Reduced hind limb ischemia-reperfusion injury in Toll-like receptor-4 mutant mice is associated with decreased neutrophil extracellular traps Rahmi Oklu,

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Reduced hind limb ischemia-reperfusion injury in Toll-like receptor-4 mutant mice is associated with decreased neutrophil extracellular traps Rahmi Oklu, MD, PhD, Hassan Albadawi, MD, John E. Jones, MD, Hyung-Jin Yoo, MS, Michael T. Watkins, MD Journal of Vascular Surgery Volume 58, Issue 6, Pages 1627-1636 (December 2013) DOI: 10.1016/j.jvs.2013.02.241 Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 1 Representative images are shown of hematoxylin and eosin staining of the murine hind limb muscle tissue sections after 1.5 hours of ischemia and 48 hours of reperfusion. A, Tissue sections from Toll-like receptor-4 mutant (TLR4m) mice show relatively preserved muscle fibers with scattered fiber injury (black arrows) and tissue edema (black bar = 100 μm). B, Wild-type (WT) tissue sections show significantly greater muscle fiber injury, with black arrows indicating examples of injured fibers (black bar = 100 μm). C, There was significantly greater muscle fiber injury in the WT hind limb muscle groups, gastrocnemius, and anterior tibialis, compared with the TLR4m tissues (*P < .05, **P < .01, respectively). D, Increased muscle fiber injury in WT mice was consistent with significantly decreased adenosine triphosphate (ATP) levels compared with the less injured TLR4m group showing much higher ATP levels (*P < .04). Journal of Vascular Surgery 2013 58, 1627-1636DOI: (10.1016/j.jvs.2013.02.241) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 2 A, Representative images are shown of immunohistochemical detection of myeloperoxidase (MPO) in murine hind limb muscle tissue sections after 1.5 hours of ischemia and 48 hours of reperfusion (black bar = 100 μm). B, Immunostaining of specimens from Toll-like receptor-4 mutant (TLR4m) mice showed significantly less MPO-positive cells (brown) in muscle tissue than the wild-type (WT) group. The black arrows indicate examples of MPO-positive cells (black bar = 100 μm). C, There were more than fivefold greater MPO immunostained cells within the tissue sections of WT mice compared with the TLR4m mice (*P < .0001). Journal of Vascular Surgery 2013 58, 1627-1636DOI: (10.1016/j.jvs.2013.02.241) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 3 Representative images are shown for immunostaining for neutrophil extracellular traps (NETs) in murine hind limb ischemia-reperfusion (IR) injury using the monoclonal antihistone H2A/H2B/DNA complex antibody. A, Wild-type (WT) tissue sections show extensive immunostaining for NETs (brown) in interstitial tissue (arrowhead) and in thrombi (arrow) within vessels. There is increased cellular density in regions of intense NETS detection. B, Tissue section from Toll-like receptor-4 mutant (TLR4m) mice shows minimal if any interstitial (arrowhead) and intravascular NETs (arrow) immunostaining. C, Contralateral hind limb muscle fibers are normal, with positive immunostaining only in the nuclei of muscle fibers. D, Negative control. The black bar in each image represents 200 μm. Journal of Vascular Surgery 2013 58, 1627-1636DOI: (10.1016/j.jvs.2013.02.241) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 4 Immunofluorescent images show neutrophil extracellular traps (NETs) in red and nuclear DNA in blue in wild-type tissue section with and without DNase treatment. A, Wild-type (WT) tissue section demonstrates detection of NETs in a thrombosed vein (arrowhead) and in the interstitium (arrows). B, Adjacent tissue section was immunostained for NETs after an initial incubation with DNase enzyme. The section shows significant decrease in NET signal, suggesting that nuclease pretreatment markedly reduced the level of antigen available for detection. The white bar in each image represents 80 μm. Journal of Vascular Surgery 2013 58, 1627-1636DOI: (10.1016/j.jvs.2013.02.241) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 5 Inducible nitric oxide synthase (iNOS) messenger RNA (mRNA) expression is seen in ischemia-reperfusion (IR) injured murine skeletal muscles using semi-quantitative reverse-transcription polymerase chain reaction. A, Toll-like receptor-4 mutant (TLR4m) mice had significantly less iNOS mRNA expression than wild-type (WT) mice (*P < .03) normalized to β-actin. B, A representative image of the agarose gel shows the iNOS and β-actin bands from the two groups of tissue samples. Journal of Vascular Surgery 2013 58, 1627-1636DOI: (10.1016/j.jvs.2013.02.241) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 6 A, Relative detection of p65 nuclear factor (NF)-κβ activity using an enzyme-linked immunosorbent assay is shown in murine hind limb muscle tissue after ischemia-reperfusion (IR). Toll-like receptor-4 mutant (TLR4m) mice had less p65 NF-κβ activity than wild-type (Wt) mice after 1.5 hours of ischemia and 1 hour of reperfusion (*P = .0025). By 48 hours there was no difference in p65 NF-κβ activity detected between the two groups. B, Protein levels of the α-subunit of inhibitor of NF-κB light polypeptide gene enhancer (IκBα) were quantitated using a Western blot analysis after 1.5 hours of ischemia and 1 hour of reperfusion. TLR4m mice had significantly greater levels of total IκBα in reperfused skeletal muscle than Wt mice (*P < .01). In contrast, there was no significant difference in the Ser32-phosphorylation of IκBα. C, Representative Western blot analysis of three Wt and three TLR4m-derived muscle tissues. D, TLR4m mice showed significant decrease in the poly adenosine diphosphate ribose-modified (PAR) proteins at 48 hours' reperfusion compared with Wt (*P = .032). E, Representative Western blot image of the detected poly ADP ribose-modified proteins in three Wt and three TLR4m skeletal muscle tissues. Journal of Vascular Surgery 2013 58, 1627-1636DOI: (10.1016/j.jvs.2013.02.241) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 7 Quantitation of systemic markers of inflammation: (A) keratinocyte-derived cytokine (KC), (B) monocyte chemotactant protein-1 (MCP-1), and (C) vascular endothelial growth factor (VEGF). A, Toll-like receptor-4 mutant (TLR4m) and wild-type (WT) mice had similar levels of the CXC cytokine KC. B, Serum MCP-1 levels in TLR4m mice, in contrast, were significantly lower than in WT mice after 48 hours of reperfusion (*P = .0002). C, TLR4m mice also demonstrated a significantly higher level of the proangiogenic factor VEGF (*P = .015). Journal of Vascular Surgery 2013 58, 1627-1636DOI: (10.1016/j.jvs.2013.02.241) Copyright © 2013 Society for Vascular Surgery Terms and Conditions