Protease-activated receptors are potential regulators in the development of arterial endofibrosis in high-performance athletes

J Vasc Surg. 2019 Apr;69(4):1243-1250. doi: 10.1016/j.jvs.2018.05.220. Epub 2018 Oct 9.


Objective: High-performance athletes can develop symptomatic arterial flow restriction during exercise caused by endofibrosis. The pathogenesis is poorly understood; however, coagulation enzymes, such as tissue factor (TF) and coagulation factor Xa, might contribute to the fibrotic process, which is mainly regulated through activation of protease-activated receptors (PARs). Therefore, the aim of this explorative study was to evaluate the presence of coagulation factors and PARs in endofibrotic tissue, which might be indicative of their potential role in the natural development of endofibrosis.

Methods: External iliac arterial specimens with endofibrosis (n = 19) were collected during surgical interventions. As control, arterial segments of the external iliac artery (n = 20) were collected post mortem from individuals with no medical history of cardiovascular disease who donated their body to medical science. Arteries were paraffinized and cut in tissue sections for immunohistochemical analysis. Positive staining within lesions was determined with ImageJ software (National Institutes of Health, Bethesda, Md).

Results: Endofibrotic segments contained a neointima, causing intraluminal stenosis, which was highly positive for collagen (+150%; P < .01) and elastin (+148%; P < .01) in comparison with controls. Intriguingly, endofibrosis was not limited to the intima because collagen (+213%) and elastin (+215%) were also significantly elevated in the media layer of endofibrotic segments. These findings were accompanied by significantly increased α-smooth muscle actin-positive cells, morphologically compatible with the presence of myofibroblasts. In addition, PAR1 and PAR4 and the membrane receptor TF were increased as well as coagulation factor X.

Conclusions: We showed that myofibroblasts and the accompanying collagen and elastin synthesis might be key factors in the development of endofibrosis. The special association with increased presence of PARs, factor X, and TF suggests that protease-mediated cell signaling could be a contributing component in the mechanisms leading to endofibrosis.

Keywords: Coagulation factors; Endofibrosis; Protease-activated receptors; Vascula fibrosis.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Athletes*
  • Athletic Performance*
  • Cadaver
  • Case-Control Studies
  • Collagen / analysis
  • Constriction, Pathologic
  • Elastin / analysis
  • Factor X / analysis
  • Female
  • Fibrosis
  • Humans
  • Iliac Artery / chemistry*
  • Iliac Artery / pathology
  • Male
  • Middle Aged
  • Myofibroblasts / chemistry
  • Myofibroblasts / pathology
  • Peripheral Arterial Disease / metabolism*
  • Peripheral Arterial Disease / pathology
  • Peripheral Arterial Disease / physiopathology
  • Receptor, PAR-1 / analysis*
  • Receptors, Thrombin / analysis*
  • Thromboplastin / analysis
  • Up-Regulation
  • Vascular Remodeling*
  • Young Adult


  • Receptor, PAR-1
  • Receptors, Thrombin
  • Factor X
  • Collagen
  • Elastin
  • Thromboplastin
  • protease-activated receptor 4