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Rojas-Torres M, Beltrán-Camacho L, Martínez-Val A, Sánchez-Gomar I, Eslava-Alcón S, Rosal-Vela A, Jiménez-Palomares M, Doiz-Artázcoz E, Martínez-Torija M, Moreno-Luna R, Olsen JV, Duran-Ruiz MC. Unraveling the differential mechanisms of revascularization promoted by MSCs & ECFCs from adipose tissue or umbilical cord in a murine model of critical limb-threatening ischemia. J Biomed Sci 2024; 31:71. [PMID: 39004727 PMCID: PMC11247736 DOI: 10.1186/s12929-024-01059-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/25/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Critical limb-threatening ischemia (CLTI) constitutes the most severe manifestation of peripheral artery disease, usually induced by atherosclerosis. CLTI patients suffer from high risk of amputation of the lower extremities and elevated mortality rates, while they have low options for surgical revascularization due to associated comorbidities. Alternatively, cell-based therapeutic strategies represent an effective and safe approach to promote revascularization. However, the variability seen in several factors such as cell combinations or doses applied, have limited their success in clinical trials, being necessary to reach a consensus regarding the optimal "cellular-cocktail" prior further application into the clinic. To achieve so, it is essential to understand the mechanisms by which these cells exert their regenerative properties. Herein, we have evaluated, for the first time, the regenerative and vasculogenic potential of a combination of endothelial colony forming cells (ECFCs) and mesenchymal stem cells (MSCs) isolated from adipose-tissue (AT), compared with ECFCs from umbilical cord blood (CB-ECFCs) and AT-MSCs, in a murine model of CLTI. METHODS Balb-c nude mice (n:32) were distributed in four different groups (n:8/group): control shams, and ischemic mice (after femoral ligation) that received 50 µl of physiological serum alone or a cellular combination of AT-MSCs with either CB-ECFCs or AT-ECFCs. Follow-up of blood flow reperfusion and ischemic symptoms was carried out for 21 days, when mice were sacrificed to evaluate vascular density formation. Moreover, the long-term molecular changes in response to CLTI and both cell combinations were analyzed in a proteomic quantitative approach. RESULTS AT-MSCs with either AT- or CB-ECFCs, promoted a significant recovery of blood flow in CLTI mice 21 days post-ischemia. Besides, they modulated the inflammatory and necrotic related processes, although the CB group presented the slowest ischemic progression along the assay. Moreover, many proteins involved in the repairing mechanisms promoted by cell treatments were identified. CONCLUSIONS The combination of AT-MSCs with AT-ECFCs or with CB-ECFCs promoted similar revascularization in CLTI mice, by restoring blood flow levels, together with the modulation of the inflammatory and necrotic processes, and reduction of muscle damage. The protein changes identified are representative of the molecular mechanisms involved in ECFCs and MSCs-induced revascularization (immune response, vascular repair, muscle regeneration, etc.).
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Affiliation(s)
- Marta Rojas-Torres
- Biomedicine, Biotechnology and Public Health Department, University of Cadiz, Cadiz, 11002, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, 11002, Spain
| | - Lucía Beltrán-Camacho
- Cell Biology, Physiology and Immunology Department, University of Cordoba, Cordoba, 14004, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, 14004, Spain
| | - Ana Martínez-Val
- National Center of Cardiovascular Research Carlos III (CNIC), Madrid, 28029, Spain
| | - Ismael Sánchez-Gomar
- Biomedicine, Biotechnology and Public Health Department, University of Cadiz, Cadiz, 11002, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, 11002, Spain
| | - Sara Eslava-Alcón
- Biomedicine, Biotechnology and Public Health Department, University of Cadiz, Cadiz, 11002, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, 11002, Spain
| | - Antonio Rosal-Vela
- Biomedicine, Biotechnology and Public Health Department, University of Cadiz, Cadiz, 11002, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, 11002, Spain
| | - Margarita Jiménez-Palomares
- Biomedicine, Biotechnology and Public Health Department, University of Cadiz, Cadiz, 11002, Spain
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, 11002, Spain
| | - Esther Doiz-Artázcoz
- Angiology & Vascular Surgery Unit, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Mario Martínez-Torija
- Pathophysiology and Regenerative Medicine Group, Hospital Nacional de Parapléjicos (SESCAM), Toledo, 45071, Spain
- Nursing department, Hospital Universitario de Toledo (SESCAM), Toledo, 45071, Spain
| | - Rafael Moreno-Luna
- Pathophysiology and Regenerative Medicine Group, Hospital Nacional de Parapléjicos (SESCAM), Toledo, 45071, Spain.
- Cooperative Research Network Orientated to Health Results, Vascular Brain Diseases, RICORS-ICTUS, SESCAM, Toledo, Spain.
| | - Jesper V Olsen
- Novo Nordisk Foundation Center for Protein Research, Copenhagen, Denmark
| | - Ma Carmen Duran-Ruiz
- Biomedicine, Biotechnology and Public Health Department, University of Cadiz, Cadiz, 11002, Spain.
- Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, 11002, Spain.
- Biomedicine, Biotechnology and Public Health Department, Science Faculty, Cádiz University. Torre Sur. Avda. República Saharaui S/N, Polígono Río San Pedro, Puerto Real, Cádiz, 11519, Spain.
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Callegari S, Romain G, Cleman J, Scierka L, Jacque F, Smolderen KG, Mena-Hurtado C. Long-Term Mortality Predictors Using a Machine-Learning Approach in Patients With Chronic Limb-Threatening Ischemia After Peripheral Vascular Intervention. J Am Heart Assoc 2024; 13:e034477. [PMID: 38761075 PMCID: PMC11179837 DOI: 10.1161/jaha.124.034477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Patients with chronic limb-threatening ischemia (CLTI) face a high long-term mortality risk. Identifying novel mortality predictors and risk profiles would enable individual health care plan design and improved survival. We aimed to leverage a random survival forest machine-learning algorithm to identify long-term all-cause mortality predictors in patients with CLTI undergoing peripheral vascular intervention. METHODS AND RESULTS Patients with CLTI undergoing peripheral vascular intervention from 2017 to 2018 were derived from the Medicare-linked VQI (Vascular Quality Initiative) registry. We constructed a random survival forest to rank 66 preprocedural variables according to their relative importance and mean minimal depth for 3-year all-cause mortality. A random survival forest of 2000 trees was built using a training sample (80% of the cohort). Accuracy was assessed in a testing sample (20%) using continuous ranked probability score, Harrell C-index, and out-of-bag error rate. A total of 10 114 patients were included (mean±SD age, 72.0±11.0 years; 59% men). The 3-year mortality rate was 39.1%, with a median survival of 1.4 years (interquartile range, 0.7-2.0 years). The most predictive variables were chronic kidney disease, age, congestive heart failure, dementia, arrhythmias, requiring assisted care, living at home, and body mass index. A total of 41 variables spanning all domains of the biopsychosocial model were ranked as mortality predictors. The accuracy of the model was excellent (continuous ranked probability score, 0.172; Harrell C-index, 0.70; out-of-bag error rate, 29.7%). CONCLUSIONS Our random survival forest accurately predicts long-term CLTI mortality, which is driven by demographic, functional, behavioral, and medical comorbidities. Broadening frameworks of risk and refining health care plans to include multidimensional risk factors could improve individualized care for CLTI.
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Affiliation(s)
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Francky Jacque
- Vascular Medicine Outcomes Program Yale University New Haven CT
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program Yale University New Haven CT
- Department of Psychiatry Yale School of Medicine New Haven CT
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Marcaccio CL, Schermerhorn ML. Using Administrative Data to Better Treat Chronic Limb Threatening Ischemia. Ann Vasc Surg 2024:S0890-5096(24)00204-8. [PMID: 38754578 DOI: 10.1016/j.avsg.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/17/2024] [Indexed: 05/18/2024]
Abstract
Chronic limb threatening ischemia (CLTI) is the most severe manifestation of peripheral arterial disease and represents a particularly high-risk subgroup of patients. As such, efforts to better understand this complex patient population through well-designed clinical research studies are critical to improving CLTI care. Prospective randomized clinical trials (RCTs) remain the gold standard in clinical research, but these trials are resource-intensive and have highly selective patient populations, which limit their feasibility and generalizability. Alternatively, retrospective studies are less expensive than RCTs, have a larger sample size, and are more generalizable owing to a broader patient population. Health care administrative data provide rich sources of information that may be used for research purposes and are increasingly being used for the study of vascular surgery conditions, including CLTI. Although administrative data are collected for billing purposes, they may be leveraged to study a broad range of topics in vascular surgery including those related to health care delivery, epidemiology, health disparities, and outcomes. This review provides an overview of administrative data available for CLTI research, the strengths and limitations of these data sources, current areas of investigation, and future opportunities for further study with the goal of improving outcomes in this high-risk population.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Brennan PG, Mota L, Aridi T, Patel N, Liang P, Ferran C. Advancements in Omics and Breakthrough Gene Therapies: A Glimpse into the Future of Peripheral Artery Disease. Ann Vasc Surg 2024:S0890-5096(24)00156-0. [PMID: 38582204 DOI: 10.1016/j.avsg.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 01/01/2024] [Indexed: 04/08/2024]
Abstract
Peripheral artery disease (PAD), a highly prevalent global disease, associates with significant morbidity and mortality in affected patients. Despite progress in endovascular and open revascularization techniques for advanced PAD, these interventions grapple with elevated rates of arterial restenosis and vein graft failure attributed to intimal hyperplasia (IH). Novel multiomics technologies, coupled with sophisticated analyses tools recently powered by advances in artificial intelligence, have enabled the study of atherosclerosis and IH with unprecedented single-cell and spatial precision. Numerous studies have pinpointed gene hubs regulating pivotal atherogenic and atheroprotective signaling pathways as potential therapeutic candidates. Leveraging advancements in viral and nonviral gene therapy (GT) platforms, gene editing technologies, and cutting-edge biomaterial reservoirs for delivery uniquely positions us to develop safe, efficient, and targeted GTs for PAD-related diseases. Gene therapies appear particularly fitting for ex vivo genetic engineering of IH-resistant vein grafts. This manuscript highlights currently available state-of-the-art multiomics approaches, explores promising GT-based candidates, and details GT delivery modalities employed by our laboratory and others to thwart mid-term vein graft failure caused by IH, as well as other PAD-related conditions. The potential clinical translation of these targeted GTs holds the promise to revolutionize PAD treatment, thereby enhancing patients' quality of life and life expectancy.
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Affiliation(s)
- Phillip G Brennan
- Division of Vascular and Endovascular Surgery, and Center for Vascular Biology Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Lucas Mota
- Division of Vascular and Endovascular Surgery, and Center for Vascular Biology Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tarek Aridi
- Division of Vascular and Endovascular Surgery, and Center for Vascular Biology Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Nyah Patel
- Division of Vascular and Endovascular Surgery, and Center for Vascular Biology Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Patric Liang
- Division of Vascular and Endovascular Surgery, and Center for Vascular Biology Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christiane Ferran
- Division of Vascular and Endovascular Surgery, and Center for Vascular Biology Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Division of Nephrology and the Transplant Institute, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Cleman J, Romain G, Callegari S, Scierka L, Jacque F, Smolderen KG, Mena-Hurtado C. Evaluation of short-term mortality in patients with Medicare undergoing endovascular interventions for chronic limb-threatening ischemia. Vasc Med 2024; 29:172-181. [PMID: 38334045 DOI: 10.1177/1358863x231224335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Patients with chronic limb-threatening ischemia (CLTI) have high mortality rates after revascularization. Risk stratification for short-term outcomes is challenging. We aimed to develop machine-learning models to rank predictive variables for 30-day and 90-day all-cause mortality after peripheral vascular intervention (PVI). METHODS Patients undergoing PVI for CLTI in the Medicare-linked Vascular Quality Initiative were included. Sixty-six preprocedural variables were included. Random survival forest (RSF) models were constructed for 30-day and 90-day all-cause mortality in the training sample and evaluated in the testing sample. Predictive variables were ranked based on the frequency that they caused branch splitting nearest the root node by importance-weighted relative importance plots. Model performance was assessed by the Brier score, continuous ranked probability score, out-of-bag error rate, and Harrell's C-index. RESULTS A total of 10,114 patients were included. The crude mortality rate was 4.4% at 30 days and 10.6% at 90 days. RSF models commonly identified stage 5 chronic kidney disease (CKD), dementia, congestive heart failure (CHF), age, urgent procedures, and need for assisted care as the most predictive variables. For both models, eight of the top 10 variables were either medical comorbidities or functional status variables. Models showed good discrimination (C-statistic 0.72 and 0.73) and calibration (Brier score 0.03 and 0.10). CONCLUSION RSF models for 30-day and 90-day all-cause mortality commonly identified CKD, dementia, CHF, need for assisted care at home, urgent procedures, and age as the most predictive variables as critical factors in CLTI. Results may help guide individualized risk-benefit treatment conversations regarding PVI.
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Affiliation(s)
- Jacob Cleman
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Santiago Callegari
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Francky Jacque
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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Li J, Varcoe R, Manzi M, Kum S, Iida O, Schmidt A, Shishehbor MH. Below-the-Knee Endovascular Revascularization: A Position Statement. JACC Cardiovasc Interv 2024; 17:589-607. [PMID: 38244007 DOI: 10.1016/j.jcin.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024]
Abstract
Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.
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Affiliation(s)
- Jun Li
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ramon Varcoe
- Prince of Wales Hospital, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marco Manzi
- Interventional Radiology Unit, Foot and Ankle Clinic, Policlinico Abano Terme, Abano Terme, Italy
| | - Steven Kum
- Department of Surgery, Changi General Hospital, Singapore
| | - Osamu Iida
- Kasai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Andrej Schmidt
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
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