Delivery of FGF-2 but not VEGF by encapsulated genetically engineered myoblasts improves survival and vascularization in a model of acute skin flap ischemia

The Effect of Fibrin on the Survival of Ischemic Skin Flaps in Rats

BACKGROUND

Skin flap necrosis is one of the hazards encountered in plastic and reconstructive surgery. Angiogenic agents may be useful for treating it by increasing blood flow. The angiogenic effect of fibrin in vitro has been demonstrated, but little is known about its in vivo effect. Te authors tested the hypothesis that local application of fibrin can improve the survival of ischemic skin flaps.

METHODS

A cranially based dorsal skin flap (3 x 7 cm) was made in each rat. Fibrin (8 mg suspended in 400 microl of phosphate-buffered saline) was applied to the subcutaneous side of elevated skin flaps in the experimental group (n = 15), and phosphate-buffered saline alone was delivered in the control group (n = 15). Tissue blood flow of the skin flaps was measured four times (before the operation and on days 1, 3, and 7) at 1, 3, and 5 cm distal to the baseline of the skin flap. The survival rate of the skin flaps was measured on day 7 and histologic assessments were performed.

RESULTS

The blood flow change rate at 5 cm in the experimental group was significantly higher than that in the control group on day 7 (60.9 +/- 5.7 percent versus 13.7 +/- 4.8 percent, p < 0.001). The survival rate of skin flaps was also significantly improved in the experimental group (77.0 +/- 2.0 percent) in comparison with the control group (54.7 +/- 2.2 percent, p < 0.01). Histologic analysis showed many more blood vessels in the experimental group in comparison with the control group.

CONCLUSION

The local application of fibrin could improve the blood flow and survival of ischemic skin flaps.

Vascularization and Improved In Vivo Survival of VEGF-Secreting Cells Microencapsulated in HEMA-MMA

Vascularization caused by encapsulated cells engineered to secrete vascular endothelial growth factor (VEGF) improved the in vivo survival of the encapsulated cells in a syngeneic mouse Matrigel plug model. Murine fibroblast cells (L929) were engineered to secrete recombinant human vascular endothelial growth factor (rhVEGF(165)). Transfected and nontransfected L929 cells were microencapsulated in a 75:25 hydroxyethyl methacrylate-methyl methacrylate (HEMA-MMA) copolymer. Capsules containing transfected cells induced vascularization in vivo at 1 and 3 weeks postimplantation. In histological sections, a significant positive correlation was seen between the number of capsules and blood vessel density for VEGF-secreting cell capsule implants. New vessels, many positively stained for smooth muscle cells and pericytes, were seen surrounding these VEGF-secreting cell capsule explants. Few vessels were seen in nontransfected L929 capsule implants. The viability of transfected and nontransfected encapsulated cells was assessed on explantation. Although the viability of all encapsulated cells decreased at both 1 and 3 weeks, encapsulated VEGF-secreting cells retained more of the viability than did encapsulated nontransfected control cells. Genetically modified cells promoted vascularization in this context and appeared to enhance the viability of the encapsulated cells, although the extent of the functional benefit was less than expected. Additional effort is required to enhance the benefit, to quantify it, and to understand further the host response to HEMA-MMA microencapsulated cells and tissue constructs, more generally.

Expression of FGF-2 in neural progenitor cells enhances their potential for cellular brain repair in the rodent cortex

Strategies to enhance the capacity of grafted stem/progenitors cells to generate multipotential, proliferative and migrating pools of cells in the postnatal brain could be crucial for structural repair after brain damage. We investigated whether the over-expression of basic fibroblast growth factor 2 (FGF-2) in neural progenitor cells (NPCs) could provide a robust source of migrating NPCs for tissue repair in the rat cerebral cortex. Using live imaging we provide direct evidence that FGF-2 over-expression significantly enhances the migratory capacity of grafted NPCs in complex 3D structures, such as cortical slices. Furthermore, we show that the migratory as well as proliferative properties of FGF-2 over-expressing NPCs are maintained after in vivo transplantation. Importantly, after transplantation into a neonatal ischaemic cortex, FGF-2 over-expressing NPCs efficiently invade the injured cortex and generate an increased pool of immature neurons available for brain repair. Differentiation of progenitor cells into immature neurons was correlated with a gradual down-regulation of the FGF-2 transgene. These results reveal an important role for FGF-2 in regulating NPCs functions when interacting with the host tissue and offer a potential strategy to generate a robust source of migrating and immature progenitors for repairing a neonatal ischaemic cortex.

Perivascular cells in a skin graft are rapidly repopulated by host cells

Survival of grafted tissues is dependent upon revascularisation. This study investigated revascularisation in a murine skin graft model, using two methods. The first involved 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine (DiI) labelling of the wound bed, prior to replacing the skin graft, to allow tracking of host cells into the grafts. At time points between day 3 and day 14 post-surgery, DiI-labelled cells which had tracked into the grafts, were found to co-localise with CD31 positive endothelial cells and patent perfused vessels (fluorescein isothiocyanate (FITC)-dextran perfusion), to show possible association with the vasculature. To further differentiate between graft and host-derived cells, C57BL/6 wild-type grafts were placed on enhanced-green fluorescent protein (e-GFP) transgenic mouse hosts, and at set times post-grafting examined using confocal microscopy. Patent vessels were found at all depths of the graft by day 3. Host (DiI- or GFP-positive) cells were predominantly co-localised with graft vessels in grafts from day 3 onwards, with a similar morphology to control skin. Significantly more GFP labelled host cells were visualised in the superficial dermis at day 5 compared to day 3. Initial restoration of circulation appears to be due to linkage between existing graft and bed vessels, followed by an influx of host cells with a definite perivascular distribution. These findings have implications for skin autografts and tissue engineered skin substitutes.

An arteriovenous loop in a protected space generates a permanent, highly vascular, tissue‐engineered construct

A major obstacle to 3-dimensional tissue engineering is incorporation of a functional vascular supply to support the expanding new tissue. This is overcome in an in vivo intrinsic vascularization model where an arteriovenous loop (AVL) is placed in a noncollapsible space protected by a polycarbonate chamber. Vascular development and hypoxia were examined from 3 days to 112 days by vascular casting, morphometric, and morphological techniques to understand the model's vascular growth and remodeling parameters for tissue engineering purposes. At 3 days a fibrin exudate surrounded the AVL, providing a scaffold to migrating inflammatory, endothelial, and mesenchymal cells. Capillaries formed between 3 and 7 days. Hypoxia and cell proliferation were maximal at 7 days, followed by a peak in percent vascular volume at 10 days (23.20+/-3.14% compared with 3.59+/-2.68% at 3 days, P<0.001). Maximal apoptosis was observed at 112 days. The protected space and spontaneous microcirculatory development in this model suggest it would be applicable for in vivo tissue engineering. A temporal window in a period of intense angiogenesis at 7 to 10 days is optimal for exogenous cell seeding and survival in the chamber, potentially enabling specific tissue outcomes to be achieved.

Oral administration of nicorandil enhances the survival of ischemic skin flaps in rats

Nicorandil has an anti-apoptotic effect on ischemic myocardium through the activation of ATP-sensitive potassium (K(ATP)) channel. We tested the hypothesis that oral administration of nicorandil had a protective effect on ischemic skin flaps. A cranially based skin flap measuring 3x7 cm in full thickness was made on the back of rats. The rats were divided into a control group and 8 nicorandil groups (group 1-8) according to different doses and timings of administration. On day 7 at 5 cm, groups 1 to 6 (10 or 30 mg/kg twice per day for 3 days starting at 24 h before, 0.5 h before or 0.5 h after the operation) showed significantly higher blood perfusion change rate (73.3+/-2.9%-79.1+/-4.1% vs. 25.9+/-8.6%, P<0.01), and significantly higher survival rate (68.8+/-4.8-75.2+/-8.2% vs. 47.0+/-2.8%, P<0.05) than the control group. Many more surviving blood vessels were also observed in these groups. In contrast, no significant effects were found either in group 7 (30 mg/kg twice per day for 3 days starting 24 h after the operation) or group 8 (30 mg/kg once at 0.5 h after the operation). We did not find an angiogenic effect of nicorandil in vitro. Therefore, our results confirmed that the oral administration of nicorandil could protect tissues from necrosis in ischemic skin flaps. In addition, its protective effect depends on the time of first administration and the duration.

Gene-modified tissue-engineered skin: the next generation of skin substitutes

Tissue engineering combines the principles of cell biology, engineering and materials science to develop three-dimensional tissues to replace or restore tissue function. Tissue engineered skin is one of most advanced tissue constructs, yet it lacks several important functions including those provided by hair follicles, sebaceous glands, sweat glands and dendritic cells. Although the complexity of skin may be difficult to recapitulate entirely, new or improved functions can be provided by genetic modification of the cells that make up the tissues. Gene therapy can also be used in wound healing to promote tissue regeneration or prevent healing abnormalities such as formation of scars and keloids. Finally, gene-enhanced skin substitutes have great potential as cell-based devices to deliver therapeutics locally or systemically. Although significant progress has been made in the development of gene transfer technologies, several challenges have to be met before clinical application of genetically modified skin tissue. Engineering challenges include methods for improved efficiency and targeted gene delivery; efficient gene transfer to the stem cells that constantly regenerate the dynamic epidermal tissue; and development of novel biomaterials for controlled gene delivery. In addition, advances in regulatable vectors to achieve spatially and temporally controlled gene expression by physiological or exogenous signals may facilitate pharmacological administration of therapeutics through genetically engineered skin. Gene modified skin substitutes are also employed as biological models to understand tissue development or disease progression in a realistic three-dimensional context. In summary, gene therapy has the potential to generate the next generation of skin substitutes with enhanced capacity for treatment of burns, chronic wounds and even systemic diseases.

Cardiovascular gene delivery: The good road is awaiting

Atherosclerotic cardiovascular disease is a leading cause of death worldwide. Despite recent improvements in medical, operative, and endovascular treatments, the number of interventions performed annually continues to increase. Unfortunately, the durability of these interventions is limited acutely by thrombotic complications and later by myointimal hyperplasia followed by progression of atherosclerotic disease over time. Despite improving medical management of patients with atherosclerotic disease, these complications appear to be persisting. Cardiovascular gene therapy has the potential to make significant clinical inroads to limit these complications. This article will review the technical aspects of cardiovascular gene therapy; its application for promoting a functional endothelium, smooth muscle cell growth inhibition, therapeutic angiogenesis, tissue engineered vascular conduits, and discuss the current status of various applicable clinical trials.

The tetrapeptide acetyl-serine-aspartyl-lysine-proline improves skin flap survival and accelerates wound healing

The tetrapeptide acetyl-serine-aspartyl-lysine-proline (AcSDKP) has recently been recognized as a potent angiogenic factor. Given the importance of vascular blood supply in the process of tissue repair we have investigated the ability of AcSDKP to contribute to the repair of cutaneous injuries by using dorsal and abdominal skin flap models. Postoperative subdermal AcSDKP injections (5 microg/kg/injection twice a day for 3 days following flap elevation) prevented marginally perfused areas from undergoing necrosis. Mean skin survival area of abdominal and dorsal flaps ranged, respectively, from 50.9+/-19.3 and 53.4+/-4.2% in the control groups to 66.4+/-7.5 and 74.7+/-6.6% in AcSDKP-treated groups. Furthermore, in an ex vivo assay, AcSDKP applied locally to skin explants at doses from 10(-8) to 10(-5) M improved survival of the explanted skin exposed to UVB irradiation at 10 J/cm2. Increased reepithelialization, as well as higher levels of expression of basal keratin 14 and increased expression of fibronectin was observed after topical application of AcSDKP. These data provide experimental evidence that AcSDKP can improve the viability of ischemic skin flaps in the rat by promoting angiogenesis. Moreover, it enhances wound healing of injured avascular skin explants. Thus, these findings identify AcSDKP as a new tissue-repair agent and suggest its potential clinical use for the management of skin wounds.

Angiogenesis-like activity of endothelial cells co-cultured with VEGF-producing smooth muscle cells

A number of strategies have been investigated to improve therapeutic vascularization of ischemic and bioengineered tissues. In these studies, we genetically modified vascular smooth muscle cells (VSMC) to promote endothelial cell proliferation, migration, and formation of microvascular networks. VSMCs were virally transduced to produce vascular endothelial growth factor (VEGF), which acts as a chemoattractant and mitogen of endothelial cells (EC). VSMCs transduced with VEGF(165) cDNA produced significant levels of the protein (2-4 ng/10(5) cell/day). The proliferation of ECs increased after exposure to VEGF-transfected SMCs or their conditioned media. The chemotactic response of ECs to the VEGF-producing cells was explored in two in vitro systems, the modified Boyden chamber assay and a 2-D fence-style migration assay, and both demonstrated increased migration of ECs in response to VEGF-transfected cells. Furthermore, endothelial cells seeded on top of the VEGF-transfected SMCs formed capillary-like structures. These results suggest that VSMCs genetically modified to produce VEGF could be a potential delivery mechanism to enhance endothelial cell migration and subsequent capillary formation, which in turn could improve vascularization of ischemic or regenerating tissue. Furthermore, this system could potentially be used as an in vitro test bed for evaluation of novel angiogenic and anti-angiogenic compounds.

[Regenerative medicine and plastic surgery]

Regenerative medicine recently evolved as a new medical field that includes tissue engineering, cell/system biology, nanotechnology, pharmacology, stem-cell biology, and bioengineering. Regenerative medicine targets new forms of therapy to promote and support the intrinsic, autologous, regenerative potential of human biological systems. All fields of surgery have profited from these developments, and spectacular experimental results and clinical benefits have been obtained. Plastic surgery has shown interest in regenerative medicine due to its focus on reconstructive surgery. Early on, several interdisciplinary experimental working groups were founded including plastic surgery. This overview takes a closer look at common experimental and clinical results of regenerative medicine and plastic surgery.

In Vitro Functional Assessment of Human Skeletal Myoblasts After Transduction With Adenoviral Bicistronic Vector Carrying Human VEGF165 and Angiopoietin-1

OBJECTIVES

We report in vitro functional assessment of human skeletal myoblasts with adenoviral bicistronic vector carrying human vascular endothelial growth factor-165 (hVEGF165) and angiopoietin-1 (Ang-1).

METHODS

Myoblasts were assessed for their purity by desmin expression. A replication incompetent adenoviral bicistronic vector (Ad-Bic) carrying both hVEGF165 and Ang-1 was used for transduction of myoblasts. Transduction efficiency was assessed by dual fluorescent immunostaining of the transduced myoblasts. Expression efficiency was analyzed by enzyme linked immunosorbent assay (ELISA), Western blot and reverse transcription polymerase chain reaction (RT-PCR). The biological activity of the secreted human VEGF165 and Ang-1 was determined by human umbilical vein endothelial cells (HUVEC) proliferation assay, Thymidine [H3] incorporation assay and capillary-like structure formation.

RESULTS

The myoblasts preparation was >98% pure. Fluorescent immunostaining showed >95% transduction efficiency. The transduced myoblasts secreted VEGF(165) for up to 30 days after transduction, with peak level (32 +/- 4 ng/ml) at day 8 after transduction as revealed by VEGF ELISA. Western blot further confirmed that both angiogenic factors were actively secreted by transduced myoblasts. The molecular weight was 42 kD for hVEGF165 and 70 kD for Ang-1 respectively. The expression of hVEGF165 and Ang-1 was significantly reduced at day-30 after transduction as seen by RT-PCR. The conditioned medium from bicistronic vector transduced myoblasts stimulated HUVEC to proliferate much faster than other conditioned media (>1.5 folds). Thymidine incorporation assay further confirmed this finding. Matrigel experiment suggested that HUVEC under the condition of both growth factors formed significantly more capillary-like structure.

CONCLUSIONS

The bicistronic vector transduced myoblasts provides a novel strategy for therapeutic angiomyogenesis for cardiac repair.

Therapeutic neovascularization: contributions from bioengineering

A number of pathological entities and surgical interventions could benefit from therapeutic stimulation of new blood vessel formation. Although strategies designed for promoting neovascularization have shown promise in preclinical models, translation to human application has met with limited success when angiogenesis is used as the single therapeutic mechanism. While clinical protocols continue to be optimized, a number of exciting new approaches are being developed. Bioengineering has played an important role in the progress of many of these innovative new strategies. In this review, we present a general outline of therapeutic neovascularization, with an emphasis on investigations using engineering principles to address this vexing clinical problem. In addition, we identify some limitations and suggest areas for future research.

Gene transfer of bFGF to recipient bed improves survival of ischemic skin flap

BACKGROUND

The recipient bed is a promising target of angiogenic therapy to treat ischemic skin flaps. We delivered basic fibroblast growth factor (bFGF) gene to the recipient bed by a plasmid-based method with electroporation, and assessed the effects on flap viability in a rat dorsal skin flap model.

METHODS

A 25 x 90 mm(2) axial skin flap was elevated on the back of male Sprague-Dawley rats. Two days before flap elevation, an expression plasmid vector containing the bFGF gene with the signal sequence was injected into the dorsal muscles beneath the skin flap, and then electroporation was delivered (FGF-E(+) group). As control, rats were injected with a plasmid vector containing LacZ gene (LacZ-E(+) group), instead of bFGF gene. Other groups of animals received plasmid vector containing bFGF (FGF-E(-) group) or LacZ (LacZ-E(-) group) gene without electroporation. Seven days later, the area of necrosis and neovascularisation of the skin flap were evaluated.

RESULTS

The bFGF gene was successfully transferred to the dorsal muscles, and bFGF was expressed in muscle tissue. The area of flap necrosis (%) in the FGF-E(+) group (21.7+/-5.3%) was significantly smaller than that in the LacZ-E(+) (28.3+/-4.1%), FGF-E(-) (29.7+/-3.3%), and LacZ-E(-) (28.1+/-2.5%) groups. Postmortem angiograms and histological analyses showed that vascularisation in the distal part of the skin flap was significantly increased in the FGF-E(+) group compared with the other groups.

CONCLUSION

These findings suggested that gene delivery of bFGF to the recipient bed muscles enhanced vascularity and viability of an ischemic skin flap, and that plasmid-based gene delivery with electroporation was a suitable delivery method.

Adult stem cell lines in regenerative medicine and reconstructive surgery

In recent years, there has been a tremendous increase in the understanding of stem cell biology. The potential clinical applications lead to an extended interest in the use of stem cells in many medical disciplines. Multipotent adult stem cells seem to be almost comparable to embryonic stem cells with respect to their ability to differentiate into various tissues in vitro and in vivo, a function that has been termed "stem cell plasticity". In vivo experiments in rodents have shown that adult stem cells participate in tissue- and organ regeneration in almost all lesions. Although stem cell populations isolated from the bone marrow are usually a heterogeneous mix of different subpopulations, cloned adult stem cell lines from any source also show a broad spectrum of differentiation potential, e.g., osteogenesis, myogenesis, neurogenesis, or angiogenesis in wound healing. Angiogenesis in particular is a subject in tissue regeneration with tremendous implication in reconstructive surgery. This comprehensive plasticity makes it possible to use stem cell lines for biomedical research, tissue engineering, regenerative surgery, and organ repair. Adult stem cell lines are molecularly well defined with respect to transcription factors, active signal transduction pathways, and expression of receptors/ligand pairs. We performed experiments with adult stem cell lines, which are not subject to stem cell heterogeneity. Results obtained with stem cell lines can reliably be ascribed to the stem cell population under scrutiny. Adult stem cell lines can be obtained with the necessary quality and quantity also to study many effects of human stem cells in vitro and in vivo. In this paper, we summarize some of the tremendous therapeutic implications of adult stem cell lines in surgery and surgical research.

Comparison of the effectiveness of gene therapy with transforming growth factor-beta or extracorporal shock wave therapy to reduce ischemic necrosis in an epigastric skin flap model in rats

The induction of neoangiogenesis by exogenous growth factors in failing skin flaps has recently yielded promising results. Gene transfer with virus vectors has been introduced as a highly capable route of administration for growth factors, such as vascular endothelial growth factor or fibroblast growth factor. Extracorporal shock waves (ESW) deliver energy by means of high amplitudes of sound to the target tissue and have been shown to induce angiogenesis. We compared the effectiveness of gene therapy with adenovirus-mediated transforming growth factor-beta (TGF-beta) and ESW therapy to treat ischemically challenged epigastric skin flaps in a rat model. Thirty male Sprague-Dawley rats were divided into three groups of 10 each with an 8 x 8 cm epigastric skin flap. Rats received either subdermal injections of adenovirus (Ad) encoding TGF-beta (10(8) pfu) or ESW treatment with 750 impulses at 0.15 mJ/mm2. The third group received no treatment and served as a control group. Flap viability was evaluated after 7 days and digital images of the epigastric flaps were taken and areas of necrotic zones relative to total flap surface area calculated. Histologic evaluation and increased angiogenesis were confirmed by CD31 immunohistochemistry. Overall, there was a significant increase in mean percent surviving area in the Ad-TGF-beta group and the ESW group compared to the control group (ESW group: 97.7 +/- 1.8% vs. Ad-TGF-beta: 90.3 +/- 4.0% and control group: 82.6 +/- 4.3%; p < 0.05). Furthermore, in the ESW group mean percent surviving areas were significantly larger than in the Ad-TGF-beta group (ESW group: 97.7 +/- 1.8% vs. Ad-TGF-beta: 90.3 +/- 4.0%; p < 0.05). Flap vascularization was increased by Ad-TGF-beta and ESW with numerous vessels, however, there was no significant difference between the two treatment groups. We conclude that treatment with ESW enhances epigastric skin flap survival significantly more than Ad-TGF-beta treatment and thus represents a modality that is feasible, cost-effective, and less invasive compared to gene therapy with growth factors to improve blood supply to ischemic tissue.

Gene transfer to epidermal stem cells: implications for tissue engineering

The skin is an attractive target for gene therapy because it is easily accessible and shows great potential as an ectopic site for protein delivery in vivo. Genetically modified epidermal cells can be used to engineer three-dimensional skin substitutes, which when transplanted can act as in vivo 'bioreactors' for delivery of therapeutic proteins locally or systemically. Although some gene transfer technologies have the potential to afford permanent genetic modification, differentiation and eventual loss of genetically modified cells from the epidermis results in temporary transgene expression. Therefore, to achieve stable long-term gene expression, it is critical to deliver genes to epidermal stem cells, which possess unlimited growth potential and self-renewal capacity. This review discusses the recent advances in epidermal stem cell isolation, gene transfer and engineering of skin substitutes. Recent efforts that employ gene therapy and tissue engineering for the treatment of genetic diseases, chronic wounds and systemic disorders, such as leptin deficiency or diabetes, are reviewed. Finally, the use of gene-modified tissue-engineered skin as a biological model for understanding tissue development, wound healing and epithelial carcinogenesis is also discussed.

Human-compatible collagen matrix for prolonged and reversible systemic delivery of erythropoietin in mice from gene-modified marrow stromal cells

Bone marrow stromal cells (MSCs) can be exploited therapeutically in transgenic cell therapy approaches. Our aim was to determine if gene-modified MSCs sequestered within a clinically approved, bovine type I collagen-based viscous bulking material could serve as a retrievable implant for systemic delivery of erythropoietin (Epo). To test this hypothesis, we embedded Epo-secreting MSCs in viscous collagen (Contigen) and determined the pharmacological effect following implantation in normal mice. Primary MSCs from C57Bl/6 mice were retrovirally engineered to express murine Epo (mEpo) and 10(7) cells of a clonal population secreting 3 U of mEpo/10(6) cells/24 h were implanted subcutaneously in normal C57Bl/6 mice with and without viscous collagen. Without matrix support, Hct rose to >70% for <25 days and returned to baseline by 60 days. However, in mice implanted with viscous collagen-embedded MSCs, the Hct rose to >70% up to 203 days postimplantation (P < 0.0001). In parallel, plasma Epo concentration was significantly increased (P < 0.05) for >145 days. Moreover, surgical removal of the viscous collagen organoid 24 days after implantation led to reduction of Hct to baseline levels within 14 days. In conclusion, this investigation demonstrates that mEpo(+) MSCs embedded in a human-compatible viscous collagen matrix offers a potent, durable, and reversible approach for delivery of plasma-soluble therapeutic proteins.

Growth factors and flap survival

Growth factors are members of a large functional group of polypeptide regulatory molecules that influence the biological activities of responsive cells. In the last decade, the use of a variety of growth factors as therapeutic agents to improve wound healing and the viability of ischemic skin flaps has aroused considerable interest. Here, we review the literature concerning the regulation of growth factors in a flap, the role of angiogenesis in flap survival, the effect of growth factors on the metabolism of a flap, and angiogenesis in flap prefabrication and maturation. The potential application of growth factors in gene therapies is also reviewed.

Vascular endothelial growth factor‐C gene therapy restores lymphatic flow across incision wounds

Edema and insufficient blood perfusion are common problems in reconstructive surgery. The blood vasculature is reconstructed in microvascular flaps, whereas lymphatic vessel function is lost after surgical incision. Here, we demonstrate that vascular endothelial growth factor C (VEGF-C) gene transfer can be used to reconstruct a lymphatic vessel network severed by incision of skin flaps. We used adenoviral VEGF-C gene transfer at the edges of epigastric skin flaps in mice. Our results show that VEGF-C gene expression results in the formation of anastomoses between the lymphatic vessels of the skin flap and the surrounding lymphatic vasculature. Some spontaneous lymphangiogenesis also took place in the control mice, but the lymphatic vessels generated remained nonfunctional even 2 months postoperatively. In contrast, the VEGF-C treated mice demonstrated persistent lymphatic vessel function during the 2 month follow-up despite the transient nature of the adenoviral VEGF-C gene expression. The restoration of lymphatic function by VEGF-C in skin flaps provides new tools to promote vascular perfusion and to reduce tissue edema in skin and muscle flaps. These results have important implications for the prevention and treatment of surgically induced secondary lymphedema.

Transplantation of the urinary bladder and other organs in the subcutaneous tissue induces cyst formation and epithelialization: its potential usefulness in regenerative medicine

Certain hollow organs are known to form cysts when heterologously transplanted. In order to examine the usefulness of the phenomenon for regenerative medicine, rat urinary bladders and other organs were allo-transplanted under the subcutaneous tissue of the back. These transplanted tissues very often formed cysts covered with epithelia. The epithelia covered an area about twice the original size. In the case of the urinary bladder, the epithelium started moving from the edge of the transplants around day 3 after the operation, and as time proceeded, the tela submucosa and tunica muscularis also moved to encircle the epithelium, and formed the wall of the cyst. The basal laminae were formed under the newly expanded epithelium slightly behind the leading tip. All of the organs tested had the capability of cyst formation and epithelialization, although their rate differed between organs. The results are discussed with reference to the potential use of cyst formation for regenerating damaged organs.

Gene therapy in flap survival

Growth factors are members of a large functional group of polypeptide regulatory molecules that exert a powerful influence on all phases of wound healing and repair through interactions with specific cell surface receptors. The use of growth factors to improve wound healing and the viability of ischemic skin flaps has been well-documented throughout the last decade. In this article, we review the literature concerning the use gene therapy in flap survival, including the various methods employed to transplant plasmids or viruses capable of coding and producing growth factors in ischemic tissue.

Approaches to utilize mesenchymal progenitor cells as cellular vehicles

Mammalian cells represent a novel vector approach for gene delivery that overcomes major drawbacks of viral and nonviral vectors and couples cell therapy with gene delivery. A variety of cell types have been tested in this regard, confirming that the ideal cellular vector system for ex vivo gene therapy has to comply with stringent criteria and is yet to be found. Several properties of mesenchymal progenitor cells (MPCs), such as easy access and simple isolation and propagation procedures, make these cells attractive candidates as cellular vehicles. In the current work, we evaluated the potential utility of MPCs as cellular vectors with the intent to use them in the cancer therapy context. When conventional adenoviral (Ad) vectors were used for MPC transduction, the highest transduction efficiency of MPCs was 40%. We demonstrated that Ad primary-binding receptors were poorly expressed on MPCs, while the secondary Ad receptors and integrins presented in sufficient amounts. By employing Ad vectors with incorporated integrin-binding motifs (Ad5lucRGD), MPC transduction was augmented tenfold, achieving efficient genetic loading of MPCs with reporter and anticancer genes. MPCs expressing thymidine kinase were able to exert a bystander killing effect on the cancer cell line SKOV3ip1 in vitro. In addition, we found that MPCs were able to support Ad replication, and thus can be used as cell vectors to deliver oncolytic viruses. Our results show that MPCs can foster expression of suicide genes or support replication of adenoviruses as potential anticancer therapeutic payloads. These findings are consistent with the concept that MPCs possess key properties that ensure their employment as cellular vehicles and can be used to deliver either therapeutic genes or viruses to tumor sites.

VEGF is a chemoattractant for FGF-2-stimulated neural progenitors

Mmigration of undifferentiated neural progenitors is critical for the development and repair of the nervous system. However, the mechanisms and factors that regulate migration are not well understood. Here, we show that vascular endothelial growth factor (VEGF)-A, a major angiogenic factor, guides the directed migration of neural progenitors that do not display antigenic markers for neuron- or glia-restricted precursor cells. We demonstrate that progenitor cells express both VEGF receptor (VEGFR) 1 and VEGFR2, but signaling through VEGFR2 specifically mediates the chemotactic effect of VEGF. The expression of VEGFRs and the chemotaxis of progenitors in response to VEGF require the presence of fibroblast growth factor 2. These results demonstrate that VEGF is an attractive guidance cue for the migration of undifferentiated neural progenitors and offer a mechanistic link between neurogenesis and angiogenesis in the nervous system.

Selective recruitment of endothelial progenitor cells to ischemic tissues with increased neovascularization

Tissue ischemia remains a common problem in plastic surgery and one for which proangiogenic approaches have been investigated. Given the recent discovery of circulating endothelial stem or progenitor cells that are able to form new blood vessels, the authors sought to determine whether these cells might selectively traffic to regions of tissue ischemia and induce neovascularization. Endothelial progenitor cells were isolated from the peripheral blood of healthy human volunteers and expanded ex vivo for 7 days. Elevation of a cranially based random-pattern skin flap was performed in nude mice, after which they were injected with fluorescent-labeled endothelial progenitor cells (5 x 10(5); n = 15), fluorescent-labeled human microvascular endothelial cells (5 x 10(5); n = 15), or media alone (n = 15). Histologic examination demonstrated that endothelial progenitor cells were recruited to ischemic tissue and first appeared by postoperative day 3. Subsequently, endothelial progenitor cell numbers increased exponentially over time for the remainder of the study [0 cells/mm2 at day 0 (n = 3), 9.6 +/- 0.9 cells/mm2 at day 3 (n = 3), 24.6 +/- 1.5 cells/mm2 at day 7 (n = 3), and 196.3 +/- 9.6 cells/mm2 at day 14 (n = 9)]. At all time points, endothelial progenitor cells localized preferentially to ischemic tissue and healing wound edges, and were not observed in normal, uninjured tissues. Endothelial progenitor cell transplantation led to a statistically significant increase in vascular density in ischemic tissues by postoperative day 14 [28.7 +/- 1.2 in the endothelial progenitor cell group (n = 9) versus 18 +/- 1.1 in the control media group (n = 9) and 17.7 +/- 1.0 in the human microvascular endothelial cell group (n = 9; p < 0.01)]. Endothelial progenitor cell transplantation also showed trends toward increased flap survival [171.2 +/- 18 mm2 in the endothelial progenitor cell group (n = 12) versus 134.2 +/- 10 mm2 in the media group (n = 12) and 145.0 +/- 13 mm2 in the human microvascular endothelial cell group (n = 12)], but this did not reach statistical significance. These findings indicate that local tissue ischemia is a potent stimulus for the recruitment of circulating endothelial progenitor cells. Systemic delivery of endothelial progenitor cells increased neovascularization and suggests that autologous endothelial progenitor cell transplantation may have a role in the salvage of ischemic tissue.

Expression of an Ets-1 dominant-negative mutant perturbs normal and tumor angiogenesis in a mouse ear model

We and others have shown that members of the Ets family of transcription factors are involved in morphogenic properties of endothelial cells in vitro. To investigate the role of these factors in the transcriptional regulation of angiogenesis in vivo, we set up a nontraumatic model that allows daily macroscopic examination of both growth factor- and tumor-induced angiogenesis in mouse ears. In the same animal, we were thus able to record variations in the patterns of neovessels induced and cell populations recruited by the angiogenic factors FGF-2 and VEGF. In this model, inhibition of FGF-2-induced angiogenesis by the pharmacological compound TNP-470 was readily observed, demonstrating that the mouse ear model is also useful in the evaluation of antiangiogenic strategies. Our functional analysis of Ets transcription factors activity utilized a competitor protein, Ets1-DB, a dominant negative Ets1 mutant lacking the transactivation domain. Retrovirus-mediated expression of Ets1-DB inhibited FGF-2-induced angiogenesis, while the expression of Ets1-DB in cancerous and stromal cells disturbed tumor-induced angiogenesis. These results illustrate the value of the ear model and highlight the role of Ets family members in the transcriptional regulation of tumor angiogenesis.

The role of fibroblast growth factors in vascular development

Fibroblast growth factors (FGFs) are considered angiogenic factors, yet the exact relationship between FGF and vascular development in normal and pathological tissue has long remained elusive. However, recent results from gene inactivation and transgenic studies in mice and in culture systems have demonstrated the role of FGFs in vessel assembly and sprouting. FGFs also promote blood-vessel branching and induce lymphangiogenesis. Novel players in FGF-mediated angiogenesis have been identified, such as p38 mitogen-activated protein kinase. Tumour angiogenesis is regulated by FGFs directly or indirectly via secondary angiogenesis factors, such as vascular endothelial growth factor. The newly established angiogenic role of FGFs makes FGF or molecules targeting FGF and its receptor promising candidates for the development of novel therapeutics.

Exogenous application of transforming growth factor beta 1 stimulates arteriogenesis in the peripheral circulation

Increased expression of transforming growth factor beta1 (TGF-beta1) during collateral artery growth, as well as its numerous effects on monocytes/macrophages and the smooth muscle cell cycle and differentiation, suggest a modulating role for this growth factor during arteriogenesis. We studied the effects of exogenously applied TGF-beta1 on arteriogenesis as well as its interactions with monocytes, endothelial cells, and smooth muscle cells. In a New Zealand White (NZW) rabbit model of femoral artery ligation, increased expression of active TGF-beta1 was found around proliferating arteries in NZW rabbits. The exogenous application of TGF-beta1 led to an increase in both the number of visible collateral arteries as well as the conductance of the collateral circulation (4.0 +/- 0.5 ml/min/100 mmHg vs. 28.9 +/- 3.7 ml/min/100 mmHg, P<0.05). Fluorescence activated cell sorting analysis showed an increase in the expression of the MAC-1 receptor in both rabbit and human monocytes after treatment with TGF-beta1 (control: 91.2 +/- 4.2/482 +/- 21.7; TGF-beta1 200 ng/ml 193.9 +/- 6.7/ 675.5 +/- 25.7, P<0.05 for all differences). TGF-beta1 treated monocytes showed an increased endothelial adhesion and transmigration in transendothelial migration assays (5.75 +/- 0.63 x 10(5) vs. 10.11 +/- 0.04 x 10(5), P<0.05). TGF-beta1 had no direct pro-angiogenic effect on human umbilical vein endothelial cells in a spheroid model of angiogenesis and inhibited the angiogenic effects of vascular endothelial growth factor.

Morphometric and dynamic studies of bone changes in hyperthyroidism

Bone biopsies were performed after tetracycline double-labelling by transfixing the right iliac crest in forty hyperthyroid patients. The bone changes in cortical and trabecular bone were determined by simple measurement and point counting on decalcified and undecalcified stained sections. A slight decrease in the amount of cancellous bone was found. The mean cortical width was normal. The amount of osteoid and the length of the osteoid seams were increased, whereas the mean width of osteoid seams was decreased. The cortical osteoclastic activity and porosity were markedly increased. The trabecular osteoclasic activity was moderately increased and the mean size of periosteocytic lacunae was slightly increased. The calcification rate in cancellous bone was increased as were the active calcification surfaces (tetracycline-labelled). The osteoclastic activity in cortical bone was positively correlated to the free thyroxine index and to the urinary calcium and phosphorus excretion. The findings indicate that the bone changes in hyperthyroidism are specific and that thyroid hormone(s) stimulates both bone formation and resorption followed by increased porosity in cortical bone and by mobilization of bone mineral.