1
|
Jeyaraman M, Nagarajan S, Maffulli N, R P P, Jeyaraman N, N A, Khanna M, Yadav S, Gupta A. Stem Cell Therapy in Critical Limb Ischemia. Cureus 2023; 15:e41772. [PMID: 37575721 PMCID: PMC10416751 DOI: 10.7759/cureus.41772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Critical limb ischemia (CLI), a serious outcome of peripheral artery disease, is frequently associated with morbid outcomes. The available treatment modalities do not provide satisfactory results, leading to marked morbidities such as joint contracture and amputations, resulting in a high economic burden. The peripheral vascular disease tends to cause more morbidity in patients with diabetes and atherosclerosis, given the pre-existing compromised perfusion of medium and small vessels in diabetic patients. With surgical procedures, the chance of vascular compromise further increases, inducing a significantly greater rate of amputation. Hence, the need for nonsurgical treatment modalities such as stem cell therapy (SCT), which promotes angiogenesis, is warranted. In CLI, SCT acts through neovascularization and the development of collateral arteries, which increases blood supply to the soft tissues of the ischemic limb, providing satisfactory outcomes. An electronic database search was performed in PubMed, SCOPUS, EMBASE, and ScienceDirect to identify published clinical trial data, research studies, and review articles on stem cell therapy in critical limb ischemia. The search resulted in a total of 2391 results. Duplicate articles screening resulted in 565 articles. In-depth screening of abstracts and research titles excluded 520 articles, yielding 45 articles suitable for full-text review. On review of full text, articles with overlapping and similar results were filtered, ending in 25 articles. SCT promotes arteriogenesis, and bone marrow-derived mesenchymal stromal cells produce significant effects like reduced morbidity, improved amputation-free survival (AFS ) rate, and improved distal perfusion even in "no-option" CLI patients. SCT is a promising treatment modality for CLI patients, even in those in whom endovascular and revascularization procedures are impossible. SCT assures a prolonged AFS rate, improved distal perfusion, improved walking distances, reduced amputation rates, and increased survival ratio, and is well-tolerated.
Collapse
Affiliation(s)
- Madhan Jeyaraman
- Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, IND
- Regenerative Medicine, Indian Stem Cell Study Group Association, Lucknow, IND
- Regenerative Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, IND
- Biotechnology, School of Engineering and Technology, Sharda University, Greater Noida, IND
- Orthopaedics, South Texas Orthopaedic Research Institute, Laredo, USA
| | - Somumurthy Nagarajan
- Orthopaedic Rheumatology, Dr. Ram Manohar Lohiya National Law University, Lucknow, IND
| | - Nicola Maffulli
- Orthopedics, School of Medicine and Surgery, University of Salerno, Fisciano, ITA
- Orthopaedics, San Giovanni di Dio e Ruggi D'Aragona Hospital, Hospital of Salerno, Salerno, ITA
- Orthopedics, Barts and the London School of Medicine and Dentistry, London, GBR
- Orthopedics, Keele University School of Medicine, Stoke-on-Trent, GBR
| | - Packkyarathinam R P
- Regenerative Medicine, Indian Stem Cell Study Group Association, Lucknow, IND
- Orthopaedic Rheumatology, Dr. Ram Manohar Lohiya National Law University, Lucknow, IND
- Regenerative and Interventional Orthobiologics, Dr. Ram Manohar Lohiya National Law University, Lucknow, IND
| | - Naveen Jeyaraman
- Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, IND
- Regenerative Medicine, Indian Stem Cell Study Group Association, Lucknow, IND
- Regenerative Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, IND
- Orthopaedic Rheumatology, Dr. Ram Manohar Lohiya National Law University, Lucknow, IND
- Regenerative and Interventional Orthobiologics, Dr. Ram Manohar Lohiya National Law University, Lucknow, IND
| | - Arulkumar N
- Orthopaedics, ACS Medical College and Hospital, Dr. MGR Educational and Research Institute, Chennai, IND
- Regenerative Medicine, Indian Stem Cell Study Group Association, Lucknow, IND
- Regenerative Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, IND
- Orthopaedic Rheumatology, Dr. Ram Manohar Lohiya National Law University, Lucknow, IND
- Regenerative and Interventional Orthobiologics, Dr. Ram Manohar Lohiya National Law University, Lucknow, IND
| | - Manish Khanna
- Regenerative Medicine, Indian Stem Cell Study Group Association, Lucknow, IND
- Orthopaedics, Autonomous State Medical College, Ayodhya, IND
| | - Sankalp Yadav
- Internal Medicine, Shri Madan Lal Khurana Chest Clinic, New Delhi, IND
| | - Ashim Gupta
- Regenerative Medicine, Indian Stem Cell Study Group Association, Lucknow, IND
- Orthopaedics, South Texas Orthopaedic Research Institute, Laredo, USA
- Regenerative Medicine, Future Biologics, Lawrenceville, USA
- Regenerative Medicine, BioIntegrate, Lawrenceville, USA
- Regenerative Medicine, Regenerative Orthopaedics, Noida, IND
| |
Collapse
|
2
|
Rojas-Torres M, Sánchez-Gomar I, Rosal-Vela A, Beltrán-Camacho L, Eslava-Alcón S, Alonso-Piñeiro JÁ, Martín-Ramírez J, Moreno-Luna R, Durán-Ruiz MC. Assessment of endothelial colony forming cells delivery routes in a murine model of critical limb threatening ischemia using an optimized cell tracking approach. Stem Cell Res Ther 2022; 13:266. [PMID: 35729651 PMCID: PMC9210810 DOI: 10.1186/s13287-022-02943-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 01/15/2023] Open
Abstract
Background Endothelial colony forming cells (ECFCs), alone or in combination with mesenchymal stem cells, have been selected as potential therapeutic candidates for critical limb-threatening ischemia (CLTI), mainly for those patients considered as “no-option,” due to their capability to enhance revascularization and perfusion recovery of ischemic tissues. Nevertheless, prior to translating cell therapy to the clinic, biodistribution assays are required by regulatory guidelines to ensure biosafety as well as to discard undesired systemic translocations. Different approaches, from imaging technologies to qPCR-based methods, are currently applied. Methods In the current study, we have optimized a cell-tracking assay based on DiR fluorescent cell labeling and near-infrared detection for in vivo and ex vivo assays. Briefly, an improved protocol for DiR staining was set up, by incubation of ECFCs with 6.67 µM DiR and intensive washing steps prior cell administration. The minimal signal detected for the residual DiR, remaining after these washes, was considered as a baseline signal to estimate cell amounts correlated to the DiR intensity values registered in vivo. Besides, several assays were also performed to determine any potential effect of DiR over ECFCs functionality. Furthermore, the optimized protocol was applied in combination with qPCR amplification of specific human Alu sequences to assess the final distribution of ECFCs after intramuscular or intravenous administration to a murine model of CLTI. Results The optimized DiR labeling protocol indicated that ECFCs administered intramuscularly remained mainly within the hind limb muscle while cells injected intravenously were found in the spleen, liver and lungs. Conclusion Overall, the combination of DiR labeling and qPCR analysis in biodistribution assays constitutes a highly sensitive approach to systemically track cells in vivo. Thereby, human ECFCs administered intramuscularly to CLTI mice remained locally within the ischemic tissues, while intravenously injected cells were found in several organs. Our data corroborate the need to perform biodistribution assays in order to define specific parameters such as the optimal delivery route for ECFCs before their application into the clinic. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-022-02943-8.
Collapse
Affiliation(s)
- Marta Rojas-Torres
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), Cádiz, Spain
| | - Ismael Sánchez-Gomar
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), Cádiz, Spain
| | - Antonio Rosal-Vela
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), Cádiz, Spain
| | - Lucía Beltrán-Camacho
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), Cádiz, Spain
| | - Sara Eslava-Alcón
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), Cádiz, Spain
| | - José Ángel Alonso-Piñeiro
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), Cádiz, Spain
| | | | - Rafael Moreno-Luna
- Laboratory of Neuroinflammation, Hospital Nacional de Paraplejicos, SESCAM, Toledo, Spain
| | - Mª Carmen Durán-Ruiz
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain. .,Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), Cádiz, Spain.
| |
Collapse
|
3
|
Hussein EA. Stem Cell Therapy for Vascular Disorders. VASCULAR AND ENDOVASCULAR REVIEW 2018. [DOI: 10.15420/ver.2018.3.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Peripheral vascular disease results from narrowing of the peripheral arteries that supply oxygenated blood and nutrients to the legs and feet. This pathology causes symptoms such as intermittent claudication (pain with walking), painful ischaemic ulcerations, or even limbthreatening gangrene. It is generally believed that the vascular endothelium, a monolayer of endothelial cells (ECs) that lines the luminal surface of all blood and lymphatic vessels, plays a dominant role in vascular homeostasis and vascular regeneration. As a result, stem cell-based regeneration of the endothelium may be a promising approach for the treatment of PAD. Critical limb ischaemia (CLI) is an advanced form of peripheral artery disease which is responsible for about 100,000 amputations each year in the US. Trials to date have reported clinical improvement and reduced need for amputation in patients with CLI who receive autologous bone marrow or mobilised peripheral blood stem cells for stimulation of angiogenesis. There is no effective treatment for lower limb ischaemia caused by peripheral vascular disease and it is necessary to amputate the limb at the end stage. Therefore, the concept of effective therapeutic angiogenesis has become widely accepted during the past few years and it has emerged as a strategy to treat tissue ischaemia by promoting collateral growth using drug, gene or cell therapy. This article provides an overview of current therapeutic challenges for the treatment of critical limb ischaemia, the basic mechanisms of stem cell therapy, the most relevant clinical trials as well as future directions for translational research in this area.
Collapse
|
5
|
Forsythe RO, Brownrigg J, Hinchliffe RJ. Peripheral arterial disease and revascularization of the diabetic foot. Diabetes Obes Metab 2015; 17:435-44. [PMID: 25469642 DOI: 10.1111/dom.12422] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 11/19/2014] [Accepted: 11/28/2014] [Indexed: 01/03/2023]
Abstract
Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration. In addition to peripheral arterial disease, functional changes in the microcirculation also contribute to the development of a diabetic foot ulcer, along with other factors such as infection, oedema and abnormal biomechanical loading. Peripheral arterial disease typically affects the distal vessels, resulting in multi-level occlusions and diffuse disease, which often necessitates challenging distal revascularisation surgery or angioplasty in order to improve blood flow. However, technically successful revascularisation does not always result in wound healing. The confounding effects of microvascular dysfunction must be recognised--treatment of a patient with a diabetic foot ulcer and peripheral arterial disease should address this complex interplay of pathophysiological changes. In the case of non-revascularisable peripheral arterial disease or poor response to conventional treatment, alternative approaches such as cell-based treatment, hyperbaric oxygen therapy and the use of vasodilators may appear attractive, however more robust evidence is required to justify these novel approaches.
Collapse
Affiliation(s)
- R O Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | | |
Collapse
|
8
|
Díaz D, Muñoz-Castañeda R, Alonso JR, Weruaga E. Bone Marrow-Derived Stem Cells and Strategies for Treatment of Nervous System Disorders: Many Protocols, and Many Results. Neuroscientist 2014; 21:637-52. [PMID: 25171812 DOI: 10.1177/1073858414547538] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Bone marrow stem cells are the best known stem cell type and have been employed for more than 50 years, especially in pathologies of the hematopoietic and immune systems. However, their therapeutic potential is much broader, and they can also be employed to palliate neural diseases. Apart from their plastic properties, these cells lack the legal or ethical constraints of other stem cell populations, that is, embryonic stem cells. Current research addressing the integration of bone marrow-derived cells into the neural circuits of the central nervous system, their features, and applications is a hotspot in neurobiology. Nevertheless, as in other leading research lines the efficacy and possibilities of their application depend on technical procedures, which are still far from being standardized. Accordingly, for efficient research this large range of variants should be taken into account as they could lead to unexpected results. Rather than focusing on clinical aspects, this review offers a compendium of the methodologies aimed at providing a guide for researchers who are working in the field of bone marrow transplantation in the central nervous system. It seeks to be useful for both introductory and trouble-shooting purposes, and in particular for dealing with the large array of bone marrow transplantation protocols available.
Collapse
Affiliation(s)
- David Díaz
- Laboratory of Neuronal Plasticity and Neurorepair, Institute for Neuroscience of Castilla y León (INCyL), Universidad de Salamanca, Salamanca, Spain Institute of Biomedical Research of Salamanca, IBSAL, Spain
| | - Rodrigo Muñoz-Castañeda
- Laboratory of Neuronal Plasticity and Neurorepair, Institute for Neuroscience of Castilla y León (INCyL), Universidad de Salamanca, Salamanca, Spain Institute of Biomedical Research of Salamanca, IBSAL, Spain
| | - José Ramón Alonso
- Laboratory of Neuronal Plasticity and Neurorepair, Institute for Neuroscience of Castilla y León (INCyL), Universidad de Salamanca, Salamanca, Spain Institute of Biomedical Research of Salamanca, IBSAL, Spain Instituto de Alta Investigación, Universidad de Tarapacá, Arica, Chile
| | - Eduardo Weruaga
- Laboratory of Neuronal Plasticity and Neurorepair, Institute for Neuroscience of Castilla y León (INCyL), Universidad de Salamanca, Salamanca, Spain Institute of Biomedical Research of Salamanca, IBSAL, Spain
| |
Collapse
|