Drug-eluting stents implanted after ischaemic injury reduce the proliferation of endothelial cells and vascular smooth muscle cells and thus neointimal hyperplasia. However, the eluted drug also slows down the re-endothelialization process, delays arterial healing and can increase the risk of late restenosis. Here we show that stents releasing exosomes derived from mesenchymal stem cells in the presence of reactive oxygen species enhance vascular healing in rats with renal ischaemia-reperfusion injury, promoting endothelial cell tube formation and proliferation, and impairing the migration of smooth muscle cells. Compared with drug-eluting stents and bare-metal stents, the exosome-coated stents accelerated re-endothelialization and decreased in-stent restenosis 28 days after implantation. We also show that exosome-eluting stents implanted in the abdominal aorta of rats with unilateral hindlimb ischaemia regulated macrophage polarization, reduced local vascular and systemic inflammation, and promoted muscle tissue repair.
Subscribe to Journal
Get full journal access for 1 year
only $8.25 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
The main data supporting the results in this study are available within the paper and its Supplementary Information. The raw and analysed datasets generated during the study are too large to be publicly shared, but are available for research purposes from the corresponding author on reasonable request. GeneQuery rat macrophage polarization markers qPCR array data are available on the NCBI database with the identifier GSE155793. ToF-SIMS, XPS and histopathological data are available on reasonable request.
Tayal, R. et al. Totally percutaneous insertion and removal of impella device using axillary artery in the setting of advanced peripheral artery disease. J. Invasive Cardiol. 28, 374–380 (2016).
Khawaja, F. J. & Kullo, I. J. Novel markers of peripheral arterial disease. Vasc. Med. 14, 381–392 (2009).
Katsanos, K. et al. Wound healing outcomes and health-related quality-of-life changes in the achilles trial: 1-year results from a prospective randomized controlled trial of infrapopliteal balloon angioplasty versus sirolimus-eluting stenting in patients with ischemic peripheral arterial disease. JACC Cardiovasc. Interv. 9, 259–267 (2016).
Alfonso, F., Byrne, R. A., Rivero, F. & Kastrati, A. Current treatment of in-stent restenosis. J. Am. Coll. Cardiol. 63, 2659–2673 (2014).
Brasen, J. H. et al. Angiogenesis, vascular endothelial growth factor and platelet-derived growth factor-BB expression, iron deposition, and oxidation-specific epitopes in stented human coronary arteries. Arterioscler. Thromb. Vasc. Biol. 21, 1720–1726 (2001).
McGinty, S., Vo, T. T., Meere, M., McKee, S. & McCormick, C. Some design considerations for polymer-free drug-eluting stents: a mathematical approach. Acta Biomater. 18, 213–225 (2015).
Worthley, S. G. et al. First-in-human evaluation of a novel polymer-free drug-filled stent: angiographic, IVUS, OCT, and clinical outcomes from the RevElution study. JACC Cardiovasc. Interv. 10, 147–156 (2017).
Nakazawa, G. et al. Anti-CD34 antibodies immobilized on the surface of sirolimus-eluting stents enhance stent endothelialization. JACC Cardiovasc. Interv. 3, 68–75 (2010).
Karjalainen, P. P. & Nammas, W. Titanium-nitride-oxide-coated coronary stents: insights from the available evidence. Ann. Med. 49, 299–309 (2017).
Rani, S., Ryan, A. E., Griffin, M. D. & Ritter, T. Mesenchymal stem cell-derived extracellular vesicles: toward cell-free therapeutic applications. Mol. Ther. 23, 812–823 (2015).
Zhang, K. & Li, Z. Molecular imaging of therapeutic effect of mesenchymal stem cell-derived exosomes for hindlimb ischemia treatment. Methods Mol. Biol. 2150, 213–225 (2020).
Vandergriff, A. et al. Targeting regenerative exosomes to myocardial infarction using cardiac homing peptide. Theranostics 8, 1869–1878 (2018).
Aghajani Nargesi, A., Lerman, L. O. & Eirin, A. Mesenchymal stem cell-derived extracellular vesicles for kidney repair: current status and looming challenges. Stem Cell Res. Ther. 8, 273 (2017).
Mendt, M., Rezvani, K. & Shpall, E. Mesenchymal stem cell-derived exosomes for clinical use. Bone Marrow Transplant. 54, 789–792 (2019).
Forsberg, M. H., Kink, J. A., Hematti, P. & Capitini, C. M. Mesenchymal stromal cells and exosomes: progress and challenges. Front. Cell Dev. Biol. 8, 665 (2020).
Nassar, W. et al. Umbilical cord mesenchymal stem cells derived extracellular vesicles can safely ameliorate the progression of chronic kidney diseases. Biomater. Res. 20, 21 (2016).
Yang, J., Zhang, X., Chen, X., Wang, L. & Yang, G. Exosome mediated delivery of miR-124 promotes neurogenesis after ischemia. Mol. Ther. Nucleic Acids 7, 278–287 (2017).
Bian, X., Ma, K., Zhang, C. & Fu, X. Therapeutic angiogenesis using stem cell-derived extracellular vesicles: an emerging approach for treatment of ischemic diseases. Stem Cell Res. Ther. 10, 158 (2019).
Tsimikas, S. et al. Percutaneous coronary intervention results in acute increases in oxidized phospholipids and lipoprotein(a): short-term and long-term immunologic responses to oxidized low-density lipoprotein. Circulation 109, 3164–3170 (2004).
Laurindo, F. R. et al. Evidence for superoxide radical-dependent coronary vasospasm after angioplasty in intact dogs. Circulation 83, 1705–1715 (1991).
Galkina, E. & Ley, K. Immune and inflammatory mechanisms of atherosclerosis. Annu. Rev. Immunol. 27, 165–197 (2009).
Bennett, M. R., Sinha, S. & Owens, G. K. Vascular smooth muscle cells in atherosclerosis. Circ. Res. 118, 692–702 (2016).
Raines, E. W. The extracellular matrix can regulate vascular cell migration, proliferation, and survival: relationships to vascular disease. Int. J. Exp. Pathol. 81, 173–182 (2000).
Su, Z. et al. ROS-triggered and regenerating anticancer nanosystem: an effective strategy to subdue tumor’s multidrug resistance. J. Control. Release 196, 370–383 (2014).
Hulsmans, M. & Holvoet, P. MicroRNA-containing microvesicles regulating inflammation in association with atherosclerotic disease. Cardiovasc. Res. 100, 7–18 (2013).
Oikawa, S., Wada, S., Lee, M., Maeda, S. & Akimoto, T. Role of endothelial microRNA-23 clusters in angiogenesis in vivo. Am. J. Physiol. 315, H838–H846 (2018).
Cheng, J., Zhang, P. & Jiang, H. Let-7b-mediated pro-survival of transplanted mesenchymal stem cells for cardiac regeneration. Stem Cell Res. Ther. 6, 216 (2015).
Castner, D. G. & Ratner, B. D. Biomedical surface science: foundations to frontiers. Surf. Sci. 500, 28–60 (2002).
Draude, F. et al. Characterization of freeze-fractured epithelial plasma membranes on nanometer scale with ToF-SIMS. Anal. Bioanal. 407, 2203–2211 (2015).
Chung, T. W., Liu, D. Z., Wang, S. Y. & Wang, S. S. Enhancement of the growth of human endothelial cells by surface roughness at nanometer scale. Biomaterials 24, 4655–4661 (2003).
Xu, L. C., Bauer, J. W. & Siedlecki, C. A. Proteins, platelets, and blood coagulation at biomaterial interfaces. Colloid Surf. B 124, 49–68 (2014).
de Gracia Lux, C. et al. Biocompatible polymeric nanoparticles degrade and release cargo in response to biologically relevant levels of hydrogen peroxide. J. Am. Chem. Soc. 134, 15758–15764 (2012).
Starke, R. D. et al. Endothelial von Willebrand factor regulates angiogenesis. Blood 117, 1071–1080 (2011).
Rensen, S. S., Doevendans, P. A. & van Eys, G. J. Regulation and characteristics of vascular smooth muscle cell phenotypic diversity. Neth. Heart J. 15, 100–108 (2007).
Langeveld, B. et al. Rat abdominal aorta stenting: a new and reliable small animal model for in-stent restenosis. J. Vasc. Res. 41, 377–386 (2004).
Tsai, Y. C. et al. Angiopoietin-2, Angiopoietin-1 and subclinical cardiovascular disease in chronic kidney disease. Sci. Rep. 6, 39400 (2016).
Wasik, U., Milkiewicz, M., Kempinska-Podhorodecka, A. & Milkiewicz, P. Protection against oxidative stress mediated by the Nrf2/Keap1 axis is impaired in primary biliary cholangitis. Sci. Rep. 7, 44769 (2017).
Douglas, G. et al. Endothelial cell repopulation after stenting determines in-stent neointima formation: effects of bare-metal vs. drug-eluting stents and genetic endothelial cell modification. Eur. Heart J. 34, 3378–3388 (2013).
Bedair, T. M., ElNaggar, M. A., Joung, Y. K. & Han, D. K. Recent advances to accelerate re-endothelialization for vascular stents. J. Tissue Eng. 8, 2041731417731546 (2017).
Tan, A., Alavijeh, M. S. & Seifalian, A. M. Next generation stent coatings: convergence of biotechnology and nanotechnology. Trends Biotechnol. 30, 406–409 (2012).
Getz, G. S. & Reardon, C. A. Animal models of atherosclerosis. Arterioscler. Thromb. Vasc. Biol. 32, 1104–1115 (2012).
Lee, J. G. et al. Knockout rat models mimicking human atherosclerosis created by Cpf1-mediated gene targeting. Sci. Rep. 9, 2628 (2019).
Allahverdian, S., Chaabane, C., Boukais, K., Francis, G. A. & Bochaton-Piallat, M. L. Smooth muscle cell fate and plasticity in atherosclerosis. Cardiovasc. Res. 114, 540–550 (2018).
Greenberger, S. & Bischoff, J. Pathogenesis of infantile haemangioma. Br. J. Dermatol. 169, 12–19 (2013).
Yonetsu, T. et al. Comparison of incidence and time course of neoatherosclerosis between bare metal stents and drug-eluting stents using optical coherence tomography. Am. J. Cardiol. 110, 933–939 (2012).
Slevin, M., Krupinski, J. & Badimon, L. Controlling the angiogenic switch in developing atherosclerotic plaques: possible targets for therapeutic intervention. J. Angiogenes. Res. 1, 4 (2009).
He, X. et al. MSC-derived exosome promotes M2 polarization and enhances cutaneous wound healing. Stem Cells Int. 2019, 7132708 (2019).
Mahdavi Gorabi, A. et al. The role of mesenchymal stem cells in atherosclerosis: prospects for therapy via the modulation of inflammatory milieu. J. Clin. Med. 8, 1413 (2019).
Li, J. et al. Exosomes derived from mesenchymal stem cells attenuate the progression of atherosclerosis in ApoE−/− mice via miR-let7 mediated infiltration and polarization of M2 macrophage. Biochem. Bioph. Res. Commun. 510, 565–572 (2019).
Boss, M., Kemmerer, M., Brüne, B. & Namgaladze, D. FABP4 inhibition suppresses PPARγ activity and VLDL-induced foam cell formation in IL-4-polarized human macrophages. Atherosclerosis 240, 424–430 (2015).
Koltsova, E. K. et al. Interleukin-27 receptor limits atherosclerosis in Ldlr−/− mice. Circ. Res. 111, 1274–1285 (2012).
Van Weel, V. et al. Natural killer cells and CD4+ T-cells modulate collateral artery development. Arterioscler. Thromb. Vasc. Biol. 27, 2310–2318 (2007).
Welt, F. G. & Rogers, C. Inflammation and restenosis in the stent era. Arterioscler. Thromb. Vasc. Biol. 22, 1769–1776 (2002).
Vandergriff, A. C. et al. Intravenous cardiac stem cell-derived exosomes ameliorate cardiac dysfunction in doxorubicin induced dilated cardiomyopathy. Stem Cells Int. 2015, 960926 (2015).
Qiao, L. et al. MicroRNA-21-5p dysregulation in exosomes derived from heart failure patients impairs regenerative potential. J. Clin. Invest. 129, 2237–2250 (2019).
Xu, Q., He, C., Xiao, C. & Chen, X. Reactive oxygen species (ROS) responsive polymers for biomedical applications. Macromol. Biosci. 16, 635–646 (2016).
Gallet, R. et al. Exosomes secreted by cardiosphere-derived cells reduce scarring, attenuate adverse remodelling, and improve function in acute and chronic porcine myocardial infarction. Eur. Heart J. 38, 201–211 (2017).
Zhang, B. et al. Mesenchymal stromal cell exosome-enhanced regulatory T-cell production through an antigen-presenting cell-mediated pathway. Cytotherapy 20, 687–696 (2018).
Poh, K. K. et al. Repeated direct endomyocardial transplantation of allogeneic mesenchymal stem cells: safety of a high dose, ‘off-the-shelf’, cellular cardiomyoplasty strategy. Int. J. Cardiol. 117, 360–364 (2007).
Elnaggar, M. A. et al. Nitric oxide releasing coronary stent: a new approach using layer-by-layer coating and liposomal encapsulation. Small 12, 6012–6023 (2016).
Liang, X. L., Zhang, L. N., Wang, S. H., Han, Q. & Zhao, R. C. Exosomes secreted by mesenchymal stem cells promote endothelial cell angiogenesis by transferring miR-125a. J. Cell Sci. 129, 2182–2189 (2016).
Ferguson, S. W. et al. The microRNA regulatory landscape of MSC-derived exosomes: a systems view. Sci. Rep. 8, 1419 (2018).
Beltrami, C. et al. Human pericardial fluid contains exosomes enriched with cardiovascular-expressed micrornas and promotes therapeutic angiogenesis. Mol. Ther. 25, 679–693 (2017).
Anderson, J. D. et al. Comprehensive proteomic analysis of mesenchymal stem cell exosomes reveals modulation of angiogenesis via nuclear factor-kappa B signaling. Stem Cells 34, 601–613 (2016).
Owens, G. K., Kumar, M. S. & Wamhoff, B. R. Molecular regulation of vascular smooth muscle cell differentiation in development and disease. Physiol. Rev. 84, 767–801 (2004).
Lavin, B. et al. Nitric oxide prevents aortic neointimal hyperplasia by controlling macrophage polarization. Arterioscler. Thromb. Vasc. Biol. 34, 1739–1746 (2014).
McDonald, R. A. et al. Reducing in-stent restenosis: therapeutic manipulation of mirna in vascular remodeling and inflammation. J. Am. Coll. Cardiol. 65, 2314–2327 (2015).
Yan, W. et al. M2 macrophage-derived exosomes promote the c-KIT phenotype of vascular smooth muscle cells during vascular tissue repair after intravascular stent implantation. Theranostics 10, 10712–10728 (2020).
Grasset, E. K. et al. Sterile inflammation in the spleen during atherosclerosis provides oxidation-specific epitopes that induce a protective B-cell response. Proc. Natl Acad. Sci. USA 112, E2030–E2038 (2015).
Piccolo, R. et al. Drug-eluting or bare-metal stents for percutaneous coronary intervention: a systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet 393, 2503–2510 (2019).
Alraies, M. C., Darmoch, F., Tummala, R. & Waksman, R. Diagnosis and management challenges of in-stent restenosis in coronary arteries. World J. Cardiol. 9, 640–651 (2017).
Huang, P. et al. Atorvastatin enhances the therapeutic efficacy of mesenchymal stem cells-derived exosomes in acute myocardial infarction via up-regulating long non-coding RNA H19. Cardiovasc. Res. 116, 353–367 (2020).
Lim, S. Y. et al. Inflammation and delayed endothelization with overlapping drug-eluting stents in a porcine model of in-stent restenosis. Circ. J. 72, 463–468 (2008).
Liu, F. et al. Hyaluronic acid hydrogel integrated with mesenchymal stem cell-secretome to treat endometrial injury in a rat model of asherman’s syndrome. Adv. Healthc. Mater. 8, 1900411 (2019).
Dinh, P. C. et al. Inhalation of lung spheroid cell secretome and exosomes promotes lung repair in pulmonary fibrosis. Nat. Commun. 11, 1064 (2020).
Ozbilgin, S. et al. Renal ischemia/reperfusion injury in diabetic rats: the role of local ischemic preconditioning. Biomed. Res. Int. 2016, 8580475 (2016).
Johnson, T. W. et al. Stent-based delivery of tissue inhibitor of metalloproteinase-3 adenovirus inhibits neointimal formation in porcine coronary arteries. Arterioscler. Thromb. Vasc. Biol. 25, 754–759 (2005).
Huang, C., Mei, H., Zhou, M. & Zheng, X. A novel PDGF receptor inhibitor-eluting stent attenuates in-stent neointima formation in a rabbit carotid model. Mol. Med. Rep. 15, 21–28 (2017).
Wang, Q. & Zou, M. H. Measurement of reactive oxygen species (ROS) and mitochondrial ROS in AMPK knockout mice blood vessels. Methods Mol. Biol. 1732, 507–517 (2018).
This work was supported by grants from the National Institutes of Health (HL123920, HL137093, HL144002, HL146153, HL147357 and HL149940 to K.C.) and the American Heart Association (18TPA34230092 and 19EIA34660286 to K.C.). We thank the Analytical Instrumentation Facility at North Carolina State University (supported by the State of North Carolina and the National Science Foundation ECCS-1542015 and DMR-1726294). XPS and ToF-SIMS were performed and analysed at the Analytical Instrumentation Facility. Confocal imaging was performed at the Cellular and Molecular Imaging Facility at North Carolina State University.
The authors declare no competing interests.
Peer review information Nature Biomedical Engineering thanks Gordana Vunjak-Novakovic and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Hu, S., Li, Z., Shen, D. et al. Exosome-eluting stents for vascular healing after ischaemic injury. Nat Biomed Eng (2021). https://doi.org/10.1038/s41551-021-00705-0