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Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication. Transplantation 2021; 105:1188-1202. [PMID: 33148978 DOI: 10.1097/tp.0000000000003518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Peripheral vascular disease (PVD) is highly prevalent in patients on the waiting list for kidney transplantation (KT) and after transplantation and is associated with impaired transplant outcomes. Multiple traditional and nontraditional risk factors, as well as uremia- and transplant-related factors, affect 2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD. Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD. Early detection of PVD before and after KT, better understanding of the mechanisms of vascular damage, and application of suitable therapeutic approaches could all minimize the impact of PVD on transplant outcomes. This review focuses on the following issues: (1) definition, epidemiological data, diagnosis, risk factors, and pathogenic mechanisms in KT candidates and recipients; (2) adverse clinical consequences and outcomes; and (3) classical and new therapeutic approaches.
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Abstract
Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.
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Affiliation(s)
- Joshua A Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, TN (J.A.B.)
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco (P.A.S., M.S.C.)
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco (P.A.S., M.S.C.)
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Ipema J, Roozendaal NC, Bax WA, de Borst GJ, de Vries JPPM, Ünlü Ç. Medical adjunctive therapy for patients with chronic limb-threatening ischemia: a systematic review. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:642-651. [PMID: 31603294 DOI: 10.23736/s0021-9509.19.11108-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of this article is to systematically review the literature on medical adjunctive therapy for patients with chronic limb-threatening ischemia (CLTI). EVIDENCE ACQUISITION MEDLINE, Embase, and Cochrane Database of Systematic Reviews were searched for studies published between January 1st, 2009, and June 1st, 2019. Articles that studied medical treatment of CLTI patients and reported clinical outcomes were eligible. Main exclusion criteria were case reports <20 patients, incorrect publication type, and CLTI caused by Buerger disease. The primary end point was major amputation (above the ankle) in studies with a follow-up of ≥6 months. Secondary end points were other clinical end points such as death and wound healing. Study quality was assessed according to the Downs and Black checklist. EVIDENCE SYNTHESIS Included were 42 articles: four focused on antiplatelet therapy, five on antihypertensive medication, 6 on lipid-lowering therapy, 16 on stem cell therapy, three on growth factors, five on prostanoids, and one study each on cilostazol, glucose-lowering therapy, spinal cord stimulation, sulodexide, and hemodilution. Calcium channel blockers, iloprost, cilostazol, and hemodilution showed significant improvement of limb salvage, but data are limited. Stem cell therapy showed no significant improvement of limb salvage but could potentially improve wound healing. Antiplatelets, antihypertensives, and statins showed significantly lower cardiovascular events rates but not evident lower major amputation rates. The quality of the studies was fair to good. CONCLUSIONS Certain medical therapies serve to improve limb salvage next to revascularization in CLTI patients, whereas others are important in secondary prevention. Because high quality evidence is limited, further research is needed.
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Affiliation(s)
- Jetty Ipema
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands -
| | - Nicolaas C Roozendaal
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Willem A Bax
- Department of Internal Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jean Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Çağdaş Ünlü
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Haghighat L, Ionescu CN, Regan CJ, Altin SE, Attaran RR, Mena-Hurtado CI. Review of the Current Basic Science Strategies to Treat Critical Limb Ischemia. Vasc Endovascular Surg 2019; 53:316-324. [DOI: 10.1177/1538574419831489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Critical limb ischemia (CLI) is a highly morbid disease with many patients considered poor surgical candidates. The lack of treatment options for CLI has driven interest in developing molecular therapies within recent years. Through these translational medicine studies in CLI, much has been learned about the pathophysiology of the disease. Here, we present an overview of the macrovascular and microvascular changes that lead to the development of CLI, including impairment of angiogenesis, vasculogenesis, and arteriogenesis. We summarize the randomized clinical controlled trials that have used molecular therapies in CLI, and discuss the novel imaging modalities being developed to assess the efficacy of these therapies.
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Affiliation(s)
- Leila Haghighat
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Costin N. Ionescu
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher J. Regan
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sophia Elissa Altin
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert R. Attaran
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos I. Mena-Hurtado
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
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Jiang Y, Li M, Fu X. Biotechnological Management of Angiopathic Wounds: Challenges and Perspectives. INT J LOW EXTR WOUND 2018; 17:214-217. [PMID: 30474446 DOI: 10.1177/1534734618813232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Angiopathic wound is a wound that develops as a result of a local vascular lesion. Angiogenesis is an important aspect underlying repair, and increased angiogenesis could accelerate and improve the healing outcome. Biotherapy has been used more and more in clinic and brings hope for angiopathic wound treatment, through the rapid recovery of angiogenesis and regulation and correction of the whole wound microenvironment. In this article, we discuss the advantages and disadvantages of various technologies ranging from presentation of angiogenic growth factors, genetic strategies, stem cells, and biomaterials engineering in angiopathic wound treatment.
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Affiliation(s)
- Yufeng Jiang
- Chinese PLA 306th Hospital, Beijing, People’s Republic of China
- Chinese PLA General Hospital and Chinese PLA Medical College, Beijing, People’s Republic of China
- The Key Laboratory of Wound Repair and Regeneration of PLA, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Meirong Li
- Chinese PLA General Hospital and Chinese PLA Medical College, Beijing, People’s Republic of China
- The Key Laboratory of Wound Repair and Regeneration of PLA, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Xiaobing Fu
- Chinese PLA General Hospital and Chinese PLA Medical College, Beijing, People’s Republic of China
- The Key Laboratory of Wound Repair and Regeneration of PLA, Chinese PLA General Hospital, Beijing, People’s Republic of China
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Makarevich PI, Dergilev KV, Tsokolaeva ZI, Boldyreva MA, Shevchenko EK, Gluhanyuk EV, Gallinger JO, Menshikov MY, Parfyonova YV. Angiogenic and pleiotropic effects of VEGF165 and HGF combined gene therapy in a rat model of myocardial infarction. PLoS One 2018; 13:e0197566. [PMID: 29787588 PMCID: PMC5963747 DOI: 10.1371/journal.pone.0197566] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 05/05/2018] [Indexed: 12/31/2022] Open
Abstract
Since development of plasmid gene therapy for therapeutic angiogenesis by J. Isner this approach was an attractive option for ischemic diseases affecting large cohorts of patients. However, first placebo-controlled clinical trials showed its limited efficacy questioning further advance to practice. Thus, combined methods using delivery of several angiogenic factors got into spotlight as a way to improve outcomes. This study provides experimental proof of concept for a combined approach using simultaneous delivery of VEGF165 and HGF genes to alleviate consequences of myocardial infarction (MI). However, recent studies suggested that angiogenic growth factors have pleiotropic effects that may contribute to outcome so we expanded focus of our work to investigate potential mechanisms underlying action of VEGF165, HGF and their combination in MI. Briefly, Wistar rats underwent coronary artery ligation followed by injection of plasmid bearing VEGF165 or HGF or mixture of these. Histological assessment showed decreased size of post-MI fibrosis in both—VEGF165- or HGF-treated animals yet most prominent reduction of collagen deposition was observed in VEGF165+HGF group. Combined delivery group rats were the only to show significant increase of left ventricle (LV) wall thickness. We also found dilatation index improved in HGF or VEGF165+HGF treated animals. These effects were partially supported by our findings of c-kit+ cardiac stem cell number increase in all treated animals compared to negative control. Sporadic Ki-67+ mature cardiomyocytes were found in peri-infarct area throughout study groups with comparable effects of VEGF165, HGF and their combination. Assessment of vascular density in peri-infarct area showed efficacy of both–VEGF165 and HGF while combination of growth factors showed maximum increase of CD31+ capillary density. To our surprise arteriogenic response was limited in HGF-treated animals while VEGF165 showed potent positive influence on a-SMA+ blood vessel density. The latter hinted to evaluate infiltration of monocytes as they are known to modulate arteriogenic response in myocardium. We found that monocyte infiltration was driven by VEGF165 and reduced by HGF resulting in alleviation of VEGF-stimulated monocyte taxis after combined delivery of these 2 factors. Changes of monocyte infiltration were concordant with a-SMA+ arteriole density so we tested influence of VEGF165 or HGF on endothelial cells (EC) that mediate angiogenesis and inflammatory response. In a series of in vitro experiments we found that VEGF165 and HGF regulate production of inflammatory chemokines by human EC. In particular MCP-1 levels changed after treatment by recombinant VEGF, HGF or their combination and were concordant with NF-κB activation and monocyte infiltration in corresponding groups in vivo. We also found that both–VEGF165 and HGF upregulated IL-8 production by EC while their combination showed additive type of response reaching peak values. These changes were HIF-2 dependent and siRNA-mediated knockdown of HIF-2α abolished effects of VEGF165 and HGF on IL-8 production. To conclude, our study supports combined gene therapy by VEGF165 and HGF to treat MI and highlights neglected role of pleiotropic effects of angiogenic growth factors that may define efficacy via regulation of inflammatory response and endothelial function.
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Affiliation(s)
- Pavel I. Makarevich
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
- Laboratory of Gene and Cell Therapy, Institute of Regenerative Medicine, Lomonosov Moscow State University, Moscow, Russia
- * E-mail:
| | - Konstantin V. Dergilev
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
| | - Zoya I. Tsokolaeva
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
- Laboratory of Gene and Cell Technology, Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Maria A. Boldyreva
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
- Laboratory of Gene and Cell Technology, Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Evgeniy K. Shevchenko
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
- Laboratory of Gene and Cell Technology, Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Evgeny V. Gluhanyuk
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
| | - Julia O. Gallinger
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
| | - Mikhail Yu. Menshikov
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
- Laboratory of Gene and Cell Technology, Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
| | - Yelena V. Parfyonova
- Laboratory of Angiogenesis, National Medical Research Center of Cardiology, Moscow, Russia
- Laboratory of Gene and Cell Technology, Faculty of Medicine, Lomonosov Moscow State University, Moscow, Russia
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Abstract
BACKGROUND Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular disease in the general population. Although numerous treatments have been adopted for patients at different disease stages, no option other than amputation is available for patients presenting with critical limb ischaemia (CLI) unsuitable for rescue or reconstructive intervention. In this regard, prostanoids have been proposed as a therapeutic alternative, with the aim of increasing blood supply to the limb with occluded arteries through their vasodilatory, antithrombotic, and anti-inflammatory effects. This is an update of a review first published in 2010. OBJECTIVES To determine the effectiveness and safety of prostanoids in patients with CLI unsuitable for rescue or reconstructive intervention. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (January 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). In addition, we searched trials registries (January 2017) and contacted pharmaceutical manufacturers, in our efforts to identify unpublished data and ongoing trials. SELECTION CRITERIA Randomised controlled trials describing the efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments for patients presenting with CLI without chance of rescue or reconstructive intervention. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. We resolved disagreements by consensus or by consultation with a third review author. MAIN RESULTS For this update, 15 additional studies fulfilled selection criteria. We included in this review 33 randomised controlled trials with 4477 participants; 21 compared different prostanoids versus placebo, seven compared prostanoids versus other agents, and five conducted head-to-head comparisons using two different prostanoids.We found low-quality evidence that suggests no clear difference in the incidence of cardiovascular mortality between patients receiving prostanoids and those given placebo (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.41 to 1.58). We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared with placebo (RR 0.97, 95% CI 0.86 to 1.09). Adverse events were more frequent with prostanoids than with placebo (RR 2.11, 95% CI 1.79 to 2.50; moderate-quality evidence). The most commonly reported adverse events were headache, nausea, vomiting, diarrhoea, flushing, and hypotension. We found moderate-quality evidence showing that prostanoids reduced rest-pain (RR 1.30, 95% CI 1.06 to 1.59) and promoted ulcer healing (RR 1.24, 95% CI 1.04 to 1.48) when compared with placebo, although these small beneficial effects were diluted when we performed a sensitivity analysis that excluded studies at high risk of bias. Additionally, we found evidence of low to very low quality suggesting the effects of prostanoids versus other active agents or versus other prostanoids because studies conducting these comparisons were few and we judged them to be at high risk of bias. None of the included studies assessed quality of life. AUTHORS' CONCLUSIONS We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared against placebo. Moderate-quality evidence showed small beneficial effects of prostanoids for rest-pain relief and ulcer healing when compared with placebo. Additionally, moderate-quality evidence showed a greater incidence of adverse effects with the use of prostanoids, and low-quality evidence suggests that prostanoids have no effect on cardiovascular mortality when compared with placebo. None of the included studies reported quality of life measurements. The balance between benefits and harms associated with use of prostanoids in patients with critical limb ischaemia with no chance of reconstructive intervention is uncertain; therefore careful assessment of therapeutic alternatives should be considered. Main reasons for downgrading the quality of evidence were high risk of attrition bias and imprecision of effect estimates.
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Affiliation(s)
- Valeria Vietto
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceBuenos AiresArgentina
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentreBuenos AiresArgentina
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentreBuenos AiresArgentina
| | - Victoria Saenz
- Unidad Asistencial Dr. César MilsteinInternal MedicineLa Rioja 951Ciudad Autónoma de Buenos AiresBuenos AiresArgentinaC1221ACI
| | - Denise Cytryn
- Hospital Italiano de Buenos AiresFamily and Community Medicine ServiceBuenos AiresArgentina
| | - Jose Chas
- Hospital Italiano de Buenos AiresCardiovascular Surgery DepartmentBuenos AiresArgentinaPerón 4190
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
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Papadopoulos K, Wattanaarsakit P, Prasongchean W, Narain R. Gene therapies in clinical trials. POLYMERS AND NANOMATERIALS FOR GENE THERAPY 2016. [DOI: https:/doi.org/10.1016/b978-0-08-100520-0.00010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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