Cardiovascular Research

Cardiovascular Research 1999 41(1):9-13; doi:10.1016/S0008-6363(98)00289-2
© 1999 by European Society of Cardiology

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Copyright © 1999, European Society of Cardiology

Vascular remodelling of resistance vessels: can we define this?

Michael J. Mulvany^*

Department of Pharmacology, University of Aarhus, 8000 Aarhus C, Denmark

^* Tel.: +45-8942-1726; fax: +45-8612-8804; e-mail: mm@farm.aau.dk

Received 3 March 1998; accepted 19 September 1998

	1 Introduction

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 
As pointed out originally by Folkow [1], many of the haemodynamic features associated with essential hypertension can be accounted for by alterations in the structure of the resistance vessels. In vivo haemodynamic experiments (where forearm blood flow was measured with the vasculature fully relaxed under conditions of reactive hyperaemia) showed that the relaxed peripheral resistance in essential hypertensive patients was increased, that the pressor response to maximal concentrations of agonists was increased, but that the threshold concentration of agonists which caused vascular contraction was not altered. From simple physical reasoning, it was suggested that these findings could be accounted for by a slight change in the structure of the resistance vessels, such that there is a decrease in the lumen diameter and an increase in the wall (or media) thickness to lumen diameter ratio [2–5]. It is, however, only recently that it has become possible to quantify resistance vessel structure, and thus to describe the results of the remodelling process with any precision. This development has inevitably brought with it controversy about the terminology which is appropriate for characterizing the remodelling process. In this review, I will briefly summarize a recent scheme which has been proposed to define the forms of remodelling, and the current information concerning the remodelling of resistance vessel structure. I will then discuss the current debate concerning the terminology to be used. The review is restricted to the morphology of individual vessels, and not to possible changes in branching vascularity [6].

	2 Resistance vessel structure

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 
The resistance vessels exert their function through the resistance which they present to the blood flow. The resistance is determined by the lumen diameter (to the fourth power according to the Poiseuille relation), and the lumen diameter is a function of the passive and active mechanical properties of the vessel. The passive properties may be described by the lumen diameter:pressure relation under conditions where the smooth muscle cells are fully relaxed. The active properties are a function of the activation level of the individual smooth muscle cells, and the quantity and arrangement of these. Assuming a given level of activation within the individual smooth muscle cells, and that these produce a given level of force per cross-sectional area, then the pressure against which the vessel can contract will (according to the Laplace relation) be proportional to the wall:lumen ratio (or more correctly the media:lumen ratio on the basis that the force-producing smooth muscle cells lie within the media) [7]. The primary structural features of the vessel are thus the diameter and the wall (or media) thickness, measured under conditions of zero smooth muscle cell activation, and under a given transmural pressure. From knowledge of diameter and wall thickness another key parameter can be determined, namely the wall cross-sectional area; the importance of this parameter is that it indicates the amount of material within the vascular wall, and thus provides information about the biological processes which determine the vascular structure as regards growth and/or regression. Finally, as indicated above the wall:lumen ratio can be calculated, this parameter providing information about the ability of the vessels to contract against an intravascular pressure, the parameter thus having important physiological implications.

	3 Definitions of resistance vessel remodelling

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 
In 1989, Baumbach and Heistad [8]demonstrated that hypertension could be associated with changes in the structure of resistance vessels, such that the vessels had a decreased lumen and increased media:lumen ratio, but no change in media cross-sectional area (or volume). This ability for structure to be altered without change in volume confirmed earlier results by Short [9]concerning resistance vessels in essential hypertension. Baumbach and Heistad [8]described this ability of resistance vessels to change their structure without changing their volume just as ‘remodelling'. Thus for a number of years after this, the term ‘vascular remodelling’ was used alone to describe a change in lumen associated with rearrangement of material. However, this term clashed with the way in which cardiologists, and indeed vascular biologists, used the term to describe any change in the structure of the cardiovascular system. Therefore, together with Baumbach and Heistad, a number of workers in the field (including the present author) made the new suggestion shown in Fig. 1 for describing ‘remodelling’ more precisely [10].

View larger version (13K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 1 The figure shows the manner in which remodelling can modify the cross-sections of blood vessels. The starting point is the vessel at the centre (shaded). Remodelling can be hypertrophic (e.g. increase of cross-sectional area, vessels in right column), eutrophic (no change in cross-sectional area, vessels in centre column), or hypotrophic (e.g. decrease of cross-sectional area, vessels in left column). These forms of remodelling can be inward (i.e. reduction in lumen diameter, vessels in top row), or outward (i.e increase in lumen diameter, vessels in bottom row).

 
It was proposed that the term remodelling be used in situations where there is a structurally determined change in lumen diameter, and that it be classified into the six changes indicated in Fig. 1. It was suggested that remodelling should be termed inward or outward remodelling, depending on whether the process has resulted in a decrease or increase, respectively, in the diameter. Furthermore, since as discussed below, remodelling can result in either an increase, no change, or a decrease in the amount of material, that there should be a sub-classification into hypertrophic, eutrophic, and hypotrophic remodelling, respectively. It was hoped that by providing a framework for defining the various modes of vascular remodelling that it would be easier to discuss the mechanisms involved.

	4 Remodelling of resistance vessel structure in hypertension

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 
Previous histological studies [11–13]demonstrated increased media:lumen ratios in the resistance vasculature of essential hypertensive patients. These findings were based on immersion-fixed material, and on the assumption that the length of the internal elastic lamina divided by was a measure of the true diameter. Although this assumption is debatable, the findings have been confirmed by in vitro experiments [14–18]. Other early work was that of Short [9]who used perfusion-fixed material to show that indeed the wall:lumen ratio of resistance vessels was increased in hypertensive patients, but that this was not associated with any increase in the cross-sectional area of the media (measured normally to the longitudinal axis). These findings too were confirmed by in vitro experiments which also indicated that the cross-sectional area of the tunica media is unchanged [19]. Thus the available evidence indicates that in essential hypertension the resistance vessels have experienced inward eutrophic remodelling (see Fig. 1, top, centre). Furthermore, the size of the individual smooth muscle cells within the media is also normal [16], while the functional responses of the smooth muscle are little affected [14]. These findings support the concept that the altered haemodynamic characteristics of the resistance vasculature in essential hypertension are due mainly to a rearrangement of otherwise normal cells around a smaller diameter.

The inward eutrophic remodelling seen in essential hypertension is in contrast to other situations, where different modes of remodelling have been noted. Thus in human renal hypertension, the reduction in resistance vessel lumen diameter is accompanied by an increase in media cross-sectional area, an inward hypertrophic response [20](see Fig. 1, top, right). In kidney afferent arterioles of the spontaneously hypertensive rat (SHR), the narrowing of the lumen diameter is accompanied by a decrease in media cross-sectional area, an inward hypotrophic response [21](see Fig. 1, top, left). Inward hypotrophic remodelling is also seen in rat mesenteric small arteries with reduction in flow [22]. Outward remodelling of resistance vessel structure is in general seen during antihypertensive treatment, and in situations with increased flow. Thus with ACE-inhibitor treatment, the abnormalities indicated in Fig. 1, top, left and centre are reversed [18, 23]: outward hypertrophic and eutrophic remodelling, respectively (Fig. 1, bottom, centre and right). Information about reversal of inward hypertrophic remodelling in man is not available, but outward hypotrophic remodelling (Fig. 1, bottom left), has been seen with ACE-inhibitor treatment of SHR [24]. The vascular changes seen with increased flow are characterized as outward hypertrophic remodelling [22].

Thus, all the forms of remodelling denoted in Fig. 1 have been demonstrated. It should be noted that the changes within Fig. 1 are not necessarily restricted to those involving the control situation, and it is possible for example that the vessel could first experience inward ‘hypertrophic remodelling’ (Fig. 1, left upper), which could then move to ‘inward eutrophic remodelling’ (Fig. 1, centre upper).

It should be noted that the mode of remodelling in the resistance vessels of hypertensive individuals differs from that seen in large arteries. This is likely because the functional requirements of large arteries do not include a narrowing of the lumen, their function being primarily to transport blood, the flow-rate being unchanged in hypertension. Thus, an increase in media:lumen ratio of a large artery will – with a normal lumen – necessarily involve an increase in the amount of material [25].

	5 How should remodelling be defined?

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 
Given that the term ‘vascular remodelling’ has been used rather indiscriminantly to describe any form of change, it was hoped [10], first, that the scheme would allow more precision, and second, that it would allow better discussion of the mechanisms involved. The suggestion has not, however, met with universal acceptance, as indicated by several authors [26–28]. Although these authors have in general welcomed the idea of trying to classify the term ‘remodelling', they have criticisms of the way in which this has been done.

First, it was argued [27]that processes likely involved in remodelling processes could be active, yet give zero change in morphology (e.g. a combination of apoptosis and proliferation). The suggested scheme (Fig. 1) was, however, that remodelling should be used only for situations where there are morphologically observed, structurally determined, changes in lumen diameter, irrespective of why these occur. Thus if no net change in morphology occurs, this is not defined as remodelling.

Second, it was thought to be debatable whether the term ‘remodelling’ is appropriate for normal development [27]. It was not, however, our intention to limit the definition, and we suggested that any change which resulted in a change in diameter should be included, for how can one in practice distinguish between developmental and other changes? Thus, changes in vascular morphology occurring during normal development would, according to Fig. 1, be termed remodelling.

Another criticism [27]was that measurement of remodelling requires a standard method of determining remodelling, but that this is not available. Obviously, given the elastic nature of blood vessels, vascular morphology can be measured in many ways. Thus, it is important that if vessels from different situations are to be compared, then the measurements should be made under well-defined conditions; for example, we have suggested that the standard conditions should be when vessels are relaxed and subjected to a transmural pressure of 100 mmHg [29, 30]. Other workers have favoured other conditions, and agreement about the precise protocols to be used is unlikely. Nevertheless, despite the disagreement, the concept that structural changes can occur with hypertrophy or hypotrophy, or by a rearrangement of material (eutrophy) is, I suggest, still valid.

Another point which was raised [26]was that when the term ‘remodelling’ is used for describing differences between the normotensive and hypertensive vasculature, it implies that the structure changes from the one to the other, whereas of course (as we pointed out [10]), what we are actually seeing in most cases is a difference in development, from a situation which may or may not have been the same (Fig. 2). For example, there is substantial evidence that, even in young SHR when they are still normotensive, their resistance vessels differ from those of normotensive controls [31]. Thus the term ‘remodelling’ in hypertension should be viewed as a short-hand for saying that there have been differences in the remodelling processes in hyper- and normotensives. It would be advantageous if there were more investigations into the manner in which the vasculature develops in hypertensive and normotensive individuals.

View larger version (11K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 2 Possible development (remodelling) of vessel cross-sections in hypertensive and normotensive individuals. The difference in the vascular structure in the later stages (right), here smaller lumen but similar wall cross-sectional area, is due to differences in the remodelling which has occurred over time, from a situation which may or may not have been identical (left).

 
A crucial point raised by Folkow [28]was that the terminology does not provide any information about the functionally important media:lumen ratio. Clearly, lumen, media cross-section and media:lumen ratio are all relevant. In this respect, Prof. J.G.R. DeMey (University of Maastricht) has, however, made a valuable point to me, which I have used in a modification of the original schematic. Prof. DeMey pointed out that the diagram contains a diagonal axis, from top left to bottom right, along which changes occur without changes in media:lumen ratio (Fig. 3). Upward and to the right of this axis, the media:lumen ratio increases. Below and to the left of the axis, the media:lumen ratio decreases. Therefore when considering the schematic, it may be worth including this axis.

View larger version (58K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 3 Modification of Fig. 1 suggested by Prof. J.G.R. DeMey, University of Maastricht. The diagram shows a diagonal axis from top left to bottom right, along which the media:lumen ratio of vessels does not change. Upward and to the right of this axis, the media:lumen ratio increases. Below and to the left of the axis, the media:lumen ratio decreases. By including this axis, all three important parameters of vascular morphology (lumen, media cross-sectional area, and media:lumen ratio) can be depicted.

 
A final concern seems to be the term ‘remodelling’ itself, since this could be taken to imply that the differences are adaptive, and not primary causes of the hypertension. Although it was not the intention of our definition to take sides as regards this old chestnut, the concern is appreciated, and it is perhaps correct that while the authors of the original letter [10]) place more emphasis on the vascular changes in hypertension being adaptive, the critics place more emphasis on the possible primary role of vascular structure in the pathogenesis of hypertension. That, however, is another story.

	6 Measurement of remodelling

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 
The above considerations of how remodelling of resistance vessels should be defined presupposes that accurate measurements of their dimensions can in fact be made. Currently many measurements are made using myographs, either with vessels mounted on wires as ring preparations [29], or with vessels cannulated and under pressure [32]. Commonly, in both cases, they are examined at extensions corresponding to 100 mmHg intravascular pressure, and with the vessels relaxed. Such in vitro measurements have the advantage over histological measurements that fixation artifacts are avoided. On the other hand, in the wire-myographs, vessels are examined with zero longitudinal force, so that retraction artifacts are introduced [33]. With the pressure-myograph, the precision of measurement of media thickness is not optimal. Nevertheless, comparisons of vessels from normotensive and hypertensive individuals provide qualitatively similar results with both techniques [33, 34], and the findings can be reproduced in different laboratories [14–18]. For a given patient group, the inter-individual coefficient of variance (SD/mean) is approximately 20% for lumen diameter, and 35% for media cross-sectional area (see e.g. Ref. [18]). Accurate comparisons therefore require large numbers of subjects; development of techniques which will allow non-invasive measurement of larger amounts of material are needed.

	7 Conclusion

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 
In conclusion, it is my hope (like that of my co-authors [10]) that the schematic shown in Fig. 1 can provide a basis for describing the results of vascular remodelling. It is hoped that it can also form the basis for fruitful further discussion about the mechanisms involved in the vascular remodelling processes.

Time for primary review 31 days.

	Acknowledgements

 
The author is supported by the Danish Medical Research Council and the Danish Heart Foundation.

	References

Top 1 Introduction 2 Resistance vessel structure 3 Definitions of resistance... 4 Remodelling of resistance... 5 How should remodelling... 6 Measurement of remodelling 7 Conclusion References

 

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