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Chao CL, Applewhite B, Reddy NK, Matiuto N, Dang C, Jiang B. Advances and challenges in regenerative therapies for abdominal aortic aneurysm. Front Cardiovasc Med 2024; 11:1369785. [PMID: 38895536 PMCID: PMC11183335 DOI: 10.3389/fcvm.2024.1369785] [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] [Received: 01/12/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Abdominal aortic aneurysm (AAA) is a significant source of mortality worldwide and carries a mortality of greater than 80% after rupture. Despite extensive efforts to develop pharmacological treatments, there is currently no effective agent to prevent aneurysm growth and rupture. Current treatment paradigms only rely on the identification and surveillance of small aneurysms, prior to ultimate open surgical or endovascular repair. Recently, regenerative therapies have emerged as promising avenues to address the degenerative changes observed in AAA. This review briefly outlines current clinical management principles, characteristics, and pharmaceutical targets of AAA. Subsequently, a thorough discussion of regenerative approaches is provided. These include cellular approaches (vascular smooth muscle cells, endothelial cells, and mesenchymal stem cells) as well as the delivery of therapeutic molecules, gene therapies, and regenerative biomaterials. Lastly, additional barriers and considerations for clinical translation are provided. In conclusion, regenerative approaches hold significant promise for in situ reversal of tissue damages in AAA, necessitating sustained research and innovation to achieve successful and translatable therapies in a new era in AAA management.
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Affiliation(s)
- Calvin L. Chao
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Brandon Applewhite
- Department of Biomedical Engineering, Northwestern University McCormick School of Engineering, Chicago, IL, United States
| | - Nidhi K. Reddy
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Natalia Matiuto
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Caitlyn Dang
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Bin Jiang
- Division of Vascular Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Department of Biomedical Engineering, Northwestern University McCormick School of Engineering, Chicago, IL, United States
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The mechanism and therapy of aortic aneurysms. Signal Transduct Target Ther 2023; 8:55. [PMID: 36737432 PMCID: PMC9898314 DOI: 10.1038/s41392-023-01325-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 12/15/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
Aortic aneurysm is a chronic aortic disease affected by many factors. Although it is generally asymptomatic, it poses a significant threat to human life due to a high risk of rupture. Because of its strong concealment, it is difficult to diagnose the disease in the early stage. At present, there are no effective drugs for the treatment of aneurysms. Surgical intervention and endovascular treatment are the only therapies. Although current studies have discovered that inflammatory responses as well as the production and activation of various proteases promote aortic aneurysm, the specific mechanisms remain unclear. Researchers are further exploring the pathogenesis of aneurysms to find new targets for diagnosis and treatment. To better understand aortic aneurysm, this review elaborates on the discovery history of aortic aneurysm, main classification and clinical manifestations, related molecular mechanisms, clinical cohort studies and animal models, with the ultimate goal of providing insights into the treatment of this devastating disease. The underlying problem with aneurysm disease is weakening of the aortic wall, leading to progressive dilation. If not treated in time, the aortic aneurysm eventually ruptures. An aortic aneurysm is a local enlargement of an artery caused by a weakening of the aortic wall. The disease is usually asymptomatic but leads to high mortality due to the risk of artery rupture.
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Zilberman B, Kooragayala K, Lou J, Ghobrial G, De Leo N, Emery R, Ostrovsky O, Zhang P, Platoff R, Zhu C, Hunter K, Delong D, Hong Y, Brown SA, Carpenter JP. Treatment of Abdominal Aortic Aneurysm Utilizing Adipose-Derived Mesenchymal Stem Cells in a Porcine Model. J Surg Res 2022; 278:247-256. [DOI: 10.1016/j.jss.2022.04.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/11/2022] [Accepted: 04/23/2022] [Indexed: 12/19/2022]
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Preservation of Smooth Muscle Cell Integrity and Function: A Target for Limiting Abdominal Aortic Aneurysm Expansion? Cells 2022; 11:cells11061043. [PMID: 35326494 PMCID: PMC8947535 DOI: 10.3390/cells11061043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Abdominal aortic aneurysm (AAA) is a silent, progressive disease with significant mortality from rupture. Whilst screening programmes are now able to detect this pathology early in its development, no therapeutic intervention has yet been identified to halt or retard aortic expansion. The inability to obtain aortic tissue from humans at early stages has created a necessity for laboratory models, yet it is essential to create a timeline of events from EARLY to END stage AAA progression. (2) We used a previously validated ex vivo porcine bioreactor model pre-treated with protease enzyme to create “aneurysm” tissue. Mechanical properties, histological changes in the intact vessel wall, and phenotype/function of vascular smooth muscle cells (SMC) cultured from the same vessels were investigated. (3) The principal finding was significant hyperproliferation of SMC from EARLY stage vessels, but without obvious histological or SMC aberrancies. END stage tissue exhibited histological loss of α-smooth muscle actin and elastin; mechanical impairment; and, in SMC, multiple indications of senescence. (4) Aortic SMC may offer a therapeutic target for intervention, although detailed studies incorporating intervening time points between EARLY and END stage are required. Such investigations may reveal mechanisms of SMC dysfunction in AAA development and hence a therapeutic window during which SMC differentiation could be preserved or reinstated.
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Li K, Vela D, Migliati E, da Graca Cabreira M, Wang X, Buja LM, Perin EC. Pilot Study of Endovascular Delivery of Mesenchymal Stromal Cells in the Aortic Wall in a Pig Model. Cell Transplant 2021; 30:9636897211010652. [PMID: 33938770 PMCID: PMC8114770 DOI: 10.1177/09636897211010652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Abdominal aortic aneurysms (AAAs) have a high mortality. In small-animal models, multipotent mesenchymal stromal cells (MSCs) have shown benefits in attenuating aneurysm formation. However, an optimal cell delivery strategy is lacking. The NOGA system, which targets cell injections in a less-invasive way, has been used for myocardial cell delivery. Here, we assessed the safety and feasibility of the NOGA system for endovascular delivery of MSCs to the aortic wall in an AAA pig model. We induced AAA in 9 pigs by surgery or catheter induction. MSCs were delivered using the NOGA system 6 or 8 weeks after aneurysm induction. We euthanized the pigs and harvested the aorta for histologic analysis 1, 3, and 7 days after cell delivery. During AAA creation, 1 pig died; 8 pigs completed the study without acute adverse events or complications. The cell delivery procedure was safe and feasible. We successfully injected MSCs directly into the aortic wall in a targeted manner. Histologic and immunohistochemical analyses confirmed transmural injections in the aortic wall area of interest and the presence of MSCs. Our study showed the safety and feasibility of endovascular cell delivery to the aortic wall in a pig model.
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Affiliation(s)
- Ke Li
- Stem Cell Center, 14644Texas Heart Institute, Houston, Texas, USA
| | - Deborah Vela
- Cardiovascular Pathology, 14644Texas Heart Institute, Houston, Texas, USA
| | - Elton Migliati
- Stem Cell Center, 14644Texas Heart Institute, Houston, Texas, USA
| | | | - Xiaohong Wang
- Stem Cell Center, 14644Texas Heart Institute, Houston, Texas, USA
| | - L Maximilian Buja
- Cardiovascular Pathology, 14644Texas Heart Institute, Houston, Texas, USA.,Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA
| | - Emerson C Perin
- Stem Cell Center, 14644Texas Heart Institute, Houston, Texas, USA
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ZIDI MUSTAPHA, ALLAIRE ERIC. MECHANICAL PROPERTIES CHANGE IN THE RAT XENOGRAFT MODEL TREATED BY MESENCHYMAL CELLS CULTURED IN AN HYALURONIC ACID-BASED HYDROGEL. J MECH MED BIOL 2018. [DOI: 10.1142/s0219519418500471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study investigated the efficiency of a cellular therapy with mesenchymal stem cells (MSCs) cultured in an hyaluronic acid-based hydrogel on growth of abdominal aortic aneurysms (AAA) obtained in the rat xenograft model. The experimental model was devoted to create an AAA at D14 after grafting of a decellularized abdominal aorta obtained from guinea pigs before being transplanted into rats. At D21, geometrical measurements as radius and length of AAA were performed on untreated ([Formula: see text]) and treated ([Formula: see text]) arteries. When compared to different cases, it was shown that the proposed cellular treatment significantly reduced the expansion of radius and length of AAA. Furthermore, to explore the mechanical properties change of the arterial wall, an inverse finite element method was performed where AAA is represented by an elliptical geometry with varying thicknesses. To identify the material parameters, the AAA tissue was assumed to behave isochoric and isotropic undergoing large strains and described by the Yeoh’s strain energy function. Although limitations exist in this study such as the time of the experimental protocol, the isotropic behavior law of the AAA wall and the axisymmetric geometry of the artery, the results revealed that arterial wall stiffness change and the maximum effective stress decreased during expansion of AAA when cellular treatment is applied.
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Affiliation(s)
- MUSTAPHA ZIDI
- Bioengineering, Tissue and Neuroplasticity (BIOTN), EA 7377, Université Paris Est Créteil, Faculté de Médecine - Centre de, Recherches Chirurgicales, 8 rue du Général Sarrail, 94010 Créteil, France
| | - ERIC ALLAIRE
- Department of Vascular Surgery, Henri Mondor Hospital, AP-HP, F-94010 Créteil, France
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Parvizi M, Petersen AH, van Spreuwel-Goossens CAFM, Kluijtmans SGJM, Harmsen MC. Perivascular scaffolds loaded with adipose tissue-derived stromal cells attenuate development and progression of abdominal aortic aneurysm in rats. J Biomed Mater Res A 2018; 106:2494-2506. [DOI: 10.1002/jbm.a.36445] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 03/05/2018] [Accepted: 04/05/2018] [Indexed: 12/19/2022]
Affiliation(s)
- M. Parvizi
- Department of Pathology and Medical Biology; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | - A. H. Petersen
- Department of Pathology and Medical Biology; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
| | | | | | - M. C. Harmsen
- Department of Pathology and Medical Biology; University of Groningen, University Medical Center Groningen; Groningen The Netherlands
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Yamawaki-Ogata A, Oshima H, Usui A, Narita Y. Bone marrow–derived mesenchymal stromal cells regress aortic aneurysm via the NF-kB, Smad3 and Akt signaling pathways. Cytotherapy 2017; 19:1167-1175. [DOI: 10.1016/j.jcyt.2017.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 07/19/2017] [Accepted: 07/28/2017] [Indexed: 12/11/2022]
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Shen YH, LeMaire SA. Molecular pathogenesis of genetic and sporadic aortic aneurysms and dissections. Curr Probl Surg 2017; 54:95-155. [PMID: 28521856 DOI: 10.1067/j.cpsurg.2017.01.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/16/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Ying H Shen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX; Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX.
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX; Cardiovascular Research Institute, Baylor College of Medicine, Houston, TX; Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, TX.
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10
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Gómez-Mauricio G, Moscoso I, Martín-Cancho MF, Crisóstomo V, Prat-Vidal C, Báez-Díaz C, Sánchez-Margallo FM, Bernad A. Combined administration of mesenchymal stem cells overexpressing IGF-1 and HGF enhances neovascularization but moderately improves cardiac regeneration in a porcine model. Stem Cell Res Ther 2016; 7:94. [PMID: 27423905 PMCID: PMC4947339 DOI: 10.1186/s13287-016-0350-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/13/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022] Open
Abstract
Background Insulin-like growth factor 1 (IGF-1) and hepatocyte growth factor (HGF) are among the most promising growth factors for promoting cardiorepair. Here, we evaluated the combination of cell- and gene-based therapy using mesenchymal stem cells (MSC) genetically modified to overexpress IGF-1 or HGF to treat acute myocardial infarction (AMI) in a porcine model. Methods Pig MSC from adipose tissue (paMSC) were genetically modified for evaluation of different therapeutic strategies to improve AMI treatment. Three groups of infarcted Large White pigs were compared (I, control, non-transplanted; II, transplanted with paMSC-GFP (green fluorescent protein); III, transplanted with paMSC-IGF-1/HGF). Cardiac function was evaluated non-invasively using magnetic resonance imaging (MRI) for 1 month. After euthanasia and sampling of the animal, infarcted areas were studied by histology and immunohistochemistry. Results Intramyocardial transplant in a porcine infarct model demonstrated the safety of paMSC in short-term treatments. Treatment with paMSC-IGF-1/HGF (1:1) compared with the other groups showed a clear reduction in inflammation in some sections analyzed and promoted angiogenic processes in ischemic tissue. Although cardiac function parameters were not significantly improved, cell retention and IGF-1 overexpression was confirmed within the myocardium. Conclusions The simultaneous administration of IGF-1- and HGF-overexpressing paMSC appears not to promote a synergistic effect or effective repair. The combined enhancement of neovascularization and fibrosis in paMSC-IGF-1/HGF-treated animals nonetheless suggests that sustained exposure to high IGF-1 + HGF levels promotes beneficial as well as deleterious effects that do not improve overall cardiac regeneration. Electronic supplementary material The online version of this article (doi:10.1186/s13287-016-0350-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guadalupe Gómez-Mauricio
- Jesús Usón Minimally Invasive Surgery Center, Cáceres, Spain.,Department of Cardiovascular Development and Repair, Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain
| | - Isabel Moscoso
- Department of Cardiovascular Development and Repair, Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain.,Cardiovascular Area, CIMUS, Instituto de Investigación Sanitaria, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Cristina Prat-Vidal
- Department of Cardiovascular Development and Repair, Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain.,ICREC (Heart Failure and Cardiac Regeneration) Research Program, Health Sciences Research Institute Germans Trias i Pujol (IGTP), Badalona, Barcelona, Spain
| | | | | | - Antonio Bernad
- Department of Cardiovascular Development and Repair, Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain. .,Department of Immunology and Oncology, Centro Nacional de Biotecnología (CNB-CSIC), Darwin 3 (Campus UAM Cantoblanco), 28049, Madrid, Spain.
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Tonar Z, Tomášek P, Loskot P, Janáček J, Králíčková M, Witter K. Vasa vasorum in the tunica media and tunica adventitia of the porcine aorta. Ann Anat 2016; 205:22-36. [DOI: 10.1016/j.aanat.2016.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/14/2015] [Accepted: 01/05/2016] [Indexed: 02/07/2023]
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Sharma AK, Salmon MD, Lu G, Su G, Pope NH, Smith JR, Weiss ML, Upchurch GR. Mesenchymal Stem Cells Attenuate NADPH Oxidase-Dependent High Mobility Group Box 1 Production and Inhibit Abdominal Aortic Aneurysms. Arterioscler Thromb Vasc Biol 2016; 36:908-18. [PMID: 26988591 DOI: 10.1161/atvbaha.116.307373] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 02/23/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Abdominal aortic aneurysm (AAA) formation is characterized by inflammation, smooth muscle activation, and matrix degradation. This study tests the hypothesis that macrophage-produced high mobility group box 1 (HMGB1) production is dependent on nicotinamide adenine dinucleotide phosphate oxidase (Nox2), which leads to increase in interleukin (IL)-17 production resulting in AAA formation and that treatment with human mesenchymal stem cells (MSCs) can attenuate this process thereby inhibiting AAA formation. APPROACH AND RESULTS Human aortic tissue demonstrated a significant increase in HMGB1 expression in AAA patients when compared with controls. An elastase-perfusion model of AAA demonstrated a significant increase in HMGB1 production in C57BL/6 (wild-type [WT]) mice, which was attenuated by MSC treatment. Furthermore, anti-HMGB1 antibody treatment of WT mice attenuated AAA formation, IL-17 production, and immune cell infiltration when compared with elastase-perfused WT mice on day 14. Elastase-perfused Nox2(-/y) mice demonstrated a significant attenuation of HMGB1 and IL-17 production, cellular infiltration, matrix metalloproteinase activity, and AAA formation when compared with WT mice on day 14. In vitro studies showed that elastase-treated macrophages from WT mice, but not from Nox2(-/y) mice, produced HMGB1, which was attenuated by MSC treatment. The production of macrophage-dependent HMGB1 involved Nox2 activation and superoxide anion production, which was mitigated by MSC treatment. CONCLUSIONS These results demonstrate that macrophage-produced HMGB1 leads to aortic inflammation and acts as a trigger for CD4(+) T-cell-produced IL-17 during AAA formation. HMGB1 release is dependent on Nox2 activation, which can be inhibited by MSCs leading to attenuation of proinflammatory cytokines, especially IL-17, and protection against AAA formation.
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Affiliation(s)
- Ashish K Sharma
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.)
| | - Morgan D Salmon
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.)
| | - Guanyi Lu
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.)
| | - Gang Su
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.)
| | - Nicolas H Pope
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.)
| | - Joseph R Smith
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.)
| | - Mark L Weiss
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.)
| | - Gilbert R Upchurch
- From the Department of Surgery, University of Virginia, Charlottesville (A.K.S., M.D.S., G.L., G.S., N.H.P., G.R.U.); and Department of Anatomy and Physiology, Kansas State University, Manhattan (J.R.S., M.L.W.).
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13
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Proinflammatory role of stem cells in abdominal aortic aneurysms. J Vasc Surg 2015; 62:1303-11.e4. [DOI: 10.1016/j.jvs.2014.04.067] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/26/2014] [Indexed: 11/17/2022]
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14
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Tonar Z, Kubíková T, Prior C, Demjén E, Liška V, Králíčková M, Witter K. Segmental and age differences in the elastin network, collagen, and smooth muscle phenotype in the tunica media of the porcine aorta. Ann Anat 2015; 201:79-90. [DOI: 10.1016/j.aanat.2015.05.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 12/18/2022]
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15
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Blose KJ, Ennis TL, Arif B, Weinbaum JS, Curci JA, Vorp DA. Periadventitial adipose-derived stem cell treatment halts elastase-induced abdominal aortic aneurysm progression. Regen Med 2015; 9:733-41. [PMID: 25431910 DOI: 10.2217/rme.14.61] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM Demonstrate that periadventitial delivery of adipose-derived mesenchymal stem cells (ADMSCs) slows aneurysm progression in an established murine elastase-perfusion model of abdominal aortic aneurysm (AAA). MATERIALS & METHODS AAAs were induced in C57BL/6 mice using porcine elastase. During elastase perfusion, a delivery device consisting of a subcutaneous port, tubing and porous scaffold was implanted. Five days after elastase perfusion, 100,000 ADMSCs were delivered through the port to the aorta. After sacrifice at day 14, analyzed metrics included aortic diameter and structure of aortic elastin. RESULTS ADMSC treated aneurysms had a smaller diameter and less fragmented elastin versus saline controls. CONCLUSION Periadventitial stem cell delivery prevented the expansion of an established aneurysm between days 5 and 14 after elastase perfusion.
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Affiliation(s)
- Kory J Blose
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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Davis JP, Salmon M, Pope NH, Lu G, Su G, Sharma AK, Ailawadi G, Upchurch GR. Attenuation of aortic aneurysms with stem cells from different genders. J Surg Res 2015; 199:249-58. [PMID: 25958166 DOI: 10.1016/j.jss.2015.04.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/31/2015] [Accepted: 04/08/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND No medical therapies are yet available to slow abdominal aortic aneurysm (AAA) growth. This study sought to investigate the effect of different genders of bone marrow-derived mesenchymal stem cells (MSC) on AAA growth in a murine AAA model. Given the decreased rate of AAA in women, it is hypothesized that female MSC would attenuate AAA growth more so than male MSC. MATERIALS AND METHODS Aortas of 8-10-wk-old male C57Bl/6 mice were perfused with purified porcine pancreatic elastase to induce AAA formation. Bone marrow-derived MSC from male and female mice were dosed via tail vein injection (3 million cells per dose, 500 μL of volume per injection) on postaortic perfusion days 1, 3, and 5. Aortas were harvested after 14 d. RESULTS Mean aortic dilation in the elastase group was 121 ± 5.2% (mean ± standard error of the mean), while male MSC inhibited AAA growth (87.8 ± 6.9%, P = 0.008) compared with that of elastase. Female MSC showed the most marked attenuation of AAA growth (75.2 ± 8.3% P = 0.0004). Proinflammatory cytokines tumor necrosis factor α, interleukin 1β, and monocyte chemotactic protein-1 (MCP-1) were only decreased in tissues treated with female MSC (P = 0.017, P = 0.001, and P < 0.0001, respectively, when compared with elastase). CONCLUSIONS These data exhibit that female MSC more strongly attenuate AAA growth in the murine model. Furthermore, female MSC and male MSC inhibit proinflammatory cytokines at varying levels. The effects of MSC on aortic tissue offer a promising insight into biologic therapies for future medical treatment of AAAs in humans.
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Affiliation(s)
- John P Davis
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Morgan Salmon
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Nicolas H Pope
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Guanyi Lu
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Gang Su
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Ashish K Sharma
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Gorav Ailawadi
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Gilbert R Upchurch
- Division of Vascular and Endovascular Surgery and Cardiothoracic Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.
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Riera del Moral L, Largo C, Ramirez JR, Vega Clemente L, Fernández Heredero A, Riera de Cubas L, Garcia-Olmo D, Garcia-Arranz M. Potential of mesenchymal stem cell in stabilization of abdominal aortic aneurysm sac. J Surg Res 2014; 195:325-33. [PMID: 25592273 DOI: 10.1016/j.jss.2014.12.020] [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] [Received: 09/22/2014] [Revised: 12/03/2014] [Accepted: 12/10/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND In their origin, abdominal aortic aneurysms (AAAs) are related to an inflammatory reaction within the aortic wall, which can lead to weakness and degeneration of this structure. One of the most widely accepted treatment modalities for AAAs is the placement of stent grafts. Nevertheless, in some patients blood re-enters the aneurysm sac, creating so-called leaks, which constitute a renewed risk of rupture and death.This study explores the possibility of filling aneurysm sacs treated by endovascular aneurysm repair with adipose tissue-derived mesenchymal stem cells (ASCs) in a porcine model. METHODS We developed a porcine model using 22 animals by creating an artificial AAA made with a Dacron patch. AAAs were then treated with a coated stent that isolated the aneurysm sac, after which we introduced allogeneic ASC into the sac. Animals were followed-up for up to 3 mo. The experiment consisted of the aforementioned surgical procedure performed first, followed by computed tomography and echo-Doppler imaging during the follow-up, and finally, after sacrificing the animals, histologic analysis of tissue samples from the site of cell implantation by a blinded observer and the detection of implanted cells by immunofluorescence detection of the Y chromosome. RESULTS Our findings demonstrate the survival of ASCs over the 3 mo after implantation and histologic changes associated with this treatment. Treated animals had less acute and chronic inflammation throughout the study period, and we observed increasing fibrosis of the aneurysm sac, no accumulation of calcium, and a regeneration of elastic fibers in the artery. CONCLUSIONS The combination of endovascular aneurysm repair and cell therapy on AAAs has promising results for the stabilization of the sac, resulting in the generation of living tissue that can secure the stent graft and even showing some signs of wall regeneration. The therapeutic value of such cell-based therapy will require further investigation.
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Affiliation(s)
- L Riera del Moral
- Department of Angiology and Vascular Surgery, Hospital Universitario La Paz-Instituto de Investigación del Hospital Universitario La Paz, Madrid, Spain; Department of Surgery, Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - C Largo
- Department of Experimental Surgery, Hospital Universitario La Paz-Instituto de Investigación del Hospital Universitario La Paz, Madrid, Spain
| | - J R Ramirez
- Department of Pathology, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - L Vega Clemente
- Cell Therapy Laboratory, Research Department, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain
| | - A Fernández Heredero
- Department of Angiology and Vascular Surgery, Hospital Universitario La Paz-Instituto de Investigación del Hospital Universitario La Paz, Madrid, Spain
| | - L Riera de Cubas
- Department of Angiology and Vascular Surgery, Hospital Universitario La Paz-Instituto de Investigación del Hospital Universitario La Paz, Madrid, Spain
| | - D Garcia-Olmo
- Department of Surgery, Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Cell Therapy Laboratory, Research Department, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain; Department of Surgery, University Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - M Garcia-Arranz
- Department of Surgery, Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Cell Therapy Laboratory, Research Department, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz (IIS-FJD), Madrid, Spain.
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Yamawaki-Ogata A, Hashizume R, Fu XM, Usui A, Narita Y. Mesenchymal stem cells for treatment of aortic aneurysms. World J Stem Cells 2014; 6:278-287. [PMID: 25067996 PMCID: PMC4109132 DOI: 10.4252/wjsc.v6.i3.278] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/21/2014] [Accepted: 05/08/2014] [Indexed: 02/07/2023] Open
Abstract
An aortic aneurysm (AA) is a silent but life-threatening disease that involves rupture. It occurs mainly in aging and severe atherosclerotic damage of the aortic wall. Even though surgical intervention is effective to prevent rupture, surgery for the thoracic and thoraco-abdominal aorta is an invasive procedure with high mortality and morbidity. Therefore, an alternative strategy for treatment of AA is required. Recently, the molecular pathology of AA has been clarified. AA is caused by an imbalance between the synthesis and degradation of extracellular matrices in the aortic wall. Chronic inflammation enhances the degradation of matrices directly and indirectly, making control of the chronic inflammation crucial for aneurysmal development. Meanwhile, mesenchymal stem cells (MSCs) are known to be obtained from an adult population and to differentiate into various types of cells. In addition, MSCs have not only the potential anti-inflammatory and immunosuppressive properties but also can be recruited into damaged tissue. MSCs have been widely used as a source for cell therapy to treat various diseases involving graft-versus-host disease, stroke, myocardial infarction, and chronic inflammatory disease such as Crohn’s disease clinically. Therefore, administration of MSCs might be available to treat AA using anti-inflammatory and immnosuppressive properties. This review provides a summary of several studies on “Cell Therapy for Aortic Aneurysm” including our recent data, and we also discuss the possibility of this kind of treatment.
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19
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Long MY, Li HH, Pen XZ, Huang MQ, Luo DY, Wang PS. Expression of chemokine receptor-4 in bone marrow mesenchymal stem cells on experimental rat abdominal aortic aneurysms and the migration of bone marrow mesenchymal stem cells with stromal-derived factor-1. Kaohsiung J Med Sci 2014; 30:224-8. [DOI: 10.1016/j.kjms.2013.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 12/03/2013] [Indexed: 10/25/2022] Open
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20
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Mechanical behavior of abdominal aorta aneurysm in rat model treated by cell therapy using mesenchymal stem cells. Biomech Model Mechanobiol 2014; 14:185-94. [DOI: 10.1007/s10237-014-0586-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 04/09/2014] [Indexed: 01/18/2023]
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21
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Bashur CA, Rao RR, Ramamurthi A. Perspectives on stem cell-based elastic matrix regenerative therapies for abdominal aortic aneurysms. Stem Cells Transl Med 2013; 2:401-8. [PMID: 23677642 DOI: 10.5966/sctm.2012-0185] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Abdominal aortic aneurysms (AAAs) are potentially fatal conditions that are characterized by decreased flexibility of the aortic wall due to proteolytic loss of the structural matrix. This leads to their gradual weakening and ultimate rupture. Drug-based inhibition of proteolytic enzymes may provide a nonsurgical treatment alternative for growing AAAs, although it might at best be sufficient to slow their growth. Regenerative repair of disrupted elastic matrix is required if regression of AAAs to a healthy state is to be achieved. Terminally differentiated adult and diseased vascular cells are poorly capable of affecting such regenerative repair. In this context, stem cells and their smooth muscle cell-like derivatives may represent alternate cell sources for regenerative AAA cell therapies. This article examines the pros and cons of using different autologous stem cell sources for AAA therapy, the requirements they must fulfill to provide therapeutic benefit, and the current progress toward characterizing the cells' ability to synthesize elastin, assemble elastic matrix structures, and influence the regenerative potential of diseased vascular cell types. The article also provides a detailed perspective on the limitations, uncertainties, and challenges that will need to be overcome or circumvented to translate current strategies for stem cell use into clinically viable AAA therapies. These therapies will provide a much needed nonsurgical treatment option for the rapidly growing, high-risk, and vulnerable elderly demographic.
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MESH Headings
- Aged
- Animals
- Aorta, Abdominal/drug effects
- Aorta, Abdominal/metabolism
- Aorta, Abdominal/pathology
- Aortic Aneurysm, Abdominal/metabolism
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Abdominal/rehabilitation
- Aortic Aneurysm, Abdominal/therapy
- Becaplermin
- Elasticity/drug effects
- Elasticity/physiology
- Elastin/biosynthesis
- Extracellular Matrix/drug effects
- Extracellular Matrix/metabolism
- Humans
- Myocytes, Smooth Muscle/cytology
- Myocytes, Smooth Muscle/metabolism
- Proto-Oncogene Proteins c-sis/pharmacology
- Regeneration/drug effects
- Regeneration/physiology
- Stem Cell Transplantation/methods
- Stem Cell Transplantation/trends
- Stem Cells/cytology
- Stem Cells/metabolism
- Transforming Growth Factor beta/pharmacology
- Transplantation, Autologous
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Affiliation(s)
- Chris A Bashur
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, USA
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22
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Bone marrow mesenchymal stem cells stabilize already-formed aortic aneurysms more efficiently than vascular smooth muscle cells in a rat model. Eur J Vasc Endovasc Surg 2013; 45:666-72. [PMID: 23598054 DOI: 10.1016/j.ejvs.2013.03.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 03/11/2013] [Indexed: 11/21/2022]
Abstract
PURPOSE Abdominal aortic aneurysms (AAAs) expand because of aortic wall destruction. Enrichment in Vascular Smooth Muscle Cells (VSMCs) stabilizes expanding AAAs in rats. Mesenchymal Stem Cells (MSCs) can differentiate into VSMCs. We have tested the hypothesis that bone marrow-derived MSCs (BM-MSCs) stabilizes AAAs in a rat model. MATERIAL AND METHODS Rat Fischer 344 BM-MSCs were isolated by plastic adhesion and seeded endovascularly in experimental AAAs using xenograft obtained from guinea pig. Culture medium without cells was used as control group. The main criteria was the variation of the aortic diameter at one week and four weeks. We evaluated the impact of cells seeding on inflammatory response by immunohistochemistry combined with RT-PCR on MMP9 and TIMP1 at one week. We evaluated the healing process by immunohistochemistry at 4 weeks. RESULTS The endovascular seeding of BM-MSCs decreased AAA diameter expansion more powerfully than VSMCs or culture medium infusion (6.5% ± 9.7, 25.5% ± 17.2 and 53.4% ± 14.4; p = .007, respectively). This result was sustained at 4 weeks. BM-MSCs decreased expression of MMP-9 and infiltration by macrophages (4.7 ± 2.3 vs. 14.6 ± 6.4 mm(2) respectively; p = .015), increased Tissue Inhibitor Metallo Proteinase-1 (TIMP-1), compared to culture medium infusion. BM-MSCs induced formation of a neo-aortic tissue rich in SM-alpha active positive cells (22.2 ± 2.7 vs. 115.6 ± 30.4 cells/surface units, p = .007) surrounded by a dense collagen and elastin network covered by luminal endothelial cells. CONCLUSIONS We have shown in this rat model of AAA that BM-MSCs exert a specialized function in arterial regeneration that transcends that of mature mesenchymal cells. Our observation identifies a population of cells easy to isolate and to expand for therapeutic interventions based on catheter-driven cell therapy.
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The Compatibility of Swine BMDC-derived Bile Duct Endothelial Cells with a Nanostructured Electrospun PLGA Material. Int J Artif Organs 2013; 36:121-30. [PMID: 23335380 DOI: 10.5301/ijao.5000181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2012] [Indexed: 11/20/2022]
Abstract
Purpose To investigate the production of bile duct endothelial cells via directed differentiation of porcine bone marrow mesenchymal stem cells (BMSCs) down the hepatic lineage in vitro and the biocompatibility of differentiated bile duct endothelial cells with electrospun nanofibers. Methods Porcine BMSCs were differentiated in vitro into bile duct endothelial cells, which were identified by morphology and RT-PCR. PLGA nanofiber membranes were prepared by electrospinning. The morphology was detected by scanning electron microscopy and the short-term (two weeks) in vitro degradation rate was determined. Adhesion and proliferation of the bile duct endothelial cells on the nanofiber surface were analyzed by calculating the cell adhesion rate and MTT assay, respectively. Cell growth, morphology and distribution on the material surface were observed by fluorescence staining and scanning electron microscopy, respectively. Results After four weeks of directed differentiation of BMSCs in vitro, cells showed the typical morphology of dendritic bile duct endothelial cells and had the expression of CK19. Scanning electron micrographs showed that electrospun materials were continuous nanofibers with diameters between 200 and 500 nm. No significant degradation of the PLGA nanofibers was observed within two weeks. Based on the measured cell adhesion rate, MTT assay, fluorescence staining, and scanning electron microscopy, the differentiated cells possess a good proliferative capacity on PLGA nanofibers. Conclusions BMSCs can be differentiated into the bile duct endothelial cells in vitro. Materials prepared by the electrospinning method have a nanofiber structure, which does not significantly degrade within two weeks. Differentiated cells exhibit good biocompatibility with the nanofibers.
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Current world literature. Curr Opin Organ Transplant 2013; 18:111-30. [PMID: 23299306 DOI: 10.1097/mot.0b013e32835daf68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Park HS, Choi GH, Hahn S, Yoo YS, Lee JY, Lee T. Potential role of vascular smooth muscle cell-like progenitor cell therapy in the suppression of experimental abdominal aortic aneurysms. Biochem Biophys Res Commun 2013; 431:326-31. [PMID: 23291168 DOI: 10.1016/j.bbrc.2012.12.099] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/25/2012] [Indexed: 10/27/2022]
Abstract
Abdominal aortic aneurysms (AAA) are a growing problem worldwide, yet there is no known medical therapy. The pathogenesis involves degradation of the elastic lamina by two combined mechanisms: increased degradation of elastin by matrix metalloproteinases (MMP) and decreased formation of elastin due to apoptosis of vascular smooth muscle cells (VSMC). In this study, we set out to examine the potential role of stem cells in the attenuation of AAA formation by inhibition of these pathogenetic mechanisms. Muscle-derived stem cells from murine skeletal muscles were isolated and stimulated with PDGF-BB in vitro for differentiation to VSMC-like progenitor cells (VSMC-PC). These cells were implanted in to elastase-induced AAAs in rats. The cell therapy group had decreased rate of aneurysm formation compared to control, and MMP expression at the genetic, protein and enzymatic level were also significantly decreased. Furthermore, direct implantation of VSMC-PCs in the intima of harvested aortas was visualized under immunofluorescent staining, suggesting that these cells were responsible for the inhibition of MMPs and consequent attenuation of AAA formation. These results show a promising role of stem cell therapy for the treatment of AAAs, and with further studies, may be able to reach clinical significance.
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Affiliation(s)
- Hyung Sub Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi, Republic of Korea
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26
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Sharma AK, Lu G, Jester A, Johnston WF, Zhao Y, Hajzus VA, Saadatzadeh MR, Su G, Bhamidipati CM, Mehta GS, Kron IL, Laubach VE, Murphy MP, Ailawadi G, Upchurch GR. Experimental abdominal aortic aneurysm formation is mediated by IL-17 and attenuated by mesenchymal stem cell treatment. Circulation 2012; 126:S38-45. [PMID: 22965992 DOI: 10.1161/circulationaha.111.083451] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) formation is characterized by inflammation, smooth muscle activation and matrix degradation. This study tests the hypothesis that CD4+ T-cell-produced IL-17 modulates inflammation and smooth muscle cell activation, leading to the pathogenesis of AAA and that human mesenchymal stem cell (MSC) treatment can attenuate IL-17 production and AAA formation. METHODS AND RESULTS Human aortic tissue demonstrated a significant increase in IL-17 and IL-23 expression in AAA patients compared with control subjects as analyzed by RT-PCR and ELISA. AAA formation was assessed in C57BL/6 (wild-type; WT), IL-23(-/-) or IL-17(-/-) mice using an elastase-perfusion model. Heat-inactivated elastase was used as control. On days 3, 7, and 14 after perfusion, abdominal aorta diameter was measured by video micrometry, and aortic tissue was analyzed for cytokines, cell counts, and IL-17-producing CD4+ T cells. Aortic diameter and cytokine production (MCP-1, RANTES, KC, TNF-α, MIP-1α, and IFN-γ) was significantly attenuated in elastase-perfused IL-17(-/-) and IL-23(-/-) mice compared with WT mice on day 14. Cellular infiltration (especially IL-17-producing CD4+ T cells) was significantly attenuated in elastase-perfused IL-17(-/-) mice compared with WT mice on day 14. Primary aortic smooth muscle cells were significantly activated by elastase or IL-17 treatment. Furthermore, MSC treatment significantly attenuated AAA formation and IL-17 production in elastase-perfused WT mice. CONCLUSIONS These results demonstrate that CD4+ T-cell-produced IL-17 plays a critical role in promoting inflammation during AAA formation and that immunomodulation of IL-17 by MSCs can offer protection against AAA formation.
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Affiliation(s)
- Ashish K Sharma
- Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
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