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Ors Yildirim N, Yildirim AK, Demeli Ertus M, Dastan AO, Pehlivanoglu B, Chi YW, Gianesini S, Doganci S, Yildirim V. Sulodexide Inhibits Arterial Contraction via the Endothelium-Dependent Nitric Oxide Pathway. J Clin Med 2024; 13:2332. [PMID: 38673605 PMCID: PMC11050801 DOI: 10.3390/jcm13082332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: Sulodexide (SDX) is a drug known for restoring the glycocalyx, thereby offering endothelial protection and regulating permeability. Additionally, it has antithrombotic and anti-inflammatory properties and has shown arterial vasodilatory effects. Endothelial cells play a crucial role in maintaining homeostasis, with their dysfunction being a key contributor to loss in vasodilatory response, especially in arterial pathologies. The aim of this study was to investigate the effects of SDX on stimulated vascular tonus in human arterial samples and to assess the function of the endothelial layer as a source of nitric oxide (NO). Methods: A total of 16 internal mammary artery remnants from coronary artery bypass graft surgeries were dissected into endothelium-intact and endothelium-denuded groups (n = 8 each). The arterial rings were equilibrated under tension, with their basal tonus recorded before and after phenylephrine stimulation. SDX's impact on arterial contraction was assessed through cumulative dose-response curves. NO synthase inhibitor (Nω-nitro-L-arginine methyl ester) was used to assess SDX's vasodilatory effect over the NO pathway. Results: SDX application resulted in concentration-dependent vasorelaxation in both endothelium-intact and endothelium-denuded groups at certain doses. However, the inhibitory effect of SDX was more pronounced in endothelium-intact rings at higher doses compared to endothelium-denuded rings (p < 0.05). Similar inhibition of contraction curves was achieved for both endothelium-intact and endothelium-denuded rings after L-NAME pre-incubation, suggesting a necessity for NO-related endothelial pathways. Conclusions: SDX exerts a concentration-dependent inhibition on arterial contraction, emphasizing the critical role of an intact endothelium and NO-mediated pathways in this process. This underscores SDX's potential in treating endothelial dysfunction-related pathologies.
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Affiliation(s)
- Nadide Ors Yildirim
- Department of Anesthesiology and Reanimation, Sincan Training and Research Hospital, Ankara 06949, Turkey;
| | - Alperen Kutay Yildirim
- Department of Cardiovascular Surgery, Faculty of Medicine, Gazi University, Ankara 06560, Turkey
| | - Meric Demeli Ertus
- Department of Physiology, Zonguldak Bulent Ecevit University, Zonguldak 67600, Turkey;
| | - Ahmet Onur Dastan
- Department of Physiology, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey; (A.O.D.); (B.P.)
| | - Bilge Pehlivanoglu
- Department of Physiology, Hacettepe University Faculty of Medicine, Ankara 06100, Turkey; (A.O.D.); (B.P.)
| | - Yung-Wei Chi
- Vascular Center, University of California, Sacramento, CA 95817, USA;
| | - Sergio Gianesini
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA;
| | | | - Vedat Yildirim
- Department of Anesthesiology and Reanimation, Gulhane Training and Research Hospital, University of Health Sciences, Ankara 06010, Turkey;
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Gallo G, Picciariello A, Tufano A, Camporese G. Clinical evidence and rationale of mesoglycan to treat chronic venous disease and hemorrhoidal disease: a narrative review. Updates Surg 2024; 76:423-434. [PMID: 38356039 PMCID: PMC10995001 DOI: 10.1007/s13304-024-01776-9] [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: 12/13/2023] [Accepted: 01/29/2024] [Indexed: 02/16/2024]
Abstract
Chronic venous disease (CVD) and hemorrhoidal disease (HD) are among the most common vascular diseases in the world, with CVD affecting 22-41% of the population in Europe and HD having a point prevalence of 11-39%. The burden is substantial in terms of the effect of symptoms on patients' health-related quality of life (HRQoL) and direct/indirect medical costs. Treatment begins with lifestyle changes, compression in CVD and topical therapies in HD, and escalates as needed through oral therapies first and eventually to surgery for severe disease. CVD and HD share etiological features and pathological changes affecting the structure and function of the tissue extracellular matrix. Mesoglycan, a natural glycosaminoglycan (GAG) preparation composed primarily of heparan sulfate and dermatan sulfate, has been demonstrated to positively impact the underlying causes of CVD and HD, regenerating the glycocalyx and restoring endothelial function, in addition to having antithrombotic, profibrinolytic, anti-inflammatory, antiedema and wound-healing effects. In clinical trials, oral mesoglycan reduced the severity of CVD signs and symptoms, improved HRQoL, and accelerated ulcer healing. In patients with HD, mesoglycan significantly reduced the severity of signs and symptoms and the risk of rectal bleeding. In patients undergoing excisional hemorrhoidectomy, adding mesoglycan to standard postoperative care reduced pain, improved HRQoL, reduced incidence of thrombosis, and facilitated an earlier return to normal activities/work, compared with standard postoperative care alone. The clinical effects of mesoglycan in patients with CVD or HD are consistent with the agent's known mechanisms of action.
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Affiliation(s)
- Gaetano Gallo
- Department of Surgery, Sapienza University of Rome, Rome, Italy.
| | | | - Antonella Tufano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Camporese
- Department of Internal Medicine, Padua University Hospital, Padua, Italy
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Mammucari M, Paolucci T, Russo D, Maggiori E, Di Marzo R, Migliore A, Massafra U, Ronconi G, Ferrara PE, Gori F, Bifarini B, Brauneis S, Vellucci R, Mediati RD, Violo B, Natoli S, Pediliggieri C, Di Campli C, Collina MC. A Call to Action by the Italian Mesotherapy Society on Scientific Research. Drug Des Devel Ther 2021; 15:3041-3047. [PMID: 34285471 PMCID: PMC8285234 DOI: 10.2147/dddt.s321215] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023] Open
Abstract
Mesotherapy (local intradermal therapy, LIT) is a technique used to slowly spread drugs in tissues underlying the site of injection to prolong the pharmacological effect with respect to intramuscular injection. Recommendations for proper medical use of this technique have been made for pain medicine and rehabilitation, chronic venous disease, sport medicine, musculoskeletal disorders, several dermatological conditions, skin ageing, and immune-prophylaxis. Although mesotherapy is considered a valid technique, unresolved questions remain, which should be answered to standardize methodology and dosing regimen as well as to define the right indications in clinical practice. New randomized controlled trials are needed to test single products (dose, frequency of administration, efficacy and safety). Even infiltration of substances for dermo-cosmetic purposes must be guided by safety and efficacy tests before being proposed by mesotherapy. In this article, we put forth a preclinical and clinical research plan and a health technology assessment as a call to action by doctors, researchers and scientific societies to aid national health authorities in considering mesotherapy for prevention, treatment and rehabilitation paths.
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Affiliation(s)
| | - Teresa Paolucci
- Unit of Physical Medicine and Rehabilitation, G. D’ Annunzio University of Chieti-Pescara, Department of Oral Medical Science and Biotechnology (DSMOB), Chieti, Italy
| | | | | | | | - Alberto Migliore
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Umberto Massafra
- Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Gianpaolo Ronconi
- Physical Medicine and Rehabilitation Unit, IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Paola Emilia Ferrara
- Physical Medicine and Rehabilitation Unit, IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Fabio Gori
- Section of Anaesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - Barbara Bifarini
- Section of Anaesthesia, Intensive Care, and Pain Medicine, University Hospital Santa Maria Della Misericordia, Perugia, Italy
| | - Stefano Brauneis
- Pain Centre “Enzo BorzomatI”, University Hospital of Rome “Policlinico Umberto I”, Rome, Italy
| | - Renato Vellucci
- Anaesthesiology Department, University Hospital Careggi, Florence, Italy
| | | | - Bartolomeo Violo
- Pain Therapy Unit, S. Spirito Nuovo Regina Margherita Hospital, Rome, Italy
| | - Silvia Natoli
- Department of Clinical Science and Translational Medicine, Tor Vergata University, Rome, Italy
| | - Carmen Pediliggieri
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
| | - Cristiana Di Campli
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
| | - Maria Chiara Collina
- Department of Vascular Surgery, Limb Salvage and Diabetic Foot, IDI-IRCCS, Rome, Italy
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Belvedere R, Morretta E, Pessolano E, Novizio N, Tosco A, Porta A, Whiteford J, Perretti M, Filippelli A, Monti MC, Petrella A. Mesoglycan exerts its fibrinolytic effect through the activation of annexin A2. J Cell Physiol 2021; 236:4926-4943. [PMID: 33284486 DOI: 10.1002/jcp.30207] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022]
Abstract
Mesoglycan is a drug based on a mixture of glycosaminoglycans mainly used for the treatment of blood vessel diseases acting as antithrombotic and profibrinolytic drugs. Besides the numerous clinical studies, there is no information about its function on the fibrinolytic cascade. Here, we have elucidated the mechanism of action by which mesoglycan induces the activation of plasmin from endothelial cells. Surprisingly, by a proteomic analysis, we found that, following mesoglycan treatment, these cells show a notable amount of annexin A2 (ANXA2) at the plasma membrane. This protein has been widely associated with fibrinolysis and appears able to move to the membrane when phosphorylated. In our model, this translocation has proven to enhance cell migration, invasion, and angiogenesis. Furthermore, the interaction of mesoglycan with syndecan 4 (SDC4), a coreceptor belonging to the class of heparan sulfate proteoglycans, represents the upstream event of the ANXA2 behavior. Indeed, the activation of SDC4 triggers the motility of endothelial cells culminating in angiogenesis. Interestingly, mesoglycan can induce the release of plasmin in endothelial cell supernatants only in the presence of ANXA2. This evaluation suggests that mesoglycan triggers the formation of a chain mechanism starting from the activation of SDC4, and the related cascade of events, including src complex and PKCα activation, promoting the phosphorylation of ANXA2 and its translocation to plasma membrane. This indicates a connection among mesoglycan, SDC4-(PKCα-src), and ANXA2 which, in turn, links the tissue plasminogen activator bringing it closer to plasminogen. This latter is so cleaved to release the plasmin and degrade fibrin sleeves.
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Affiliation(s)
| | - Elva Morretta
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - Emanuela Pessolano
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
- The William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nunzia Novizio
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - Alessandra Tosco
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - Amalia Porta
- Department of Pharmacy, University of Salerno, Fisciano (SA), Italy
| | - James Whiteford
- The William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mauro Perretti
- The William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Amelia Filippelli
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Baronissi (SA), Italy
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Guarnera G. What is the role of pharmacological therapy in venous ulcers management? Minerva Cardiol Angiol 2020; 69:127-129. [PMID: 32524811 DOI: 10.23736/s2724-5683.20.05300-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Aloi TL, Camporese G, Izzo M, Kontothanassis D, Santoliquido A. Refining diagnosis and management of chronic venous disease: Outcomes of a modified Delphi consensus process. Eur J Intern Med 2019; 65:78-85. [PMID: 30898385 DOI: 10.1016/j.ejim.2019.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 12/31/2022]
Abstract
Chronic venous disease (CVD) is a common condition with major health consequences that is associated with poor long-term prognosis, significant socioeconomic impact, disabling symptoms and reduced quality of life. To provide practical guidance for diagnosis and management of CVD, a Delphi panel of 5 experts in steering committee and 28 angiologists/vascular surgeons met with the major aim of providing a supplement for established national and international guidelines. A total of 24 statements were voted upon in two rounds, of which consensus was reached on 22 statements, indicating a high level of overall agreement. Consensus was reached on 7 of 8 statements relative to diagnosis (CEAP classification, diagnostic tools, QoL assessment, diagnostic imaging) and on 15 of 16 statements on management (conservative treatments, compressive therapy, pharmacological therapy, surgical treatment). The results of the consensus reached are discussed herein from which it is clear that diagnostic and management approaches utilising personalised therapies tailored to the individual patient should be favoured. While it is clear that additional studies are needed on many aspects of diagnosis and management of CVD, the present Delphi survey provides some key recommendations for clinicians treating CVD that may be useful in daily practice.
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Affiliation(s)
- Teresa Lucia Aloi
- Istituti Clinici Scientifici Maugeri IRCCS, Cardio-Angiology Unit of Montescano and Pavia Institute, Italy.
| | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic, and Vascular Sciences, Padua University Hospital, Padua, Italy
| | - Marcello Izzo
- Math Tech Med Medicine & Bioscience - Research Center- University of Ferrara-, Italy; Compression Therapy Study Group (CTG)-, Italy
| | | | - Angelo Santoliquido
- Catholic University of Sacred Heart, Gemelli Policlinic Foundation - IRCCS, Rome, Italy
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Efficacy of Mesoglycan in Pain Control after Excisional Hemorrhoidectomy: A Pilot Comparative Prospective Multicenter Study. Gastroenterol Res Pract 2018; 2018:6423895. [PMID: 29743886 PMCID: PMC5884030 DOI: 10.1155/2018/6423895] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 12/31/2017] [Indexed: 02/07/2023] Open
Abstract
Introduction Various pain management strategies for patients undergoing open excisional hemorrhoidectomy have been proposed, yet postoperative pain remains a frequent complaint. Objective To determine whether mesoglycan (30 mg two vials i.m. once/day for the first 5 days postoperative, followed by 50 mg 1 oral tablet twice/day for 30 days) would reduce the edema of the mucocutaneous bridges and thus improve postoperative pain symptoms. Patients and Methods For this prospective observational multicenter study, 101 patients undergoing excisional diathermy hemorrhoidectomy for III-IV degree hemorrhoidal disease were enrolled at 5 colorectal referral centers. Patients were assigned to receive either mesoglycan (study group SG) or a recommended oral dose of ketorolac tromethamine of 10 mg every 4–6 hours, not exceeding 40 mg per day and not exceeding 5 postoperative days according to the indications for short-term management of moderate/severe acute postoperative pain, plus stool softeners (control group CG). Results Postoperative thrombosis (SG 1/48 versus CG 5/45) (p < 0.001) and pain after rectal examination (p < 0.001) were significantly reduced at 7–10 days after surgery in the mesoglycan-treated group, permitting a faster return to work (p < 0.001); however, in the same group, the incidence of postoperative bleeding, considered relevant when needing a readmission or an unexpected outpatient visit, was higher, possibly owing to the drug's antithrombotic properties. Conclusions The administration of mesoglycan after an open diathermy excisional hemorrhoidectomy can reduce postoperative thrombosis and pain at 7–10 days after surgery, permitting a faster return to normal activities.
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8
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Belvedere R, Bizzarro V, Parente L, Petrella F, Petrella A. Effects of Prisma® Skin dermal regeneration device containing glycosaminoglycans on human keratinocytes and fibroblasts. Cell Adh Migr 2017; 12:168-183. [PMID: 28795878 DOI: 10.1080/19336918.2017.1340137] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Prisma® Skin is a new pharmaceutical device developed by Mediolanum Farmaceutici S.p.a. It includes alginates, hyaluronic acid and mainly mesoglycan. The latter is a natural glycosaminoglycan preparation containing chondroitin sulfate, dermatan sulfate, heparan sulfate and heparin and it is used in the treatment of vascular disease. Glycosaminoglycans may contribute to the re-epithelialization in the skin wound healing, as components of the extracellular matrix. Here we describe, for the first time, the effects of Prisma® Skin in in vitro cultures of adult epidermal keratinocytes and dermal fibroblasts. Once confirmed the lack of cytotoxicity by mesoglycan and Prisma® Skin, we have shown the increase of S and G2 phases of fibroblasts cell cycle distribution. We further report the strong induction of cell migration rate and invasion capability on both cell lines, two key processes of wound repair. In support of these results, we found significant cytoskeletal reorganization, following the treatments with mesoglycan and Prisma® Skin, as confirmed by the formation of F-actin stress fibers. Additionally, together with a significant reduction of E-cadherin, keratinocytes showed an increase of CD44 expression and the translocation of ezrin to the plasma membrane, suggesting the involvement of CD44/ERM (ezrin-radixin-moesin) pathway in the induction of the analyzed processes. Furthermore, as showed by immunofluorescence assay, fibroblasts treated with mesoglycan and Prisma® Skin exhibited the increase of Fibroblast Activated Protein α and a remarkable change in shape and orientation, two common features of reactive stromal fibroblasts. In all experiments Prisma® Skin was slightly more potent than mesoglycan. In conclusion, based on these findings we suggest that Prisma® Skin may be able to accelerate the healing process in venous skin ulcers, principally enhancing re-epithelialization and granulation processes.
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Affiliation(s)
- Raffaella Belvedere
- a Department of Pharmacy , University of Salerno , Fisciano, Salerno , Italy
| | - Valentina Bizzarro
- a Department of Pharmacy , University of Salerno , Fisciano, Salerno , Italy
| | - Luca Parente
- a Department of Pharmacy , University of Salerno , Fisciano, Salerno , Italy
| | - Francesco Petrella
- b Primary Care - Wound Care Service , Health Local Agency Naples 3 South , Portici, Napoli , Italy
| | - Antonello Petrella
- a Department of Pharmacy , University of Salerno , Fisciano, Salerno , Italy
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The Pharmaceutical Device Prisma ® Skin Promotes in Vitro Angiogenesis through Endothelial to Mesenchymal Transition during Skin Wound Healing. Int J Mol Sci 2017; 18:ijms18081614. [PMID: 28757565 PMCID: PMC5578006 DOI: 10.3390/ijms18081614] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 07/12/2017] [Accepted: 07/22/2017] [Indexed: 12/18/2022] Open
Abstract
Glycosaminoglycans are polysaccharides of the extracellular matrix supporting skin wound closure. Mesoglycan is a mixture of glycosaminoglycans such as chondroitin-, dermatan-, heparan-sulfate and heparin and is the main component of Prisma® Skin, a pharmaceutical device developed by Mediolanum Farmaceutici S.p.a. Here, we show the in vitro effects of this device in the new vessels formation by endothelial cells, since angiogenesis represents a key moment in wound healing. We found a strong increase of migration and invasion rates of these cells treated with mesoglycan and Prisma® Skin which mediate the activation of the pathway triggered by CD44 receptor. Furthermore, endothelial cells form longer capillary-like structures with a great number of branches, in the presence of the same treatments. Thus, the device, thanks to the mesoglycan, leads the cells to the Endothelial-to-Mesenchymal Transition, suggesting the switch to a fibroblast-like phenotype, as shown by immunofluorescence assays. Finally, we found that mesoglycan and Prisma® Skin inhibit inflammatory reactions such as nitric oxide secretion and NF-κB nuclear translocation in endothelial cells and Tumor Necrosis Factor-α production by macrophages. In conclusion, based on our data, we suggest that Prisma® Skin may be able to accelerate angiogenesis in skin wound healing, and regulate inflammation avoiding chronic, thus pathological, responses.
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10
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Zollino I, Zuolo M, Gianesini S, Pedriali M, Sibilla MG, Tessari M, Carinci F, Occhionorelli S, Zamboni P. Autologous adipose-derived stem cells: Basic science, technique, and rationale for application in ulcer and wound healing. Phlebology 2016; 32:160-171. [PMID: 27056621 DOI: 10.1177/0268355516641546] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objectives The present review represents a translational boundary between basic research and surgery, particularly focusing on the promising application of adipose-derived stem cells harvested intra-operatively during debridement of venous leg ulcers. Methods We reviewed 830 out of 5578 articles on MEDLINE starting from 1997 and sorted by the relevance option. Results The technique currently used for adipose-derived stem cells intra-operative harvesting is presented, including a safety evaluation on a cohort of 5089 revised patients who underwent plastic surgery and maxillo-facial surgical procedures. Complications were reported in 169 cases (3.3%). One hundred and forty-one (2.77%) patients were classified as having minor complications, specifically: nodularity/induration 93 (1.83%), dysesthesia 14 (0.26%), hematoma 12 (0.23%), superficial infection 11 (0.21%), pain 7 (0.13%), poor cosmesis 3 (0.06%), and abnormal breast secretion 1 (0.02%), while 28 patients (0.55%) were classified as having major complications, specifically: deep infection 22 (0.43%), sepsis 3 (0.06%), abdominal hematoma 2 (0.04%), and pneumothorax 1 (0.02%). Application of cell therapy in venous leg ulcer is currently used only for patients not responding to the standard treatment. The review shows the lack of randomized clinical trials for application of adipose-derived stem cells among treatments for venous leg ulcer. Finally, adipose-derived stem cells implantation at the wound site promotes a new tissue formation rich in vascular structures and remodeling collagen. Conclusion Adipose-derived stem cells strategy represents a great opportunity for the treatment of chronic wounds, due to the simplicity of the technique and the application of cell treatment in the operating room immediately following debridement. However, clinical studies and data from randomized trials are currently lacking.
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Affiliation(s)
- Ilaria Zollino
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Michele Zuolo
- 2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Sergio Gianesini
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Massimo Pedriali
- 3 Department of Experimental and Diagnostic Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Maria Grazia Sibilla
- 2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Mirko Tessari
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Francesco Carinci
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Savino Occhionorelli
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Paolo Zamboni
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
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Raffetto JD, Eberhardt RT, Dean SM, Ligi D, Mannello F. Pharmacologic treatment to improve venous leg ulcer healing. J Vasc Surg Venous Lymphat Disord 2016; 4:371-4. [DOI: 10.1016/j.jvsv.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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12
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Valvano A, Bosso G, Apuzzi V, Riccone F, Saccà L, Oliviero U. Mesoglycan improves vascular reactivity and insulin sensitivity in patients with metabolic syndrome. Atherosclerosis 2015; 243:407-13. [DOI: 10.1016/j.atherosclerosis.2015.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 10/02/2015] [Accepted: 10/05/2015] [Indexed: 01/29/2023]
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13
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Varatharajan L, Thapar A, Lane T, Munster AB, Davies AH. Pharmacological adjuncts for chronic venous ulcer healing: a systematic review. Phlebology 2015; 31:356-65. [PMID: 26036247 DOI: 10.1177/0268355515587194] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to systematically review the current evidence and determine whether there is a clinical benefit for using pharmacological agents as adjunctive treatment for chronic venous ulcers. METHOD A systematic review of the MEDLINE and EMBASE (from 1 January 1947 through 15 August 2013) and Cochrane databases (from inception through 15 August 2013) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were all randomised controlled trials investigating pharmacological adjuncts for the treatment of venous ulcers with a minimum sample size of 20 patients for each treatment arm. RESULTS Ten relevant articles were identified; one pilot randomised controlled trial and four Cochrane reviews were included. Pentoxifylline, aspirin, sulodexide, mesoglycan, flavonoids, thromboxane A2 antagonist (ifetroban), zinc, prostaglandin and prostacyclin analogues were the drugs reviewed. Pentoxifylline was found to be more effective than placebo in terms of complete ulcer healing or in causing a significant improvement (greater than 60% reduction in ulcer size) (RR 1.70, 95% CI 1.30 to 2.24). Aspirin and flavonoids show potential to be effective adjuncts but methodological shortcomings and issues with bias limit the validity of results from trials involving each of these drugs, respectively. There was no significant difference between placebo and Ifetroban and likewise pooled results from trials investigating sulodexide and zinc showed no benefit in comparison to placebo. CONCLUSION Many systemic pharmacological agents have been investigated as adjuncts to venous ulcer healing; however, pentoxifylline (400 mg, three times a day) is currently the only drug that has promising evidence to support its use. Other compounds are in early stage research.
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Affiliation(s)
| | - Ankur Thapar
- Academic Section of Vascular Surgery, Imperial College London, UK
| | - Tristan Lane
- Academic Section of Vascular Surgery, Imperial College London, UK
| | - Alex B Munster
- Academic Section of Vascular Surgery, Imperial College London, UK
| | - Alun Huw Davies
- Academic Section of Vascular Surgery, Imperial College London, UK
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14
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Gethin G, Killeen F, Devane D. Heterogeneity of wound outcome measures in RCTs of treatments for VLUs: a systematic review. J Wound Care 2015; 24:211-2, 214, 216 passim. [PMID: 25970758 DOI: 10.12968/jowc.2015.24.5.211] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- G. Gethin
- Senior Lecturer, BNS 4th year Student, Professor of Midwifery, Director, Health Research Board – Trials Methodology Research Network (HRB-TMRN), School of Nursing and Midwifery, National University of Ireland Galway, Ireland
| | - F. Killeen
- Senior Lecturer, BNS 4th year Student, Professor of Midwifery, Director, Health Research Board – Trials Methodology Research Network (HRB-TMRN), School of Nursing and Midwifery, National University of Ireland Galway, Ireland
| | - D. Devane
- Senior Lecturer, BNS 4th year Student, Professor of Midwifery, Director, Health Research Board – Trials Methodology Research Network (HRB-TMRN), School of Nursing and Midwifery, National University of Ireland Galway, Ireland
- Professor of Midwifery, Director, Health Research Board – Trials Methodology Research Network (HRB-TMRN), HSE West North West Hospital groups
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15
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Affiliation(s)
- Brijesh Nair
- Department of Dermatology and Venereology, INHS Sanjivani, Kochi, India
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16
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Coccheri S, Mannello F. Development and use of sulodexide in vascular diseases: implications for treatment. Drug Des Devel Ther 2013; 8:49-65. [PMID: 24391440 PMCID: PMC3879015 DOI: 10.2147/dddt.s6762] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Sulodexide (SDX), a sulfated polysaccharide complex extracted from porcine intestinal mucosa, is a blend of two glycosaminoglycan (GAG) entities, namely a fast-moving heparin (HP) fraction and a dermatan sulfate (DS; 20%) component. The compound is unique among HP-like substances in that it is biologically active by both the parenteral and oral routes. A main feature of the agent is to undergo extensive absorption by the vascular endothelium. For this reason, in preclinical studies, SDX administered parenterally displays an antithrombotic action similar to that of HPs but associated with fewer alterations of the blood clotting mechanisms and tests, thus being much less conducive to bleeding risk than HPs. When given orally, SDX is associated with minimal changes in classic coagulation tests, but maintains a number of important effects on the structure and function of endothelial cells (EC), and the intercellular matrix. These activities include prevention or restoration of the integrity and permeability of EC, counteraction versus chemical, toxic or metabolic EC injury, regulation of EC-blood cell interactions, inhibition of microvascular inflammatory and proliferative changes, and other similar effects, thus allowing oral SDX to be considered as an endothelial-protecting agent. The best available clinical evidence of the efficacy of SDX administered orally with or without an initial parenteral phase is the following: alleviation of symptoms in chronic venous disease and especially acceleration of healing of venous leg ulcers; prevention of cardiovascular events in survivors after acute myocardial infarction; marked improvement of intermittent claudication in patients with peripheral occlusive arterial disease; and abatement of proteinuria in patients with diabetic nephropathy that may contribute to the amelioration or stabilization of kidney function. Although further clinical trials are warranted, SDX is presently widely accepted in many countries as an effective and safe long-term, endothelial-protecting drug.
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Affiliation(s)
- Sergio Coccheri
- Cardiovascular Medicine, University of Bologna, Bologna, Italy
| | - Ferdinando Mannello
- Department of Biomolecular Sciences (Section Clinical Biochemistry and Cell Biology), University ‘Carlo Bo’, Urbino, Italy
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17
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Mesoglycan: clinical evidences for use in vascular diseases. Int J Vasc Med 2010; 2010:390643. [PMID: 21152191 PMCID: PMC2989756 DOI: 10.1155/2010/390643] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 06/04/2010] [Accepted: 07/12/2010] [Indexed: 11/17/2022] Open
Abstract
Vascular glycosaminoglycans (GAG) are essential components of the endothelium and vessel wall and have been shown to be involved in several biologic functions. Mesoglycan, a natural GAG preparation, is a polysaccharide complex rich in sulphur radicals with strong negative electric charge. It is extracted from porcine intestinal mucosa and is composed of heparan sulfate, dermatan sulfate, electrophoretically slow-moving heparin, and variable and minimal quantities of chondroitin sulfate. Data on antithrombotic and profibrinolytic activities of the drug show that mesoglycan, although not indicated in the treatment of acute arterial or venous thrombosis because of the low antithrombotic effect, may be useful in the management of vascular diseases, when combined with antithrombotics in the case of disease of cerebral vasculature, and with antithrombotics and vasodilator drugs in the case of chronic peripheral arterial disease. The protective effect of mesoglycan in patients with venous thrombosis and the absence of side effects, support the use of GAG in patients with chronic venous insufficiency and persistent venous ulcers, in association with compression therapy (zinc bandages, multiple layer bandages, etc.), elastic compression stockings, and local care, and in the prevention of recurrences in patients with previous DVT following the standard course of oral anticoagulation treatment.
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18
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Abstract
BACKGROUND Valvular incompetence and reflux are common features of primary varicose veins, and have long been thought to be their cause. Recent evidence, however, suggests that changes in the vein wall may precede valvular dysfunction. METHODS A literature search was performed using PubMed and Ovid using the keywords 'varicose vein wall changes', 'pathogenesis', 'aetiology' and 'valvular dysfunction'. Articles discussing the pathophysiology of complications of varicose veins, such as ulceration, recurrence, thrombophlebitis and lipodermatosclerosis, were excluded. RESULTS AND CONCLUSION Positive family history, age, sex and pregnancy are important risk factors for varicose vein formation. Areas of intimal hyperplasia and smooth muscle cell proliferation are often noted in varicose veins, although regions of atrophy are also present. The total elastin content in varicose as opposed to non-varicose veins is reduced; changes in overall collagen content are uncertain. Matrix metalloproteinases (MMPs), including MMP-1, MMP-2, MMP-3, MMP-7 and MMP-9, and tissue inhibitor of metalloproteinase (TIMP) 1 and TIMP-3 are upregulated in varicose veins. Activation of the endothelium stimulates the recruitment of leucocytes and the release of growth factors, leading to smooth muscle cell proliferation and migration. Dysregulated apoptosis has also been demonstrated in varicose veins. An understanding of the pathophysiology of varicose veins is important in the identification of potential therapeutic targets and treatment strategies.
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Affiliation(s)
- C S Lim
- Imperial Vascular Unit, Imperial College London, 4 East, Charing Cross Hospital, Fulham Palace Road, London, UK
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19
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Estimating the Applicability of Wound Care Randomized Controlled Trials to General Wound-Care Populations by Estimating the Percentage of Individuals Excluded from a Typical Wound-Care Population in Such Trials. Adv Skin Wound Care 2009; 22:316-24. [DOI: 10.1097/01.asw.0000305486.06358.e0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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20
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Tatsioni A, Balk E, O'Donnell T, Lau J. Usual Care in the Management of Chronic Wounds: A Review of the Recent Literature. J Am Coll Surg 2007; 205:617-624e57. [PMID: 17903739 DOI: 10.1016/j.jamcollsurg.2007.05.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 05/13/2007] [Accepted: 05/24/2007] [Indexed: 12/31/2022]
Affiliation(s)
- Athina Tatsioni
- Tufts-New England Medical Center Evidence-Based Practice Center, Institute for Clinical Research and Health Policy Studies, Boston, MA 02111, USA
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21
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Rajendran S, Rigby AJ, Anand SC. Venous leg ulcer treatment and practice--Part 4: Surgery and pharmaceutical therapies. J Wound Care 2007; 16:155-6. [PMID: 17444380 DOI: 10.12968/jowc.2007.16.4.27030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S Rajendran
- Centre for Materials Research and Innovation, University of Bolton, Bolton, UK.
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22
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Simka M, Majewski E. The social and economic burden of venous leg ulcers: focus on the role of micronized purified flavonoid fraction adjuvant therapy. Am J Clin Dermatol 2003; 4:573-81. [PMID: 12862500 DOI: 10.2165/00128071-200304080-00007] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Chronic venous insufficiency (CVI) occurs in a relatively large proportion of the population and is associated with significant morbidity, high cost of healthcare, loss of productivity and reduced quality of life. Lower extremity ulcers related to CVI have been estimated to affect 0.2-1% of the population in developed countries. The prevalence of venous ulcers in the US is estimated at 500,000-600,000, and increases with age. Estimates of the annual incidence of leg ulcer in the UK and Switzerland are 3.5 and 0.2 per 1000 individuals, respectively. Treatment of venous ulcers can be expensive, leading to a large economic burden on health services in many countries. The annual cost of CVI is estimated to be more than 1 billion US dollars in the US and between pound 400-600 million in the UK. Current treatments for CVI include surgery, sclerotherapy, compressive therapy (conventional therapy) and adjuvant pharmacotherapy. Various pharmacological agents have been used as adjuvant therapy but in many cases there is no definitive evidence of their efficacy. Effective treatment programs for venous leg ulcers could substantially reduce the economic impact of CVI on health services. In controlled studies, micronized purified flavonoid fraction (MPFF) adjuvant therapy has been shown to increase significantly the number of healed venous leg ulcers and to reduce significantly the healing time of ulcers compared with conventional therapy alone, potentially leading to an improvement in patients' quality of life. The treatment of venous leg ulcers with MPFF was also found to reduce overall treatment costs compared with conventional therapy alone. In a retrospective cost-effectiveness analysis based on direct medical costs only, MPFF therapy improved the cost-effectiveness ratio by 45% compared with conventional therapy. If intangible costs, such as loss of quality of life were included, the difference in cost-effectiveness ratios is likely to be even greater in favor of MPFF. Sensitivity analyzes showed that even with a 20% increase in drug price the cost-effectiveness ratio for MPFF therapy was substantially better than that for conventional therapy (1061.8 US dollars vs 1871.9 US dollars per ulcer healed). Hence, the addition of MPFF adjuvant therapy to the treatment of venous leg ulcers would be effective and potentially cost saving.
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Affiliation(s)
- Marian Simka
- Out-Patient Department of Angiology, Pszczyna ul. Wodzislawska 78-43-200 Pszczyna, Poland.
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23
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Scientific Surgery. Br J Surg 2002. [DOI: 10.1002/bjs.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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