Sex-based differences in fibrosis markers in human abdominal aortic aneurysms

Background: Abdominal aortic aneurysms (AAA) are a complex degenerative vascular disease. The role of fibrosis in AAA progression is unclear. Our study evaluated the impact of fibroblast activation protein (FAP), collagen, and vimentin on AAA fibrosis and progression. We hypothesized that FAP may influence fibrosis and disease severity in AAA, with potential sex-specific differences. Study Design: Multi-centered transcriptomic analysis of aortic samples from 15 human AAA and 5 non-AAA was performed to evaluate cell-specific fibrosis gene expression profiles. Histopathological and molecular analysis of 26 male and female AAA samples (mAAA and fAAA) and 29 male and female normal abdominal aortas (mNAA and fNAA) was performed to assess whole-tissue fibrosis markers and signaling. Results: Single-cell RNA sequencing (scRNA-seq) analysis identified eight major cell clusters with distinct sex-based distributions. Although vascular smooth muscle cells (VSMCs) and fibroblast clusters had reduced counts in both male and female AAAs, they more highly expressed FAP and COL1A1 genes, particularly in females. Whole-tissue analysis demonstrated elevated extracellular matrix deposits with markedly increased collagen type 1 in both mAAA and fAAA. Alpha-smooth muscle actin (α-SMA)-positive VSMCs were also reduced in mAAA and fAAA, but FAP was notably elevated, and robustly in fAAA. FAP-positive fibroblasts in fAAA exhibited increased expression of fibrosis markers, suggesting a unique pro-fibrotic phenotype. Conclusion: Our study reveals a sex-based difference in AAA tissue, with elevated fibrosis markers and increased FAP levels in females, suggesting its significant role in disease progression. These findings underscore the potential of FAP as a unique tissue biomarker for AAAs and warrants further investigation into novel targeted therapies that aim to stabilize AAAs, particularly in female patients.