Acute adenosine treatment is effective in augmentation of ischemic tolerance in muscle flaps in the pig

Adenosine and chronic ischemia of the lower limbs

Adenosine is an endogenous nucleoside with multiple biological properties which plays a central role in the pathophysiology of tissue ischemia. Adenosine signals an imbalance between oxygen demand and supply, and it initiates responses to redress such a discrepancy. Besides its vasodilating properties, adenosine possesses anti-platelet and anti-neutrophil activities and provides cytoprotection. Adenosine is presumably the main mediator of the preconditioning phenomenon. During ischemia of the lower limbs, adenosine plays a physiological role by inducing vasodilatation and by preventing microcirculatory failure. Exercise training prolongs claudication distance possibly by inducing pulse increases of adenosine and consequently skeletal muscle preconditioning. Moreover, the adenosine increase which follows the administration of some drugs, such as buflomedil and propionylcarnitine, opens new perspectives in the management of leg ischemia. In fact, the concept arises of an ischemic (exercise-dependent) or pharmacologic preconditioning in the treatment of patients with claudication.

The Effect of Activated Protein C on Attenuation of Ischemia-Reperfusion Injury in a Rat Muscle Flap Model

Ischemia-reperfusion injury is often the final and irreversible factor causing flap failure in microsurgery. The salvage of a microsurgical flap with an ischemia-reperfusion injury contributes to the success of microsurgical flap transfers. Activated protein C (APC), a serine protease with anticoagulant and anti-inflammatory activities, has been shown to improve ischemic flap survival. To date, APC has yet to be applied to models of free flap with ischemia-reperfusion injury. In this study, we aimed to investigate the effect of APC on gracilis flap ischemia-reperfusion injury induced by gracilis vessels clamping and reopening. Sixty male Sprague-Dawley rats were randomly divided into 2 groups. After 4 hours of clamping for ischemia, flaps were reperfused and recombinant human APC (25 μg/kg) or saline was injected in the flaps through pedicles. At 0, 1, 4, 18, and 24 hours after injection (n = 6 for each time point), the tissue samples were harvested. The muscle viability at 24 hours in saline group was 54.8% (15.1%), whereas the APC-treated group was 90.0% (4.3%) (P < 0.05). The induced nitric oxide synthase (iNOS) mRNA expression increased with the time after reperfusion, which were 0.93 (0.25) to 2.09 (0.22) in saline group, and 0.197 (0.15) to 0.711 (0.15) in the APC-treated group. iNOS mRNA expression in the APC-treated group was significantly higher than the saline group at 1, 18, and 24 hours (P < 0.05). Numerous inflammatory cells were observed infiltrating and invading the muscle fibers in the saline group more than the APC-treated group. Increased number of polymorphonuclear cells was also noted in the saline group compared with the APC-treated group (P < 0.05). In conclusion, APC treatment can significantly attenuate ischemia-reperfusion injury and increase the survival of the free flap through down-regulating iNOS mRNA expression and reducing the inflammatory cells. Further research is still needed to be done on various mechanisms in which APC is protective to prevent tissue damage.

Pharmacologic prophylactic treatment for perioperative protection of skeletal muscle from ischemia-reperfusion injury in reconstructive surgery

BACKGROUND

In autogenous muscle transplantation, unpredictable complications can cause prolonged ischemia, resulting in ischemia-reperfusion injury. The authors investigated the efficacy and mechanism of nicorandil, a nitrovasodilator and adenosine triphosphate-sensitive potassium channel opener, in inducing perioperative protection of muscle flaps from ischemia-reperfusion injury.

METHODS

Pigs (18.2 ± 2.4 kg) were assigned to one control and eight treatment groups. Bilateral latissimus dorsi muscle flaps were raised after saline administration (control) and 0, 4, 8, 12, 24, 48, 72, and 96 hours after nicorandil administration. Subsequently, flaps were subjected to 4 hours of ischemia and 48 hours of reperfusion. Viability was assessed, and biochemical probes were used to study nicorandil-induced infarct protection.

RESULTS

Protection by nicorandil was biphasic. Infarction reduced from 40.2 ± 1.9 percent (control) to 27.3 ± 1.7 percent and 24.0 ± 2.3 percent (p < 0.05) 0 and 4 hours after nicorandil administration, respectively (early phase protection). No difference was seen between control and treatment groups between 8 and 12 hours after nicorandil administration compared with the control. Infarct protection increased again (p < 0.05) at 24 (22.4 ± 2.0 percent), 48 (25.1 ± 2.1 percent), and 72 hours (28.5 ± 2.1 percent) but not at 96 hours (43.9 ± 4.6 percent) compared with control (late phase protection). The sarcolemmal and mitochondrial channels played a central role in the trigger and mediator mechanisms, respectively. Late protection was associated with lower myeloperoxidase activity and mitochondrial calcium overload and higher adenosine triphosphate content (p < 0.05).

CONCLUSIONS

Nicorandil induced 48-hour uninterrupted muscle infarct protection, starting 24 hours after intravenous administration. This category of clinical drug is a potential prophylactic treatment against skeletal muscle ischemia-reperfusion injury in reconstructive surgery.

Intermittent ischaemia of skin flaps shortens time taken to divide pedicles: an experimental study in rats

Ischaemic preconditioning increases the survival of flaps. Random-pattern McFarlane dorsal flaps were raised in 30 female Wistar rats, which were divided into three groups. An ischaemic conditioning protocol with clamping of the pedicle was used. No clamping was used in the control group, and the pedicle was clamped for 15 minutes in the second group and 20 minutes in the third group daily to see if the duration of ischaemia had any effects on the viability of the flaps. The pedicles were divided earlier in the clamped groups than in the control group. The size of necrotic areas of the flaps in the clamped groups was smaller than on the control group. Daily postoperative intermittent ischaemic conditioning in the pedicles of the flaps had a protective effect on their survival and led to earlier division of the pedicles.

Annexin A5 scintigraphy of forearm as a novel in vivo model of skeletal muscle preconditioning in humans

BACKGROUND

Nonlethal ischemia and reperfusion reduce ischemia-reperfusion-induced cell death, a phenomenon called ischemic preconditioning. In animal models, this potent endogenous protection is mimicked in vivo by administration of adenosine. In humans, exploitation of ischemic preconditioning is hindered by the lack of an appropriate in vivo model to study this phenomenon. To solve this problem, we aimed to set up an easy-to-use human in vivo model to study ischemic or pharmacological preconditioning.

METHODS AND RESULTS

Healthy male volunteers performed unilateral ischemic handgrip. At reperfusion, we intravenously injected technetium-99m-labeled Annexin A5, a presumed marker of ischemic injury, and we imaged both forearms and hands simultaneously with a gamma camera. Region of interest analysis (counts per pixel) and subsequent calculation of the percentage difference in radioactivity between experimental and control hands (thenar muscle; mean+/-SE) revealed significant uptake to the ischemically exercised tissue (26+/-3% at 4 hours after reperfusion; P<0.05). This selective localization of Annexin A5 was reduced by ischemic preconditioning (10 minutes of ischemia plus reperfusion before ischemic exercise) or by infusion of adenosine into the brachial artery to 6+/-1% and 10+/-3%, respectively (P<0.05 versus ischemic exercise alone), resembling observations in animal models with infarct size as an end point. Appropriate control experiments supported our conclusion.

CONCLUSIONS

Annexin A5 scintigraphy can be applied to test pharmacological or physiological interventions for their ability to prevent ischemia-reperfusion injury.

Comparison of ischemic and chemical preconditioning in jejunal flaps in the rat

Jejunum is one of the most frequently used free flaps in esophagus reconstruction. However, the sensitivity of intestinal tissue to ischemia decreases the margin of safety of this donor site while increasing the risk of postoperative complications such as fistula formation and stenosis. Ischemic preconditioning can increase the tolerance of jejunal tissue to ischemia. In this study, the authors investigated the effects of chemical preconditioning with adenosine infusion on ischemia reperfusion injury in the rat jejunum, and evaluated the presence of any additive effects of adenosine administration when used together with ischemic preconditioning. Forty Sprague-Dawley rats weighting 200 to 250 mg were used in the study. Rats were randomly divided into five groups. In group I (sham-operated controls), only laparotomy was performed. In group II (ischemia-reperfusion injury), the superior mesenteric artery was clamped for 40 minutes to induce ischemia in the small bowel, followed by 60 minutes of reperfusion. In group III (ischemic preconditioning), two cycles of 5-minute ischemia and 5-minute reperfusion were performed before implementation of the ischemia-reperfusion protocol used in group II. In group IV (chemical preconditioning), adenosine (1000 microg/kg) was infused into the internal jugular vein before the group II ischemia-reperfusion schedule was implemented. In group V (adenosine-enhanced ischemic preconditioning), adenosine (1000 microg/kg) was infused into the internal jugular vein before ischemic preconditioning, followed by 40 minutes of ischemia and 60 minutes of reperfusion. At the end of the reperfusion period, samples from the jejunum were harvested and myeloperoxidase activity was determined as a measure of leukocyte accumulation. Malondialdehyde levels were measured to assess lipid peroxidation. Histopathologic sections stained with hematoxylin-eosin were evaluated for the presence of mucosal damage according to the Chiu scoring method. Immunohistochemical staining by M30 monoclonal antibodies was performed to quantify the number of ischemia-induced apoptotic cells in the intestinal mucosa. The myeloperoxidase and malondialdehyde levels were significantly lower in groups I, III, IV, and V when compared with group II. Although there were no significant differences among myeloperoxidase and malondialdehyde levels in groups III, IV, and V, group I had significantly lower levels of activity compared with the other three groups. Histological scoring reflected significantly less damage in groups I, III, IV, and V compared with group II. Similarly, the number of apoptotic cells was significantly lower in groups I, III, IV, and V when compared with group II. However, no difference was detected among these four groups with regard to either histopathological scoring or apoptosis numbers. This is the first study showing that adenosine administration is as effective as ischemic preconditioning in inducing ischemic tolerance in the rat jejunum. However, there was no enhancement of ischemic preconditioning with prior adenosine infusion.

Limitations of ischemic tolerance in oxidative skeletal muscle: perfusion vs tissue protection

OBJECTIVES

This study determined if ischemic tolerance occurs in oxidative skeletal muscle following a severe ischemia/reperfusion (I/R) insult and if such protection involves the induction of nitric oxide synthase (NOS).

METHODS

The soleus muscle of male Wistar rats (250-350 g) was preconditioned (PC + I/R) using five cycles of ischemia (10 min) and reperfusion (10 min) or had no PC (I/R) and 24 h later 2 h no-flow ischemia was induced. Calcium dependent (cNOS) and independent (iNOS) NOS activities were determined from PC (n = 5), or sham (n = 5) and the role of iNOS was tested by application of aminoguanidine (AMG) (100 microM; n = 4) to the muscle bath. Direct measures of the number of perfused capillaries (Npc; #/mm) during 90-min reperfusion were obtained using intravital microscopy. Tissue injury was estimated using the fluorescent vital dyes ethidium bromide (E; labels injured cells) and bisbenzimide (B; labels all cells) and expressed as the ratio E/B.

RESULTS

PC prevented microvascular flow deficits (Npc:I/R = 23.4 +/- 1.3 vs PC + I/R = 29.9 +/- 1.1) and resulted in a modest, but significant reduction (21%) in tissue injury (I/R = 0.82 +/- 0.03 vs PC + I/R = 0.64 +/- 0.04). PC led to a nine fold increase in iNOS activity, but decreased cNOS activity by 94% compared to sham. AMG prevented the parenchymal protection following PC, but had no effect on microvascular perfusion.

CONCLUSIONS

Ischemic tolerance, 24 h following PC, preserved microvascular perfusion, but only modestly improved tissue viability in the soleus muscle.

Repeated ischaemic isometric exercise increases muscle fibre conduction velocity in humans: involvement of Na(+)-K(+)-ATPase

This study was performed to test two hypotheses: (1) ischaemic preconditioning (development of tolerance to ischaemia) influences muscle fibre conduction velocity (MFCV) during repeated ischaemic isometric exercise and (2) the increase in MFCV to supranormal levels during recovery from ischaemic exercise is caused by activation of Na(+)-K(+)-ATPase. For this purpose, MFCV was measured with surface electromyography (sEMG) during repeated ischaemic isometric exercise of the brachioradial muscle (2 min at 30 % of maximal voluntary contraction). The involvement of ischaemic preconditioning was tested by changing the duration of ischaemia and by intra-arterial infusion of adenosine (brachial artery, 50 microg min(-1) dl(-1)). The role of Na(+)-K(+)-ATPase was explored using ouabain (0.2 microg min(-1) dl(-1)). During the exercise, MFCV decreased from 4.4 +/- 0.2 m s(-1) to 3.7 +/- 0.2 m s(-1) (P < 0.01, n = 13). Similar reductions in MFCV were observed during repeated exercise, irrespective of the reperfusion time (10 min vs. 18 min) or duration of the ischaemia (2 vs. 10 min). However, initial MFCV gradually increased for each subsequent contraction when contractions were repeated at 10 min intervals (4.4 +/- 0.2 m s(-1) vs. 4.9 +/- 0.2 m s(-1) for the first and fourth contraction respectively; P < 0.01; n = 13). This increase was not observed when contractions were performed at 18 min intervals, nor when additional ischaemia was applied. Intra-arterial adenosine did not affect MFCV. Intra-arterial ouabain did not affect the reduction in MFCV during exercise but completely prevented the increase in MFCV during recovery: from 4.7 +/- 0.2 m s(-1) to 5.2 +/- 0.2 m s(-1) vs. 4.5 +/- 0.1 m s(-1) to 4.5 +/- 0.1 m s(-1) in the absence and presence of ouabain respectively (P < 0.05 for ouabain effect; n = 6). In conclusion, ischaemic preconditioning is not involved in changes in MFCV during repeated ischaemic isometric exercise. The increase in MFCV during recovery from repeated ischaemic isometric exercise is caused by rapid activation of Na(+)-K(+)-ATPase.

Effects of adenosine pretreatment on detection of free radicals in ischemic and reperfused canine gracilis muscle flaps by use of spin-trapping electron paramagnetic resonance spectroscopy

OBJECTIVE

To determine whether adenosine pretreatment attenuates free radical production and muscle damage in ischemic and reperfused canine skeletal muscle.

ANIMALS

9 healthy mixed-breed dogs.

PROCEDURE

Dogs were anesthetized, and both gracilis muscles were isolated, leaving only the major vascular pedicle intact. Saline (0.9% NaCl) solution was injected into the artery supplying the control flap, whereas adenosine (10 mg) was injected into the contralateral artery. Ischemia was induced in both flaps for 4 hours. alpha-Phenyl-N-tert-butylnitrone was administered IV to each dog 1 hour prior to reperfusion. Following 15 minutes of reperfusion, effluent blood samples from each muscle flap were obtained and processed for spin-trapping electron paramagnetic resonance (EPR) spectroscopy. Muscle biopsy specimens were obtained for histologic evaluation, and dogs were euthanatized.

RESULTS

EPR spectra of strong intensity were obtained from analysis of 5 of 9 paired samples. Signals identified were characteristic of oxygen- and carbon-centered free radical adducts. Signal intensity of spectra from adenosine-treated flaps was significantly less than that of control flaps; mean signal attenuation was 36% in the adenosine-treated group. Histologic evaluation of muscle flaps did not reveal significant differences between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment of canine muscle flaps with adenosine prior to a period of ischemia reduced but did not completely attenuate free radical production after reperfusion. However, adenosine pretreatment did not affect histologic abnormalities.

Adenosine Treatment Augments Random Flap Survival in Rats

Adenosine and purine nucleosides are intermediates in the pathway of purine nucleotide degradation. Adenosine causes vasodilation in all arterioles, except those in the kidney, and is the major regulator of coronary blood flow. The objective of the present study was to investigate the efficacy and role of 9-beta-D-ribofuranosyl adenosine (RFA), a derivative of adenosine, for the augmentation of random flap survival in rats. Varying doses of adenosine and a nonselective adenosine antagonist, 8-phenyltheophylline, were administered before elevation of 3x10 cm dorsal random flaps in 60 rats. The rats were randomly assigned to five groups and received the following treatment: group I (controls) was treated with placebo (saline, 1 mL/day); group II was treated with RFA 25 μg/kg/day; group III was treated with RFA 50 μg/kg/day; group IV was treated with RFA 100 μg/kg/day; and group V was treated with 8-phenyltheophylline (10 mg/kg/day). All daily injections were given intravenously for seven days. Flap survival was assessed on day 8. Therapeutic and higher doses of adenosine-treated flaps showed a significant increase in viability compared with saline-treated flaps in the control group, while there was no improvement in flap survival with low dose adenosine. Phenyltheophylline reversed the beneficial effect of adenosine and increased flap necrosis, which was comparable with that of the controls. The findings show that adenosine can enhance flap survival, and this beneficial effect is possibly due to vasodilation, inhibition of noradrenalin release, reduction of energy consumption, inhibition of reactive oxygen species and a preconditioning effect; however, this effect seems to be dose-related. Adenosine is an easily available drug for clinical use in ischemic heart diseases and should be considered in potentially ischemic flaps.

Inosine attenuates tourniquet-induced skeletal muscle reperfusion injury

BACKGROUND

Adenosine attenuates skeletal muscle reperfusion injury, but its short half-life in vivo limits potential therapeutic benefits. The aim of this study was to ascertain whether inosine, a stable adenosine metabolite, modulates skeletal muscle reperfusion injury.

MATERIALS AND METHODS

C57BL/6 mice were randomized (8-10 per group) to six groups: time controls; inosine (100 mg/kg) before anesthesia; 2 h of bilateral tourniquet hindlimb ischemia; I/R (2 h of bilateral tourniquet hindlimb ischemia, 3 h of reperfusion); inosine (100 mg/kg) before I/R; drug vehicle before I/R. Serum tumor necrosis factor (TNF)-alpha and macrophage inflammatory protein (MIP)-2 were measured before ischemia and at the end of reperfusion. Tissue edema was determined by wet/dry weight ratios. Tissue leucosequestration was assessed by the myeloperoxidase (MPO) content.

RESULTS

At the end of reperfusion, inosine pretreatment resulted in lower MPO levels in muscle (P = 0.02) and lung (P = 0.0002) than saline pretreatment. Similarly, muscle (P = 0.04) and lung (P = 0.02) wet/dry ratios were significantly reduced with inosine but not with saline pretreatment. At the end of reperfusion, serum proinflammatory cytokine levels (TNF-alpha and MIP-2) were significantly reduced (P < 0.05) compared to preischemia levels following inosine pretreatment but not saline pretreatment. Ischemia alone did not alter any of the parameters assessed.

CONCLUSIONS

These findings demonstrate that pretreatment with inosine attenuates the local and systemic proinflammatory responses associated with skeletal muscle reperfusion injury.

Preconditioning of the distal portion of a rat random-pattern skin flap

It has been shown that preconditioning either by proximal pedicle clamping or by pedicle intravascular drug administration, for example with adenosine, can improve flap survival. These methods, however, are not well suited to random-pattern flap transfer in the clinical setting. The aim of this study was to evaluate clinically applicable preconditioning methods for random-pattern flaps. Eighteen male Sprague-Dawley rats were used. Bipedicled dorsal skin flaps (2 x 8cm) containing panniculus carnosus were elevated. In the ischaemic preconditioning group the cranial pedicle was clamped for 20min, followed by 40min reperfusion before the cranial pedicle was cut, producing a caudally based random-pattern flap. In the pharmacologic preconditioning group adenosine was locally injected in the cranial half of the flap before the cranial pedicle was cut. In the control group saline was locally injected instead of adenosine and the pedicle was cut in the same manner. Flap survival area was evaluated at day 7. Flap survival area in both preconditioning groups was significantly higher than in the control group (P<0.05). Both preconditioning methods can improve random-pattern flap survival in rats. These methods may prove useful in the clinical setting.

ATP-Sensitive potassium channels: a review of their cardioprotective pharmacology

ATP-sensitive potassium channels (K(ATP)) have been thought to be a mediator of cardioprotection for the last ten years. Significant progress has been made in learning the pharmacology of this channel as well as its molecular regulation with regard to cardioprotection. K(ATP)openers as a class protect ischemic/reperfused myocardium and appear to do so by conservation of energy. The reduced rate of ATP hydrolysis during ischemia exerted by these openers is not due to a cardioplegic effect and is independent of action potential shortening. Compounds have been synthesized which retain the cardioprotective effects of first generation K(ATP)openers, but are devoid of vasodilator and cardiac sarcolemmal potassium outward currents. These results suggest receptor or channel subtypes. Recent pharmacologic and molecular biology studies suggest the activation of mitochondrial K(ATP)as the relevant cardioprotective site. Implications of these results for future drug discovery and preconditioning are discussed.

Protective effect of preconditioning and adenosine pretreatment in experimental skeletal muscle reperfusion injury

BACKGROUND

Prolonged ischaemia followed by reperfusion (I/R) of skeletal muscle results in significant tissue injury. Ischaemic preconditioning (IPC), achieved by repeated brief periods of I/R before prolonged ischaemia or adenosine pretreatment, can prevent I/R injury in cardiac muscle. The aim of this study was to ascertain in a rodent model if damage to skeletal muscle due to global hindlimb tourniquet-induced I/R could be similarly attenuated.

METHODS

Anaesthetized rats were randomized (n = 6-10 per group) to five groups: sham-operated controls; I/R (4 h of ischaemia, 2 h of reperfusion); IPC (three cycles of 10 min of ischaemia/10 min of reperfusion) alone; IPC immediately preceding I/R; or adenosine 1000 microg/kg immediately before I/R. At the end of reperfusion, biopsies were taken from the left gastrocnemius muscle for measurement of myeloperoxidase (MPO) and reduced glutathione (GSH). Before ischaemia and at the end of reperfusion, blood samples were taken for measurement of nitric oxide metabolites, tumour necrosis factor (TNF) alpha and macrophage inflammatory protein (MIP) 2.

RESULTS

IPC before I/R resulted in lower levels of MPO (P < 0.001) and TNF-alpha (P = 0.004), and higher levels of GSH (P < 0.001) and nitric oxide metabolites (P = 0.002) than I/R alone. Adenosine had effects comparable to IPC pretreatment (P < 0.001 for MPO, P = 0.002 for GSH, P = 0.02 for nitric oxide metabolites and P = 0.001 for TNF-alpha). There was no difference in the blood pressure or the MIP-2 concentration among the groups.

CONCLUSION

IPC or pretreatment with adenosine ameliorates the I/R injury of skeletal muscle.