Download PDF
J Reconstr Microsurg 2008; 24(5): 361-367
DOI: 10.1055/s-2008-1080540
© Thieme Medical Publishers

Activated Protein C: An Emerging Therapeutic Agent in the Prevention of Ischemia-Reperfusion Injury

Michael Bezuhly1 , Robert Liwski2 , Kenneth A. West3 , Steven F. Morris1
  • 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Dalhousie University, Halifax, Canada
  • 2Department of Pathology, Dalhousie University, Halifax, Canada
  • 3Department of Medicine, Dalhousie University, Halifax, Canada
Further Information

Publication History

Publication Date:
02 July 2008 (online)

    Permissions and Reprints

ABSTRACT

Free flap necrosis continues to be a significant problem in microvascular surgery. Despite improved microsurgical techniques and equipment, flap loss remains the major operative complication. Although ischemia-induced reperfusion injury remains a significant etiologic factor in flap loss, there is continued interest in endothelial mechanisms that regulate microvascular injury and thrombosis. In recent years, activated protein C (APC) has emerged as a promising therapy in counteracting microcirculatory injury. APC is an anticoagulant that is also involved in signaling pathways that modulate inflammation, apoptosis, and vascular permeability. This article presents the mechanism of action of APC and the benefits of this therapeutic agent, including a possible role in the prevention of free flap ischemia-reperfusion injury.

KEYWORDS

Activated protein C - reperfusion injury - flap failure

REFERENCES

  • 1 Morris S F, Pang C Y, Zheng A, Boyd B, Forrest C R. Assessment of ischemia-induced reperfusion injury in the pig latissimus dorsi myocutaneous flap model.  Plast Reconstr Surg. 1993;  92 1162-1172
    CrossrefPubMedGoogle Scholar
  • 2 Siemionow M, Arslan E. Ischemia/reperfusion injury: a review in relation to free tissue transfers.  Microsurgery. 2004;  24 468-475
    CrossrefPubMedGoogle Scholar
  • 3 Grace P A. Ischaemia-reperfusion injury.  Br J Surg. 1994;  81 637-647
    CrossrefPubMedGoogle Scholar
  • 4 Zimmerman B J, Granger D N. Mechanisms of reperfusion injury.  Am J Med Sci. 1994;  307 284-292
    CrossrefPubMedGoogle Scholar
  • 5 Goswami S K, Maulik N, Das D K. Ischemia-reperfusion and cardioprotection: a delicate balance between reactive oxygen species generation and redox homeostasis.  Ann Med. 2007;  39 275-289
    CrossrefPubMedGoogle Scholar
  • 6 Huang L, Privalle C T, Serafin D, Klitzman B. Increased survival of skin flaps by scavengers of superoxide radicals.  FASEB J. 1987;  1 129-132
    PubMedGoogle Scholar
  • 7 Kim Y S, Im M J, Hoopes J E. The effect of a free-radical scavenger, N-2-mercaptopropionylglycine, on the survival of skin flaps.  Ann Plast Surg. 1990;  25 18-20
    CrossrefPubMedGoogle Scholar
  • 8 De Greef K E, Ysebaert D K, Ghielli M et al.. Neutrophils and acute ischemia-reperfusion injury.  J Nephrol. 1998;  11 110-122
    PubMedGoogle Scholar
  • 9 Hossain M A, Wakabayashi H, Izuishi K et al.. The role of prostaglandins in liver ischemia-reperfusion injury.  Curr Pharm Des. 2006;  12 2935-2951
    CrossrefPubMedGoogle Scholar
  • 10 Oredsson S, Plate G, Qvarfordt P. Experimental evaluation of oxygen radical scavengers in the prevention of reperfusion injury in skeletal muscle.  Eur J Surg. 1994;  160 97-103
    PubMedGoogle Scholar
  • 11 Ogawa S, Gerlach H, Esposito C, Pasagian-Macaulay A, Brett J, Stern D. Hypoxia modulates the barrier and coagulant function of cultured bovine endothelium: increased monolayer permeability and induction of procoagulant properties.  J Clin Invest. 1990;  85 1090-1098
    CrossrefPubMedGoogle Scholar
  • 12 Davies M G, Hagen P O. The vascular endothelium. A new horizon.  Ann Surg. 1993;  218 593-609
    CrossrefPubMedGoogle Scholar
  • 13 Rubanyi G M, Polokoff M A. Endothelins: molecular biology, biochemistry, pharmacology, physiology, and pathophysiology.  Pharmacol Rev. 1994;  46 325-415
    PubMedGoogle Scholar
  • 14 Barnes P J. Nuclear factor-κB.  Int J Biochem Cell Biol. 1997;  29 867-870
    CrossrefPubMedGoogle Scholar
  • 15 Toledo-Pereyra L H, Toledo A H, Walsh K, Lopez-Neblina F. Molecular signaling pathways in ischemia/reperfusion.  Exp Clin Transplant. 2004;  2 174-177
    PubMedGoogle Scholar
  • 16 Barillari G, Albonici L, Incerpi S et al.. Inflammatory cytokines stimulate vascular smooth muscle cells locomotion and growth by enhancing α5β1 integrin expression and function.  Atherosclerosis. 2001;  154 377-385
    CrossrefPubMedGoogle Scholar
  • 17 Frangogiannis N G. Chemokines in ischemia and reperfusion.  Thromb Haemost. 2007;  97 738-747
    PubMedGoogle Scholar
  • 18 Ambrosio G, Tritto I. Reperfusion injury: experimental evidence and clinical implications.  Am Heart J. 1999;  138 S69-75
    CrossrefPubMedGoogle Scholar
  • 19 Nishijima K, Kiryu J, Tsujikawa A et al.. In vivo evaluation of platelet-endothelial interactions after transient retinal ischemia.  Invest Ophthalmol Vis Sci. 2001;  42 2102-2109
    PubMedGoogle Scholar
  • 20 Okada Y, Marchevesky A, Zuo X et al.. Accumulation of platelets in rat syngeneic lung transplants.  Transplantation. 1997;  64 801-806
    CrossrefPubMedGoogle Scholar
  • 21 Roberts A M, Ovechkin A V, Mowbray J G, Robinson T W, Lominadze D. Effects of pulmonary ischemia-reperfusion on platelet adhesion in subpleural arterioles in rabbits.  Microvasc Res. 2004;  67 29-37
    CrossrefPubMedGoogle Scholar
  • 22 Piccardoni P, Evangelista V, Piccoli A, de Gaetano G, Walz A, Cerletti C. Thrombin activated human platelets release two NAP 2 variants that stimulate polymorphonuclear leukocytes.  Thromb Haemost. 1996;  76 780-785
    PubMedGoogle Scholar
  • 23 Carvalho-Tavares J, Hickey M J, Hutchison J, Michaud J, Sutcliffe I T, Kubes P. A role for platelets and endothelial selectins in tumor necrosis factor-alpha-induced leukocyte recruitment in the brain microvasculature.  Circ Res. 2000;  87 1141-1148
    CrossrefPubMedGoogle Scholar
  • 24 Faint R W. Platelet-neutrophil interactions: their significance.  Blood Rev. 1992;  6 83-91
    CrossrefPubMedGoogle Scholar
  • 25 Frenette P S, Moyna C, Hartwell D W, Lowe J B, Hynes R O, Wagner D D. Platelet-endothelial interactions in inflamed mesentric venules.  Blood. 1998;  91 1318-1324
    PubMedGoogle Scholar
  • 26 Ruf A, Patscheke H. Platelet-induced neutrophil activation: platelet-expressed fibrinogen induces the oxidative burst in neutrophils by an interaction with CD11C/CD18.  Br J Haematol. 1995;  90 791-796
    CrossrefPubMedGoogle Scholar
  • 27 Carden D L, Granger D N. Pathophysiology of ischaemia-reperfusion injury.  J Pathol. 2000;  190 255-266
    CrossrefPubMedGoogle Scholar
  • 28 Cooper D, Chitman K D, Williams M C, Granger D N. Time-dependent platelet-vessel wall interactions induced by intestinal ischemia-reperfusion.  Am J Physiol Gastrointest Liver Physiol. 2003;  284 G1027-G1033
    CrossrefPubMedGoogle Scholar
  • 29 Minamino T, Kitakaze M, Sanada S et al.. Increased expression of P-selectin on platelets is a risk factor for silent cerebral infarction in patients with atrial fibrillation: role of nitric oxide.  Circulation. 1998;  98 1721-1727
    CrossrefPubMedGoogle Scholar
  • 30 Blann A D, Nadar S K, Lip G Y. The adhesion molecule P-selectin and cardiovascular disease.  Eur Heart J. 2003;  24 2166-2179
    CrossrefPubMedGoogle Scholar
  • 31 Dardik R, Shenkman B, Tamarin I. Factor XIII mediates adhesion of platelets to endothelial cells through alpha(v) beta(3) and glycoprotein IIb/IIIa integrins.  Thromb Res. 2002;  105 317-323
    CrossrefPubMedGoogle Scholar
  • 32 Petruzzelli L, Takami M, Humes H. Structure and function of cell adhesion molecules.  Am J Med. 1999;  106 467-476
    CrossrefPubMedGoogle Scholar
  • 33 Schurmann G. Cell adhesion: molecular principles and initial implications for surgery.  Chirurg. 1997;  68 477-487
    CrossrefPubMedGoogle Scholar
  • 34 Jung U, Ley K. Regulation of E-selectin, P-selectin, and intercellular adhesion molecule 1 expression in mouse cremaster muscle vasculature.  Microcirculation. 1997;  4 311-319
    CrossrefPubMedGoogle Scholar
  • 35 Khandoga A, Biberthaler P, Enders G et al.. Platelet adhesion mediated by fibrinogen-intercellular adhesion molecule-1 binding induces tissue injury in the postischemic liver in vivo.  Transplantation. 2002;  74 681-688
    CrossrefPubMedGoogle Scholar
  • 36 Love S, Barber R. Expression of P-selectin and intracellular adhesion molecule-1 in human brain after focal infarction or cardiac arrest.  Neuropathol Appl Neurobiol. 2001;  27 465-473
    CrossrefPubMedGoogle Scholar
  • 37 Perrot M, Liu M, Waddell T, Keshavjee S. Ischemia-reperfusion-induced lung injury.  Am J Respir Crit Care Med. 2003;  167 490-511
    CrossrefPubMedGoogle Scholar
  • 38 Haug C E, Colvin R B, Delmonico F L et al.. A phase I trial of immunosuppression with anti-ICAM-1 (CD54) MAb in renal allograft recipients.  Transplantation. 1993;  55 766-772
    CrossrefPubMedGoogle Scholar
  • 39 Merchant S H, Gurule D M, Larson R S. Amelioration of ischemia-reperfusion injury with cyclic peptide blockade of ICAM-1.  Am J Physiol Heart Circ Physiol. 2003;  284 H1260-H1268
    CrossrefPubMedGoogle Scholar
  • 40 Demirseren M E, Sarici M, Gokrem S, Yenidunya S. Protective effects of monoclonal antibody to intercellular adhesion molecule-1 in venous ischemia-reperfusion injury: experimental study in rats.  J Reconstr Microsurg. 2007;  23 41-44
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Harris N R, Granger N D. Ischemia/reperfusion injury. In: Toledo-Pereyra LH Organ Procurements and Preservation for Transplantation, 2nd ed. Heidelberg; Springer-Verlag 1997: 67-81
    Google Scholar
  • 42 Carden D L, Smith J K, Korthuis R J. Neutrophil-mediated microvascular dysfunction in postischemic canine skeletal muscle. Role of granulocyte adherence.  Circ Res. 1990;  66 1436-1444
    CrossrefPubMedGoogle Scholar
  • 43 Kerrigan C L, Stotland M A. Ischemia reperfusion injury: a review.  Microsurgery. 1993;  14 165-175
    CrossrefPubMedGoogle Scholar
  • 44 Vinten-Johansen J. Involvement of neutrophils in the pathogenesis of lethal myocardial reperfusion injury.  Cardiovasc Res. 2004;  61 481-497
    CrossrefPubMedGoogle Scholar
  • 45 Stempien-Otero A, Karsan A, Cornejo C J et al.. Mechanisms of hypoxia-induced endothelial cell death. Role of p53 in apoptosis.  J Biol Chem. 1999;  274 8039-8045
    CrossrefPubMedGoogle Scholar
  • 46 Matsushita H, Morishita R, Nata T et al.. Hypoxia-induced endothelial apoptosis through nuclear factor-kappaB (NF-kappaB)-mediated Bcl-2 suppression: in vivo evidence of the importance of NF-kappaB in endothelial cell regulation.  Circ Res. 2000;  86 974-981
    CrossrefPubMedGoogle Scholar
  • 47 Walford G A, Moussignac R L, Scribner A W, Loscalzo J, Leopold J A. Hypoxia potentiates nitric oxide-mediated apoptosis in endothelial cells via peroxynitrite-induced activation of mitochondria-dependent and -independent pathways.  J Biol Chem. 2004;  279 4425-4432
    CrossrefPubMedGoogle Scholar
  • 48 Lopez-Neblina F, Toledo A H, Toledo-Pereyra L H. Molecular biology of apoptosis in ischemia and reperfusion.  J Invest Surg. 2005;  18 335-350
    CrossrefPubMedGoogle Scholar
  • 49 Scarabelli T M, Stephanou A, Pasini E et al.. Different signaling pathways induce apoptosis in endothelial cells and cardiac myocytes during ischemia/reperfusion injury.  Circ Res. 2002;  90 745-748
    CrossrefPubMedGoogle Scholar
  • 50 Kohli V, Selzner M, Madden J F, Bentley R C, Clavien P A. Endothelial cell and hepatocyte deaths occur by apoptosis after ischemia-reperfusion injury in the rat liver.  Transplantation. 1999;  67 1099-1105
    CrossrefPubMedGoogle Scholar
  • 51 Scarabelli T, Stephanou A, Rayment N et al.. Apoptosis of endothelial cells precedes myocyte cell apoptosis in ischemia/reperfusion injury.  Circulation. 2001;  104 253-256
    CrossrefPubMedGoogle Scholar
  • 52 Iwata A, Harlan J M, Vedder N B, Winn R K. The caspase inhibitor z-VAD is more effective than CD18 adhesion blockade in reducing muscle ischemia-reperfusion injury: implication for clinical trials.  Blood. 2002;  100 2077-2080
    CrossrefPubMedGoogle Scholar
  • 53 Griffin J H, Evatt B, Zimmerman T S, Kleiss A J, Wideman C. Deficiency of protein C in congenital thrombotic disease.  J Clin Invest. 1981;  68 1370-1373
    CrossrefPubMedGoogle Scholar
  • 54 Branson H E, Katz J, Marble R, Griffin J H. Inherited protein C deficiency and coumarin-responsive chronic relapsing purpura fulminans in a newborn infant.  Lancet. 1983;  2 1165-1168
    PubMedGoogle Scholar
  • 55 Bernard G R, Vincent J L, Laterre P F et al.. Efficacy and safety of recombinant human activated protein C for severe sepsis.  N Engl J Med. 2001;  344 699-709
    CrossrefPubMedGoogle Scholar
  • 56 Abraham E, Reinhart K, Opal S et al.. Efficacy and safety of tifacogin (recombinant tissue factor pathway inhibitor) in severe sepsis: a randomized controlled trial.  JAMA. 2003;  290 238-247
    Google Scholar
  • 57 Warren B L, Eid A, Singer P et al.. High-dose antithrombin III in severe sepsis: a randomized controlled trial.  JAMA. 2001;  286 1869-1878
    CrossrefPubMedGoogle Scholar
  • 58 Kerschen E J, Fernandez J A, Cooley B C et al.. Endotoxemia and sepsis mortality reduction by non-coagulant activated protein C.  J Exp Med. 2007;  204 2439-2448
    CrossrefPubMedGoogle Scholar
  • 59 Gruber A, Griffin J H. Direct detection of activated protein C in blood from human subjects.  Blood. 1992;  79 2340-2348
    PubMedGoogle Scholar
  • 60 Esmon C. The protein C pathway.  Crit Care Med. 2000;  28(suppl) S44-S48
    CrossrefPubMedGoogle Scholar
  • 61 Stearns-Kurosawa D J, Kurosawa S, Mollica J S, Ferrell G L, Esmon C T. The endothelial cell protein C receptor augments protein C activation by the thrombin-thrombomodulin complex.  Proc Natl Acad Sci U S A. 1996;  93 10212-10216
    CrossrefPubMedGoogle Scholar
  • 62 Bae J S, Yang L, Rezaie A R. Receptors of the protein C activation and activated protein C signaling pathways are colocalized in lipid rafts on endothelial cells.  Proc Natl Acad Sci U S A. 2007;  104 2867-2877
    CrossrefPubMedGoogle Scholar
  • 63 Looney M R, Matthay M A. Bench-to-bedside review: the role of activated protein C in maintaining endothelial tight junction function and its relationship to organ injury.  Crit Care. 2006;  10 239-244
    CrossrefPubMedGoogle Scholar
  • 64 Esmon C T. The protein C pathway.  Chest. 2003;  124 26S-32S
    CrossrefPubMedGoogle Scholar
  • 65 Vu T K, Hung D T, Wheaton V I, Coughlin S R. Molecular cloning of a functional thrombin receptor reveals a novel proteolytic mechanism of receptor activation.  Cell. 1991;  64 1057-1068
    CrossrefPubMedGoogle Scholar
  • 66 Joyce D E, Gelbert L, Ciaccia A, DeHoff B, Grinnell B W. Gene expression profile of antithrombotic protein C defines new mechanisms modulating inflammation and apoptosis.  J Biol Chem. 2001;  276 11199-11203
    CrossrefPubMedGoogle Scholar
  • 67 Domotor E, Benzakour O, Griffin J H et al.. Activated protein C alters cytosolic calcium flux in human brain endothelium via binding to endothelial protein C receptor and activation of protease activated receptor-1.  Blood. 2003;  101 4797-4801
    CrossrefPubMedGoogle Scholar
  • 68 Riewald M, Petrovan R J, Donner A, Mueller B M, Ruf W. Activation of endothelial cell protease activated receptor 1 by the protein C pathway.  Science. 2002;  296 1880-1882
    CrossrefPubMedGoogle Scholar
  • 69 Cheng T, Liu D, Griffin J H et al.. Activated protein C blocks p53-mediated apoptosis in ischemic human brain endothelium and is neuroprotective.  Nat Med. 2003;  9 338-342
    CrossrefPubMedGoogle Scholar
  • 70 Mosnier L O, Griffin J H. Inhibition of staurosporine-induced apoptosis of endothelial cells by activated protein C requires protease activated receptor-1 and endothelial cell protein C receptor.  Biochem J. 2003;  373 65-70
    CrossrefPubMedGoogle Scholar
  • 71 Joyce D E, Grinnell B W. Recombinant human activated protein C attenuates the inflammatory response in endothelium and monocytes by modulating nuclear factor-kappaB.  Crit Care Med. 2002;  30 S288-S293
    CrossrefPubMedGoogle Scholar
  • 72 Franscini N, Bachli E B, Blau N et al.. Gene expression profiling of inflamed human endothelial cells and influence of activated protein C.  Circulation. 2004;  110 2903-2909
    CrossrefPubMedGoogle Scholar
  • 73 Hoffmann J N, Vollmar B, Laschke M W et al.. Microcirculatory alterations in ischemia-reperfusion injury and sepsis: effects of activated protein C and thrombin inhibition.  Crit Care. 2005;  9 S33-S37
    CrossrefPubMedGoogle Scholar
  • 74 Gupta A, Rhodes G J, Berg D T et al.. Activated protein C ameliorates LPS-induced acute kidney injury and downregulates renal INOS and angiotensin 2.  Am J Physiol Renal Physiol. 2007;  293 F245-F254
    CrossrefPubMedGoogle Scholar
  • 75 Bartolome S, Wood J G, Casillan A J, Simpson S Q, O'Brien-Ladner A R. Activated protein C attenuates microvascular injury during systemic hypoxia.  Shock. 2008;  29 384-387
    PubMedGoogle Scholar
  • 76 McVerry B J, Garcia J G. Endothelial cell barrier regulation by sphingosine 1-phosphate.  J Cell Biochem. 2004;  92 1075-1085
    CrossrefPubMedGoogle Scholar
  • 77 Singleton P A, Dudek S M, Chiang E T, Garcia J G. Regulation of sphingosine 1-phosphate-induced endothelial cytoskeletal rearrangement and barrier enhancement by S1P1 receptor, PI3 kinase, Tiam1/Rac1, and alpha-actinin.  FASEB J. 2005;  19 1646-1656
    CrossrefPubMedGoogle Scholar
  • 78 Bae J S, Yang L, Manithody C, Rezaie A R. The ligand occupancy of endothelial protein C receptor switches the PAR-1-dependent signaling specificity of thrombin from a permeability-enhancing to barrier-protective response in endothelial cells.  Blood. 2007;  110 3909-3916
    CrossrefPubMedGoogle Scholar
  • 79 Feistritzer C, Sturn D H, Kaneider N C, Djanani A, Wiedermann C J. Endothelial protein C receptor-dependent inhibition of human eosinophil chemotaxis by protein C.  J Allergy Clin Immunol. 2003;  112 375-381
    CrossrefPubMedGoogle Scholar
  • 80 Galligan L, Livingstone W, Volkov Y et al.. Characterization of protein C receptor expression in monocytes.  Br J Haematol. 2001;  115 408-414
    CrossrefPubMedGoogle Scholar
  • 81 Sturn D H, Kaneider N C, Feistritzer C et al.. Expression and function of the endothelial protein C receptor in human neutrophils.  Blood. 2003;  102 1499-1505
    CrossrefPubMedGoogle Scholar
  • 82 Joyce D E, Nelson D R, Grinnell B W. Leukocyte and endothelial cell interactions in sepsis: relevance of the protein C pathway.  Crit Care Med. 2004;  32 S280-S286
    CrossrefPubMedGoogle Scholar
  • 83 Kurosawa S, Esmon C T, Stearns-Kurosawa D J. The soluble endothelial protein C receptor binds to activated neutrophils: involvement of proteinase-3 and CD11b/CD18.  J Immunol. 2000;  165 4697-4703
    CrossrefPubMedGoogle Scholar
  • 84 Murakami K, Okajima K, Uchiba M et al.. Activated protein C attenuates endotoxin-induced pulmonary vascular injury by inhibiting activated leukocytes in rats.  Blood. 1996;  87 642-647
    PubMedGoogle Scholar
  • 85 Taoka Y, Okajima K, Uchiba M et al.. Activated protein C reduces the severity of compression-induced spinal cord injury in rats by inhibiting activation of leukocytes.  J Neurosci. 1998;  18 1393-1398
    PubMedGoogle Scholar
  • 86 Liu D, Cheng T, Guo H et al.. Tissue plasminogen activator neurovascular toxicity is controlled by activated protein C.  Nat Med. 2004;  10 1379-1383
    CrossrefPubMedGoogle Scholar
  • 87 Yamaguchi Y, Hisama N, Okajima K et al.. Pretreatment with activated protein C or active human urinary thrombomodulin attenuates the production of cytokine-induced neutrophil chemoattractant following ischemia/reperfusion in rat liver.  Hepatology. 1997;  25 1136-1140
    CrossrefPubMedGoogle Scholar
  • 88 Mizutani A, Okajima K, Uchiba M, Noguchi T. Activated protein C reduces ischemia/reperfusion-induced renal injury in rats by inhibiting leukocyte activation.  Blood. 2000;  95 3781-3787
    PubMedGoogle Scholar
  • 89 Schoots I G, Levi M, van Vliet A K, Maas A M, Roossink E H, van Gulik T M. Inhibition of coagulation and inflammation by activated protein C or antithrombin reduces intestinal ischemia/reperfusion injury in rats.  Crit Care Med. 2004;  32 1375-1383
    CrossrefPubMedGoogle Scholar
  • 90 Dillon J P, Laing A J, Cahill R A et al.. Activated protein C attenuates acute ischaemia reperfusion injury in skeletal muscle.  J Orthop Res. 2005;  23 1454-1459
    CrossrefPubMedGoogle Scholar

Steven F MorrisM.D. M.Sc. 

Division of Plastic and Reconstructive Surgery, Department of Surgery, Dalhousie University

Room 4443, Halifax Infirmary, 1796 Summer Street, Halifax, Nova Scotia, Canada B3H 3A7

      >