Research ArticleAortic aneurysm

Angiotensin-Converting Enzyme–Induced Activation of Local Angiotensin Signaling Is Required for Ascending Aortic Aneurysms in Fibulin-4–Deficient Mice

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Science Translational Medicine  01 May 2013:
Vol. 5, Issue 183, pp. 183ra58
DOI: 10.1126/scitranslmed.3005025


Aortic aneurysms are life-threatening and often associated with defects in connective tissues and mutations in smooth muscle cell (SMC) contractile proteins. Despite recent advances in understanding altered signaling in aneurysms of Marfan syndrome, the underlying mechanisms and options for pharmacological treatment for other forms of aneurysms are still under investigation. We previously showed in mice that deficiency in the fibulin-4 gene in vascular SMCs (Fbln4SMKO) leads to loss of the SMC contractile phenotype, hyperproliferation, and ascending aortic aneurysms. We report that abnormal up-regulation of angiotensin-converting enzyme (ACE) in SMCs and subsequent activation of angiotensin II (AngII) signaling are involved in the onset of aortic aneurysms in Fbln4SMKO mice. In this model, aneurysm formation was completely prevented by inhibition of the AngII pathway with losartan or captopril within a narrow therapeutic window during the first month of life, even though the altered mechanical properties of blood vessel walls were not reversed by the pharmacological treatment. The therapeutic effects of losartan in Fbln4SMKO mice do not require the AngII receptor type 2 (Agtr2) but likely require both type 1a (Agtr1a) and 1b (Agtr1b) receptors. The results indicate that fibulin-4 is a vascular matrix component required for regulation of local angiotensin signaling and development and maintenance of the SMC phenotype.


Aortic aneurysms are associated with extrinsic or intrinsic defects of the blood vessel wall, including compromised vessel integrity and alterations of contractile proteins in vascular smooth muscle cells (SMCs) [reviewed in (1, 2)]. Dysregulation of transforming growth factor–β (TGFβ) has been shown to be a central mechanism of the pathology in various forms of thoracic aortic aneurysms in humans (35), a mouse model of Marfan syndrome (Fbn1C1039G/+), and Fbln4 hypomorphic mice (6, 7). Inhibition of the angiotensin II (AngII) receptor type 1 (Agtr1) by angiotensin receptor blockade (ARB) was suggested to inhibit transcription of TGFβ in Marfan mice (8) or lower blood pressure in Fbln4 hypomorphic mice (9), and was effective in the attenuation of the aneurysm phenotype in both mouse models (8, 9). However, a fundamental question remains whether the endogenous angiotensin system plays a causal role in aneurysm formation and whether ARB therapy can be applied to all congenital aortic aneurysms as a universal therapy.

Fibulin-4 localizes to microfibrils of elastic fibers and has multiple functions pertaining to vascular development, including binding to elastin and elastin cross-linking enzymes, to assist in the formation of elastic fibers and maintenance of an SMC contractile phenotype (1013). Mutations in FBLN4 in humans cause cutis laxa with various systemic vascular defects, including arterial tortuosity, aneurysms, and stenosis (1416). We have previously shown that proliferation of SMCs precedes aneurysm formation, with a marked increase of phosphorylated extracellular signal–regulated kinase 1/2 (p-ERK1/2) in the ascending aorta of mice that have a deletion of Fbln4 specifically in vascular SMCs (termed Fbln4SMKO) (13), suggesting that soluble factor(s) may be involved in the initiation and/or progression of aneurysmal lesions. Here, we used the Fbln4SMKO mouse model to further explore mechanisms underlying aneurysm development associated with defects in vascular matrix proteins.


Angiotensin-converting enzyme is up-regulated in vascular SMCs of the aneurysmal wall in Fbln4SMKO mice

To search for signaling pathways involved in proliferative changes of SMCs with elevated p-ERK1/2 in aneurysms of Fbln4SMKO mice, we performed quantitative polymerase chain reaction (qPCR) analyses on Fbln4SMKO aortas at 1 month of age. We found that transcripts of angiotensin-converting enzyme (Ace) and endopeptidase (Enpep) were increased 2.5 to 3 times (P = 0.0001 and P = 0.0008 for Ace and Enpep, respectively), whereas renin (Ren) was decreased by half in the Fbln4SMKO ascending aorta (P = 0.0039; Fig. 1A). Ace and Enpep were also up-regulated in the descending aorta where aneurysms did not develop (fig. S1). No differences in Ace expression between wild type and mutants were detected in the lung, but a 1.5-fold increase in Ace expression was observed in the kidney of Fbln4SMKO mice (fig. S2). Amounts of angiotensinogen (Agt), a precursor for angiotensin I and substrate for renin, were comparable between the liver of Fbln4SMKO and wild type (fig. S2). Consistent with qPCR results, high amounts of ACE were detected by immunostaining of aneurysmal wall SMCs in mutant aorta, whereas in the wild-type aorta, ACE staining was confined to endothelial cells (Fig. 1B). Up-regulation of ACE was apparent in 14-day-old Fbln4SMKO aorta, and it persisted throughout adult life (Fig. 1C and fig. S3). ACE was higher in ascending aorta compared to descending aorta in wild-type and Fbln4SMKO mice (Fig. 1D). ACE expression in primary SMCs from Fbln4SMKO aortas, however, was comparable to that of SMCs from wild-type aortas, suggesting that loss of Fbln4 was not sufficient to induce ACE in vitro (fig. S4) and that additional mechanical or soluble factors from other cell types or disruption of cell-matrix connections may need to be present.

Fig. 1 Up-regulation of ACE in the ascending aorta of Fbln4SMKO (SMKO) mice.

(A) qPCR analysis of mRNA from aortas of wild-type (WT, n = 4) and SMKO (n = 4) mice at 1 month of age. Bars are means ± SEM. **P < 0.01, ***P < 0.001, two-tailed Student’s t test. (B) ACE immunostaining of the aorta from WT and SMKO mice at 3 months of age. Arrows indicate ACE expressed in endothelial cells in the WT aorta. Asterisk indicates lumen, and M indicates medial layer. Scale bars, 20 μm. (C) Western blot showing ACE up-regulation in the mutant aortas throughout postnatal and adult life. GAPDH, glyceraldehyde-3-phosphate dehydrogenase. (D) Western blot showing ACE expression in the ascending (A) and descending (D) aortas of WT and SMKO mice (1 to 3 months). Experiment was repeated with a different set of animals and quantified (right). (E) Tissue AngII concentration determined by enzyme immunoassay. (a) Entire thoracic aortas from WT (n = 16) and SMKO (n = 14) mice were pooled and analyzed. (b) Kidneys from WT (n = 6) and SMKO (n = 6) mice were separately analyzed. Two-tailed Student’s t test. Bars are means ± SEM. NS, not significant. (F) BrdU proliferation assay. (a and b) Cross-sections of WT (a, n = 4) and SMKO (b, n = 4) aortas were examined. Arrows indicate BrdU-positive cells. Asterisk indicates lumen. Scale bars, 50 μm. (c) Percentage of BrdU+ cells per total nuclei. (d and e) Comparison of vessel area (d) and cell numbers per vessel area (e). Bars are means ± SEM. **P < 0.01, two-tailed Student’s t test.

We asked if the local up-regulation of ACE resulted in up-regulation of AngII in the mutant aorta. AngII levels were increased twofold in Fbln4SMKO aorta relative to wild-type aorta (Fig. 1E, a), whereas in the kidney, AngII levels were comparable between genotypes (Fig. 1E, b). This result also indicated that up-regulation of Ace resulted in a net increase in local AngII concentration despite up-regulation of Enpep, which cleaves AngII to AngIII. Because we previously reported that the vessel wall of Fbln4SMKO aorta was thicker and contained immature SMCs (13), we performed proliferation assays in 1-month Fbln4SMKO aorta using bromodeoxyuridine (BrdU). In the mutant aorta, nearly 6% of cells were positive for BrdU compared to less than 1% in the wild-type aorta (P = 0.0039; Fig. 1F, a to c). Vessel area was increased in Fbln4SMKO aorta compared to wild type (P = 0.0063; Fig. 1F, d), and cell number per vessel area (mm2) was comparable between genotypes (Fig. 1F, e), indicating that the increase in vessel area reflects an increase in cell number in the mutant aortic wall (Fig. 1F, d and e). These data suggest that local production of AngII due to increased ACE expression in SMCs causes up-regulation of local AngII-mediated signaling [for example, ERK1/2 (17)], leading to hyperproliferation of SMCs in the Fbln4SMKO ascending aorta.

Losartan and captopril effectively prevent the aneurysm phenotype in Fbln4SMKO mice

To examine the possible cause-effect relationship of the AngII pathway and aneurysm formation in Fbln4SMKO mice, we performed pharmacological experiments with captopril (ACE inhibitor, 75 mg/liter in drinking water ad libitum), losartan (ARB, 0.6 g/liter ad libitum), and propranolol (β-adrenergic receptor blocker, 0.5 g/liter ad libitum) as previously described (8). Each drug was administered from midgestation by giving it to pregnant females, and continued until 3 months of age, when all animals were sacrificed and analyzed. Large aneurysms observed in untreated Fbln4SMKO mice were completely prevented by either losartan or captopril, whereas propranolol showed only modest inhibitory effects on aneurysm formation (Fig. 2A). Similarly, internal elastic lamina (IEL) perimeter and total vessel area were completely normalized with losartan or captopril, whereas propranolol treatment only resulted in mild reduction of IEL perimeter and no effects on the total vessel area (Fig. 2B and table S1). Histologically, hyperproliferation and disarray of SMCs in the aortic wall were also completely prevented by losartan or captopril (Fig. 2C). Morphologically, SMCs in these treated animals displayed a more normal spindle cell shape with flattened nuclei, and vessel wall thickness was decreased and similar to control. Although the amount of collagen was decreased, elastic fibers remained irregular, and numerous disruptions were observed even after drug treatment (arrows in Fig. 2C). These findings indicate that ligand-dependent activation of Agtr1 is responsible for hyperproliferation of SMCs, and inhibition of AngII signaling by ACE inhibitor or ARB is equivalent and sufficient to prevent aneurysms, but without complete reversal of elastic fiber defects in the aneurysmal wall.

Fig. 2 Pharmacological prevention of aneurysms in SMKO mice.

(A) Gross morphology of the ascending aorta in WT, untreated SMKO, and SMKO mice prenatally treated with captopril (CPT), propranolol (PPL), or losartan (LSRT). A large aneurysm (single arrows) is detected in SMKO and propranolol-treated SMKO aorta. Captopril or losartan treatment prevents aneurysm formation (double arrows). Scale bars, 5 mm. (B) Morphometric analysis of cross-sections of the ascending aorta from control (Ctr), untreated, losartan-treated, captopril-treated, or propranolol-treated SMKO mice. IEL perimeter and total vessel area are shown. Bars are means ± SEM. **P < 0.01, ***P < 0.001, one-way analysis of variance (ANOVA). Number of animals is indicated on each bar. (C) Histological images of the ascending aorta from WT, untreated SMKO, and captopril- or losartan-treated SMKO mice stained with hematoxylin and eosin (H&E), Hart’s stain (for elastin), and Masson trichrome stain (for collagen). Lumen is indicated by asterisk. Fuzzy appearance and disruption of elastic fibers are detectable even after captopril or losartan treatment (arrows). Scale bars, 20 μm.

Postnatal days 7 to 30 are a critical time window for therapeutic intervention in mice

To determine the critical time window for the therapeutic effect of AngII inhibition, we used losartan to further examine the time course for prevention of the aneurysmal phenotype. We first examined early pathological changes in the Fbln4SMKO aorta at postnatal days (P) 1, P7, and P14. The ascending aorta was macroscopically indistinguishable between mutant and wild type at P1 and P7 (fig. S5A and Fig. 3A), whereas slight dilatation was noted at P14 (arrows in Fig. 3A). The aorta remained histologically normal at P1 in the mutants (fig. S5B), but cellularity increased by P7, especially in the subendothelial layer and near the adventitia (Fig. 3B, arrowhead). By P14, SMCs were morphologically abnormal, and the proliferation of SMCs extended throughout the medial layer in the mutant aorta (Fig. 3B). These data indicated that the microscopic changes began around P7 and suggested that P7 may be a target time point for postnatal drug treatment.

Fig. 3 Determining a critical time window for therapeutic intervention.

(A) Macroscopic changes in the SMKO ascending aorta at early neonatal stages. Arrows indicate aneurysm. aa, ascending aorta. Scale bars, 1 mm. (B) Cross-sections of ascending aorta at P7 and P14 stained with H&E and Hart’s (elastin). Scale bars, 50 μm. Lumen is indicated by asterisk. (C) Postnatal losartan administration protocol. All animals were evaluated at 3 months of age. (D) Morphometric analysis of aortas from SMKO mice treated with losartan at various time points according to the above protocol. Bars are means ± SEM. ***P < 0.001, one-way ANOVA.

We set up drug treatment protocols (Fig. 3C) in which losartan was administered from P7 to P90, P30 to P90, or P7 to P45, and the ascending aorta was evaluated at P90. Aneurysms were completely prevented if losartan was administered starting at P7, even if treatment stopped at P45 (Fig. 3, C and D). In contrast, administration of losartan from P30 to P90 did not prevent aneurysm development. These data indicate that the optimal therapeutic window is between P7 and P30 and that transient inhibition of AngII signaling during the early postnatal period is sufficient to prevent aneurysm development at least until 90 days of age.

Blood pressure and vessel mechanical properties are not completely normalized by losartan treatment in Fbln4SMKO mice

Hemodynamic changes occur during the transition from embryonic to adult circulation, and growth-related increases in blood pressure and body weight are prominent between P7 and P30 during mouse development (18). It is plausible that intrinsic defects in SMCs and the resultant altered response to increasing hemodynamic stress in the elevated AngII microenvironment trigger aneurysm formation in Fbln4SMKO mice. To gain insights into hemodynamic contributions to aneurysm formation, we measured blood pressure in untreated animals and those treated with losartan, propranolol, or captopril from P7 to P43 ± 2 (Fig. 4, A to D, and table S2). Average arterial systolic pressures were similar in untreated control [104 ± 1 (SEM) mmHg] and Fbln4SMKO mice [107 ± 3 (SEM) mmHg; Fig. 4A]; however, there was a trend toward lower average diastolic pressures in Fbln4SMKO mice (Fig. 4B), and thus, pulse pressures were increased 50% in untreated Fbln4SMKO mice compared to control (P = 0.004; Fig. 4D). This marked increase in pulse pressure in the mutants was similar to what has been observed in Fbln5-null (19) and Fbln4 hypomorphic mice (9), in which elastic laminae are severely disrupted. Captopril decreased systolic blood pressures about 20% in Fbln4SMKO mice [88 ± 3 (SEM) mmHg; n = 5; P = 0.006; Fig. 4A] and eliminated the increase in pulse pressure observed in untreated Fbln4SMKO mice (Fig. 4D). Losartan did not affect systolic pressures in Fbln4SMKO mice [104 ± 2 (SEM) mmHg; n = 7; Fig. 4A]; thus, pulse pressures remained higher in losartan-treated Fbln4SMKO mice. Propranolol showed no effects on blood pressures in control or Fbln4SMKO mice (Fig. 4, A to D). Because both captopril and losartan prevented the aneurysm phenotype, but only captopril had significant effects on systolic and pulse pressure in Fbln4SMKO mice, these data suggest that hemodynamic changes are not required to prevent aneurysms in Fbln4SMKO mice.

Fig. 4 Blood pressure and vessel biomechanics in SMKO mice.

(A to D) Average systolic blood pressures (BP), diastolic blood pressures, mean blood pressures, and pulse pressures in untreated or propranolol (PPL)–, captopril (CPT)–, or losartan (LSRT)–treated animals. Control (Ctr, white bars) and SMKO (black bars) are shown. Number of animals tested is indicated in parentheses. Bars are means ± SEM. *P < 0.05, **P < 0.01, one-way ANOVA. (E) Pressure-diameter curves for the ascending aorta in control (gray symbols) and SMKO (black symbols) untreated and drug-treated animals. (F) Pressure-compliance curves for the ascending aorta in control (gray symbols) and SMKO (black symbols) untreated and drug-treated animals. In (E) and (F), data were analyzed with one-way ANOVA. Error bars are not included for clarity.

The mechanical stress on the vessel wall is determined by both hemodynamic forces, such as blood pressure, and the mechanical properties of the wall, which are illustrated by pressure-diameter and pressure-compliance relationships. Pressure-diameter curves showed large starting diameters in Fbln4SMKO aorta (about twofold greater than control at zero pressure), indicating the presence of aneurysms in Fbln4SMKO ascending aorta. These diameters were significantly larger than control animals at all pressures tested (P < 0.001; Fig. 4E and table S3). Compliance of the Fbln4SMKO ascending aorta, defined as the percent change in outer diameter with each 25-mmHg pressure step, was decreased 60 to 80% in the middle- to high-pressure range (75 to 175 mmHg) compared to the control aorta (P < 0.001; Fig. 4F and table S3), indicating that the vessel wall is stiffer, similar to elastin heterozygous mutants (20). Thus, the compliance or stiffness of Fbln4SMKO vessels is similar to that of other mouse models with mild to severe elastic fiber defects that do not develop aortic aneurysms, suggesting that mechanical changes alone are not sufficient to induce aneurysm formation.

We then examined whether drug treatment altered the mechanical properties of the ascending aortas. Pressure-diameter curves were almost identical in control vessels regardless of drug treatment. Propranolol-treated Fbln4SMKO aortas showed starting diameters about twofold larger than control aortas, similar to untreated Fbln4SMKO animals, indicating the presence of aneurysms (Fig. 4E). Losartan- or captopril-treated Fbln4SMKO aortas showed about a 20% increase in starting diameter compared to controls but were smaller than untreated and propranolol-treated Fbln4SMKO aortas for every pressure tested (P < 0.001) and did not have aneurysms. Compliance of losartan- or captopril-treated Fbln4SMKO aortas was between that of control and untreated or propranolol-treated Fbln4SMKO in the low-pressure range (0 to 50 mmHg); however, all the mutant aortas, regardless of drug treatment, showed reduced compliance in the high-pressure range (100 to 175 mmHg) compared to controls (P < 0.001; Fig. 4F). These data indicate that increased stiffness of the vessel wall is not completely reversed pharmacologically. Combined with the blood pressure data, these results show that changes in mechanical stress on the vessel wall are not the primary mechanism for aneurysm prevention in losartan- and captopril-treated Fbln4SMKO mice.

Elevated p-ERK1/2 and decreased expression of SMC differentiation markers are reversed by losartan

Recently, it was shown in Fbn1C1039G/+ mice that elevated p-ERK1/2 driven by noncanonical TGFβ signaling is responsible for aneurysm development (6). We therefore examined the effect of inhibiting the AngII-Agtr1 pathway on p-ERK1/2 levels in aneurysm lesions of the Fbln4SMKO aorta. Strong up-regulation of p-ERK1/2 was observed in untreated Fbln4SMKO aorta, whereas marked down-regulation of p-ERK1/2 was found in prenatal or postnatal losartan-treated groups and the prenatal captopril-treated group (Fig. 5A). In contrast, propranolol-treated or delayed losartan-treated groups, in which modest or no preventative effects were detected, showed persistently high levels of p-ERK1/2. These data suggest that increased p-ERK1/2 driven by strong AngII-Agtr1 signaling is associated with the development of aneurysms in Fbln4SMKO mice (Fig. 5A).

Fig. 5 The effects of AngII-Agtr1 inhibition on SMCs in aneurysmal lesions.

(A) Changes in p-ERK1/2 concentration in aneurysmal lesions after pharmacological intervention for the indicated time periods. Scale bars, 20 μm. (B) Western blot showing the effect of prenatal treatment with losartan on the concentrations of p-ERK1/2, p-Smad2/3, p-Smad1/5/8, and ACE in mutant aortas. Quantification is shown below. Bars are means ± SEM. *P < 0.05, ***P < 0.001, one-way ANOVA. (C) qPCR analysis of SMC differentiation marker genes in ascending aortas of WT (n = 3) and SMKO aortas (n = 2 to 3), with and without prenatal losartan treatment. Bars are means ± SEM. *P < 0.05, **P < 0.01, ***P < 0.001, one-way ANOVA. (D) Western blot comparing MHY11 levels in WT and mutant aorta with and without losartan treatment. Housekeeping protein GAPDH is shown as a loading control. Quantification is shown below. One-way ANOVA. Bars are means ± SEM. Animals were analyzed at 3 months of age.

To compare signaling pathways implicated in aneurysm formation in congenital aortic aneurysm models, we examined p-Smad2/3, p-Smad1/5/8, and p-ERK1/2 by Western blot analysis. Our previous studies failed to detect increased Smad2/3 signaling in the aneurysmal wall (13); however, improved preparation of the aortic samples by complete removal of periaortic adipose tissues enabled us to detect elevation of p-Smad2/3 in aneurysm lesions of Fbln4SMKO mice. Losartan treatment effectively suppressed p-ERK1/2 and p-Smad2/3 levels to those of wild-type aorta (Fig. 5B), but the change in p-Smad1/5/8 levels was less prominent. qPCR analysis revealed that expression of SMC contractile genes was markedly increased by losartan treatment compared to the untreated group (Fig. 5C). Among all contractile genes, Myocd, a master regulator of SMC differentiation, and Myh11, a marker of terminal SMC differentiation, returned to normal levels with losartan treatment (Fig. 5C). MYH11 protein levels showed a trend for increase, which was not statistically significant, in losartan-treated animals (Fig. 5D). ACE protein was minimally decreased in losartan-treated animals (Fig. 5B), consistent with ACE being upstream of the AngII-Agtr1 pathway.

Genetic ablation of Agtr1a alone is insufficient for prevention of ascending aortic aneurysms in Fbln4SMKO mice

We used a genetic approach to examine whether Agtr1-mediated pathways are essential for aneurysm formation in Fbln4SMKO mice. AngII is known to bind two types of G protein (heterotrimeric guanine nucleotide–binding protein)–coupled receptors: Agtr1 and Agtr2. In mice, two subtypes of Agtr1, Agtr1a and Agtr1b, are generated by duplication of Agtr1. Because Agtr1a is the predominant receptor in adult tissues (21), we used mice null for Agtr1a (Agtr1a−/−; termed 1aKO) and crossed them with Fbln4SMKO mice to generate Agtr1a−/−;Fbln4SMKO (termed 1aDKO), and then examined aneurysm formation at 3 months compared with their littermates. Morphology of SMCs and elastic fibers in 1aDKO aorta was comparable to that of 1aKO aorta; however, the aortic wall was thicker in 1aDKO mice compared to 1aKO (Fig. 6A). Morphometric analysis showed that although 2 of 10 1aDKO aortas had large IEL perimeters (>0.6 mm2), average IEL perimeter was improved compared to Fbln4SMKO animals (Fig. 6B). Nevertheless, the total vessel areas of 1aDKO aortas were larger than control or 1aKO. This result was in stark contrast to losartan-treated animals in which aneurysm formation was prevented completely (Fig. 2A), suggesting that Agtr1b may also contribute to aneurysm formation in 1aDKO mice. This suggestion is supported by persistent elevation of p-ERK1/2 in the 1aDKO aorta (Fig. 6A). These results indicate that the therapeutic effect of losartan was achieved by blocking both Agtr1a and Agtr1b.

Fig. 6 Evaluation of the role of Agtr1a and Agtr2 in formation of aortic aneurysms.

(A) Histological images of the ascending aorta from Agtr1a-null (1aKO) and Agtr1a-null;Fbln4SMKO (1aDKO) mice at 3 months of age stained with H&E and Hart’s (for elastin) and immunostained with anti-pERK1/2. Lumen is indicated by asterisk. Scale bars, 50 μm. (B) Effect of the loss of an Agtr1a allele in Fbln4SMKO mice on IEL perimeter and total vessel area. Bars are means ± SEM. ***P < 0.001, one-way ANOVA. (C) Histological images of the ascending aorta from Agtr2-null (2KO) and Agtr2-null;Fbln4SMKO (2DKO) mice at 3 months of age stained with H&E and Hart’s and immunostained with anti-pERK1/2. Scale bars, 50 μm. (D) Effect of prenatal treatment with losartan on IEL perimeter and total vessel area in Agtr2-null (2KO, black columns) and Agtr2-null;Fbln4SMKO (2DKO, shaded columns) mice evaluated at 3 months of age. Bars are means ± SEM. **P < 0.01, ***P < 0.001, one-way ANOVA.

Agtr2 is not required for losartan-mediated prevention of ascending aortic aneurysms in Fbln4SMKO mice

In contrast to the defined intracellular signaling pathway and biological functions of Agtr1 in vivo, the role of Agtr2 has been elusive (22). Recently, deletion of Agtr2 in Fbn1C1039G/+ mice was shown to exacerbate aortic root enlargement, and losartan was ineffective at preventing aneurysm formation in Fbn1C1039G/+;Agtr2-null mice, suggesting that Agtr2 functions as a protective receptor and acts antagonistically to Agtr1 in vivo (23). We therefore asked if Agtr2 is required for the therapeutic effect of losartan by rendering the AngII signal to exert protective effects through Agtr2 on SMCs in Fbln4SMKO mice. Deletion of Agtr2 (Agtr2Y/−; termed 2KO) in Fbln4SMKO mice (Fbln4SMKO;Agtr2Y/−; termed 2DKO) did not affect aneurysm formation (Fig. 6C). The medium of the aortic wall was much thicker in the double mutants than in 2KO, with hyperproliferation and disarray of SMCs observed at 3 months of age (Fig. 6C). Administration of losartan completely prevented the aneurysm phenotype in 2DKO mice (Fig. 6, C and D), and p-ERK1/2 concentrations were much lower in the losartan-treated group than in the untreated 2DKO group (Fig. 6C), indicating that the therapeutic effect of losartan does not require the action of Agtr2 on SMCs. These results suggest that Agtr2 is a bystander receptor in the process of aneurysm formation, and the protective effect of AngII-Agtr1 inhibition is independent of Agtr2 action in Fbln4SMKO mice.


Here, we have shown that loss of one extracellular matrix (ECM) protein produced by vascular SMCs is sufficient to drive up-regulation of ACE in the aortic wall of Fbln4SMKO mice. Because angiotensinogen expression in the liver and ACE expression in the lung were comparable between controls and Fbln4SMKO mice and AngII concentration in the aorta was increased in Fbln4SMKO mice, it is likely that local conversion of AngI to AngII contributes to the cellular changes in the mutant aorta. This is consistent with the previous report showing that local ACE serves as a key rate-limiting enzyme for AngII-mediated vascular hypertrophy in the rat carotid artery overexpressing the Ace gene (24). Note that Fbln4SMKO aorta shows marked proliferation and disarray of SMCs. We speculate that the absence of intact elastic laminae and thus loss of physical barriers within the vessel wall further facilitate migration of SMCs across the lamellar unit and expansion of immature SMCs in the Fbln4SMKO aorta.

Up-regulation of ACE is associated with various pathological conditions, including hypertension, atherosclerosis, and diabetic nephropathy [reviewed in (25, 26)]. Although the endothelium is a prominent source of ACE in the vasculature, ACE has also been shown to be up-regulated in SMCs of diseased vessels in humans and animal models, such as neointima induced by wire denudation injury, percutaneous transluminal coronary angioplasty (27, 28), and small pulmonary arteries in hypoxia-induced pulmonary hypertension (29). SMCs explanted from thoracic aneurysms of patients carrying MYH11 mutations show high levels of ACE transcripts (30). The exact mechanism of ACE up-regulation in SMCs has not been completely understood; however, soluble factors such as basic fibroblast growth factor and endothelin were suggested to mediate up-regulation of ACE (31, 32). Mechanical forces such as shear stress and pulsatile pressure, as well as hypoxia, can also increase expression of ACE in SMCs (33, 34). Our study provides evidence that loss of fibulin-4 in the context of vessel wall is sufficient for up-regulation of ACE in SMCs in vivo. The resulting activation of local AngII signaling caused ascending aortic aneurysms in Fbln4SMKO mice, as evidenced by the complete prevention of aneurysm formation through perturbation of this pathway at the level of either AngII production or receptor activation. The results also suggest that fibulin-4 is required to prevent overactivation of local AngII-induced pathways that result in loss of the SMC phenotype but may be largely overcome by early interruption of AngII signaling.

Our study allowed us to determine the critical therapeutic time window for prevention of aneurysm development in vivo. Inhibition of AngII-mediated pathway by losartan effectively suppressed local proliferative changes in SMCs if treatment was initiated at P7, and these effects persisted even after withdrawal of losartan at P45. In contrast, after P30, mutant SMCs did not respond to losartan and up-regulation of p-ERK1/2 continued. Thus, a critical therapeutic time window is between P7 and P30, and proliferation of mutant SMCs is dependent on AngII signaling during this period. The mechanism underlying the irreversible change in SMCs after P30 was not examined in this study; however, it is possible that AngII activates alternative signaling pathways that independently sustain the abnormal SMC phenotype in Fbln4SMKO aorta and/or that the vessel microenvironment containing high AngII may induce chromatin modification to alter the response to losartan and/or suppress SMC differentiation markers.

Results from genetic studies with AngII receptor–deficient mice demonstrated that inhibition of Agtr1a alone is not sufficient to achieve complete prevention of aneurysms in Fbln4SMKO mice. The fact that losartan completely prevented aneurysmal phenotypes indicated that Agtr1b also mediates pathological signals in the Fbln4SMKO aorta. Agtr1a is the dominant receptor in adult tissues in mice, and Agtr1b expression is limited to a few organs, including adrenal glands, testis, and brain (21). Up-regulation of Agtr1b, however, was shown to be responsible for augmenting glomerular lesions in the absence of Agtr1a in murine autoimmune nephritis (35). Therefore, it is possible that AngII-mediated signaling through Agtr1b participates in the development of aneurysms in 1aDKO aorta and that losartan effectively prevents the aneurysm formation by blocking both Agtr1a and Agtr1b in Fbln4SMKO mice. Generation of triple knockout mice for Agtr1a, Agtr1b, and Fbln4 in an SMC-specific manner will provide information on the role of Agtr1 receptors in the development of aneurysms in SMKO mice. Our results also show that Agtr2 is not required for mediating the protective action of losartan in Fbln4SMKO mice, unlike its critical role described in Fbn1C1039G/+ mice (23). Prevention of the aneurysm phenotype by captopril also confirms that blocking AngII signals mediated by both Agtr1 and Agtr2 is an effective strategy in prevention of aneurysm formation in Fbln4SMKO mice and provides evidence against an antagonistic interaction between Agtr1 and Agtr2 in the development of aortic aneurysms in Fbln4SMKO mice. This finding is of particular importance in designing a strategy to stimulate Agtr2 as a potential treatment for cardiovascular diseases (36). Recently, direct stimulation of Agtr2 by a nonpeptide agonist compound 21 (C21) was shown to reduce arterial stiffness independent of blood pressure in rats treated with nitric oxide synthase inhibitor (37). C21-mediated beneficial effects were also reported on scar size and cardiac function in rat myocardial infarction (MI) model (38), as well as on perivascular fibrotic changes in stroke-prone rats (39), whereas another study in a mouse MI model did not support a protective effect of Agtr2 stimulation (40). Our animal model will be useful to determine the effect of Agtr2 agonists in aneurysm progression in vivo.

A protective association between ACE inhibitors and risk of aneurysm rupture was reported in a large population-based case-control study in abdominal aortic aneurysm patients, in which an ACE inhibitor, but not ARB or other antihypertensive reagents, decreased the risk of aneurysm rupture independent of lowering blood pressures (41). In a study targeted to Marfan patients, an ACE inhibitor reduced arterial stiffness and aortic root diameters compared to placebo-treated group (42) or β blocker (43). Additional clinical trails with a larger cohort are testing the effects of ARB on Marfan patients (44, 45). Our in vivo results provide further support for the idea that inhibition of AngII-Agtr pathway by ACE inhibitors or ARBs may be equally effective for the treatment of ascending aortic aneurysms during the early postnatal period. The application of these findings in human ascending aortic aneurysm patients warrants further investigation.

By combining hemodynamic and mechanical studies with pharmacological experiments, we were able to assess the relationship between mechanical stress on the vessel wall and aneurysm phenotypes. Although our data indicate that loss of integrity of the vessel wall is coupled with cellular changes in SMCs, the aneurysm phenotype can be prevented without completely reversing increased pulse pressures (for losartan-treated animals) or the altered mechanical properties of the aorta, including decreased compliance and increased stiffness. The absence of pressure changes in Fbln4SMKO mice with losartan treatment implies that signaling through Agtr2 is sufficient to maintain blood pressure in these mice and provides further evidence against the complete dependence on pressure changes for the aneurysm prevention. Our results show that aneurysm in our model is a disease affecting SMC phenotypes and ECM-cell interactions, rather than a condition resulting solely from increased hemodynamic forces and/or mechanical defects of the vessel wall, and that intervention to alter SMC phenotypes by captopril or losartan leads to effective prevention of the aneurysm formation.

Although fibulin-4 is expressed in both ascending and descending aorta, the aneurysms resulting from a lack of this protein are confined to the ascending aorta, suggesting that SMCs in this region may have unique characteristics that confer susceptibility to external growth signals in addition to the direct influence of outflow pressure. One possibility is that SMCs with a diverse embryonic origin may contribute to the differential response to AngII signals in the vessel wall. SMCs are derived from the neural crest in the ascending aorta (46) and are distinct from SMCs in the descending/abdominal aorta derived from the somite (47). Our data indicating that ACE expression is higher in the ascending aorta than descending aorta support this possibility. Regional differences in ACE activity were also reported in chick embryos, demonstrating significantly increased ACE activity in the ascending aorta compared to the abdominal aorta (48). Furthermore, endothelial cells incubated with conditioned medium harvested from neural crest–derived SMCs exhibited a marked increase in ACE activity compared with those from mesenchyme-derived SMCs. Therefore, basal ACE activity may be regulated in a cell lineage–dependent manner and may contribute to the regional difference in formation of aortic aneurysms.

In summary, our results highlight the AngII pathway as a cause of ascending aortic aneurysms in Fbln4SMKO mice and provide a basis for the effective prevention of aneurysms with postnatal administration of ACE inhibitor and/or ARB. Our study underscores differences in the pathological basis of aortic aneurysms and suggests that therapeutic regimens need to be tailored according to underlying disease mechanisms in human patients. The limitations of this study include a lack of observations of the aneurysm phenotype over an extended period of time after early losartan treatment, which would have enabled us to evaluate the long-term effects of losartan on aneurysm prevention in Fbln4SMKO mice. We recognize that our mouse model is a cell type–specific inactivation of Fbln4, whereas reported human patients have systemic inactivation of FBLN4 (1416) and more severe symptoms than the present mouse model. Thus, additional information regarding tissue/serum levels of fibulin-4 in a large cohort of patients with aortic aneurysms and the correlation with clinical features and severity of the disease would be valuable. In addition, results from this mouse model of aneurysm development indicate that further investigations are needed to address intracellular signaling pathways downstream of AngII-Agtr that are responsible for induction of proliferative changes in SMCs, as well as identification of specific SMC populations activated by AngII signals.

Materials and Methods


Fbln4SMKO (Fbln4fl/KO containing SM22α-Cre transgene) and Agtr2 knockout mice were generated and described previously (13, 49). Agtr1a knockout mice were purchased from Jackson Laboratory (B6.129P2-Agtr1atm1Unc/J). Comparisons of the phenotype between animals were performed on the same genetic background, and wild-type littermates containing Cre transgenes were used as controls (tables S1 to S3). Both female and male mice were used in this study. All mice were kept on a 12-hour/12-hour light/dark cycle under specific pathogen–free conditions, and all animal protocols were approved by the Institutional Animal Care and Use Committee of the University of Texas Southwestern Medical Center.

Histology and immunohistochemistry

Aortas were harvested and perfusion-fixed in 4% paraformaldehyde and embedded in paraffin. Five-micrometer sections were stained with H&E for routine histology and Masson trichrome and Hart’s staining for detection of collagen fibers and elastic fibers, respectively. Immunostaining was performed with antibodies for ACE (1:100, Santa Cruz Biotechnology) and p-ERK1/2 (1:100, Cell Signaling) as previously described (13). A minimum of four animals were analyzed in each experiment.

Western blot analysis

Aortas were harvested, and perivascular adipose tissues were thoroughly removed. Wild-type aortas (n = 2 to 6) and Fbln4SMKO aortas (n = 1 to 4) were pooled in each experiment and minced in 2× Laemmli buffer or radioimmunoprecipitation assay buffer containing 1% protease inhibitor (Sigma) and 1% phosphatase inhibitor (Sigma), then boiled at 95°C for 10 min, and subjected to SDS–polyacrylamide gel electrophoresis. SMCs were prepared from P45 wild-type and Fbln4SMKO aortas as previously described (13), and passage number 5 was used for protein extraction. Proteins were transferred to a Western polyvinylidene difluoride membrane (Millipore Inc.) and immunoblotted with antibodies to p-ERK1/2 (1:1000, Cell Signaling), ACE (1:1000, Santa Cruz Biotechnology), or GAPDH (1:3000, Cell Signaling). Membranes were then incubated with anti-mouse or anti-rabbit horseradish peroxidase–conjugated secondary antibody, as appropriate (1:3000, Bio-Rad), and visualized with a chemiluminescence kit (Santa Cruz Biotechnology Inc.). Quantification of Western blots was performed with Scion Image software [National Institutes of Health (NIH)].

Quantitative PCR

RNA was isolated from aortas at the indicated ages with an RNeasy Plus Micro Kit (Qiagen), and 1 μg of total RNA was subjected to reverse transcription reactions with SuperScript III reverse transcriptase (Invitrogen). SYBR Green was used for amplicon detection, and gene expression was normalized to the expression of housekeeping genes β2-microglobulin and GAPDH. PCRs were carried out in triplicate in a CFX96 real-time PCR detection system (Bio-Rad) with one cycle of 3 min at 95°C, then 40 cycles of 10 s at 95°C and 30 s at 60°C. mRNA concentrations were determined with the ΔΔCt method and expressed relative to wild-type controls. Wild-type aortas (n = 4 to 6) and Fbln4SMKO aortas (n = 1 to 3) were pooled and analyzed in each experiment. Primer sequences are provided in table S4.

BrdU proliferation assay

Wild-type (n = 4) and Fbln4SMKO (n = 4) mice at 1 month of age were given BrdU (100 mg/kg) by intraperitoneal injection once per day on four consecutive days. Aortas were harvested 1 hour after the final BrdU injection and embedded in OCT (Tissue-Tek). Tissue sections (10-μm thick) were fixed in 4% paraformaldehyde for 10 min and treated with 2N HCl containing 0.5% Triton X-100 for 1 hour, followed by tris-buffered saline (pH 8.4) for 5 min to neutralize HCl. Sections were blocked for 30 min and incubated with rat anti-mouse BrdU antibody (Abcam, 1:100) overnight followed by Alexa Fluor 488–conjugated donkey anti-rat antibody (Invitrogen, 1:200) for 1 hour. Sections were mounted with 4′,6-diamidino-2-phenylindole and photographed with a Zeiss Axio Observer.Z1 microscope and Axiovision software. BrdU+ nuclei and total nuclei were counted in four high-powered fields (40×) for each tissue sample and expressed as a percentage of BrdU+ cells. Vessel areas were measured with ImageJ software (NIH).

Tissue AngII measurement

Aortas from 3-month-old wild-type (n = 16) and Fbln4SMKO mice (n = 14) were pooled and processed for tissue extraction. Kidneys from 3- to 4-month-old wild-type (n = 6) and Fbln4SMKO (n = 6) mice were individually processed. Tissues were boiled in 2 ml of water for 20 min to deactivate endogenous peptidases. The solution was then adjusted to 1N CH3COOH and homogenized. After centrifugation (2600g × 40 min), the supernatant was loaded onto Oasis HLB Extraction Cartridges (Waters), washed with water/0.1% TFA, and eluted with 100%CH3CN/0.1% TFA. The eluates were lyophilized and dissolved in the EIA buffer of the Angiotensin II ELISA kit (SPI-BIO). AngII levels were measured in duplicate according to the manufacturer’s instructions.

Pharmacological experiments

Losartan (0.6 g/liter in drinking water, ad libitum, provided by Merck Inc.), captopril (75 mg/liter in drinking water, ad libitum, Sigma-Aldrich), and propranolol (0.5 g/liter in drinking water, ad libitum, Sigma-Aldrich) were administered during the indicated periods. The numbers of animals used in each group are provided in each graph. For prenatal treatment, drugs were administered to the pregnant mother and then given to the mother through the period of lactation until weaning.

Morphometric analysis

Cross-sections of the aorta were stained with Hart’s stain, and images were digitally captured with a Leica DM2000 microscope. Morphometric analysis was performed with Scion Image software (NIH). At least three sections were taken from different levels of ascending and descending aorta, and measurements were done three times per section by a blinded examiner.

Blood pressure measurement

The mice used for this experiment were all male, except for one female included for losartan treatment in both control and Fbln4SMKO groups (6 to 8 weeks). For drug-treated animals, losartan, captopril, or propranolol was administered from P7 to P43 ± 2, and then the drugs were removed and animals were acclimated for 5 days before blood pressure measurement. The animals were anesthetized with 1.5% isoflurane, and body temperature was maintained with a feedback-controlled heating pad. Arterial pressure was measured with a catheter (1.2 French, SciSense Inc.) inserted in the ascending aorta through the right common carotid artery.

Mechanical testing

Mechanical testing was performed on the ascending aorta with a pressure myograph (Danish Myo Technology), as previously described (18). Briefly, each aorta was mounted in the test system in physiologic saline at 37°C, stretched to its approximate in vivo length, and preconditioned. Each aorta was then pressurized for three cycles from 0 to 175 mmHg in steps of 25 mmHg with 12 s per step. Compliance was defined as the percent change in outer diameter with each pressure step.

Statistical analysis

One-way analysis of variance (ANOVA) with the Bonferroni post hoc test was used for comparison of drug effects (Figs. 2B, 3D, 4, and 5C) and Agtr1a allelic difference (Fig. 6B) on aneurysm phenotypes, and two-tailed Student’s t test was used for the rest of the statistical analysis. Bars are means ± SEM and P < 0.05 was considered significant.

Supplementary Materials

Fig. S1. qPCR analysis of the renin-angiotensin pathway in the descending aortas.

Fig. S2. qPCR analysis of the renin-angiotensin pathway in the lung, kidney, and liver.

Fig. S3. Quantification of ACE in Fbln4SMKO (SMKO) mice throughout postnatal and adult life.

Fig. S4. ACE expression in primary Fbln4SMKO SMCs.

Fig. S5. Morphological analysis of Fbln4SMKO ascending aorta at P1.

Table S1. Animals used in morphometric analysis.

Table S2. Animals used in blood pressure measurement.

Table S3. Animals used in vessel biomechanics.

Table S4. qPCR primer sequences.

References and Notes

  1. Acknowledgments: We thank G. Urquhart, M. Hiroshima, and the Pathology Core Laboratories for technical assistance; J. Richardson for assistance in evaluation of histological sections; and E. Olson, A. Word, and M. Yanagisawa for critical reading of the manuscript. Funding: Supported by NIH grants R01HL106305 (H.Y.), R00HL087653 (J.E.W.), R01HL105314 (J.E.W.), and R37HL58205 (T.I.); American Heart Association (Grant-In-Aid, 0855200F, H.Y.); The National Marfan Foundation (HY426g, H.Y.); and NIH Institutional Training in Cardiovascular Research grant 5T32HL007360-34 (C.L.P.). H.Y. is a recipient of the Established Investigator Award from the American Heart Association. Author contributions: J.H., Y.Y., Y.I., and C.L.P. contributed to conception and design, acquired experimental data, were involved in analysis and interpretation of the data, and drafted the manuscript. Y.L., M.P., and V.P.L. helped design, performed experiments, and analyzed and interpreted the data. T.I. made contributions to this study by generating reagents, interpreting the data, and providing intellectual input to the manuscript. J.E.W. contributed to the design of experiments, analysis and interpretation of data, and writing of the manuscript. H.Y. is the senior author of this manuscript, provided funding, and contributed to its conception and design, acquisition of experimental data and interpretation of data, and writing the manuscript. Competing interests: The authors declare that they have no competing interests. Data and materials availability: Losartan was obtained from Merck & Co. Inc. under materials transfer agreement 38648.
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