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Thrombosis Research 129 (2012) 220–224

Contents lists available at SciVerse ScienceDirect

Thrombosis Research
journal homepage: www.elsevier.com/locate/thromres

Mini Review

Platelets and Primary Haemostasis

Kenneth J. Clemetson ⁎
Department of Haematology, Inselspital, University of Berne, CH-3010 Berne, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Platelets have a critical role in haemostasis when vessel wall is injured. Platelet receptors are involved in se-
Received 13 September 2011 quence in this process by slowing platelets down via GPIb/von Willebrand factor to bring them into contact
Received in revised form 20 November 2011 with exposed collagen, then activating them via GPVI to release granule contents and express integrins in a
Accepted 22 November 2011
matrix protein binding state. More platelets are incorporated into the growing thrombus and a series of
Available online 16 December 2011
events are set off that finishes with the exposed subendothelium protected by a non-thrombogenic platelet
surface and tissue repair underway and the blood flow through the vessel maintained. GPIb is also involved
in thrombin activation and, together with GPVI, in the formation of COAT platelets. In thrombosis, patholog-
ical changes occur that may lead to life-threatening blockage of vessels. Prevention of thrombosis while
maintaining haemostasis remains a major goal of medical research.
© 2011 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Initial platelet-vessel wall interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Platelet activation on vessel wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Platelet-platelet interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Platelet spreading and interplatelet linkage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
More platelets attach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Microparticles in thrombosis and haemostasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Thrombus size regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Leukocyte association with thrombus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Secondary platelet activators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Thrombin and thrombin-generation as major players in haemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Methods to study platelet activation in primary haemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Thrombus models/intravital microscopy/perfusion chambers in haemostasis research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
What are the major problems facing platelet research with respect to haemostasis? Development of better anti-thrombotics. . . . . . . . . . . . 224
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Introduction that otherwise healthy people experience bleeding under conditions

Platelets are well-known to have a critical role in haemostasis –
stopping bleeding – which is easily demonstrated by bleeding prob-
lems in thrombocytopenia and in genetic disorders affecting several
of the major platelet receptors involved in haemostasis. Primary hae-
mostasis refers to the early stages of haemostasis when coagulation
has not yet developed to play its role in preventing blood loss. The fact
⁎ Tel.: + 41 319215443; fax: + 41 316313799.
E-mail address: clemetson@tki.unibe.ch.
of extreme thrombocytopenia (generally defined as b10,000 platelets/
l blood) has long been taken as proof that a major function of platelets
is keeping the vascular system intact. It was initially thought that this
involved simply repairing small subendothelium exposures caused by
loss of individual endothelial cells due to age and/or high local shear
stress. However, part of this process has now been shown to involve ac-
tivated platelets capturing endothelial precursor cells to fill the gap [1].
These are on-going processes that happen day-in, day-out, irrespective
of injuries as such. We all bump into things and some people bruise
more easily than others. Bruising is simply local capillary bleeding into

0049-3848/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.thromres.2011.11.036
 Author's personal copy
K.J. Clemetson / Thrombosis Research 129 (2012) 220–224
extravascular tissue. This is a sign of how efficiently platelets do their
main job. Heavy bruising in response to mild injury is often taken as a
sign of platelet deficiencies.
Vascular and tissue injury involves removal of the anti-thrombotic
endothelial cell layer and exposure of matrix molecules to varying
degrees and varying according to the depth of the injury. Major
matrix molecules include several types of collagen and laminin. Von
Willebrand factor (VWF) has a major role in haemostasis by binding
to collagen in the first instance and by binding to activated platelets
at a later stage [2]. Platelets, carried by the blood stream are swept
up against exposed matrix, adhere, become activated, undergo a
number of changes and, in turn, bind further platelets to form a
thrombus preventing further bleeding but limited in size. Each of
these phases is thought to involve specific (or specific sets of) platelet
receptors.
Thrombosis is the pathological version of haemostasis where
normal feedback controls to regulate thrombus size and stability
no longer appear to function appropriately so that life-threatening
occlusions of vessels can occur. Despite many advances over the
past decades, thrombosis remains the major cause of death and dis-
ability in the developed world and, with the adoption of similar
(unhealthy!) life styles, is rapidly spreading into new developing
regions. In order to tackle these diseases it remains important to
understand better the basic mechanisms involved in haemostasis
and how these are changed in thrombosis. Inhibition of platelets
via aspirin (TXA2 synthesis inhibitor) or P2Y12 inhibitors are well-
established and effective treatments and, even if they do not solve
all problems, have contributed to reducing premature deaths and
disablement [3].
In this review the role of platelets in basic mechanisms of pri-
mary haemostasis is discussed. In addition, attention is drawn to
those aspects where knowledge is still somewhat sketchy or where
there are clearly holes to be filled or controversies to settle. At pre-
sent, there is heavy emphasis on mouse models, often involving
depletion of particular proteins, as a guide to physiological and path-
ological processes. While these may be perfectly adequate in many
cases, it still remains to be shown that they are infallible in others.
Comparison of human and mouse platelet transcriptosomes have
shown that there are considerable differences, which may influence
mechanisms [4]. If one is interested in human health and disease it is
important to show that mouse models are applicable here as well.
A better understanding of basic mechanisms of haemostasis and
what differentiates it from thrombosis is also critical to development
of improved treatments for thrombosis and, even more desirable,
superior methods for its prevention.
Initial platelet-vessel wall interaction
The first step in primary haemostasis involves rapidly moving
platelets interacting with the exposed matrix to be slowed down so
that they can adhere (Fig. 1). Two molecules are mainly responsible
for this, VWF and the GPIb complex on platelets [2]. The VWF comes
primarily from plasma but VWF from activated platelets and/or en-
dothelial cells, both made up of higher multimers, may play a major
role at a later stage. Whatever the source, VWF binds specifically to
sites on exposed collagen and is stretched by the shear stress of the
flowing blood to expose binding sites on the A1 domains for GPIb. The
VWF monomers are joined via disulphide bonds to dimers, linked
head to head and then further multimerized tail to tail. This means
that A1 domains occur in proximal pairs, thought to bind two GPIb
complexes. Larger VWF multimers are more haemostatically efficient
on a mass basis either because they stretch more easily at the same
shear, exposing the GPIb binding sites on the A1 domains, or because
they link more GPIb complexes together on the platelet surface. The
GPIb complexes on the platelet membrane are linked to the sub-
membranous cytoskeleton via filamin. This is important because it
221
Fig. 1. A simplified diagram of the stages involved in primary haemostasis. A. Platelets
arrive with the blood stream from the left, contact exposed subendothelium matrix,
form tethers and are slowed to a stop in contact with subendothelium. B. The platelet
integrins are activated to support platelet adhesion. C. The platelets spread on suben-
dothelial substrates. D. Additional platelets can adhere to activated integrins via fibrin-
ogen and von Willebrand factor to form a thrombus. The major platelet receptors
involved in each stage are indicated below and, at the bottom, the major processes at
each stage are shown. After the first few seconds all these processes are concurrent.
provides a solid anchorage for GPIb [5]. Following platelet contact
with the VWF-coated subendothelial matrix, GPIb binds to VWF at
the contact site. Since the platelet is still moving rapidly at that point,
it draws out the patch of bound GPIb together with membrane and
associated cytoskeleton to form an elongated tether. Either this tether
is sufficiently strong to bring the platelet to a standstill in contact with
the subendothelium or it breaks allowing the platelet to continue but
now moving more slowly. Since, even if it breaks the tether has main-
tained contact with the subendothelium, the chances are high that a
second tether forms until the platelet is finally brought to a stop [6].
There is still some controversy concerning internal platelet sig-
nalling as a consequence of VWF-induced GPIb clustering and tether
formation. Certainly, several authors have reported brief Ca2 + sig-
nals as well as ADP release and integrin activation based on GPIb/
VWF interaction alone [7]. This may account for some of the obser-
vations in patients lacking other receptors where no major bleeding
problems have been reported. However, in the generally accepted
model for primary haemostasis, integrin activation is mainly thought
to occur only after activation of other receptors.
Platelet activation on vessel wall
The major signalling receptor involved is thought to be GPVI [8]
via binding to specific GPO (glycine-proline-hydroxyproline) sites
on exposed collagens. Since collagens vary considerably in GPO con-
tent the degree of activation will depend on extent of injury. GPVI
was also shown to bind laminin, which is also exposed in vascular in-
jury. Following GPVI interaction with collagen platelets are strongly
activated and release the content of α- and dense granules. These
feed back to their platelet receptors to enhance platelet activation,
in particular activation of integrins including α2β1 and αIIbβ3. Once
these integrins are activated and able to bind collagen and fibrinogen/
fibrin, respectively, the next phase of platelet/subendothelial interac-
tion starts. Calcium signalling plays an important role here too. Sig-
nalling from surface receptors leads to formation of IP3 which triggers
Ca2 + release from its storage organelle, the dense tubular system, and
opens channels in the plasma membrane allowing Ca 2 + to enter
from the plasma [9]. When activation ceases Ca 2 + is pumped back to
the dense tubular system and extracellular space by Ca 2 + ATPases.
The raised Ca 2 +levels are involved in many of the platelet signal-
ling process and lead, among others, to the exposure of negatively
charged phospholipids, such as phosphatidylserine, on the platelet
 Author's personal copy
222 K.J. Clemetson / Thrombosis Research 129 (2012) 220–224
surface. The negatively charged surface is critical for conversion of
prothrombin to thrombin via the coagulation cascade.
Platelet-platelet interactions
Normally, resting platelets circulate without interacting. Only
when they are activated, either via interaction with exposed suben-
dothelium or by agonists released from activated platelets or dam-
aged erythrocytes or endothelium cells do they become reactive.
The major interactive mechanism is via activation of the major platelet
integrin αIIbβ3, which binds a number of plasma and platelet releasate
proteins but principally fibrinogen [10]. As fibrinogen is a bivalent li-
gand it can bind to αIIbβ3 on two platelets, leading to platelet aggrega-
tion. VWF also has a binding site for αIIbβ3 and under high shear also
binds to GPIb, also participating in platelet aggregation. A number of
other platelet receptors may also contribute to the aggregation process
but αIIbβ3 is by far the major one and thus, has been and is, a major
target for preventing thrombosis. Under acute conditions, such as
major surgery ths approach has been very successful and is widely
applied. Attempts to use it for preventive and chronic situations
have so far been unsuccessful because the inhibitory compounds
used had the side effect of activating resting αIIbβ3 so that platelet
aggregation was finally induced rather than prevented. Recently, a
great deal of research has been directed towards developing drugs
that inhibit αIIbβ3 in the resting state and stop the integrin from
being activated and it is hoped that these will be more successful
in the clinic. A major problem remains that even when αIIbβ3 acti-
vation and interaction with fibrinogen is prevented, many of the
platelet activation steps may still occur, shape change, release of
granules and activation of signalling pathways among others [11].
These may still lead to recruitment of leukocytes and other aspects
of inflammation that it had been hoped blocking αIIbβ3 would pre-
vent. In the formation of a thrombus, αIIbβ3-fibrinogen-induced
platelet aggregation is only a first step and other receptor-ligand
interactions, over a longer period than is generally understood as
primary haemostasis, stabilize and anchor the critical central plate-
let layer involved in presenting a non-thrombotic surface [12].
Platelet spreading and interplatelet linkage
Integrin binding to matrix-linked proteins such as collagen is the
signal for the platelet to spread out on the subendothelial surface
(Fig. 1). Studies in vitro show that first of all the platelet extends
pseudopods in all directions and once these have become fixed, the
gaps in between are filled leading to a completely spread platelet.
On a flat surface it is virtually circular with two membranes separated
by a small amount of submembranous cytoskeleton. In the centre this
is somewhat thicker as all the remnant cytoplasmic components
(mitochondria, granule membranes, etc.) are collected together by
cytoskeletal contraction. Where two spread platelets come in contact
they form tight junctions, preventing blood loss. There is evidence
that these junctions involve several of the molecules that form endo-
thelial junctions.
More platelets attach
Activated platelets form a surface on which other platelets can in
turn attach (Fig. 1). Although this is most likely a complex process
the most likely mechanism involves plasma VWF binding to activated
αIIbβ3. This in turn provides anchored VWF to bind to GPIb on in-
coming platelets and stop them via tether formation. In this case
however there is no possibility of incoming platelets being activated
via the GPVI/collagen route. Therefore, the main activation pathway
must be via activators released by the first layer of platelets, such as
ADP. Binding between the first layer and subsequent incoming
platelets also involves fibrinogen binding to activated αIIbβ3 and
is defective in Glanzmann's thrombasthenia where platelets have
absent or defective αIIbβ3.
An important new aspect to be considered is the role of COAT
platelets in this stage. COAT platelets are platelets activated by a com-
bination of thrombin and collagen, which are coated with a covalently
bound layer (involving serotonin and transglutaminase) and repre-
sent the most activated form of platelets [13]. Although little is
known of the role of COAT platelets under physiological conditions
in haemostasis, it seems reasonable to assume that they would be
predominantly formed by the layer of platelets directly in contact
with collagen and exposed to thrombin at a slightly later stage. This
may explain the stability of the early platelet layers in a thrombus
compared to those arriving later that, after adding material to the
thrombus, finally revert to the circulation.
Microparticles in thrombosis and haemostasis
Microparticles are small membrane vesicles or cell fragments de-
rived from activated or apoptotic cells, which circulate in the blood
of healthy individuals but may be increased in a variety of diseases,
including cardiovascular diseases, cancer, sepsis and diabetes [14].
They range in size from 100 to 1000 nm in diameter and are typically
around 300 nm. The major part of circulating microparticles >90% are
normally derived from platelets. The platelet-derived microparticles
are thought to be highly procoagulant and to express phosphatidyl
serine on their surface. As such they might be expected to have a
critical role in susceptibility to thrombosis or even efficiency of
haemostasis. However, this has been highly controversial and there re-
mains little uncontested evidence that this is the case. On the other
hand, tissue factor (TF) carrying microparticles, derived from activated
monocytes are another matter and there is a great deal of evidence
that this is an important pathway for adding TF to a growing thrombus
[15]. TF is critical for coagulation pathways and thrombin generation.
Thrombus size regulation
If a vessel has not been completely sectioned haemostasis should
prevent blood loss from the damaged wall but not obstruct the
blood flow through the vessel [16]. To do this the size of the growing
thrombus has to be limited at some point. As a thrombus grows the
shear over its surface increases. This means that the force to be over-
come by the incoming platelet to adhere also increases. At the same
time, as the thrombus increases in size, the platelets at the exterior
are progressively more weakly activated and adhere less strongly.
At some point the two reach equilibrium and platelets cease to be de-
posited. Further, because the outer platelets are less activated their
receptors may become deactivated and allow the platelets to detach.
If large parts of the thrombus are torn off by shear they form an em-
bolus. Under normal physiological conditions such an embolus seems
to dissociate rapidly into individual platelets, which may continue to
circulate normally or perhaps be removed if they have undergone too
dramatic changes. Once removed from the injury site platelets are ex-
posed to prostaglandins and nitric oxide that quieten platelet activity
and any associated ADP is rapidly removed by apyrase expressed on
the endothelial surface [17]. Platelet fate following partial activation
is one aspect of platelet physiology that is still poorly understood.
Thus, in the end the damaged vessel wall is covered with a non-
thrombogenic layer of platelets, stopping further blood loss. It is not
clear how the thrombus surface becomes non-thrombogenic. Pre-
sumably, no VWF/fibrinogen binding sites are expressed on, or have
been removed from, this surface.
Leukocyte association with thrombus
Platelet activation involving granule release includes expression of
granule membrane components on the platelet surface. These include
 Author's personal copy
K.J. Clemetson / Thrombosis Research 129 (2012) 220–224
P-selectin (CD62p) and CD40 ligand (CD40L, CD154). These are im-
portant receptors/ligands for leukocytes, on the one hand allowing
leukocytes to roll via CD62p/P-selectin glycoprotein receptor-1 (PSGL-
1) interactions and on the other to activate them via CD154/CD40
interactions. Leukocytes may be involved in early stages of thrombus
formation, releasing and reacting to chemokines and other vasoactive
substances [18]. They are certainly critical to later stages involving
cleaning up dead cells and damaged tissue and helping the wound
healing process.
Secondary platelet activators
Although the number of primary activators of platelet activity
are limited, being largely confined to GPIb complex and the integrins
α2β1 and αIIbβ3, secondary activators are a much larger group. Mainly
they consist of molecules released from platelet granules that feedback
to platelet receptors principally of the G-protein coupled, seven trans-
membrane group. Among these the ADP receptors P2Y1 and P2Y12,
the thrombin receptors PAR1 and PAR4 and the thromboxane receptor
for TXA2 are particularly important but there are many others that play
subsidiary roles [19].
Thrombin and thrombin-generation as major players
in haemostasis
Thrombin is a major platelet activator via several receptors and
thrombin-generation by converting prothrombin to thrombin am-
plifies platelet activation and fibrinogen conversion to fibrin and is
a critical contributor to secondary haemostasis via coagulation cas-
cades. All these aspects are complicated and all the problems are
far from being solved. Here, only the first two aspects will be dis-
cussed. It is generally well known that PAR1 and PAR4 are the two
proteolytically-activated, G-protein-coupled, seven transmem-
brane receptors on human platelets. Both these receptors function
by proteolysis of an external N-terminal sequence exposing a new
N-terminus that can act as a ligand for the receptor. However, the
situation is different on mouse platelets with PAR3 and PAR4 the
two receptors. PAR3 presents thrombin to PAR4 and thus acceler-
ates platelet activation by increasing PAR4 cleavage. In human
platelets PAR1 is rapidly cleaved, providing early platelet activa-
tion while PAR4 requires higher thrombin concentrations and re-
sponds more slowly. The evolutionary logic behind this is to
allow platelets to respond to radically different thrombin concen-
trations without all the receptor (PAR1) being quickly removed by
high concentrations. PAR1 is also rapidly down-regulated by inter-
nalization following phosphorylation of cytoplasmic domains thus
protecting part for re-expression later and maintaining platelet
sensitivity. This model is widely accepted [20] and can be demon-
strated using peptides from the new thrombin-cleaved N-terminus
of both PAR1 and PAR4. However, they do not account fully for all
platelet responses to thrombin. This is a very controversial area and
while most authors agree on the parameters of platelet response, no-
one has yet provided a completely convincing explanation for all the
observations. The main problem is the role of GPIb in platelet re-
sponses to thrombin [21]. This first came to light in studies on
Bernard-Soulier syndrome platelets where it was observed that
they not only show a defect in responses to VWF but also to throm-
bin. These observations were supported by other studies either
blocking the thrombin binding site on GPIb with antibodies or
other inhibitors or proteolytically removing all or part of the GPIb
extracellular domain. In human platelets blockage or cleavage of
GPIbα strongly inhibits the early stages of platelet response to
thrombin, suggesting the GPIbα has a critical role but the mecha-
nism is still obscure. Together with other data a possible explana-
tion might be that thrombin binding to GPIbα facilitates presentation
to PAR1 and accelerates its cleavage.
223
It is generally suggested in reviews that platelet adhesion to VWF
via GPIb, involved in arresting platelets at an injury site, is not suffi-
cient to lead to integrin activation and secure adhesion. A major rea-
son for this interpretation may be that in many of the thrombus
models, or in the perfusion chambers used to explore platelet in-
teraction with various matrix molecules the role of GPIb/VWF en-
gagement and integrin activation were not directly examined. In
vitro studies using artificial methods to induce VWF/GPIb intera-
tions, such as ristocetin or botrocetin, or using other snaclecs (snake
C-type lectins) that cluster GPIb on platelets without VWF, cause
platelet activation involving ADP release and second wave aggrega-
tion. In mouse vasculature models, using molecules that chelate and
fluoresce in the presence of Ca 2 +, brief, weak fluorescence signals
were ascribed to GPIb/VWF binding, while stronger, longer-lasting
signals indicated integrin activation [7]. The absence of GPVI, the
major collagen receptor involved in platelet activation only causes
very mild bleeding problems suggesting that GPIb binding/clustering
does lead to considerable integrin activation and consequent platelet
adhesion. There is considerable interest in GPIb as a target for inhi-
bition to prevent thrombotic disorders [22].
Methods to study platelet activation in primary haemostasis
Over the last 50 years or so there has been increasing interest
in defining the role of platelets in both haemostasis and thrombo-
sis. A recurrent theme has been the measurement of the ability of
platelets to become activated and to what extent this plays a role
in platelet-related bleeding disorders (decreased platelet responses)
or in thrombotic disorders (hyperactive platelets). One of the earliest
and still much used methods is platelet aggregometry based on the
absorption of a light beam passing through a platelet suspension (PRP
or washed platelets) [23]. Platelet aggregates allow more light to pass
than resting platelet suspension allowing aggregation curves to be
obtained which provide information about several aspects of platelet
function that are otherwise difficult to obtain. These include platelet
shape and shape change kinetics (related to “chatter” in transmission
signal) as well as speed of aggregation, maximum size of platelet
aggregates and whether aggregation is reversible.
This is also an extremely useful method of testing limiting agonist
concentrations and synergism between agonists as well as down-
regulation of responses by low doses.
More recently, a series of more or less automated techniques have
been developed into commercial devices to try to measure more
global platelet responses in whole blood by simulating high shear
situations comparable to those in vivo. These include aspirating
whole blood through a small hole in a membrane coated either with
collagen and ADP or collagen and epinephrine. The platelets in the
blood interact with the collagen and ADP and bind via VWF and then
aggegate. The kinetics of closure of the hole measured by the vacuum
in the system provides information about platelet function as well as
about VWF function and can be used to decide further diagnostic tests
to apply [24]. Another method applies shear to a small volume of
whole blood in a miniature cone and plate device. Platelets are acti-
vated, release high molecular mass VWF, which adheres to the plate
surface, and platelets subsequently adhere to the VWF and aggre-
gate. The pattern obtained, measured in terms of surface coated
and density of aggregated platelets can provide much useful infor-
mation about platelet function[25].
Flow cytometry is widely used to investigate expression of platelet
receptors as well as platelet responses to agonists. It is being increas-
ingly applied to more complex measurements such as calcium release
and phosphorylation of signaling molecules.
Finally, more recent approaches, particularly in mouse models try
to emulate in vivo conditions and have been applied extensively in
mice with particular genes knocked out as well as using various ap-
proaches to thrombus induction.
 Author's personal copy
224 K.J. Clemetson / Thrombosis Research 129 (2012) 220–224
Thrombus models/intravital microscopy/perfusion chambers in
haemostasis research
Thrombus models in mice and other small animals are really
haemostasis models because the pathological conditions necessary
are generally not met. They fall into two major categories: In the
laser injury model, which does not result in significant collagen
exposure, platelet accumulation is thought to be tissue factor-
and thrombin-dependent and independent of the GPVI collagen
receptor and VWF. In contrast, in thrombosis models where the
endothelium is removed and collagen exposed, both GPVI and GPIbα
are important for thrombus formation. These results suggest two
independent pathways to platelet activation, either in parallel or
separately [26]. Platelet activation may occur either through suben-
dothelial collagen exposure, or by thrombin generated by the tissue
factor pathway of blood coagulation. Following platelet activation
by either pathway thrombus formation is similar. It is not yet clear
what recruits platelets to the laser-injured vessel wall when collagen
is not exposed or in how far this represents the physiological or patho-
logical situation in vivo.
Protein disulfide isomerase appears rapidly after laser-induced
vessel wall injury, prior to the appearance of the platelet thrombus.
Inhibition of protein disulfide isomerase activity with bacitracin A, a
non-specific thiol isomerase inhibitor, or an inhibitory monoclonal
anti-protein disulfide isomerase antibody inhibited platelet thrombus
formation and fibrin generation. Infusion of an inhibitory monoclonal
anti-protein disulfide isomerase antibody into the circulation of a
PAR4−/− mouse prior to vessel wall injury inhibited fibrin genera-
tion indicating, that protein disulfide isomerase is required in vivo
for both fibrin generation and platelet thrombus formation [27].
Two photon, intravital microscopy has been used to follow dif-
ferent thrombus components in real time [28].
What are the major problems facing platelet research with respect
to haemostasis? Development of better anti-thrombotics
The years since the major platelet activators and receptors as well
as haemostasis mechanisms started to be identified and clarified have
lead to major improvements in treatment for thrombosis. As a result
many lives can be usefully prolonged and better quality of life as-
sured. Despite this cardiovascular diseases are still major health prob-
lems for society. Some of these problems are genetic in origin and,
since genomic studies became available, it becomes easier to identify
people who may be at higher risk. Problems of life style are another
factor – obesity and diabetes – smoking and other preventable hazards.
Even people with healthy lifestyles could be helped if appropriate
treatments were available and considerable effort is being made
in this direction.
Conflict of interest
None.
References
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