Macrophage pyroptosis inhibition alleviates postinjury neointimal formation and vascular restenosis

Clinically, restenosis remains the leading cause of long-term failure following endovascular interventions for cardiovascular diseases. However, the underlying pathogenesis of restenosis is not yet fully elucidated. Current therapeutic devices, such as drug-coated balloons or stents, are typically loaded with non-specific antiproliferative agents, whose broad cytotoxic effects may exacerbate vascular inflammation. This study investigates the mechanism of restenosis following endovascular interventions and develops a novel targeted therapeutic strategy based on the identified mechanism. Single-cell transcriptomic sequencing was employed to investigate cellular and gene changes in restenotic vessels. Macrophage-specific knockdown of GSDMD was performed, and disulfiram-coated balloon (DCB) is developed to deliver disulfiram (DSF) to the target vessel, blocking GSDMD-mediated pyroptosis. The effects of this strategy were validated through systematic in vivo and in vitro experiments. Here, elevated expression levels of pyroptosis-related genes were observed in blood samples from patients with restenosis. Single-cell transcriptomic analysis revealed that macrophages were the key cell population undergoing pyroptosis in vessels with restenosis. Immunofluorescence co-staining of rat vessels demonstrated that GSDMD was localized in the macrophages within restenotic vessels. Immunoblot analysis further confirmed that GSDMD was in its activated state in restenotic vessels. Knockdown of specific macrophage GSDMD ameliorated inflammatory response, promoted vascular endothelial repair, and inhibited neointimal formation. To translate these mechanistic insights into therapy, the DCB was developed to enable localized delivery of DSF to the injured vessel wall, thereby effectively inhibiting GSDMD pore formation. Results from the rat carotid artery balloon injury model indicated that by targeting GSDMD, DCB inhibited macrophage pyroptosis and associated inflammation, promoting functional re-endothelialization, and reducing neointimal hyperplasia. Mechanistically, in vitro co-culture experiments demonstrated that GSDMD-mediated macrophage pyroptosis plays a key role in the differential regulation of vascular endothelial cells and smooth muscle cells by DSF. Collectively, our findings identify GSDMD as a novel and therapeutically relevant target in vascular restenosis. Based on this mechanism, DCB, which inhibits pyroptosis by targeting GSDMD, represents a promising therapeutic strategy for prevention of restenosis. Newly infiltrated macrophages undergo GSDMD-mediated pyroptosis in injured vessels after endovascular interventions. GSDMD-mediated macrophage pyroptosis contributes to endothelial damage and neointimal formation. The disulfiram-coated balloon (DCB) is specifically engineered for targeted delivery of disulfiram to the injured vessel wall, inhibiting GSDMD activation and pyroptotic pore formation. DCB promotes functional re-endothelialization and suppresses neointimal hyperplasia in the injured vessel.