosis and aneurysm formation in the major arteries owing to dis ruption of elastic fibers in the media caused by increased tGF1 activity in the arterial wall.120 associated features inc lude micrognathia, an elongated face, downslanting palpebral fissures and a beaked nose. mutations in the SLC2A10 gene, which encodes the facilitative glucose transporter Glut10, have been linked to the syn drome.120,121 extended followup of affected individuals and increased awareness and recogn ition of this syn drome will increase understanding of the clinical course of associated taas. Other syndromes several other genetic syndromes, including noonan syn drome122 and polycystic kidney disease123 show features of aortic aneurysms (table 1). However, the incidence of taas in these syndromes is significantly lower than those described above, and the mechanisms remain unknown.
manifestation, but follow a familial pattern of inheri tance, often autosomal dominant, with decreased pene trance (especially in female family members) and variable expression.125,126 the incidence of taas in firstdegree relatives of patients with isolated taas is 1119%.127 129 six different genetic loci have been recognized in families with familial nonsyndromic taas (table 1), but only three genes have been identified: TGFBR2 in ta 2, ACTA2 in ta 4 and MYH11 in a a familial ta a and patent ductus arteriosus. the remaining loci are 5q1314 (ta 1, about 1030% of familial a nonsyndromic taas), 130 11q23.3 24 (Fa 1, a less than 5% of familial nonsyndromic taas) 131 and 15q24 26 (ta 3, about a 1020% of familial nonsyndromic taas). 132 studies to identify the specific genes involved in the pathogenesis of these different taas are in progress. 133 ACTA2 mutations ACTA2 mutations were first identified in a large family affected by nonsyndromic taas that have an autosomal dominant inheritance mode and decreased penetrance (ta 4). 25 in addition to taas, patients can a also present with levido reticularis, iris f loculi, a patent ductus
Familial nonsyndromic Taas

the existence of familial but nonsyndromic taas was recognized in the 1980s.124 these taas occur as a single
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arteriosus and nonthoracic aneurysms. the ACTA2 gene encodes smooth muscle 2actin (one of six identified actin isoforms). vsmCs isolated from two individuals heterozygous for ACTA2 mutations showed signifi cantly reduced smooth muscle 2actincontaining fila ments and aggregates of unpolymerized smooth muscle 2actin in the analysis of 97 unrelated cytoplasm. families revealed ACTA2 mutations in 14 families (14%), making such mutations the most commonly identified cause of familial taas. Clinically, the penetrance of this mutation is low (0.48%) and does not increase with age, unlike other forms of ta . analysis of aneurysmal aortic tissue a shows a decreased number of vsmCs, fragmenta tion and loss of elastic fibers and accumulation of proteo glycans in the media. 25 Focal areas of increased vsmCs that have no organized alignment, as well as increased vsmC proliferation in the adventitial vasa vasorum, have also been observed. the precise mechanisms responsible for the aneurysmal vascular disorders remain largely unknown. However, ACTA2 mutations are thought to affect local adaptation of cellular and extracellular ele ments to mechanical stresses through dysfunction of the mechanotransduction pathways. evaluation of ACTA2 mutation carriers in 20 families has been associated with premature onset of coronary artery disease and ischemic strokes, 134 suggesting a widespread dysregulation of mechanotransduction pathways causing tissuespecific local responses. MYH11 mutations MYH11 mutations have been linked to familial ta a and patent ductus arteriosus formation.26,27,135,136 MYH11 encodes smooth muscle mHC, a major specific contrac tile protein in vsmCs. the mutations originally identi fied caused inframe deletions in MYH11 that seem to reduce the probability of adoption of a coiledcoil struc ture by mHC, resulting in failure of assembly of myosin thick filaments. subsequent analysis of three unrelated families with taa and patent ductus arteriosus identi fied missense point mutations in the MYH11 gene in two families (the remaining family had a TGFR2 muta tion). 137 Histological analysis of affected aortas showed focal areas of vsmC loss, and loss of elastic fibers and collagen.26 vsmC disarray and focal areas of cell hyper plasia were also observed.137 notably, as observed with ACTA2 mutations, there was increased vascularity and marked fibromuscular dysplasia in the adventitial these changes translate into decreased aortic wall compli ance, a hallmark of aneurysmal aortas.
26
the presence of
a concomitant patent ductus arteriosus in patients with MYH11 mutations probably reflects a reduced ability of vsmCs to proliferate, migrate and contract.138,139
Familial TAA2 vasa vasorum, which seemed to invade the media. 137 the increase in vasa vasorum suggests possible inflamma tor y processes originating from the adventitial wall. as will be discussed later, histological analysis of other taas has consistently shown the presence of inflam matory and immune infiltrates in the aortic wall that seem to originate from the vasa vasorum (the socalled outsidein theory). 23,24,98 increased expression of insulin growth factor i and angiotensin ii were also observed in aortas of MYH11 mutation carriers but their functional significance remains poorly defined. 137 Functionally,
Familial ta 2 is one of the nonsyndromic a familial taas (table 1). ta 2 is an a autosomaldominant disorder with reduced penetrance and variable expression. Patients with ta 2 present with aortic a aneurysms at varying ages and phenotypic manifestation shows reduced penetrance. the causative mutations are located in the ta 2 a locus on chromosome 3p2425, which encodes tGFr2.83,140 in all cases, the ta 2 a mutation involves arg460 in the intracellular receptor domain.83,141 mutations in the arg460 amino acid are thought to disrupt Fhelix Dhelix communications within the threedimensional struc ture of the receptor, thus reducing signal transduction. However, the extracellular tGFbinding domain remains structurally intact and presumably its ability to bind tGF1 is preserved. similarly to observations in patients with loeys Dietz syndrome, mutations in the ta 2 a locus result in increased tGF1 activity. this obser vation is consistent with findings of increased tGF1 signaling in a transgenic
mouse model of fibro blastspecific kinasedeficient tGFr2.142 However, as previously mentioned, the precise mechanisms under lying the increased tGF signaling remain unknown. interestingly, somatic mutations in tGFr2 have been associated with an increased risk of cancer, yet hetero zygous germ line mutations in the same gene result in the vascular phenotype and no apparent predisposition to cancer, possibly because a wildtype receptor is present in addition to the mutated receptor in patients with ta 2,83 or because tGF might have a role a in cancer progression but not in tumor initiation.
Sporadic Taas
sporadic taas occur in isolation and do not show any familial transmission. they encompass a range of causative etiologies, but the precise cellular and molecu lar mechanisms remain poorly understood. sporadic taas can originate from degenerative, inflammatory (giant cell arteritis143), autoimmune (takayasu arteritis, rheumatoid arthritis or reiter syndrome), infectious (syphilis or tuberculosis) or traumatic conditions. little is known about the precise pathophysiological mecha nisms involved in sporadic taas. most of these aneu rysms are characterized by inflammatory and immune cell infiltration in the aortic wall, accompanied by matrix degradation and elastin fragmentation.
New therapeutic approaches

on the basis of the present understanding of the patho genic mechanisms of taa formation, several new approaches targeting molecular pathways have shown promising results.

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a Bs r
administration of tGF1neutralizing antibodies to fibrillin 1deficient mice reverses the damaging effects associated with tGF1 hyperactivity in the aortic wall.144 the a B losartan mediates a similar r effect. Habashi et al. treated 7weekold fibrillin 1deficient mice with documented taas with the adrenoceptor antagonist propranol or with losartan for a period of 6 months.144 losartan treatment resulted in a significant reduction in aortic size and growth, as well as improved aortic wall architecture.144 the precise mechanisms explaining the role of losartan are still poorly understood although it is thought to reduce the expression of tsP1, a potent mediator of angiotensin iiinduced tGF1 activation via at1, 145,146 as well as decreasing smad activation through tGF1independent pathways.147 a pilot study in 18 pediatric patients with marfan syndrome (median age 6.5 years) showed a significant reduction in the rate of progression of aortic wall dilatation following treat ment with a Bs, decreasing from 3.54 mm per r year to 0.46 mm per year.148 a prospective, randomized trial is currently underway comparing losartan to atenolol (a blocker) in a larger cohort of patients. 149 tGF1 in ta formation, a they suggest a potentially dif ferent pathophysiological role of tGF1 in degenerative taas, highlighting its pleiotropic effects.
anti-inflammatory and antioxidative agents

although the role of inflammatory and oxidative mecha nisms in the pathogenesis of taas remains unclear, we believe that valuable data from the abdominal aneurysm
doxycyclin
Doxycyclin is a nonspecific mm P inhibitor that has been used for the treatment of conditions associated with increased mm P activity, such as rheumatoid arthritis. Xiong et al. showed a decrease in elastic fiber fragmen tation and decreased expression of mm P2 and mm P9 in fibrillin 1deficient mice. 150 these results were corro borated by a separate study comparing doxycyclin with atenolol in the treatment of fibrillin 1deficient mice.151 in addition to the decrease in mmP2 and mmP9 activation, the authors demonstrated a decrease in tGF1 expres sion and activity in the doxycyclin group. importantly, treated mice did not develop taas and had normal mechanical properties of the ascending aorta.151 to date, no human studies have been performed but preliminary results from animal models are promising.
TgF-1
although most evidence points to a putative role of increased tGF1 activity in the pathogenesis of taas, tGF1 / supplementation in ApoE mice was found to prevent aortic root dilatation in a single study.152 these aortas had fewer t lymphocytes, more collagen, a lower expression of inflammatory cytokines and a reduction in mm P13 expression.152 although these findings are provocative, given the cumulative evidence implicating
literature should be considered in the study of taas, par ticularly sp oradi c forms of the disease. in this regard, researchers using animal models of abdominal aneurysms have found a role for cyclophilin a or JnK inhibition in preventing aneurysm formation.100,101 these data are of particular interest and represent a promising avenue in the prevention or mitigation of the progression of aneurysms.
Future directions
the past 1015 years have witnessed an unprecedented rate of advance in the understanding of taa patho genesis. these findings have changed our perception of the disease and paved the way for many more develop ments in the future. in addition to genetic and mechanis tic understanding of cellular and molecular mechanisms of taas, three important areasmolecular imaging, identification of biomarkers and computational model ing might have major clinical implications by allowing individualized manageme nt of patients with taas.
research is currently ongoing to identify circulating or genetic biomarkers of taas. For example, a study has sug gested that serum tGF1 levels correlate with the aortic size in patients with marfan syndrome.154 more impor tantly, treatment with losartan, adrenoceptor antago nists or a combination of both resulted in a significant decrease in the levels of circulating tGF1, which could therefore be evaluated as a potential therapeutic target.154 other possible targets include mm P2 and mm P9 but their circulating serum levels have not yet yielded enough sensitivity and specificity to be clinically useful.155157
Molecular imaging
aikawa et al. have examined the pathophysiology of aortic valve disease and have demonstrated the feasibility of in vivo molecular imaging of the pathophysiological steps involved in valve calcification, including the level and location of mm P activity.153 similar studies would allow a better understanding of the spatiotemporal sequence of events leading to ta formation and would also allow detection of a firstdegree relatives with meta bolically active aortas (for example, high mm P activity) despite a normal aortic diameter. Finally, such studies could help identify highrisk, mildly dilated aortas (4050 mm).
computational imaging
the rapid development of computational fluid dynamics and structural mechanics for the assessment of the aortic root allows creation of patientspecific models that esti mate stresses along the aortic root (wall shear stress and tens ile stress), as well as the tensile strength of the aorta (Figure 9).158 these estimations take into account the individual properties of the aorta, which can vary con siderably between patients whose disease shares a similar etiology. a tailored evaluation of a patients risk of aortic
Biomarkers
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a 36
140 Din Dout Pressure 120
Principal stress (kPa) 200 150 100 50 0
34 32 30 28 26 0
100
80
60 0.5 Time (s) 1
c MR-based inflow velocity profiles
90 60 40 20 0 20 0 0.2 0.4 0.6 Time (s) 0.8 1
Velocity (m/s) 0.15 0.10 0.05 0.00 0.05
ESS (Pa) 1.00 0.75 0.50 0.25 0.00
Velocity (m/s) 0.32 0.24 0.16 0.08 0.00
Figure 9 | Computational modeling of structural and fluid mechanics in the aortic wall of a patient with aortic root dilatation. Structural mechanical analysis of the aortic root shows a | the pressure waveform in the aortic root (red) and b | the tensile stress along the wall of the aortic root. Modeling of fluid mechanics shows c | flow velocity profiles in the neoaortic root, d | endothelial shear stress values (ESS) and e | swirling flow velocities in the entire aorta. Abbreviation: ESS, endothelial shear stress.
complications then becomes possible, which allows more individualized treatment.
Review criteria
The PubMed database was used with no limits on language or the year of publication. The search was performed using the keyword aortic aneurysms in conjunction with any of the following keywords: mechanisms, molecular and cellular. Articles specific for thoracic aortic aneurysms were given primary attention. Reference lists from all identified papers were searched for further specific references. Papers on individual proteins were searched using the protein name and aorta, vascular or aneurysms. Only full-text articles were used (with the exception of one important abstract). No limits on the year of publication were imposed. English and French language articles were considered.
Conclusions
the last decade has witnessed the discovery of major find ings that have provided valuable insight into the under standing of the cellular and molecular mechanisms leading to taa formation. Continued research and combined efforts will lead to further elucidation of the inherited and sporadic forms of the disease. this cumulative knowledge will undoubtedly translate into individualized and effec tive pharmacological treatments oriented towards molecu lar and genetic mechanisms, allowing for tailored medical and surgical approaches to this serious condition.
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acknowledgments Dr El-Hamamsy is supported by a fellowship grant from the Canadian Institute for Health Research (CIHR) and by the Magdi Yacoub Institute. The authors would like to acknowledge Dr Padmini Sarathchandra for the electron micrograph and immunohistochemical staining, and Dr Ryo Torii for for his help with functional imaging of aortic biomechanics.
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Hamamsy Yacoub - 2009 - Cellular and Molecular Mechanisms of Thoracic Aortic Aneurysms

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Hamamsy Yacoub - 2009 - Cellular and Molecular Mechanisms of Thoracic Aortic Aneurysms

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R EvI E W S

cellular and molecular mechanisms of thoracic aortic aneurysms

Harefield Heart Science

Aortic structure and function

nating from the left ventricle. the unique shape and

competing interests The authors declare no competing interests.

nat r e rev ews | cardiolog u i | 771

volume 6 | DeCem Ber 2009

players in aortic wall homeostasis (cells, collagen, elastin

Key structural componentsof the aorta

| DECEMBER 2009 | voluME 6

nat r e rev ews | cardiolog u i | 773

volume 6 | DeCem Ber 2009

Major regulato pathways ry

| DECEMBER 2009 | voluME 6

3 Sequestering soluble ECM cytokines 2

4 Interaction with ECM proteins

Activation of signaling cascades

Binding of various ECM proteins (LTBP, BMP, decorin)

Direct interaction with cell receptors

Stiffening of the aortic wall

In ammation MMP upregulation

Elastolysis Cell disarray

directly with integrin receptors on vSMCs.

Mutations in the fibrillin 1-encoding

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Jiang et al. Development 127, 16071616 (2000).

regulation through biochemical signaling

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TSP1 FBN fragments MMPs LLC

Emilin 1 Inactive T G F 1 T G F LAP LTBP Fibrillin 1 T G F TG F

ECM Matrix proteolysis

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Blood vessel lumen

Macrophage Elastin Smooth muscle cell

Aneurysm granuloma T cells

Endothelial cells of vasa vasorum

inflammation and oxidative stress

Clinical classificationof TAAs

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Familial nonsyndromic Taas

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New therapeutic approaches

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anti-inflammatory and antioxidative agents

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Principal stress (kPa) 200 150 100 50 0

60 0.5 Time (s) 1

c MR-based inflow velocity profiles

90 60 40 20 0 20 0 0.2 0.4 0.6 Time (s) 0.8 1

Velocity (m/s) 0.15 0.10 0.05 0.00 0.05

ESS (Pa) 1.00 0.75 0.50 0.25 0.00

Velocity (m/s) 0.32 0.24 0.16 0.08 0.00

complications then becomes possible, which allows more individualized treatment.

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