Arterial gene transfer for therapeutic angiogenesis in patients with peripheral artery disease

Efficacy and safety of intramuscular administration of allogeneic adipose tissue derived and expanded mesenchymal stromal cells in diabetic patients with critical limb ischemia with no possibility of revascularization: study protocol for a randomized controlled double-blind phase II clinical trial (The NOMA Trial)

Background

Chronic lower limb ischemia develops earlier and more frequently in patients with type 2 diabetes mellitus. Diabetes remains the main cause of lower-extremity non-traumatic amputations. Current medical treatment, based on antiplatelet therapy and statins, has demonstrated deficient improvement of the disease. In recent years, research has shown that it is possible to improve tissue perfusion through therapeutic angiogenesis. Both in animal models and humans, it has been shown that cell therapy can induce therapeutic angiogenesis, making mesenchymal stromal cell-based therapy one of the most promising therapeutic alternatives. The aim of this study is to evaluate the feasibility, safety, and efficacy of cell therapy based on mesenchymal stromal cells derived from adipose tissue intramuscular administration to patients with type 2 diabetes mellitus with critical limb ischemia and without possibility of revascularization.

Methods

A multicenter, randomized double-blind, placebo-controlled trial has been designed. Ninety eligible patients will be randomly assigned at a ratio 1:1:1 to one of the following: control group (n = 30), low-cell dose treatment group (n = 30), and high-cell dose treatment group (n = 30). Treatment will be administered in a single-dose way and patients will be followed for 12 months. Primary outcome (safety) will be evaluated by measuring the rate of adverse events within the study period. Secondary outcomes (efficacy) will be measured by assessing clinical, analytical, and imaging-test parameters. Tertiary outcome (quality of life) will be evaluated with SF-12 and VascuQol-6 scales.

Discussion

Chronic lower limb ischemia has limited therapeutic options and constitutes a public health problem in both developed and underdeveloped countries. Given that the current treatment is not established in daily clinical practice, it is essential to provide evidence-based data that allow taking a step forward in its clinical development. Also, the multidisciplinary coordination exercise needed to develop this clinical trial protocol will undoubtfully be useful to conduct academic clinical trials in the field of cell therapy in the near future.

Trial registration

ClinicalTrials.govNCT04466007. Registered on January 07, 2020. All items from the World Health Organization Trial Registration Data Set are included within the body of the protocol.

Is gene therapy for limb ischemia a reality?

The concept of angiogenic therapy emerged in the early 1990s. The method employs genes that encode growth factors to promote formation of new vessels and remodeling of collateral vessels. Since the procedure involved in this therapy usually only consists of local injections of vectors, the process is minimally invasive, quick, and simple to perform. However, since the first clinical evidence of the effects of gene therapy with vascular endothelial growth factor (VEGF) was observed in patients with peripheral artery disease, to date only two angiogenic therapy drugs have been approved, one in Russia and another in Japan, which seem a very small number, in view of the large volume of investment made in pre-clinical and clinical studies. After all, can we conclude that angiogenic therapy is a reality?

Perspectives on Using Platelet-Rich Plasma and Platelet-Rich Fibrin for Managing Patients with Critical Lower Limb Ischemia After Partial Foot Amputation

The problem of lower limb preservation with symptoms of critical ischemia, resulting in necrosis of the distal foot portion, remains open. These cases require solving few tactical questions, such as the primary revascularization method, limb-preserving amputation, stimulation of regeneration, and finally, determining the criteria for auto-dermal transplantation. We analyzed 29 patient cases with critical lower limb ischemia of fourth grade, according to the Fontaine classification (or the sixth category according to Rutherford's classification), who underwent partial foot amputation due to dry gangrene and were threated using PRGF®-ENDORET® platelet-rich plasma and platelet-rich fibrin technology. The control group was comprised of 21 patients who received traditional postoperative wound treatment. All patients went through a combination of transluminal revascularization and platelet-rich plasma to create a "therapeutic" neoangiogenic effect. Indications for these procedures were severe distal arterial occlusion and stenosis. Using transluminal procedures with platelet-rich plasma therapy improves the blood perfusion to the distal portions of the limb in patients with critical ischemia in a short time, which is an informative diagnostic criterion for wound healing after amputation. Plasmatic membranes create an optimal environment for tissue regeneration, thus reducing the wound closure time using an auto-dermal transplant.

Challenges in Translating from Bench to Bed-Side: Pro-Angiogenic Peptides for Ischemia Treatment

We describe progress and obstacles in the development of novel peptide-hydrogel therapeutics for unmet medical needs in ischemia treatment, focusing on the development and translation of therapies specifically in peripheral artery disease (PAD). Ischemia is a potentially life-threatening complication in PAD, which affects a significant percentage of the elderly population. While studies on inducing angiogenesis to treat PAD were started two decades ago, early results from animal models as well as clinical trials have not yet been translated into clinical practice. We examine some of the challenges encountered during such translation. We further note the need for sustained angiogenic effect involving whole growth factor, gene therapy and synthetic growth factor strategies. Finally, we discuss the need for tissue depots for de novo formation of microvasculature. These scaffolds can act as templates for neovasculature development to improve circulation and healing at the preferred anatomical location.

The Impact of CRISPR/Cas9 Technology on Cardiac Research: From Disease Modelling to Therapeutic Approaches

Genome-editing technology has emerged as a powerful method that enables the generation of genetically modified cells and organisms necessary to elucidate gene function and mechanisms of human diseases. The clustered regularly interspaced short palindromic repeats- (CRISPR-) associated 9 (Cas9) system has rapidly become one of the most popular approaches for genome editing in basic biomedical research over recent years because of its simplicity and adaptability. CRISPR/Cas9 genome editing has been used to correct DNA mutations ranging from a single base pair to large deletions in both in vitro and in vivo model systems. CRISPR/Cas9 has been used to increase the understanding of many aspects of cardiovascular disorders, including lipid metabolism, electrophysiology and genetic inheritance. The CRISPR/Cas9 technology has been proven to be effective in creating gene knockout (KO) or knockin in human cells and is particularly useful for editing induced pluripotent stem cells (iPSCs). Despite these progresses, some biological, technical, and ethical issues are limiting the therapeutic potential of genome editing in cardiovascular diseases. This review will focus on various applications of CRISPR/Cas9 genome editing in the cardiovascular field, for both disease research and the prospect of in vivo genome-editing therapies in the future.

Predictors of Failure of Endovascular Therapy for Peripheral Arterial Disease

The objective of this study was to assess the usefulness of a comparison of clinical failure and restenosis rates of endovascular procedures at 1 year in patients with peripheral arterial disease. The resulting comparison is presented as “clinical failure/restenosis coordinate.” The authors screened 171 papers describing the outcome of lower extremity angioplasty or stent placement. In 20 of them, authors reported detailed outcomes of interest, including baseline demographic measurements, location of arterial occlusive lesions, a measure of restenosis (measured by ankle-brachial indices, ultrasonography, or angiography), and clinical outcomes (mortality, repeat percutaneous transluminal angioplasty, or amputation). An overview of these 20 angioplasty papers was performed. Besides the usual meta-analyses of each end point separately, data were also plotted as coordinates of clinical failure versus restenosis. The clinical failure-to-restenosis coordinate was calculated and reported for percutaneous transluminal angioplasty of the aortoiliac and femoropopliteal distributions. Clinically reported outcomes in the literature were used to calculate the clinical failure/restenosis coordinate. This value was significantly different for various locations of the angioplasty and various baseline angiographic characteristics. A numeric coordinate pair of clinical failure and restenosis is identifiable in patients undergoing endovascular treatment of peripheral arterial disease. The varying coordinates may be important in elucidating the incidence and mechanisms of clinical failure after endovascular treatment. The coordinate reported in this article is hypothesis-generating about mechanisms of endovascular treatment failure. This coordinate is important in determining the role of restenosis in the clinical failure of endovascular therapy of peripheral arterial disease.

A slow-release fibrin matrix increases adeno-associated virus transduction of wound repair cells in vivo

Virus-mediated gene therapy is a promising strategy for numerous tissue engineering applications. Fibrin-based scaffolds have been previously used as vehicles for localised delivery of adenovirus to wound sites. However, their utility in the delivery of adeno-associated viruses to wound repair cells has not yet been determined. The influence of fibrin concentration on efficacy of delivery of AAV-2 to wound tissue was assessed in this study. Fibrin scaffolds containing recombinant AAV-2 encoding for β-galactosidase were polymerised in porous polyurethane discs and implanted subcutaneously in rats. A fibrin scaffold with a concentration of 50 mg/ml showed significantly elevated levels of β-galactosidase activity within explanted discs at 10 days compared to 10 mg/ml and 25 mg/ml fibrin. These findings inform efforts to optimise biodegradable scaffolds for the localised delivery of AAV in tissue engineering.

Drug delivery systems for the treatment of ischemic stroke

Stroke is the third leading cause of death in the United States. Reduced cerebral blood flow causes acute damage to the brain due to excitotoxicity, reactive oxygen species (ROS), and ischemia. Currently, the main treatment for stroke is to revive the blood flow by using thrombolytic agents. Reviving blood flow also causes ischemia-reperfusion (I/R) damage. I/R damage results from inflammation and apoptosis and can persist for days to weeks, increasing the infarct size. Drugs can be applied to stroke to intervene in the sub-acute and chronic phases. Chemical, peptide, and genetic therapies have been evaluated to reduce delayed damage to the brain. These drugs have different characteristics, requiring that delivery carriers be developed based on these characteristics. The delivery route is another important factor affecting the efficiency of drug delivery. Various delivery routes have been developed, such as intravenous injection, intranasal administration, and local direct injection to overcome the blood-brain-barrier (BBB). In this review, the delivery carriers and delivery routes for peptide and gene therapies are discussed and examples are provided. Combined with new drugs, drug delivery systems will eventually provide useful treatments for ischemic stroke.

Regulatory systems for hypoxia-inducible gene expression in ischemic heart disease gene therapy

Ischemic heart diseases are caused by narrowed coronary arteries that decrease the blood supply to the myocardium. In the ischemic myocardium, hypoxia-responsive genes are up-regulated by hypoxia-inducible factor-1 (HIF-1). Gene therapy for ischemic heart diseases uses genes encoding angiogenic growth factors and anti-apoptotic proteins as therapeutic genes. These genes increase blood supply into the myocardium by angiogenesis and protect cardiomyocytes from cell death. However, non-specific expression of these genes in normal tissues may be harmful, since growth factors and anti-apoptotic proteins may induce tumor growth. Therefore, tight gene regulation is required to limit gene expression to ischemic tissues, to avoid unwanted side effects. For this purpose, various gene expression strategies have been developed for ischemic-specific gene expression. Transcriptional, post-transcriptional, and post-translational regulatory strategies have been developed and evaluated in ischemic heart disease animal models. The regulatory systems can limit therapeutic gene expression to ischemic tissues and increase the efficiency of gene therapy. In this review, recent progresses in ischemic-specific gene expression systems are presented, and their applications to ischemic heart diseases are discussed.

Fragmin/protamine microparticles as cell carriers to enhance viability of adipose-derived stromal cells and their subsequent effect on in vivo neovascularization

We prepared fragmin/protamine microparticles (F/P MPs) as cell carriers to enhance cell viability. Use of material consisting of a low-molecular-weight heparin (fragmin) mixed with protamine resulted in water-insoluble microparticles (about 0.5-1 microm in diameter). In this study, we investigated the capability of F/P MPs to enhance the viabilities of human microvascular endothelial cells (HMVECs), human dermal fibroblasts (fibroblasts), and adipose tissue-derived stromal cells (ATSCs) in suspension culture. F/P MPs were bound to the surfaces of these cells, and the interaction of these cells with F/P MPs induced cells/F/P MPs-aggregate formations in vitro, and maintained viabilities of those cells for at least 3 days. The ATSCs/F/P MPs-aggregates adhered to and grew on suspension culture plates in a fashion similar to those on type I collagen-coated plates. The cultured ATSCs secreted significant amounts of angiogenic heparin-binding growth factors such as FGF-2. When the ATSCs/F/P MPs-aggregates were subcutaneously injected into the back of nude mice, significant neovascularization and fibrous tissue formation were induced near the site of injection from day 3 to week 2. The ATSCs/F/P MPs-aggregates were thus useful and convenient biomaterials for cell-therapy of angiogenesis.

Increased antiangiogenic protein expression in the skeletal muscle of diabetic swine and patients

HYPOTHESIS

Antiangiogenic protein expression is increased in skeletal muscle in the setting of diabetes.

DESIGN, SETTING, AND PARTICIPANTS

In animal studies, diabetes was induced in 8 Yucatan miniswine via single alloxan injection at age 8 months, followed by skeletal muscle harvest 15 weeks later. Eight nondiabetic Yucatan miniswine served as controls. In patient studies, skeletal muscle was harvested from 11 nondiabetic patients and 10 patients with type 2 diabetes mellitus undergoing initial elective coronary artery bypass graft surgery. Skeletal muscle samples were analyzed via Western blotting and zymography for protein expression and enzyme activity. The study was performed in an academic medical center.

MAIN OUTCOME MEASURES

Skeletal muscle expression of plasminogen, collagen XVIII, angiostatin, endostatin, matrix metalloproteinases 2 and 9, and tissue inhibitor of metalloproteinase 2.

RESULTS

Skeletal muscle expression of plasminogen and collagen XVIII (precursors of angiostatin and endostatin, respectively) remained similar between nondiabetic and diabetic swine and patients. Expression of angiostatin and endostatin was increased 1.70-fold and 1.84-fold, respectively, in diabetic swine relative to control swine. Endostatin expression was increased 1.69-fold in diabetic patients relative to nondiabetic patients. Matrix metalloproteinase 2 expression and activity were significantly increased in the skeletal muscle of diabetic swine and patients.

CONCLUSIONS

Antiangiogenic protein levels are increased in the skeletal muscle in the setting of diabetes. Angiostatin, endostatin, and matrix metalloproteinases may offer novel therapeutic targets to improve collateral formation in patients with diabetes.

Novel three-dimensional analysis tool for vascular trees indicates complete micro-networks, not single capillaries, as the angiogenic endpoint in mice overexpressing human VEGF(165) in the brain

To adequately supply tissues with oxygen and nutrients, the formation of functional vascular networks requires generation of normal, healthy vessels and their arrangement into an effective network architecture. While our knowledge about the development of single vessels significantly increased during the last years, mechanisms responsible for network formation are still poorly understood. This is probably due to the lack of suitable methods for quantification of structural properties of microvascular networks. Previously we showed that cerebral blood flow is not increased in mice exhibiting a 2- to 3-fold higher density of normal and perfused capillaries as a result of transgenic overexpression of the human vascular endothelial growth factor (VEGF(165)). Here we used vascular corrosion casting and hierarchical micro-computed tomography combined with a new network analysis tool to characterize the vascular architecture in gray and white matter of these mice. Our results indicate that VEGF overexpression leads to formation of additional micro-networks connected to higher order vessels rather than insertion of individual capillaries into the existing vessel structure. This implies that the smallest "angiogenic quantum", i.e. the final, stable result of angiogenesis and subsequent remodeling, is not a single microvessel, but a complete micro-network. In conclusion, high-resolution 3D imaging combined with network analysis can substantially improve our understanding of vascular architecture, beneficial for the development of therapeutic angiogenesis as a clinical tool for applications such as wound healing or treatment of ischemic diseases.

Growth factors for therapeutic angiogenesis in peripheral arterial disease

PURPOSE OF REVIEW

Peripheral arterial disease is a common disease that has few treatment options. Angiogenesis is defined as the growth of new blood vessels from preexisting vasculature. Therapeutic angiogenesis is an investigational method that uses vascular growth to alleviate disorders of tissue ischemia, such as coronary artery disease and peripheral arterial disease. There have been tremendous changes in the field of therapeutic angiogenesis over the past decade, and there is much promise for the future.

RECENT FINDINGS

Initial preclinical work with cytokine growth factor delivery resulted in a great deal of enthusiasm, but larger clinical studies have failed to achieve similar success. With an increased understanding of the complex mechanisms involved in angiogenesis, gene therapy and cell therapy have moved to the forefront of therapeutic angiogenesis. Novel therapies which target multiple different angiogenic pathways are also being developed and tested.

SUMMARY

Therapeutic angiogenesis is an exciting field that continues to evolve. This review will focus on the different growth factors being used, their routes of delivery, the results of clinical trials, and some of the novel therapies being developed.

Transcriptional and post-translational regulatory system for hypoxia specific gene expression using the erythropoietin enhancer and the oxygen-dependent degradation domain

Gene therapy with angiogenic factors is a promising strategy for the treatment of ischemic diseases. However, unregulated expression of an angiogenic factor may induce pathological angiogenesis. In this study, a hypoxia specific gene expression plasmid, pSV-Luc-ODD, was constructed with the oxygen-dependent degradation (ODD) domain for rapid degradation of a target protein under normoxia. In the transfection assay, luciferase activity in the pSV-Luc-ODD transfected cells was much lower under normoxia than that under hypoxia. However, the luciferase mRNA levels under hypoxia and normoxia were not significantly different. Therefore, decrease of luciferase activity under normoxia is not due to pre-translational events such as change of transcription rate or mRNA stability, but to post-translational degradation. For more hypoxia specific gene expression, pEpo-SV-Luc-ODD was constructed with the erythropoietin (Epo) enhancer and the ODD domain. pEpo-SV-Luc-ODD showed more than 1000 times increase of gene expression under hypoxia in Neuro2A cells, compared to normoxia. In addition, reoxygenation studies after hypoxia incubation showed that gene expression was decreased in response to increased oxygen concentration. This highly hypoxia specific gene expression system will be useful for development of targeting gene therapy for ischemic diseases.

Uncoupling of the VEGF-endothelial nitric oxide axis in diabetic nephropathy: an explanation for the paradoxical effects of VEGF in renal disease

In many forms of experimental kidney diseases, renal VEGF is low, and administering VEGF can be shown to be protective. A paradox occurs in diabetes, in which renal VEGF levels are high and a deleterious effect of VEGF on kidney disease has been shown. We have hypothesized that endothelial dysfunction induced by hyperglycemia or other factors may underlie the pathogenic mechanisms of a high VEGF state. VEGF normally stimulates endothelial nitric oxide (NO) release and acts in concert with elevated NO levels as a trophic factor for vascular endothelium. The increased NO derived from the endothelial cell acts as an inhibitory factor that prevents excess endothelial cell proliferation, vascular smooth muscle cell proliferation, and macrophage infiltration. In the setting where NO bioavailability is reduced in diabetes, high levels of VEGF lead to excessive endothelial cell proliferation, stimulation of macrophage chemotaxis, and vascular smooth muscle cell activation. Consistent with this hypothesis is our recent observation that diabetes induced in endothelial NO-deficient mice results in clinical and histological features identical to human diabetic nephropathy. The discovery of the key role for impaired endothelial NO bioavailability in the stimulation of VEGF and VEGF-dependent disease may provide key insights into not only the pathogenesis of diabetic nephropathy but also the utility and hazard of administering VEGF as a treatment for kidney disease.

Cardiovascular gene therapy: current status and therapeutic potential

Gene therapy is emerging as a potential treatment option in patients suffering from a wide spectrum of cardiovascular diseases including coronary artery disease, peripheral vascular disease, vein graft failure and in-stent restenosis. Thus far preclinical studies have shown promise for a wide variety of genes, in particular the delivery of genes encoding growth factors such as vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) to treat ischaemic vascular disease both peripherally and in coronary artery disease. VEGF as well as other genes such as TIMPs have been used to target the development of neointimal hyperplasia to successfully prevent vein graft failure and in-stent restenosis in animal models. Subsequent phase I trials to examine safety of these therapies have been successful with low levels of serious adverse effects, and albeit in the absence of a placebo group some suggestion of efficacy. Phase 2 studies, which have incorporated a placebo group, have not confirmed this early promise of efficacy. In the next generation of clinical gene therapy trials for cardiovascular disease, many parameters will need to be adjusted in the search for an effective therapy, including the identification of a suitable vector, appropriate gene or genes and an effective vector delivery system for a specific disease target. Here we review the current status of cardiovascular gene therapy and the potential for this approach to become a viable treatment option.

Therapeutic angiogenesis induced by controlled release of fibroblast growth factor-2 from injectable chitosan/non-anticoagulant heparin hydrogel in a rat hindlimb ischemia model

The addition of non-anticoagulant heparin [periodate-oxidized (IO4) heparin] and fibroblast growth factor (FGF)-2 to a viscous water-soluble chitosan (CH-LA) aqueous solution produces an injectable FGF-2/CH-LA/IO4-heparin hydrogel. The purpose of this study was to examine the ability of the injected FGF-2/CH-LA/IO4-heparin hydrogel to induce vascularization and fibrous tissue formation. FGF-2/CH-LA/IO4-heparin hydrogels (100 microL of hydrogel consisting of 20 mg/mL of CH-LA, 2 mg/mL of IO4-heparin, and 50 microg/mL of FGF-2) were subcutaneously injected into the backs of wound healing-impaired diabetic (db/db) mice. Furthermore, the effect of percutaneous injection of FGF-2/CH-LA/IO4-heparin hydrogel at eight sites (25 microL/site) into ischemic left lower limbs of rats was examined from day 4 to at least day 28 postinjection. The injection of FGF-2/CH-LA/IO4-heparin hydrogels into the backs of db/db mice resulted in significant increases in blood vessel formation, significant vascularization, and fibrous tissue formation near the injection site. Injection of FGF-2/CH-LA/IO4-heparin hydrogel into ischemic left lower limbs of rats also significantly recovered and increased blood flow and blood oxygen in the calf and thigh. These results indicate that the controlled release of biologically active FGF-2 molecules from FGF-2/CH-LA/IO4-heparin induces angiogenesis and possibly collateral circulation in db/db mice and the ischemic limbs of rats.

Therapeutic Angiogenesis Inhibits or Rescues Chemotherapy-induced Peripheral Neuropathy: Taxol- and Thalidomide-induced Injury of Vasa Nervorum is Ameliorated by VEGF

Toxic neuropathy represents an important clinical problem in the use of the chemotherapeutic substances Taxol and thalidomide. Sensory neuropathy has a high incidence, lacks an effective treatment and is the dose-limiting factor for these drugs. The pathogenic basis of these neuropathies is unknown. We investigated the hypothesis that the experimental toxic neuropathies from Taxol and thalidomide results from destruction of vasa nervorum and can be reversed by the administration of an angiogenic cytokine. In animal models of Taxol- and thalidomide-induced neuropathy, nerve blood flow has been attenuated and the number of vasa nervorum has been reduced. Intramuscular gene transfer of naked plasmid DNA encoding VEGF-1 administered in parallel with Taxol injections completely inhibited deterioration of nerve function and diminution of the peripheral nerve vasculature. Gene therapy in animals with established Taxol- or thalidomide-induced neuropathies resulted in recovery of vascularity and improved nerve electrophysiology. These findings implicate microvascular damage as the basis for toxic neuropathy and suggest that angiogenic growth factors may constitute a novel treatment for this disorder.

Percutaneous transplantation of genetically-modified autologous fibroblasts in the rabbit femoral artery: a novel approach for cardiovascular gene therapy

OBJECTIVE

Arterial cell and gene therapies are promising strategies for the treatment of cardiovascular diseases; however, the optimal cell type and delivery technique for such treatment remain to be determined. The aim of the present study was to design a new approach for arterial cell and gene therapy in which genetically modified autologous skin fibroblasts are percutaneously delivered in stented rabbit femoral arteries in vivo.

METHODS

Autologous skin fibroblasts underwent in vitro transfection with the cationic lipid FuGene and plasmids expressing the human form of the tissue inhibitor of metalloproteinase (hTIMP-1) or nls-LacZ reporter genes.

RESULT

Transfection efficiency was about 50% and there were high levels of hTIMP-1 secretion up to 14 days after gene transfer. We demonstrated the feasibility of in vivo percutaneous transplantation of fluorescent fibroblasts in the rabbit femoral artery. Results were confirmed by scanning electron microscopy. In vivo local delivery of hTIMP-1-expressing fibroblasts in stented femoral arteries also resulted in high-levels of hTIMP-1 secretion ex vivo for 7 days. Fibroblast transplantation resulted in a modest increase in intimal hyperplasia at the target site, which was reversed with hTIMP-1-transfected fibroblasts.

CONCLUSION

Percutaneous transplantation of genetically modified autologous fibroblasts could be used as a cellular platform for locoregional secretion of therapeutic proteins to treat either specific arterial diseases or the diseased organ (eg, the heart) supplied by the target artery.

CLINICAL RELEVANCE

Cell and gene therapies are potential new treatments for cardiovascular diseases. We demonstrated that autologous fibroblasts could be easily harvested from a skin biopsy specimen, genetically modified in vitro with nonviral vectors, and percutaneously seeded in vivo in rabbit femoral arteries, leading to locoregional secretion of abundant amounts of recombinant proteins. This new approach has important advantages over alternative approaches that use endothelial cells, viral vectors, and intraoperative cell delivery. Clinical applications may include local treatment of atherosclerotic plaques or aneurysms and also treatment of the diseased organs supplied by the target artery (eg, ischemic or failing heart).

Hypoxia-inducible gene expression system using the erythropoietin enhancer and 3′-untranslated region for the VEGF gene therapy

Gene therapy with the vascular endothelial growth factor (VEGF) gene is a potential treatment for many disorders or injuries with ischemia. However, unregulated expression of VEGF may induce pathological angiogenesis, promoting tumor growth, diabetic proliferative retinopathy and rupture of atherosclerotic plaque. Therefore, the effective regulation of the gene expression is one of the requirements for the VEGF gene therapy. In this research, we evaluated the hypoxia-inducible gene expression system with the erythropoietin (Epo) enhancer and the Epo 3'-untranslated region (UTR). The luciferase plasmids were constructed with the Epo enhancer (pEpo-SV-Luc), the Epo 3'-UTR (pSV-Luc-EpoUTR) or both (pEpo-SV-Luc-EpoUTR). The polyethylenimine/plasmid complexes were transfected to 293 or A7R5 cells and the cells were incubated under normoxia or hypoxia. The results showed that the Epo enhancer or Epo 3'-UTR increased the target gene expression under hypoxia. pEpo-SV-Luc-EpoUTR showed the highest luciferase expression. The VEGF expression plasmid with the Epo enhancer and 3'-UTR was also constructed. The VEGF expression by pEpo-SV-VEGF-EpoUTR showed the highest specificity of the gene expression in the hypoxic cells. The results suggest that the VEGF plasmid with the Epo enhancer and the Epo 3'-UTR may be useful for gene therapy for ischemic diseases.

Proliferation of endothelial cell on polytetrafluoroethylene vascular graft materials carried VEGF gene plasmid

OBJECTIVE

To investigate whether vascular endothelial growth factor (VEGF) gene plasmid carried by polytetrafluoroethylene (PTFE) vascular graft materials could transfect endothelial cells (ECs) and promote their growth.

METHODS

PTFE vascular graft materials carried with pCDI-hVEGF(121), pCDI or pEGFP were incubated in Tris-buffer solution and the values of optical density of 260 nm at different time were plotted, then the DNA controlled release curve was made. ECs derived from human umbilical vein were seeded on the pCDI-hVEGF(121)/pCDI/pEGFP-PTFE materials or tissue culture plates, ECs numbers were counted and VEGF protein concentrations at different time were measured by enzyme-linked immunoadsorbent assay method. Green fluorescent protein (GFP) expression in ECs on pEGFP-PTFE materials was examined with fluorescence microscopy.

RESULTS

The controlled release curve showed that the gene released from PTFE materials was rapid within 8 h, then slowed down and that the gene released continuously even after 72 h. At 24, 72 and 120 h, ECs number and proliferation rate of pCDI-hVEGF(121)-PTFE materials were higher than those of pCDI or pEGFP-PTFE materials (P<0.05). VEGF protein concentration of pCDI-hVEGF(121)-PTFE materials was higher than that of pCDI or pEGFP-PTFE materials at 6, 24, 72 and 120 h (P<0.01). GFP expression in ECs on the pEGFP-PTFE materials could be detected by fluorescence microscopy.

CONCLUSION

PTFE graft can be used as a carrier of VEGF gene plasmid, VEGF gene carried by PTFE can transfect ECs and promote ECs growth.

Buerger's disease: What has the last decade taught us?

Thrombangiitis obliterans (TAO), or Buerger's disease, is most likely an endarteritis that is introduced by T-cell-mediated cellular immunity and B-cell-mediated humoral immunity associated with the activation of macrophages or dendritic cells in the intima. There is no specific marker of the disease, and the diagnosis is based on clinical and angiographic criteria. The disease spontaneously leads to tissue loss and major amputations and is self-limiting in the 5th to 6th decades of life. Patients should quit smoking and be offered treatment with prostaglandin or prostacyclin, modern wound management, and pain-relieving drugs. Surgical revascularization may be indicated in elective patients, and amputation should only be the last option. It has been suggested that environmental factors may play a major role in the modification of the disease process. TAO is a typical lower class disease, the social and psychological components of which are widely unexplored. Unfortunately, the last decade has not taught us anything to enable us to improve the treatment of TAO patients.

Angiogenic and antiangiogenic gene therapy

Gene therapy is thought to be a promising method for the treatment of various diseases. One gene therapy strategy involves the manipulations on a process of formation of new vessels, commonly defined as angiogenesis. Angiogenic and antiangiogenic gene therapy is a new therapeutic approach to the treatment of cardiovascular and cancer patients, respectively. So far, preclinical and clinical studies are successfully focused mainly on the treatment of coronary artery and peripheral artery diseases. Plasmid vectors are often used in preparations in angiogenic gene therapy trials. The naked plasmid DNA effectively transfects the skeletal muscles or heart and successfully expresses angiogenic genes that are the result of new vessel formation and the improvement of the clinical state of patients. The clinical preliminary data, although very encouraging, need to be well discussed and further study surely continued. It is really possible that further development of molecular biology methods and advances in gene delivery systems will cause therapeutic angiogenesis as well as antiangiogenic methods to become a supplemental or alternative option to the conventional methods of treatment of angiogenic diseases.

Exercise after heparin administration: new therapeutic program for patients with-option arteriosclerosis oblitrans

BACKGROUND

A prospective study examined whether a combination of an exercise program and heparin administration improves the clinical symptoms of patients with arteriosclerosis obliterans (ASO) without an indication for surgical revascularization because of the lack of distal target vessels or other reasons such as high surgical risk or lack of a vein conduit from previous coronary artery bypass surgery.

METHODS AND RESULTS

A total of 19 consecutive patients with symptomatic non-option ASO diagnosed by angiography were randomly assigned to 3 groups: heparin + exercise (walking for 60 min after heparin injection [3,000 units/day IV for 14 days], n = 6), heparin administration only (n = 6), and exercise only (n = 7). Plasma levels of hepatocyte growth factor (HGF) were serially measured before and after intravenous administration of heparin. Ankle brachial pressure index was measured and treadmill exercise test (2.5 km/h, 12% slope) was performed before the 2-week treatment, just after finishing treatment, and 12 weeks after beginning the treatment. Ophthalmic examinations, including visual acuity test, ocular fundoscopy and fluorescein angiographic fundus photography, were performed before and 12 weeks after the treatment program. In all patients, HGF levels increased more than 4-fold of the basal level at 30 min after heparin injection. Maximum walking time was significantly higher in the heparin + exercise group than in the other 2 groups (p < 0.05). There were no patients who showed pathological retinal angiogenesis.

CONCLUSION

The combination of an exercise program and heparin administration improves the clinical symptoms of patients with non-option ASO.

Construction and deconstruction of PLL/DNA multilayered films for DNA delivery: Effect of ionic strength

Through the layer-by-layer (LbL) self-assembly technique, DNA was incorporated into the multilayered films with poly-l-lysine (PLL). The effect of ionic strength on the construction and deconstruction of the PLL/DNA films was investigated. It was found that the salt concentration of the deposition solution had a significant effect on the construction of the films, which might attribute to the effect of salt ions on the conformation of polyelectrolytes and interaction between PLL and DNA molecules. A salt-induced deconstruction of the PLL/DNA films was observed. The extent of the deconstruction increased with the salt concentration in the incubation solution. The mechanism of the deconstruction was discussed. Taking the advantages of the LbL technique, the erasable PLL/DNA films could deposit onto a variety of surfaces, such as vascular stent, intervention catheter and tissue engineering scaffold, to serve as a novel DNA delivery system.

E2F decoy oligodeoxynucleotides on neointimal hyperplasia in canine vein graft

Double-stranded DNA with high affinity to E2F as a decoy cis-element blocks the activation of genes mediating the cell cycle, resulting in effective suppression of the smooth muscle cell proliferation that causes intimal hyperplasia. To evaluate the effect of the E2F decoy to suppress neointimal hyperplasia autogenous venous bypass grafts were performed in dogs after incubation with heparin (group 1), with E2F decoy oligodeoxynucleotides (ODN) (groups 2 and 3), or with a random ODN (group 4) using a Japan-liposomeal method based on a hemagglutinating virus. The intimal and medial cross-sectional surface area of the anastomotic site was measured at 4 months after bypass surgery in groups 1, 3, and 4 by computerized planimetry and at 4 weeks in group 2 to compare the intimal/medial (I/M) area ratios. Autogenous vein grafts treated with E2F decoy showed a significant reduction in I/M area ratio (0.26 +/- 0.11) compared with the heparin-treated control group (1.49 +/- 0.29) or the mismatched ODN-treated group (1.61 +/- 0.28; P = .000). There was no difference in the I/M area ratio according to experimental periods (groups 2 vs 3: 0.26 +/- 0.11 vs 0.37 +/- 0.32; P = .446) or the anastomotic sites (proximal vs distal; P = .934). In conclusion, an E2F decoy can suppress neointimal hyperplasia in autogenous vein grafts, which may prolong patency by reducing graft stenosis.

Efficacy of Photocrosslinkable Chitosan Hydrogel Containing Fibroblast Growth Factor-2 in a Rabbit Model of Chronic Myocardial Infarction

BACKGROUND

Therapeutic angiogenesis in ischemic myocardium has been shown to be an effective strategy to improve regional blood flow and myocardial function. However, no effective delivery system for growth factor administration is yet known to induce important therapeutic angiogenic responses in ischemic myocardium.

MATERIALS AND METHODS

FGF-2-incorporated chitosan (FGF-2/chitosan) hydrogels were immobilized on the surface of ischemic myocardium of rabbit models of chronic myocardial infarction by UV-irradiation. After 4 weeks, cardiac functional analyses by noradrenalin challenge and histopathological analyses were performed to evaluate the efficacy of a controlled release of FGF-2 from FGF-2/chitosan hydrogel immobilized on the surface of ischemic myocardium.

RESULTS

Significant improvement by application of FGF-2/chitosan hydrogels was found in systolic pressure at the left ventricle, +dp/dt maximum, and -dp/dt maximum during noradrenalin challenge at a dose of 1 microg/kg/min. Histological observations showed that a significantly larger amount of viable myocardium and CD 31 immunostained blood vessels were found in the FGF-2/chitosan hydrogel-applied group than only the chitosan-applied and control groups.

CONCLUSIONS

These preliminary results indicate that the controlled release of biologically active FGF-2 molecules from FGF-2/chitosan hydrogel induces angiogenesis and possibly collateral circulation in ischemic myocardium, thereby protecting the myocardium.

Antiangiogenesis mediates cisplatin-induced peripheral neuropathy: attenuation or reversal by local vascular endothelial growth factor gene therapy without augmenting tumor growth

BACKGROUND

Toxic neuropathies induced by cisplatin and other chemotherapeutic agents are important clinical problems because of their high incidence, their lack of effective treatment, and the fact that neuropathy represents a dose-limiting factor for these therapies. The pathogenic basis for toxic neuropathies induced by chemotherapeutic agents has not been completely elucidated.

METHODS AND RESULTS

We investigated the hypothesis that experimental toxic neuropathy results from an antiangiogenic effect of these drugs, resulting in destruction of the vasa nervorum, and accordingly that the neuropathy could be prevented or reversed by locally administered VEGF gene transfer without augmenting tumor growth. In an animal model of cisplatin-induced neuropathy, nerve blood flow was markedly attenuated, and there was a profound reduction in the number of vasa nervorum associated with marked endothelial cell apoptosis, resulting in a severe peripheral neuropathy with focal axonal degeneration characteristic of ischemic neuropathy. After intramuscular gene transfer of naked plasmid DNA encoding VEGF-1 in animals with an established neuropathy, vascularity and blood flow returned to levels similar to those of control rats, peripheral nerve function was restored, and histological nerve architecture was normalized. Gene therapy administered in parallel with cisplatin chemotherapy completely attenuated endothelial cell apoptosis and inhibited destruction of nerve vasculature, deterioration of nerve function, and axonal degeneration. In a rat tumor model, VEGF gene transfer administered locally did not alter tumor growth or vascularity.

CONCLUSIONS

These findings implicate microvascular damage as the basis for toxic neuropathy induced by cisplatin and suggest that local angiogenic gene therapy may constitute a novel prevention or treatment for this disorder without augmenting tumor growth or vascularization.

Nonviral monocyte chemoattractant protein-1 gene transfer improves arteriogenesis after femoral artery occlusion

Local infusion of recombinant monocyte chemoattractant protein-1 (MCP-1) has been shown to enhance collateral artery formation in rabbit and pig hindlimb models. Owing to clinical disadvantages of protein infusion, a nonviral, liposome-based MCP-1 gene transfer was developed. Collateralization in a porcine hindlimb model served to provide a proof-of-principle for the functional benefit of MCP-1 overexpression. Development of arterial conductance as a measure of functionally relevant collateralization was evaluated in occluded as well as untreated hindlimbs in each animal. At the time of occlusion, MCP-1 and control DNA/DC-30 lipoplexes were transferred to femoral arteries of Goettingen minipigs (two therapeutic MCP-1 groups: 2 and 4 microg and one control group), using the Infiltrator local drug-delivery device. At 2 weeks following occlusion, collateralization was determined as changes in peripheral haemodynamic conductance, peripheral over aortic blood pressure ratio and angiographically visible morphology of the peripheral vessel tree. Nonviral MCP-1 gene transfer significantly improved peripheral conductance (control 11.69+/-2.78%, 2 microg 23.81+/-2.81%, P<0.05 and 4 microg 23.36+/-3.1%, P<0.05; n=12 per group) as well as the ratio of peripheral over aortic blood pressure (control 0.64+/-0.03%, 2 microg 0.75+/-0.02%, P<0.05 and 4 mug 0.75+/-0.02%, P<0.05; n=12 per group) when compared to the untreated controls 2 weeks after occlusion. Thus, it could be demonstrated for the first time that in situ overexpression of MCP-1 following local nonviral gene transfer is a potential approach to improve peripheral collateralization.

Saikosaponin C induces endothelial cells growth, migration and capillary tube formation

Saikosaponin C is one of the saikosaponins that are consisted in a Chinese herb, Radix Bupleuri. Recently, saikosaponins have been reported to have properties of cell growth inhibition, inducing cancer cells differentiation and apoptosis. However, saikosaponin C had no correlation with cell growth inhibition. In this study, we investigated the role of saikosaponin C on the growth of endothelial cells and angiogenesis. We found that saikosaponin C yielded a potent effect on inducing human umbilical vein endothelial cells (HUVECs) viability and growth. In addition to inducing endothelial cells growth, saikosaponin C also induced endothelial cells migration and capillary tube formation. The gene expression or activation of matrix metalloproteinase-2 (MMP-2), vascular endothelial growth factor (VEGF) and the p42/p44 mitogen-activated protein kinase (MAPK, ERK) that correlated with endothelial cells growth, migration and angiogenesis were also induced by saikosaponin C. From these results, we suggest that saikosaponin C may have the potential for therapeutic angiogenesis but is not suitable for cancer therapy.

Effects of calcium and thrombin on growth factor release from platelet concentrates: kinetics and regulation of endothelial cell proliferation

Platelet concentrates (PCs) constitute new biological mediators used in osseous reconstructive surgery. In this study, we assessed (i) the effects of various concentrations of calcium and thrombin on the kinetics of platelet-derived growth factor (PDGF-BB), transforming growth factor-beta1(TGF-beta 1), basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF) release by PCs and (ii) the contribution of PC supernatants to endothelial cell proliferation. Our results indicate that high concentrations of calcium (Ca) and thrombin (Thr) trigger an immediate and significant increase in bFGF, TGF-beta 1 and PDGF-BB concentrations. Thereafter, PDGF-BB, VEGF and TGF-beta 1 levels remained generally constant over a 6-day period while a decrease in bFGF concentrations was noted after 24h. Lower Ca and Thr concentrations tended to reduce and delay growth factors release from PCs. Endothelial cell proliferation was greatly enhanced with PC supernatants (mean: 20-fold increase). This was especially evident when endothelial cells were treated with supernatants harvested early after PC treatment with high concentrations of Ca and Thr or later after PC treatment with low Ca and Thr concentrations. Additional research aiming to measure the effects of Ca and Thr on bone formation in vivo is needed.

Gene Therapy for Chronic Peripheral Arterial Disease: What Role for the Vascular Surgeon?

The incidence of peripheral arterial disease is rising and despite advances in clinical management, many problems remain unsolved. Better knowledge of the mechanisms and consequences associated with chronic muscle ischemia has opened the way for development of new treatment strategies, including therapeutic angiogenesis. Therapeutic angiogenesis is a promising technique based on experimental studies showing that growth factors or genes able to increase capillary density can be used to reduce the impact of muscle ischemia and increase blood flow to ischemic tissue. Enthusiasm for this technique has prompted numerous clinical trials with encouraging results, but data are still inconclusive. Optimal indications for gene therapy must be defined and further experimental progress is needed to respond to ethical issues. Therapeutic angiogenesis should be viewed as an adjunct to rather than as a competitor of current surgical revascularization techniques.

Biopolymeric delivery matrices for angiogenic growth factors

The development of new therapeutic approaches that aim to help the body exert its natural mechanisms for vascularized tissue growth (therapeutic angiogenesis) has become one of the most active areas of tissue engineering. Through basic research, several growth factor families and cytokines that are capable to induce physiological blood vessel formation have been identified. Indeed, preclinical and clinical investigations have indicated that therapeutic administration of angiogenic factors, such as the prototypic vascular endothelial growth factor (VEGF) or basic fibroblast growth factor (bFGF), to sites of ischemia in the heart or the limb can improve regional blood flow. For new and lasting tissue vascularization, prolonged tissue exposure to these factors could be critical. Furthermore, as shown for VEGF, dosage must be tightly controlled, as excess amounts of VEGF can cause severe vascular leakage and hypotension. This review emphasizes natural and synthetic polymer matrices with respect to their development as vehicles for local and controlled delivery of angiogenic proteins, such as VEGF and bFGF, and their clinical applicability. In the dawn of experimental vascular engineering, new biomaterial schemes for clinical growth factor administration that take better account of biological principles of angiogenic growth factor function and the cell biological basis necessary to produce functional vasculature are evolving. Alongside their base function as protective embedment for angiogenic growth factors, these new classes of bioactive polymers are engineered with additional functionalities that better preserve growth factor activity and more closely mimic the in vivo release mechanisms and profiles of angiogenic growth factors from the extracellular matrix (ECM). Consequently, the preparation of both natural or completely synthetic materials with biological characteristics of the ECM has become central to many tissue engineering approaches that aim to deliver growth factors in a therapeutically efficient mode. Another promising venue to improve angiogenic performance is presented by biomaterials that allow sequential delivery of growth factors with complementary roles in blood vessel initiation and stabilization.

Quantitative microcomputed tomography analysis of collateral vessel development after ischemic injury

Transgenic mouse models are increasingly being used to investigate the functions of specific growth factors or matrix proteins to design therapeutic strategies for controlling blood vessel growth. However, the available methodologies for evaluating angiogenesis and arteriogenesis in these models are limited by animal size, user subjectivity, the power to visualize the three-dimensional vessel networks, or the capability to employ a vigorous quantitative analysis. In this study, we employed contrast-enhanced microcomputed tomography imaging to assess collateral development after induction of hindlimb ischemia in the mouse. The morphological parameters vessel volume, connectivity, number, thickness, thickness distribution, separation, and degree of anisotropy were evaluated in control and surgery limbs 0, 3, and 14 days postsurgery. Results indicate that the vascular volume of the surgically manipulated limb was reconstituted as early as 3 days after femoral artery excision through development of a series of highly connected, small caliber, closely spaced, and isotropically oriented collateral vessels. Parametric analyses were completed to assess the sensitivity of the calculated morphological parameters to variations in image binarization threshold and voxel size. Images taken at the 36-μm voxel size were found to be optimal for evaluating collateral vessel formation, whereas 8- to 16-μm voxel sizes were needed to resolve smaller vascular structures. This study demonstrates the utility of microcomputed tomography as a robust method for quantitative, three-dimensional analysis of blood vessel networks. Whereas these initial efforts focused on the mouse hindlimb ischemia model, the developed techniques may be applied to a variety of model systems to investigate mechanisms of angiogenesis and arteriogenesis.

No influence of tumor growth by intramuscular injection of hepatocyte growth factor plasmid DNA: safety evaluation of therapeutic angiogenesis gene therapy in mice

Recently, a novel therapeutic treatment for ischemic diseases using angiogenic growth factors to augment collateral artery development has been proposed. As intramuscular injection of naked human hepatocyte growth factor (HGF) plasmid DNA induced therapeutic angiogenesis in several animal test subjects, we have started a clinical trial to treat peripheral arterial disease. However, one might assume that over-expression of angiogenic growth factors could enhance tumor growth. To resolve this issue, we examined the over-expression of HGF in tumor bearing mice. Tumors on their backs were prepared with an intradermal inoculation of A431, human epidermoid cancer cells expressing c-Met. These mice were intramuscularly injected with human HGF plasmid or control plasmid into the femoral muscle. Human HGF concentration was increased only in the femoral muscle, but not in blood. Although recombinant HGF stimulated the growth of A431 cells in vitro, temporally and locally HGF elevation in hindlimb had no effect on tumor growth in mice.

Molecular imaging in nuclear cardiology

State-of-the-art techniques have been used to measure key aspects of cardiovascular pathophysiology from the birth of radionuclide cardiovascular imaging. However, during the last 30 years, there have been few innovative imaging advances to further our understanding of the complex physiologic processes. Molecular imaging now offers an array of tools to develop advanced diagnostic approaches and therapies for patients with coronary artery disease and heart failure. For example, the enhanced understanding of the pathophysiology of atheroma makes it possible to identify vulnerable plaque based on its metabolic signature or the presence of excessive apoptosis. Because the metabolic and apoptotic signals are large, it is likely that even small lesions will be visible. Of the many approaches that are being developed, 2 tracers appear most likely to be tested in the near future: (1) [18F]-fluorodeoxyglucose, to determine macrophage metabolism; and (2) radiolabeled annexin, to measure apoptosis of the inflammatory cells. Using existing techniques such as perfusion imaging, appropriate patients can be selected for treatment with novel therapies, such as stem cell transplantation or vascular gene therapy. Using positron tomography in place of single photon imaging adds the capability for the measurement of absolute perfusion and perfusion reserve to the information on regional perfusion. Flow reserve detects global decreases in perfusion and refines the determination of lesion severity available from perfusion imaging.

Factors regulating arteriogenesis

Growth of collateral vessels is potentially able to preserve structure and a variable degree of function in subtended tissues in the presence of arterial occlusions. The process of transformation of a small arteriole into much larger conductance artery is called arteriogenesis. Small arterioles that interconnect side branches proximal from the arterial occlusion with distal ones experience increased fluid shear stress because of the increased blood flow velocity attributable to the pressure gradient along the bridging collaterals. This activates the endothelium and leads to monocyte adhesion and infiltration with the subsequent production of growth factors and proteases. Preexistent arterioles are essential. Their presence is genetically determined. Arteriogenesis is not organ- or species-specific; coronary or peripheral collateral vessels develop following the same design principles in mice, rats, rabbits, or dogs. In contrast to angiogenesis, arteriogenesis is not dependent on the presence of hypoxia/ischemia.

Myocardial injection of CA promoter-based plasmid mediates efficient transgene expression in rat heart

BACKGROUND

Although naked plasmid injection is the safest and most convenient method for gene delivery, a major limitation of this approach is currently poor transgene expression. The CA promoter (chicken beta-actin promoter with cytomegalovirus, CMV, enhancer) is one of the strongest transcriptional control modules found; however, it is uncertain whether a CA promoter-based vector is efficient enough for naked gene therapy in a cardiovascular context.

METHODS

The beta-galactosidase (LacZ) expression provided by CA promoter plasmid (pCAZ2) injection into the skeletal muscle or the heart of Lewis rats was compared with CMV promoter plasmid or adenoviral vector (AxCAZ3). The effect of Simian virus 40 of the replication origin (SV40ori) deletion from pCAZ2 on transgene expression was also evaluated.

RESULTS

pCAZ2 showed the highest LacZ expression in both skeletal muscle and heart in comparison with the CMV promoter-based vector 5 days after naked plasmid injection. LacZ expression in the heart obtained using 20 micro g of pCAZ2 was almost equivalent to that shown with AxCAZ3 at 6.0 x 10(9) optical particle units. The time course of transgene expression driven by CMV and CA promoters in the heart were similar, with the CA promoter providing significantly higher gene expression than the CMV promoter across all time points examined. SV40ori deletion from pCAZ2 did not affect transgene expression in either skeletal muscle or heart.

CONCLUSIONS

Transgene expression mediated by naked CA promoter-based plasmid injection was shown to be quite efficient in the heart. We propose that the CA promoter vector is suitable for myocardial gene therapy.

Therapeutic angiogenesis with vascular endothelial growth factor in peripheral and coronary artery disease: a review

Therapeutic angiogenesis constitutes an alternative treatment for patients with extensive tissue ischaemia in whom primary vascular reconstruction procedures are not feasible or have previously failed. At present vascular endothelial growth factor (VEGF) has been the most widely used angiogenic factor in experimental and human clinical trials. Early clinical data provide evidence that gene transfer of the VEGF gene can achieve beneficial angiogenesis, with minimal side-effects. Ongoing phase III clinical studies will reveal definitive efficacy.

Gene transfer strategies to inhibit neointima formation

Vascular smooth muscle cell (VSMC) proliferation after arterial injury results in neointima formation and plays an important role in the pathogenesis of restenosis after angioplasty, in-stent restenosis, vascular bypass graft occlusion, and allograft vasculopathy. Major progress has been made recently in elucidating the cellular and molecular mechanisms underlying neointima formation. However, no known curative treatment currently exists. In cases in which pharmacologic and surgical interventions have had limited success, gene therapy remains a potential strategy for the treatment of such vascular proliferative diseases. To date, recombinant adenoviral vectors continue to be the most efficient methods of gene transfer into the arterial wall. However, concerns over the safety of using viral vectors in a clinical situation have inspired the considerable progress that has been made in improving both viral and nonviral modes of gene transfer. This review discusses some of the recent insights and outstanding progress in vascular gene therapeutic approaches to inhibit neointima both from a biologic and therapeutic perspective.

Heterologous expression of human VEGF165 in rat brain: dose-dependent, heterogeneous effects on CBF in relation to vascular density and cross-sectional area

Vascular endothelial growth factor (VEGF) induces increased vessel permeability and formation of abnormal vessels. To investigate cerebral blood flow (CBF) during local overexpression of VEGF recombinant adenoviruses carrying the human VEGF165 complementary DNA (2.3 to 23. 108 pfu/mL) were injected stereotactically into the caudate nucleus of anesthetized rats. Saline and adenoviruses carrying the beta-galactosidase gene served as controls. Eleven days later (1) size and density of vessels were assessed in hematoxylin-eosin-stained sections, (2) vascular permeability was measured by intravenous Evans blue injections, and (3) local CBF (lCBF) was quantified using the iodo-[14C]antipyrine technique. Dose-dependent increases were found in (1) vessel density and size (only vessels >43 microm could be quantified morphologically), (2) Evans blue extravasation and brain edema formation, and (3) lCBF (up to eightfold). At medium doses, hyperemic areas and smaller areas of decreased lCBF were found. In low flow areas, vascular cross-sectional areas were increased 223-fold and vessel density up to 10-fold. In high flow areas, these parameters were increased 32-fold and up to 15-fold, respectively. Adenovirus mediated VEGF overexpression results in (1) increased vessel size and density, (2) areas of increased and of decreased flow, and (3) more and smaller vessels in high flow than in low flow areas. These results indicate a diverging flow pattern of newly formed vessels.

VEGF-C gene therapy augments postnatal lymphangiogenesis and ameliorates secondary lymphedema

Although lymphedema is a common clinical condition, treatment for this disabling condition remains limited and largely ineffective. Recently, it has been reported that overexpression of VEGF-C correlates with increased lymphatic vessel growth (lymphangiogenesis). However, the effect of VEGF-C-induced lymphangiogenesis on lymphedema has yet to be demonstrated. Here we investigated the impact of local transfer of naked plasmid DNA encoding human VEGF-C (phVEGF-C) on two animal models of lymphedema: one in the rabbit ear and the other in the mouse tail. In a rabbit model, following local phVEGF-C gene transfer, VEGFR-3 expression was significantly increased. This gene transfer led to a decrease in thickness and volume of lymphedema, improvement of lymphatic function demonstrated by serial lymphoscintigraphy, and finally, attenuation of the fibrofatty changes of the skin, the final consequences of lymphedema. The favorable effect of phVEGF-C on lymphedema was reconfirmed in a mouse tail model. Immunohistochemical analysis using lymphatic-specific markers: VEGFR-3, lymphatic endothelial hyaluronan receptor-1, together with the proliferation marker Ki-67 Ab revealed that phVEGF-C transfection potently induced new lymphatic vessel growth. This study, we believe for the first time, documents that gene transfer of phVEGF-C resolves lymphedema through direct augmentation of lymphangiogenesis. This novel therapeutic strategy may merit clinical investigation in patients with lymphedema.

Plasma vascular endothelial growth factor (VEGF) levels after intramuscular and intramyocardial gene transfer of VEGF-1 plasmid DNA

The purpose of this study was to document the kinetics of vascular endothelial growth factor (VEGF) protein release into the systemic circulation after phVEGF gene transfer for therapeutic angiogenesis. VEGF plasma levels were measured by ELISA in 64 patients undergoing gene transfer of plasmid DNA: intramuscular in 34 patients with peripheral artery disease, and intramyocardial in 30 patients with coronary disease. Baseline plasma VEGF was highly variable and not normally distributed. After intramuscular gene transfer, median plasma VEGF rose slightly, although significantly, by 7 days (38 to 41 pg/ml, p < 0.05), but was not different from baseline at 14, 21, or 28 days. After intramyocardial gene transfer, median plasma VEGF levels were significantly elevated compared with baseline on days 2, 3, and 7 (39, 38, and 45 pg/ml, respectively, each p < 0.05 vs. baseline value of 21 pg/ml). Day 7 plasma levels did not differ significantly as a function of phVEGF dose, or between intramyocardial and intramuscular injections (1.8 and 1.3 times baseline levels, respectively, p = 0.6), despite an almost 10-fold difference in mean phVEGF dose. Intramuscular and intramyocardial phVEGF injections result in significant, although modest, elevations of circulating gene product for <14 days, with no relationship to injected dose. While a statistically significant increase in circulating VEGF level can provide evidence of successful gene transfer for groups of patients, interpretation of results for individual subjects is complicated by wide variation in baseline VEGF and low circulating levels compared with baseline after gene transfer.