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Tan LT, Mokhtari-Esbuie F, Shababi N, Harmon JW. Stem Cell Therapy for Wound Healing in Ischemic Limbs: Is It Effective? Adv Surg 2024; 58:235-247. [PMID: 39089780 DOI: 10.1016/j.yasu.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Critical limb ischemia is an important clinical entity due to its association with increased morbidity and mortality. The mortality and amputation-free survival remains poor especially in those where revascularization is not an option. Recently, the role of cellular therapy has emerged as a promising therapeutic measure that may aid in wound healing and revascularization and improve functional outcomes.
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Affiliation(s)
- Li Ting Tan
- Department of Surgery, The Johns Hopkins Hospital, Blalock 658, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Farzad Mokhtari-Esbuie
- Department of Surgery, Johns Hopkins University, Surgery A Building 5th Floor, 4940 Eastern Avenue, Baltimore, MD 21224, USA
| | - Niloufar Shababi
- Department of Surgery, Johns Hopkins University, Surgery A Building 5th Floor, 4940 Eastern Avenue, Baltimore, MD 21224, USA
| | - John W Harmon
- Department of Surgery, Johns Hopkins University, Surgery A Building 5th Floor, 4940 Eastern Avenue, Baltimore, MD 21224, USA.
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Dubský M, Husáková J, Sojáková D, Fejfarová V, Jude EB. Cell Therapy of Severe Ischemia in People with Diabetic Foot Ulcers-Do We Have Enough Evidence? Mol Diagn Ther 2023; 27:673-683. [PMID: 37740111 PMCID: PMC10590286 DOI: 10.1007/s40291-023-00667-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 09/24/2023]
Abstract
This current opinion article critically evaluates the efficacy of autologous cell therapy (ACT) for chronic limb-threatening ischemia (CLTI), especially in people with diabetes who are not candidates for standard revascularization. This treatment approach has been used in 'no-option' CLTI in the last two decades and more than 1700 patients have received ACT worldwide. Here we analyze the level of published evidence of ACT as well as our experience with this treatment method. Many studies have shown that ACT is safe and an effective method for patients with the most severe lower limb ischemia. However, some trials did not show any benefit of ACT, and there is some heterogeneity in the types of injected cells, route of administration and assessed endpoints. Nevertheless, we believe that ACT plays an important role in a comprehensive treatment of patients with diabetic foot and severe ischemia.
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Affiliation(s)
- Michal Dubský
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
- First Faculty of Medicine, Charles Universtiy, Prague, Czech Republic.
| | - Jitka Husáková
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- First Faculty of Medicine, Charles Universtiy, Prague, Czech Republic
| | - Dominika Sojáková
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- First Faculty of Medicine, Charles Universtiy, Prague, Czech Republic
| | | | - Edward B Jude
- Diabetes Center, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton Under Lyne, UK.
- University of Manchester, Lancashire, UK.
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Moazzami B, Mohammadpour Z, Zabala ZE, Farokhi E, Roohi A, Dolmatova E, Moazzami K. Local intramuscular transplantation of autologous bone marrow mononuclear cells for critical lower limb ischaemia. Cochrane Database Syst Rev 2022; 7:CD008347. [PMID: 35802393 PMCID: PMC9266992 DOI: 10.1002/14651858.cd008347.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Peripheral arterial disease is a major health problem, and in about 1% to 2% of patients, the disease progresses to critical limb ischaemia (CLI), also known as critical limb-threatening ischaemia. In a substantial number of individuals with CLI, no effective treatment options other than amputation are available, with around a quarter of these patients requiring a major amputation during the following year. This is the second update of a review first published in 2011. OBJECTIVES To evaluate the benefits and harms of local intramuscular transplantation of autologous adult bone marrow mononuclear cells (BMMNCs) as a treatment for CLI. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 8 November 2021. SELECTION CRITERIA We included all randomised controlled trials (RCTs) of CLI in which participants were randomly allocated to intramuscular administration of autologous adult BMMNCs or control (either no intervention, conventional conservative therapy, or placebo). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes of interest were all-cause mortality, pain, and amputation. Our secondary outcomes were angiographic analysis, ankle-brachial index (ABI), pain-free walking distance, side effects and complications. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included four RCTs involving a total of 176 participants with a clinical diagnosis of CLI. Participants were randomised to receive either intramuscular cell implantation of BMMNCs or control. The control arms varied between studies, and included conventional therapy, diluted autologous peripheral blood, and saline. There was no clear evidence of an effect on mortality related to the administration of BMMNCs compared to control (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.15 to 6.63; 3 studies, 123 participants; very low-certainty evidence). All trials assessed changes in pain severity, but the trials used different forms of pain assessment tools, so we were unable to pool data. Three studies individually reported that no differences in pain reduction were observed between the BMMNC and control groups. One study reported that reduction in rest pain was greater in the BMMNC group compared to the control group (very low-certainty evidence). All four trials reported the rate of amputation at the end of the study period. We are uncertain if amputations were reduced in the BMMNC group compared to the control group, as a possible small effect (RR 0.52, 95% CI 0.27 to 0.99; 4 studies, 176 participants; very low-certainty evidence) was lost after undertaking sensitivity analysis (RR 0.52, 95% CI 0.19 to 1.39; 2 studies, 89 participants). None of the included studies reported any angiographic analysis. Ankle-brachial index was reported differently by each study, so we were not able to pool the data. Three studies reported no changes between groups, and one study reported greater improvement in ABI (as haemodynamic improvement) in the BMMNC group compared to the control group (very low-certainty evidence). One study reported pain-free walking distance, finding no clear difference between BMMNC and control groups (low-certainty evidence). We pooled the data for side effects reported during the follow-up, and this did not show any clear difference between BMMNC and control groups (RR 2.13, 95% CI 0.50 to 8.97; 4 studies, 176 participants; very low-certainty evidence). We downgraded the certainty of the evidence due to the concerns about risk of bias, imprecision, and inconsistency. AUTHORS' CONCLUSIONS We identified a small number of studies that met our inclusion criteria, and these differed in the controls they used and how they measured important outcomes. Limited data from these trials provide very low- to low-certainty evidence, and we are unable to draw conclusions to support the use of local intramuscular transplantation of BMMNC for improving clinical outcomes in people with CLI. Evidence from larger RCTs is needed in order to provide adequate statistical power to assess the role of this procedure.
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Affiliation(s)
- Bobak Moazzami
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zinat Mohammadpour
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Zohyra E Zabala
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ermia Farokhi
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Aria Roohi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Elena Dolmatova
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kasra Moazzami
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Khodayari S, Khodayari H, Ebrahimi-Barough S, Khanmohammadi M, Islam MS, Vesovic M, Goodarzi A, Mahmoodzadeh H, Nayernia K, Aghdami N, Ai J. Stem Cell Therapy in Limb Ischemia: State-of-Art, Perspective, and Possible Impacts of Endometrial-Derived Stem Cells. Front Cell Dev Biol 2022; 10:834754. [PMID: 35676930 PMCID: PMC9168222 DOI: 10.3389/fcell.2022.834754] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
As an evidence-based performance, the rising incidence of various ischemic disorders has been observed across many nations. As a result, there is a growing need for the development of more effective regenerative approaches that could serve as main therapeutic strategies for the treatment of these diseases. From a cellular perspective, promoted complex inflammatory mechanisms, after inhibition of organ blood flow, can lead to cell death in all tissue types. In this case, using the stem cell technology provides a safe and regenerative approach for ischemic tissue revascularization and functional cell formation. Limb ischemia (LI) is one of the most frequent ischemic disease types and has been shown to have a promising regenerative response through stem cell therapy based on several clinical trials. Bone marrow-derived mononuclear cells (BM-MNCs), peripheral blood CD34-positive mononuclear cells (CD34+ PB-MNCs), mesenchymal stem cells (MSCs), and endothelial stem/progenitor cells (ESPCs) are the main, well-examined stem cell types in these studies. Additionally, our investigations reveal that endometrial tissue can be considered a suitable candidate for isolating new safe, effective, and feasible multipotent stem cells for limb regeneration. In addition to other teams’ results, our in-depth studies on endometrial-derived stem cells (EnSCs) have shown that these cells have translational potential for limb ischemia treatment. The EnSCs are able to generate diverse types of cells which are essential for limb reconstruction, including endothelial cells, smooth muscle cells, muscle cells, and even peripheral nervous system populations. Hence, the main object of this review is to present stem cell technology and evaluate its method of regeneration in ischemic limb tissue.
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Affiliation(s)
- Saeed Khodayari
- Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Science, Tehran, Iran
- Breast Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
- International Center for Personalized Medicine (P7MEDICINE), Düsseldorf, Germany
| | - Hamid Khodayari
- Breast Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
- International Center for Personalized Medicine (P7MEDICINE), Düsseldorf, Germany
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Somayeh Ebrahimi-Barough
- Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Mehdi Khanmohammadi
- Skull Base Research Center, The Five Senses Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Md Shahidul Islam
- Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Miko Vesovic
- Department of Mathematics, Statistics, and Computer Science, University of Illinois at Chicago, Chicago, IL, United States
| | - Arash Goodarzi
- Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Science, Tehran, Iran
| | | | - Karim Nayernia
- International Center for Personalized Medicine (P7MEDICINE), Düsseldorf, Germany
| | - Nasser Aghdami
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
- Department of Infectious Diseases and Tropical Medicines, Tehran University of Medical Sciences, Tehran, Iran
- *Correspondence: Jafar Ai, ; Nasser Aghdami,
| | - Jafar Ai
- Tissue Engineering and Applied Cell Sciences, School of Advanced Technologies in Medicine, Tehran University of Medical Science, Tehran, Iran
- *Correspondence: Jafar Ai, ; Nasser Aghdami,
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Husakova J, Bem R, Jirkovska A, Nemcova A, Fejfarova V, Sutoris K, Kahle M, Jude EB, Dubsky M. Comparison of Three Methods for Preparation of Autologous Cells for Use in Cell Therapy of Chronic Limb-Threatening Ischemia in People with Diabetes. INT J LOW EXTR WOUND 2022:15347346221095954. [PMID: 35466748 DOI: 10.1177/15347346221095954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Autologous cell therapy (ACT) is a new therapeutic approach for diabetic patients with no-option chronic limb-threatening ischemia (NO-CLTI). The aim of our study was to quantify cell populations of cell therapy products (CTPs) obtained by three different isolation methods and to correlate their numbers with changes in transcutaneous oxygen pressure (TcPO2). CTPs were separated either from stimulated peripheral blood (PB) (n = 11) or harvested from bone marrow (BM) processed either by Harvest SmartPReP2 (n = 50) or sedimented with succinate gelatin (n = 29). The clinical effect was evaluated by the change in TcPO2 after 1, 3 and 6 months. TcPO2 increased significantly in all three methods at each time point in comparison with baseline values (p < .01) with no significant difference among them. There was no correlation between the change in TcPO2 and the size of injected cell populations. We only observed a weak correlation between the number of injected white blood cells (WBC) and an increase in TcPO2 at 1 and 3 months. Our study showed that all three isolation methods of ACT were similarly relatively efficient in the treatment of NO-CLTI. We observed no correlation of TcPO2 increase with the number of injected monocytes, lymphocytes or CD34+. We observed a weak correlation between TcPO2 increase and the number of injected WBCs.
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Affiliation(s)
- Jitka Husakova
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Robert Bem
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Alexandra Jirkovska
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Andrea Nemcova
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Vladimira Fejfarova
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Karol Sutoris
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Michal Kahle
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Edward B Jude
- Diabetes Center, 9386Tameside Hospital NHS Foundation Trust and University of Manchester, Lancashire, UK
| | - Michal Dubsky
- 360783Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- First Faculty of Medicine, Charles University, Prague, Czech Republic
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Implantation of Hypoxia-Induced Mesenchymal Stem Cell Advances Therapeutic Angiogenesis. Stem Cells Int 2022; 2022:6795274. [PMID: 35355589 PMCID: PMC8958070 DOI: 10.1155/2022/6795274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 12/13/2022] Open
Abstract
Hypoxia preconditioning enhances the paracrine abilities of mesenchymal stem cells (MSCs) for vascular regeneration and tissue healing. Implantation of hypoxia-induced mesenchymal stem cells (hi-MSCs) may further improve limb perfusion in a murine model of hindlimb ischemia. This study is aimed at determining whether implantation of hi-MSCs is an effective modality for improving outcomes of treatment of ischemic artery diseases. We evaluated the effects of human bone marrow-derived MSC implantation on limb blood flow in an ischemic hindlimb model. hi-MSCs were prepared by cell culture under 1% oxygen for 24 hours prior to implantation. A total of 1 × 105 MSCs and hi-MSCs and phosphate-buffered saline (PBS) were intramuscularly implanted into ischemic muscles at 36 hours after surgery. Restoration of blood flow and muscle perfusion was evaluated by laser Doppler perfusion imaging. Blood perfusion recovery, enhanced vessel densities, and improvement of function of the ischemia limb were significantly greater in the hi-MSC group than in the MSC or PBS group. Immunochemistry revealed that hi-MSCs had higher expression levels of hypoxia-inducible factor-1 alpha and vascular endothelial growth factor A than those in MSCs. In addition, an endothelial cell-inducing medium showed high expression levels of vascular endothelial growth factor, platelet endothelial cell adhesion molecule-1, and von Willebrand factor in hi-MSCs compared to those in MSCs. These findings suggest that pretreatment of MSCs with a hypoxia condition and implantation of hi-MSCs advances neovascularization capability with enhanced therapeutic angiogenic effects in a murine hindlimb ischemia model.
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Dubský M, Husáková J, Bem R, Jirkovská A, Němcová A, Fejfarová V, Sutoris K, Kahle M, Jude EB. Comparison of the impact of autologous cell therapy and conservative standard treatment on tissue oxygen supply and course of the diabetic foot in patients with chronic limb-threatening ischemia: A randomized controlled trial. Front Endocrinol (Lausanne) 2022; 13:888809. [PMID: 36105404 PMCID: PMC9464922 DOI: 10.3389/fendo.2022.888809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/09/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Autologous cell therapy (ACT) is a new treatment method for patients with diabetes and no-option chronic limb-threatening ischemia (NO-CLTI). We aimed to assess the impact of ACT on NO-CLTI in comparison with standard treatment (ST) in a randomized controlled trial. METHODS Diabetic patients with NO-CLTI were randomized to receive either ACT (n=21) or ST (n=19). After 12 weeks, those in the ST group, who did not improve were treated with ACT. The effect of ACT on ischemia and wound healing was assessed by changes in transcutaneous oxygen pressure (TcPO2) and the number of healed patients at 12 weeks. Pain was evaluated by Visual Analogue Scale (VAS). Amputation rates and amputation-free survival (AFS) were assessed in both groups. RESULTS During the first 12 weeks, TcPO2 increased in the ACT group from 20.8 ± 9.6 to 41.9 ± 18.3 mm Hg (p=0.005) whereas there was no change in the ST group (from 21.2 ± 11.4 to 23.9 ± 13.5 mm Hg). Difference in TcPO2 in the ACT group compared to ST group was 21.1 mm Hg (p=0.034) after 12 weeks. In the period from week 12 to week 24, when ST group received ACT, the TcPO2 in this group increased from 20.1 ± 13.9 to 41.9 ± 14.8 (p=0.005) while it did not change significantly in the ACT in this period. At 24 weeks, there was no significant difference in mean TcPO2 between the two groups. Wound healing was greater at 12 weeks in the ACT group compared to the ST group (5/16 vs. 0/13, p=0.048). Pain measured using VAS was reduced in the ACT group after 12 weeks compared to the baseline, and the difference in scores was again significant (p<0.001), but not in the ST group. There was no difference in rates of major amputation and AFS between ACT and ST groups at 12 weeks. CONCLUSIONS This study has showed that ACT treatment in patients with no-option CLTI and diabetic foot significantly improved limb ischemia and wound healing after 12 weeks compared to conservative standard therapy. Larger randomized controlled trials are needed to study the benefits of ACT in patients with NO-CLTI and diabetic foot disease. TRIAL REGISTRATION The trial was registered in the National Board of Health (EudraCT 2016-001397-15).
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Affiliation(s)
- Michal Dubský
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- First Faculty of Medicine, Charles University, Prague, Czechia
- *Correspondence: Michal Dubský,
| | - Jitka Husáková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- First Faculty of Medicine, Charles University, Prague, Czechia
| | - Robert Bem
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Alexandra Jirkovská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Andrea Němcová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Vladimíra Fejfarová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Karol Sutoris
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- Clinic of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Michal Kahle
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- Department of Data Analysis, Statistics and Artificial Intelligence, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Edward B. Jude
- Tameside and Glossop Integrated Care NHS Foundation Trust and University of Manchester, Ashton under Lyne, United Kingdom
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Autologous Stem Cell Therapy for Chronic Lower Extremity Wounds: A Meta-Analysis of Randomized Controlled Trials. Cells 2021; 10:cells10123307. [PMID: 34943815 PMCID: PMC8699089 DOI: 10.3390/cells10123307] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 12/15/2022] Open
Abstract
Lower extremity chronic wounds (LECWs) commonly occur in patients with diabetes mellitus (DM) and peripheral arterial disease (PAD). Autologous stem cell therapy (ASCT) has emerged as a promising alternative treatment for those who suffered from LECWs. The purpose of this study was to assess the effects of ASCT on LECWs. Two authors searched three core databases, and independently identified evidence according to predefined criteria. They also individually assessed the quality of the included randomized controlled trials (RCTs), and extracted data on complete healing rate, amputation rate, and outcomes regarding peripheral circulation. The extracted data were pooled using a random-effects model due to clinical heterogeneity among the included RCTs. A subgroup analysis was further performed according to etiology, source of stem cells, follow-up time, and cell markers. A total of 28 RCTs (n = 1096) were eligible for this study. The pooled results showed that patients receiving ASCT had significantly higher complete healing rates (risk ratio (RR) = 1.67, 95% confidence interval (CI) 1.28–2.19) as compared with those without ASCT. In the CD34+ subgroup, ASCT significantly led to a higher complete healing rate (RR = 2.70, 95% CI 1.50–4.86), but there was no significant difference in the CD34− subgroup. ASCT through intramuscular injection can significantly improve wound healing in patients with LECWs caused by either DM or critical limb ischemia. Lastly, CD34+ is an important cell marker for potential wound healing. However, more extensive scale and well-designed studies are necessary to explore the details of ASCT and chronic wound healing.
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A Meta-Analysis of Randomized Controlled Trials on Therapeutic Efficacy and Safety of Autologous Cell Therapy for Atherosclerosis Obliterans. J Vasc Surg 2021; 75:1440-1449.e5. [PMID: 34788653 DOI: 10.1016/j.jvs.2021.10.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 10/27/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Atherosclerosis obliterans (ASO) is a chronic occlusive arterial disease and the most common type of peripheral arterial disease. Current treatment options like medication and vascularization have limited effects for "no-option" patients, and stem cell therapy is considered a viable option although its application and efficacy have not been standardized. The objective of this review was to assess the safety and efficacy of autologous stem cell therapy in patients with ASO. METHODS We performed a literature search of published RCTs for ASO patients receiving stem cell therapy without a revascularization option. PubMed, Embase, and the Cochrane Library were searched. This study was conducted by a pair of authors independently and audited by a third author. Data were synthesized with a random-effect model. RESULTS 630 patients in 12 RCTs were included. The results showed that cell therapy significantly improved total amputation (RR: 0.64, p = 0.004, 95% CI: [0.47, 0.87]), major amputation (RR: 0.69, p = 0.02, 95% CI: [0.50, 0.94]), ankle-brachial index (ABI) (MD = 0.08, p = 0.004, 95% CI: [0.02, 0.13]), transcutaneous oxygen tension (TcO2) (MD = 11.52, p = 0.004, 95% CI: [3.60, 19.43]) and rest pain score (MD = -0.64, p = 0.007, 95% CI: [-1.10, -0.17]) compared to placebo or standard care. However, current studies showed cell therapy was not superior to placebo or standard care in all-cause death (RR: 0.75, p = 0.34, 95% CI: [0.41, 1.36]) and ulcer size (MD = -8.85, p = 0.39, CI: [-29.05,11.36]). LIMITATION The number of trials included was limited. Moreover, most trials were designed for "no-option" patients and thus the results should be applied with caution to other PAD patients. CONCLUSION ASO patients can benefit from autologous cell therapy in limb salvage, limb blood perfusion, and rest pain alleviation.
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10
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Yang N, Moore MJ, Michael PL, Santos M, Lam YT, Bao S, Ng MKC, Rnjak‐Kovacina J, Tan RP, Wise SG. Silk Fibroin Scaffold Architecture Regulates Inflammatory Responses and Engraftment of Bone Marrow-Mononuclear Cells. Adv Healthc Mater 2021; 10:e2100615. [PMID: 33963682 DOI: 10.1002/adhm.202100615] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Indexed: 12/13/2022]
Abstract
Despite being one of the most clinically trialed cell therapies, bone marrow-mononuclear cell (BM-MNC) infusion has largely failed to fulfill its clinical promise. Implanting biomimetic scaffolds at sites of injury prior to BM-MNC infusion is a promising approach to enhance BM-MNC engraftment and therapeutic function. Here, it is demonstrated that scaffold architecture can be leveraged to regulate the immune responses that drive BM-MNC engraftment. Silk scaffolds with thin fibers and low porosity (LP) impairs immune activation in vitro compared with thicker fiber, high porosity (HP) scaffolds. Using the authors' established in vivo bioluminescent BM-MNC tracking model, they showed that BM-MNCs home to and engraft in greater numbers in HP scaffolds over 14 days. Histological analysis reveals thicker fibrous capsule formation, with enhanced collagen deposition in HP compared to LP scaffolds consistent with substantially more native CD68+ macrophages and CD4+ T cells, driven by their elevated pro-inflammatory M1 and Th1 phenotypes, respectively. These results suggest that implant architecture impacts local inflammation that drives differential engraftment and remodeling behavior of infused BM-MNC. These findings inform the future design of biomimetic scaffolds that may better enhance the clinical effectiveness of BM-MNC infusion therapy.
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Affiliation(s)
- Nianji Yang
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
| | - Matthew J. Moore
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
| | - Praveesuda L. Michael
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
| | - Miguel Santos
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
| | - Yuen Ting Lam
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
| | - Shisan Bao
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
| | - Martin K. C. Ng
- Sydney Medical School The University of Sydney Sydney NSW 2006 Australia
- Department of Cardiology Royal Prince Alfred Hospital Sydney NSW 2042 Australia
| | - Jelena Rnjak‐Kovacina
- Graduate School of Biomedical Engineering University of New South Wales Sydney NSW 2052 Australia
| | - Richard P. Tan
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
| | - Steven G. Wise
- School of Medical Sciences Faculty of Health and Medicine The University of Sydney Sydney NSW 2006 Australia
- Charles Perkins Centre The University of Sydney Sydney NSW 2006 Australia
- The University of Sydney Nano Institute (Sydney Nano) The University of Sydney Sydney NSW 2006 Australia
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11
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Gu Y, Rampin A, Alvino VV, Spinetti G, Madeddu P. Cell Therapy for Critical Limb Ischemia: Advantages, Limitations, and New Perspectives for Treatment of Patients with Critical Diabetic Vasculopathy. Curr Diab Rep 2021; 21:11. [PMID: 33651185 PMCID: PMC7925447 DOI: 10.1007/s11892-021-01378-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To provide a highlight of the current state of cell therapy for the treatment of critical limb ischemia in patients with diabetes. RECENT FINDINGS The global incidence of diabetes is constantly growing with consequent challenges for healthcare systems worldwide. In the UK only, NHS costs attributed to diabetic complications, such as peripheral vascular disease, amputation, blindness, renal failure, and stroke, average £10 billion each year, with cost pressure being estimated to get worse. Although giant leaps forward have been registered in the scope of early diagnosis and optimal glycaemic control, an effective treatment for critical limb ischemia is still lacking. The present review aims to provide an update of the ongoing work in the field of regenerative medicine. Recent advancements but also limitations imposed by diabetes on the potential of the approach are addressed. In particular, the review focuses on the perturbation of non-coding RNA networks in progenitor cells and the possibility of using emerging knowledge on molecular mechanisms to design refined protocols for personalized therapy. The field of cell therapy showed rapid progress but has limitations. Significant advances are foreseen in the upcoming years thanks to a better understanding of molecular bottlenecks associated with the metabolic disorders.
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Affiliation(s)
- Y Gu
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - A Rampin
- Laboratory of Cardiovascular Research, IRCCS, MultiMedica, Milan, Italy
| | - V V Alvino
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK
| | - G Spinetti
- Laboratory of Cardiovascular Research, IRCCS, MultiMedica, Milan, Italy
| | - P Madeddu
- Bristol Medical School, Translational Health Sciences, University of Bristol, Upper Maudlin Street, Bristol, BS2 8HW, UK.
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Current Status of Angiogenic Cell Therapy and Related Strategies Applied in Critical Limb Ischemia. Int J Mol Sci 2021; 22:ijms22052335. [PMID: 33652743 PMCID: PMC7956816 DOI: 10.3390/ijms22052335] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 02/06/2023] Open
Abstract
Critical limb ischemia (CLI) constitutes the most severe form of peripheral arterial disease (PAD), it is characterized by progressive blockade of arterial vessels, commonly correlated to atherosclerosis. Currently, revascularization strategies (bypass grafting, angioplasty) remain the first option for CLI patients, although less than 45% of them are eligible for surgical intervention mainly due to associated comorbidities. Moreover, patients usually require amputation in the short-term. Angiogenic cell therapy has arisen as a promising alternative for these "no-option" patients, with many studies demonstrating the potential of stem cells to enhance revascularization by promoting vessel formation and blood flow recovery in ischemic tissues. Herein, we provide an overview of studies focused on the use of angiogenic cell therapies in CLI in the last years, from approaches testing different cell types in animal/pre-clinical models of CLI, to the clinical trials currently under evaluation. Furthermore, recent alternatives related to stem cell therapies such as the use of secretomes, exosomes, or even microRNA, will be also described.
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Hénon P, Lahlil R. CD34+ Stem Cells and Regenerative Medicine. Stem Cells 2021. [DOI: 10.1007/978-3-030-77052-5_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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14
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Rojas-Torres M, Jiménez-Palomares M, Martín-Ramírez J, Beltrán-Camacho L, Sánchez-Gomar I, Eslava-Alcon S, Rosal-Vela A, Gavaldá S, Durán-Ruiz MC. REX-001, a BM-MNC Enriched Solution, Induces Revascularization of Ischemic Tissues in a Murine Model of Chronic Limb-Threatening Ischemia. Front Cell Dev Biol 2020; 8:602837. [PMID: 33363160 PMCID: PMC7755609 DOI: 10.3389/fcell.2020.602837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/19/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Bone Marrow Mononuclear Cells (BM-MNC) constitute a promising alternative for the treatment of Chronic Limb-Threatening ischemia (CLTI), a disease characterized by extensive blockade of peripheral arteries, clinically presenting as excruciating pain at rest and ischemic ulcers which may lead to gangrene and amputation. BM-MNC implantation has shown to be efficient in promoting angiogenesis and ameliorating ischemic symptoms in CLTI patients. However, the variability seen between clinical trials makes necessary a further understanding of the mechanisms of action of BM-MNC, and moreover, to improve trial characteristics such as endpoints, inclusion/exclusion criteria or drug product compositions, in order to implement their use as stem-cell therapy. Materials: Herein, the effect of REX-001, a human-BM derived cell suspension enriched for mononuclear cells, granulocytes and CD34+ cells, has been assessed in a murine model of CLTI. In addition, a REX-001 placebo solution containing BM-derived red blood cells (BM-RBCs) was also tested. Thus, 24 h after double ligation of the femoral artery, REX-001 and placebo were administrated intramuscularly to Balb-c nude mice (n:51) and follow-up of ischemic symptoms (blood flow perfusion, motility, ulceration and necrosis) was carried out for 21 days. The number of vessels and vascular diameter sizes were measured within the ischemic tissues to evaluate neovascularization and arteriogenesis. Finally, several cell-tracking assays were performed to evaluate potential biodistribution of these cells. Results: REX-001 induced a significant recovery of blood flow by increasing vascular density within the ischemic limbs, with no cell translocation to other organs. Moreover, cell tracking assays confirmed a decrease in the number of infused cells after 2 weeks post-injection despite on-going revascularization, suggesting a paracrine mechanism of action. Conclusion: Overall, our data supported the role of REX-001 product to improve revascularization and ischemic reperfusion in CLTI.
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Affiliation(s)
- Marta Rojas-Torres
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Margarita Jiménez-Palomares
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | | | - Lucía Beltrán-Camacho
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Ismael Sánchez-Gomar
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Sara Eslava-Alcon
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Antonio Rosal-Vela
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
| | - Sandra Gavaldá
- R&D Department at Rexgenero Biosciences Sociedad Limitada (SL), Seville, Spain
| | - Mª Carmen Durán-Ruiz
- Biomedicine, Biotechnology and Public Health Department, Cádiz University, Cádiz, Spain.,Institute of Research and Innovation in Biomedical Sciences of Cadiz (INIBICA), Cádiz, Spain
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Yusoff FM, Kajikawa M, Takaeko Y, Kishimoto S, Hashimoto H, Maruhashi T, Nakashima A, Wahid SFSA, Higashi Y. Relationship between cell number and clinical outcomes of autologous bone-marrow mononuclear cell implantation in critical limb ischemia. Sci Rep 2020; 10:19891. [PMID: 33199760 PMCID: PMC7669841 DOI: 10.1038/s41598-020-76886-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/23/2020] [Indexed: 11/24/2022] Open
Abstract
Cell therapy using intramuscular injections of autologous bone-marrow mononuclear cells (BM-MNCs) improves clinical symptoms and can prevent limb amputation in atherosclerotic peripheral arterial disease (PAD) patients with critical limb ischemia (CLI). The purpose of this study was to evaluate the effects of the number of implanted BM-MNCs on clinical outcomes in atherosclerotic PAD patients with CLI who underwent cell therapy. This study was a retrospective observational study with median follow-up period of 13.5 years (range, 6.8–15.5 years) from BM-MNC implantation procedure. The mean number of implanted cells was 1.2 ± 0.7 × 109 per limb. There was no significant difference in number of BM-MNCs implanted between the no major amputation group and major amputation group (1.1 ± 0.7 × 109 vs. 1.5 ± 0.8 × 109 per limb, P = 0.138). There was also no significant difference in number of BM-MNCs implanted between the no death group and death group (1.5 ± 0.9 × 109 vs. 1.8 ± 0.8 × 109 per patient, P = 0.404). Differences in the number of BM-MNCs (mean number, 1.2 ± 0.7 × 109 per limb) for cell therapy did not alter the major amputation-free survival rate or mortality rate in atherosclerotic PAD patients with CLI. A large number of BM-MNCs will not improve limb salvage outcome or mortality.
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Affiliation(s)
- Farina Mohamad Yusoff
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Masato Kajikawa
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuji Takaeko
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Shinji Kishimoto
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Haruki Hashimoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Ayumu Nakashima
- Department of Stem Cell Biology and Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - S Fadilah S Abdul Wahid
- Pusat Terapi Sel (Cell Therapy Centre), Universiti Kebangsaan Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine (RIRBM), Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. .,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan.
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Osipova OS, Saaia SB, Karpenko AA, Zakiian SM. [Problems and prospects of cell therapy for critical ischaemia of lower limbs]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:23-33. [PMID: 32597882 DOI: 10.33529/angio2020220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cell therapy was proposed as a procedure of indirect revascularization for patients with critical ischaemia of lower extremities for whom endovascular and surgical revascularization is impossible. We present herein a review of the state of the art of studies in the field of cell therapy of this cohort of patients. BASIC PROVISIONS Cell therapy has proved safe, however, the results of studies of efficacy are relatively ambiguous and unconvincing. The number of patients in separately taken clinical trials is minimal. The reviewed studies differed not only by heterogeneity of the cell types used but by the routes of administration of cells (cells were delivered either intramuscularly (predominantly) or intraarterially) and the duration of follow up (time of assessment and duration of follow up varied from 1 month to 2 years). One of the problems became the lack of the routine study of the angiogenic potential of stem cells prior to their clinical application. It is known that the angiogenic activity of multipotent cells of apparently healthy patients may differ from that of patients suffering from atherosclerosis, chronic renal failure, diabetes. CONCLUSIONS It is supposed that treatment with stem cells or precursor cells is more efficient as compared to protein or gene therapy not only owing to direct vasculogenic properties but a paracrine action through excretion of proangiogenic biologically active substances. More studies with larger cohorts are necessary to provide stronger safety and efficacy data on cell therapy. Besides, a promising trend in the field of cellular approaches is modulation of regenerative capability of stem cells, which may help overcome difficulties in understanding the place of cell therapy in therapeutic angiogenesis.
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Affiliation(s)
- O S Osipova
- Department of Vascular Pathology and Hybrid Surgery, National Medical Research Centre named after Academician Meshalkin E.N. under the RF Ministry of Public Health, Novosibirsk, Russia
| | - Sh B Saaia
- Department of Vascular Pathology and Hybrid Surgery, National Medical Research Centre named after Academician Meshalkin E.N. under the RF Ministry of Public Health, Novosibirsk, Russia
| | - A A Karpenko
- Department of Vascular Pathology and Hybrid Surgery, National Medical Research Centre named after Academician Meshalkin E.N. under the RF Ministry of Public Health, Novosibirsk, Russia
| | - S M Zakiian
- Department of Vascular Pathology and Hybrid Surgery, National Medical Research Centre named after Academician Meshalkin E.N. under the RF Ministry of Public Health, Novosibirsk, Russia
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A. Everts P, Flanagan II G, Rothenberg J, Mautner K. The Rationale of Autologously Prepared Bone Marrow Aspirate Concentrate for use in Regenerative Medicine Applications. Regen Med 2020. [DOI: 10.5772/intechopen.91310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Abstract
Peripheral artery disease is a common disorder and a major cause of morbidity and mortality worldwide. Therapy is directed at reducing the risk of major adverse cardiovascular events and at ameliorating symptoms. Medical therapy is effective at reducing the incidence of myocardial infarction and stroke to which these patients are prone but is inadequate in relieving limb-related symptoms, such as intermittent claudication, rest pain, and ischemic ulceration. Limb-related morbidity is best addressed with surgical and endovascular interventions that restore perfusion. Current medical therapies have only modest effects on limb blood flow. Accordingly, there is an opportunity to develop medical approaches to restore limb perfusion. Vascular regeneration to enhance limb blood flow includes methods to enhance angiogenesis, arteriogenesis, and vasculogenesis using angiogenic cytokines and cell therapies. We review the molecular mechanisms of these processes; briefly discuss what we have learned from the clinical trials of angiogenic and cell therapies; and conclude with an overview of a potential new approach based upon transdifferentiation to enhance vascular regeneration in peripheral artery disease.
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Affiliation(s)
- John P Cooke
- From the Department of Cardiovascular Sciences, Center for Cardiovascular Regeneration, Houston Methodist Research Institute, TX
| | - Shu Meng
- From the Department of Cardiovascular Sciences, Center for Cardiovascular Regeneration, Houston Methodist Research Institute, TX
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Shoji K, Yanishi K, Shiraishi H, Yamabata S, Yukawa A, Teramukai S, Imai K, Ito-Ihara T, Tao M, Higashi Y, Ishigami T, Fukumoto Y, Kuwahara K, Matoba S. Establishment of optimal exercise therapy using near-infrared spectroscopy monitoring of tissue muscle oxygenation after therapeutic angiogenesis for patients with critical limb ischemia: A multicenter, randomized, controlled trial. Contemp Clin Trials Commun 2020; 17:100542. [PMID: 32072074 PMCID: PMC7015992 DOI: 10.1016/j.conctc.2020.100542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/20/2020] [Accepted: 02/02/2020] [Indexed: 01/14/2023] Open
Abstract
Critical limb ischemia (CLI) is a potentially life-threatening condition that involves severely reduced blood flow to the peripheral arteries due to arteriosclerosis obliterans (ASO) of the limbs or a similar condition. CLI patients must undergo revascularization to avoid amputation of the lower limbs and improve their survival prognosis. However, the outcomes of conventional surgical revascularization or endovascular therapy are inadequate; therefore, establishing further effective treatment methods is an urgent task. We perform therapeutic angiogenesis using autologous bone marrow-derived mononuclear cells in clinical practice and demonstrated its safety and efficacy for CLI patients for whom conventional treatments failed or are not indicated. Exercise therapies must be devised for CLI patients who have undergone therapeutic angiogenesis to save their limbs and improve survival. Because evidence regarding the efficacy and safety of exercise therapy for CLI patients is lacking, we plan to perform a prospective trial of the efficacy and safety of optimal exercise therapy following therapeutic angiogenesis for CLI patients.The trial will enroll 30 patients between 20 and 79 years with Rutherford category 4 or 5 CLI caused by ASO who will undergo therapeutic angiogenesis. Participants will be randomly allocated to receive either optimal exercise therapy or fixed exercise therapy. Those receiving optimal exercise therapy will undergo tissue muscle oxygen saturation monitoring using near-infrared spectroscopy while performing exercises and will be prescribed optimal exercise therapy. The optimal amount of exercise will be determined on day 8, 31, 61, 91 and 181 after therapeutic angiogenesis. ETHICS AND DISSEMINATION This protocol was approved by the Institutional Review Boards of Kyoto Prefectural University of Medicine. In accordance with the Helsinki Declaration, written informed consent has been obtained from all participants prior to enrollment. The results of this trial will be disseminated by publication in a peer-reviewed journal. TRIAL REGISTRATION This trial is registered at http://www.umin.ac.jp/ctr/index.htm (identifier: UMIN000035288).
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Key Words
- ASO, arteriosclerosis obliterans
- Arteriosclerosis obliterans
- BM-MNC, bone marrow-derived mononuclear cells
- CLI, critical limb ischemia
- CT, computed tomography
- Critical limb ischemia
- NIRS, near-infrared spectroscopy
- NO, nitric oxide
- Near-infrared spectroscopy
- Optimal exercise therapy
- PAD, peripheral artery disease
- RHI, reactive hyperemia index
- SPP, skin perfusion pressure
- StO2, thenar tissue oxygen saturation
- TAO, thromboangiitis obliterans
- TOI, tissue oxygenation index
- TcPO2, transcutaneous oxygen pressure
- Therapeutic angiogenesis
- Tissue muscle oxygen saturation
- VAS, visual analogue scale
- WIQ, walking impairment questionnaire
- eNOS, endothelial nitric oxide synthase
- nTHI, normalized tissue hemoglobin index
- ΔHHb, change in deoxygenated hemoglobin concentration
- ΔO2Hb, change in oxygenated hemoglobin concentration
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Affiliation(s)
- Keisuke Shoji
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirokazu Shiraishi
- Rehabilitation Unit, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shiho Yamabata
- Rehabilitation Unit, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Arito Yukawa
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kojiro Imai
- Department for Medical Innovation and Translational Medical Science, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Toshiko Ito-Ihara
- The Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masami Tao
- The Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Tomoaki Ishigami
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Yoshihiro Fukumoto
- Department of Internal Medicine, Division of Cardiovascular Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Nagano, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
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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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Dubský M, Jirkovská A, Bem R, Němcová A, Fejfarová V, Hazdrová J, Sutoris K, Chlupáč J, Skibová J, Jude EB. Impact of severe diabetic kidney disease on the clinical outcome of autologous cell therapy in people with diabetes and critical limb ischaemia. Diabet Med 2019; 36:1133-1140. [PMID: 31077439 DOI: 10.1111/dme.13985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2019] [Indexed: 12/21/2022]
Abstract
AIM To assess the impact of autologous cell therapy on critical limb ischaemia in people with diabetes and diabetic kidney disease. METHODS A total of 59 people with diabetes (type 1 or type 2) and critical limb ischaemia, persisting after standard revascularization, were treated with cell therapy in our foot clinic over 7 years; this group comprised 17 people with and 42 without severe diabetic kidney disease. The control group had the same inclusion criteria, but was treated conservatively and comprised 21 people with and 23 without severe diabetic kidney disease. Severe diabetic kidney disease was defined as chronic kidney disease stages 4-5 (GFR <30 ml/min/1.73 m²). Death and amputation-free survival were assessed during the 18-month follow-up; changes in transcutaneous oxygen pressure were evaluated at 6 and 12 months after cell therapy. RESULTS Transcutaneous oxygen pressure increased significantly in both groups receiving cell therapy compared to baseline (both P<0.01); no significant change in either of the control groups was observed. The cell therapy severe diabetic kidney disease group had a significantly longer amputation-free survival time compared to the severe diabetic kidney disease control group (hazard ratio 0.36, 95% CI 0.14-0.91; P=0.042); there was no difference in the non-severe diabetic kidney disease groups. The severe diabetic kidney disease control group had a tendency to have higher mortality (hazard ratio 2.82, 95% CI 0.81-9.80; P=0.062) than the non-severe diabetic kidney disease control group, but there was no difference between the severe diabetic kidney disease and non-severe diabetic kidney disease cell therapy groups. CONCLUSIONS The present study shows that autologous cell therapy in people with severe diabetic kidney disease significantly improved critical limb ischaemia and lengthened amputation-free survival in comparison with conservative treatment; however, the treatment did not influence overall survival.
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Affiliation(s)
- M Dubský
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - A Jirkovská
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - R Bem
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - A Němcová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - V Fejfarová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Hazdrová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - K Sutoris
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Chlupáč
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Skibová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - E B Jude
- Diabetes Centre, Tameside Hospital NHS Foundation Trust and University of Manchester, Manchester, UK
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22
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Al-Rifai R, Nguyen P, Bouland N, Terryn C, Kanagaratnam L, Poitevin G, François C, Boisson-Vidal C, Sevestre MA, Tournois C. In vivo efficacy of endothelial growth medium stimulated mesenchymal stem cells derived from patients with critical limb ischemia. J Transl Med 2019; 17:261. [PMID: 31399109 PMCID: PMC6688282 DOI: 10.1186/s12967-019-2003-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 07/27/2019] [Indexed: 12/24/2022] Open
Abstract
Background Cell therapy has been proposed for patients with critical limb ischemia (CLI). Autologous bone marrow derived cells (BMCs) have been mostly used, mesenchymal stem cells (MSCs) being an alternative. The aim of this study was to characterize two types of MSCs and evaluate their efficacy. Methods MSCs were obtained from CLI-patients BMCs. Stimulated- (S-) MSCs were cultured in endothelial growth medium. Cells were characterized by the expression of cell surface markers, the relative expression of 6 genes, the secretion of 10 cytokines and the ability to form vessel-like structures. The cell proangiogenic properties was analysed in vivo, in a hindlimb ischemia model. Perfusion of lower limbs and functional tests were assessed for 28 days after cell infusion. Muscle histological analysis (neoangiogenesis, arteriogenesis and muscle repair) was performed. Results S-MSCs can be obtained from CLI-patients BMCs. They do not express endothelial specific markers but can be distinguished from MSCs by their secretome. S-MSCs have the ability to form tube-like structures and, in vivo, to induce blood flow recovery. No amputation was observed in S-MSCs treated mice. Functional tests showed improvement in treated groups with a superiority of MSCs and S-MSCs. In muscles, CD31+ and αSMA+ labelling were the highest in S-MSCs treated mice. S-MSCs induced the highest muscle repair. Conclusions S-MSCs exert angiogenic potential probably mediated by a paracrine mechanism. Their administration is associated with flow recovery, limb salvage and muscle repair. The secretome from S-MSCs or secretome-derived products may have a strong potential in vessel regeneration and muscle repair. Trial registration NCT00533104 Electronic supplementary material The online version of this article (10.1186/s12967-019-2003-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rida Al-Rifai
- EA-3801, SFR CAP-santé, Université de Reims Champagne-Ardenne, 51092, Reims Cedex, France
| | - Philippe Nguyen
- EA-3801, SFR CAP-santé, Université de Reims Champagne-Ardenne, 51092, Reims Cedex, France.,Laboratoire d'Hématologie, CHU Robert Debré, Reims, France
| | - Nicole Bouland
- Laboratoire d'Anatomie Pathologique, Université de Reims Champagne-Ardenne, Reims, France
| | - Christine Terryn
- Plateforme PICT, Université de Reims Champagne Ardenne, Reims, France
| | | | - Gaël Poitevin
- EA-3801, SFR CAP-santé, Université de Reims Champagne-Ardenne, 51092, Reims Cedex, France
| | - Caroline François
- EA-3801, SFR CAP-santé, Université de Reims Champagne-Ardenne, 51092, Reims Cedex, France
| | - Catherine Boisson-Vidal
- Inserm UMR S1140, Faculté de Pharmacie de Paris, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | | | - Claire Tournois
- EA-3801, SFR CAP-santé, Université de Reims Champagne-Ardenne, 51092, Reims Cedex, France. .,Laboratoire d'Hématologie, CHU Robert Debré, Reims, France.
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23
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 721] [Impact Index Per Article: 144.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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24
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Gaspar D, Peixoto R, De Pieri A, Striegl B, Zeugolis DI, Raghunath M. Local pharmacological induction of angiogenesis: Drugs for cells and cells as drugs. Adv Drug Deliv Rev 2019; 146:126-154. [PMID: 31226398 DOI: 10.1016/j.addr.2019.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 05/12/2019] [Accepted: 06/16/2019] [Indexed: 12/12/2022]
Abstract
The past decades have seen significant advances in pro-angiogenic strategies based on delivery of molecules and cells for conditions such as coronary artery disease, critical limb ischemia and stroke. Currently, three major strategies are evolving. Firstly, various pharmacological agents (growth factors, interleukins, small molecules, DNA/RNA) are locally applied at the ischemic region. Secondly, preparations of living cells with considerable bandwidth of tissue origin, differentiation state and preconditioning are delivered locally, rarely systemically. Thirdly, based on the notion, that cellular effects can be attributed mostly to factors secreted in situ, the cellular secretome (conditioned media, exosomes) has come into the spotlight. We review these three strategies to achieve (neo)angiogenesis in ischemic tissue with focus on the angiogenic mechanisms they tackle, such as transcription cascades, specific signalling steps and cellular gases. We also include cancer-therapy relevant lymphangiogenesis, and shall seek to explain why there are often conflicting data between in vitro and in vivo. The lion's share of data encompassing all three approaches comes from experimental animal work and we shall highlight common technical obstacles in the delivery of therapeutic molecules, cells, and secretome. This plethora of preclinical data contrasts with a dearth of clinical studies. A lack of adequate delivery vehicles and standardised assessment of clinical outcomes might play a role here, as well as regulatory, IP, and manufacturing constraints of candidate compounds; in addition, completed clinical trials have yet to reveal a successful and efficacious strategy. As the biology of angiogenesis is understood well enough for clinical purposes, it will be a matter of time to achieve success for well-stratified patients, and most probably with a combination of compounds.
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Affiliation(s)
- Diana Gaspar
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland; Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland
| | - Rita Peixoto
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland; Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland
| | - Andrea De Pieri
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland; Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland; Proxy Biomedical Ltd., Coilleach, Spiddal, Galway, Ireland
| | - Britta Striegl
- Competence Centre Tissue Engineering for Drug Development (TEDD), Centre for Cell Biology & Tissue Engineering, Institute for Chemistry and Biotechnology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Dimitrios I Zeugolis
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland; Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI Galway), Galway, Ireland
| | - Michael Raghunath
- Competence Centre Tissue Engineering for Drug Development (TEDD), Centre for Cell Biology & Tissue Engineering, Institute for Chemistry and Biotechnology, Zurich University of Applied Sciences, Zurich, Switzerland.
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25
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 693] [Impact Index Per Article: 138.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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26
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Yusoff FM, Kajikawa M, Matsui S, Hashimoto H, Kishimoto S, Maruhashi T, Chowdhury M, Noma K, Nakashima A, Kihara Y, Sueda T, Higashi Y. Review of the Long-term Effects of Autologous Bone-Marrow Mononuclear Cell Implantation on Clinical Outcomes in Patients with Critical Limb Ischemia. Sci Rep 2019; 9:7711. [PMID: 31118440 PMCID: PMC6531470 DOI: 10.1038/s41598-019-44176-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/10/2019] [Indexed: 11/23/2022] Open
Abstract
Critical limb ischemia (CLI) is associated with a high risk of limb amputation. It has been shown that cell therapy is safe and has beneficial effects on ischemic clinical symptoms in patients with CLI. The aim of this study was to further investigate the outcomes of intramuscular injection of autologous bone-marrow mononuclear cells (BM-MNCs) in a long-term follow-up period in atherosclerotic peripheral arterial disease (PAD) patients who have no optional therapy. This study was a retrospective and observational study that was carried out to evaluate long-term clinical outcomes in 42 lower limbs of 30 patients with atherosclerotic PAD who underwent BM-MNC implantation. The median follow-up period was 9.25 (range, 6–16) years. The overall amputation-free rates were 73.0% at 5 years after BM-MNC implantation and 70.4% at 10 years in patients with atherosclerotic PAD. The overall amputation-free rates at 5 years and at 10 years after implantation of BM-MNCs were significantly higher in atherosclerotic PAD patients than in internal controls and historical controls. There were no significant differences in amputation rates between the internal control group and historical control group. The rate of overall survival was not significantly different between the BM-MNC implantation group and the historical control group. Implantation of autologous BM-MNCs is feasible for a long-term follow-up period in patients with CLI who have no optional therapy.
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Affiliation(s)
- Farina Mohamad Yusoff
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Masato Kajikawa
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Shogo Matsui
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Haruki Hashimoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Shinji Kishimoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Tatsuya Maruhashi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Moniruddin Chowdhury
- Department of Medicine & Centre for Research on Non-Communicable Diseases, Faculty of Medicine & Health Sciences, Universiti Tunku Abdul Rahman, Selangor, Malaysia
| | - Kensuke Noma
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Ayumu Nakashima
- Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Taijiro Sueda
- Department of Surgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan. .,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan.
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27
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Osipova O, Saaya S, Karpenko A, Zakian S, Aboian E. Cell therapy of critical limb ischemia-problems and prospects. VASA 2019; 48:461-471. [PMID: 30969159 DOI: 10.1024/0301-1526/a000787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cell therapy is proposed for indirect revascularization for the patient's incurable by endovascular or surgical revascularization. The therapy with stem cells (SCs) or progenitor cells is assumed to be more efficient as compared with protein or gene therapy not only because of their direct vasculogenic properties, but also thanks to their paracrine effect via secretion of manifold biologically active substances. This review gives an overview of the potential of SC-based therapy for critical limb ischemia (CLI), putative mechanism underlying cell therapy, and comparison of cell therapy to angiogenesis gene therapy in CLI treatment. Human trial data and meta-analysis, as well as some problems of clinical trials and considerations for future SC-based therapy in CLI are also discussed.
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Affiliation(s)
- Olesia Osipova
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Shoraan Saaya
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Andrei Karpenko
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Suren Zakian
- Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Edouard Aboian
- Division of Vascular Surgery, Palo Alto Medical Foundation, Burlingame, USA
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28
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Shoji K, Yanishi K, Yoshimi R, Hamada N, Kondo K, Fujimoto K, Nakajima H, Kuwahara K, Higashi Y, Fukumoto Y, Murohara T, Matoba S. Impact of Therapeutic Angiogenesis Using Autologous Bone Marrow-Derived Mononuclear Cells Implantation in Critical Limb Ischemia With Scleroderma ― Subanalysis of the Long-Term Clinical Outcomes Survey ―. Circ J 2019; 83:662-671. [DOI: 10.1253/circj.cj-18-1044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Keisuke Shoji
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine
| | - Naoki Hamada
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine
| | - Kazuhisa Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kazuteru Fujimoto
- Department of Cardiology, National Hospital Organization Kumamoto Medical Center
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University
| | - Yoshihiro Fukumoto
- Department of Internal Medicine, Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine
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29
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Pan T, Liu H, Fang Y, Wei Z, Gu S, Fang G, Liu Y, Luo Y, Guo D, Xu X, Chen B, Jiang J, Yang J, Shi Z, Zhu T, Shi Y, Liu P, Dong Z, Fu W. Predictors of responders to mononuclear stem cell-based therapeutic angiogenesis for no-option critical limb ischemia. Stem Cell Res Ther 2019; 10:15. [PMID: 30635050 PMCID: PMC6329149 DOI: 10.1186/s13287-018-1117-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 12/10/2018] [Accepted: 12/19/2018] [Indexed: 01/15/2023] Open
Abstract
Background Although the mononuclear cell (MNC) transplantation could theoretically induce therapeutic angiogenesis in the patients with no-option critical limb ischemia (NO-CLI), the clinical responses to this approach are inconsistent among different clinical trials. The purpose of this study was to identify the prognostic factors of responders and develop a predictive nomogram to guide patient selection. Methods We retrospectively reviewed a consecutive NO-CLI cohort who received peripheral blood-derived transplantation in our center. The patients who survived and achieved complete remission of CLI at 6 months post-transplantation were defined as responders. Logistic regression models were used to screen and identify the prognostic factors based on which predictive nomogram was developed. A receiver operating characteristic (ROC) curve and a calibration curve were drawn to determine the discrimination level and predictive accuracy. Results The study ultimately enrolled 103 patients, including 58 responders and 45 non-responders. Based on the multivariate regression analysis, age ≥ 50 years (odds ratio [OR] 0.201, P = 0.004), blood fibrinogen > 4 g/L (OR 0.176, P = 0.003), arterial occlusion above the knee/elbow (OR 0.232, P = 0.010), the transcutaneous pressure of oxygen (TcPO2) (OR 1.062, P = 0.006), and the Log total transplanted CD34+ cell count (OR 3.506, P = 0.046) were identified as independent prognostic factors of the responders in the nomogram. An area under the ROC curve of 0.851 indicated good discrimination, and the calibration curve of the predicted probability showed optimal agreement with that of the observed probability. Conclusions Age, blood fibrinogen, arterial occlusion level, TcPO2, and the total transplanted CD34+ cell count were independent prognostic factors of the responders. A nomogram with high discrimination and accuracy was developed to provide individualized predictions. Trail registration ChiCTR, ChiCTR1800019401. Registered 9 November 2018—Retrospectively registered Electronic supplementary material The online version of this article (10.1186/s13287-018-1117-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tianyue Pan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Hao Liu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yuan Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Zheng Wei
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shiyang Gu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Gang Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yifan Liu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yang Luo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Xin Xu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Bin Chen
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Junhao Jiang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Jue Yang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Ting Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Yun Shi
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.,Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China. .,Institute of Vascular Surgery, Fudan University, Shanghai, China.
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, 200032, China. .,Institute of Vascular Surgery, Fudan University, Shanghai, China.
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Abdul Wahid SF, Ismail NA, Wan Jamaludin WF, Muhamad NA, Abdul Hamid MKA, Harunarashid H, Lai NM. Autologous cells derived from different sources and administered using different regimens for 'no-option' critical lower limb ischaemia patients. Cochrane Database Syst Rev 2018; 8:CD010747. [PMID: 30155883 PMCID: PMC6513643 DOI: 10.1002/14651858.cd010747.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Revascularisation is the gold standard therapy for patients with critical limb ischaemia (CLI). In over 30% of patients who are not suitable for or have failed previous revascularisation therapy (the 'no-option' CLI patients), limb amputation is eventually unavoidable. Preliminary studies have reported encouraging outcomes with autologous cell-based therapy for the treatment of CLI in these 'no-option' patients. However, studies comparing the angiogenic potency and clinical effects of autologous cells derived from different sources have yielded limited data. Data regarding cell doses and routes of administration are also limited. OBJECTIVES To compare the efficacy and safety of autologous cells derived from different sources, prepared using different protocols, administered at different doses, and delivered via different routes for the treatment of 'no-option' CLI patients. SEARCH METHODS The Cochrane Vascular Information Specialist (CIS) searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED), and trials registries (16 May 2018). Review authors searched PubMed until February 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) involving 'no-option' CLI patients comparing a particular source or regimen of autologous cell-based therapy against another source or regimen of autologous cell-based therapy. DATA COLLECTION AND ANALYSIS Three review authors independently assessed the eligibility and methodological quality of the trials. We extracted outcome data from each trial and pooled them for meta-analysis. We calculated effect estimates using a risk ratio (RR) with 95% confidence interval (CI), or a mean difference (MD) with 95% CI. MAIN RESULTS We included seven RCTs with a total of 359 participants. These studies compared bone marrow-mononuclear cells (BM-MNCs) versus mobilised peripheral blood stem cells (mPBSCs), BM-MNCs versus bone marrow-mesenchymal stem cells (BM-MSCs), high cell dose versus low cell dose, and intramuscular (IM) versus intra-arterial (IA) routes of cell implantation. We identified no other comparisons in these studies. We considered most studies to be at low risk of bias in random sequence generation, incomplete outcome data, and selective outcome reporting; at high risk of bias in blinding of patients and personnel; and at unclear risk of bias in allocation concealment and blinding of outcome assessors. The quality of evidence was most often low to very low, with risk of bias, imprecision, and indirectness of outcomes the major downgrading factors.Three RCTs (100 participants) reported a total of nine deaths during the study follow-up period. These studies did not report deaths according to treatment group.Results show no clear difference in amputation rates between IM and IA routes (RR 0.80, 95% CI 0.54 to 1.18; three RCTs, 95 participants; low-quality evidence). Single-study data show no clear difference in amputation rates between BM-MNC- and mPBSC-treated groups (RR 1.54, 95% CI 0.45 to 5.24; 150 participants; low-quality evidence) and between high and low cell dose (RR 3.21, 95% CI 0.87 to 11.90; 16 participants; very low-quality evidence). The study comparing BM-MNCs versus BM-MSCs reported no amputations.Single-study data with low-quality evidence show similar numbers of participants with healing ulcers between BM-MNCs and mPBSCs (RR 0.89, 95% CI 0.44 to 1.83; 49 participants) and between IM and IA routes (RR 1.13, 95% CI 0.73 to 1.76; 41 participants). In contrast, more participants appeared to have healing ulcers in the BM-MSC group than in the BM-MNC group (RR 2.00, 95% CI 1.02 to 3.92; one RCT, 22 participants; moderate-quality evidence). Researchers comparing high versus low cell doses did not report ulcer healing.Single-study data show similar numbers of participants with reduction in rest pain between BM-MNCs and mPBSCs (RR 0.99, 95% CI 0.93 to 1.06; 104 participants; moderate-quality evidence) and between IM and IA routes (RR 1.22, 95% CI 0.91 to 1.64; 32 participants; low-quality evidence). One study reported no clear difference in rest pain scores between BM-MNC and BM-MSC (MD 0.00, 95% CI -0.61 to 0.61; 37 participants; moderate-quality evidence). Trials comparing high versus low cell doses did not report rest pain.Single-study data show no clear difference in the number of participants with increased ankle-brachial index (ABI; increase of > 0.1 from pretreatment), between BM-MNCs and mPBSCs (RR 1.00, 95% CI 0.71 to 1.40; 104 participants; moderate-quality evidence), and between IM and IA routes (RR 0.93, 95% CI 0.43 to 2.00; 35 participants; very low-quality evidence). In contrast, ABI scores appeared higher in BM-MSC versus BM-MNC groups (MD 0.05, 95% CI 0.01 to 0.09; one RCT, 37 participants; low-quality evidence). ABI was not reported in the high versus low cell dose comparison.Similar numbers of participants had improved transcutaneous oxygen tension (TcO₂) with IM versus IA routes (RR 1.22, 95% CI 0.86 to 1.72; two RCTs, 62 participants; very low-quality evidence). Single-study data with low-quality evidence show a higher TcO₂ reading in BM-MSC versus BM-MNC groups (MD 8.00, 95% CI 3.46 to 12.54; 37 participants) and in mPBSC- versus BM-MNC-treated groups (MD 1.70, 95% CI 0.41 to 2.99; 150 participants). TcO₂ was not reported in the high versus low cell dose comparison.Study authors reported no significant short-term adverse effects attributed to autologous cell implantation. AUTHORS' CONCLUSIONS Mostly low- and very low-quality evidence suggests no clear differences between different stem cell sources and different treatment regimens of autologous cell implantation for outcomes such as all-cause mortality, amputation rate, ulcer healing, and rest pain for 'no-option' CLI patients. Pooled analyses did not show a clear difference in clinical outcomes whether cells were administered via IM or IA routes. High-quality evidence is lacking; therefore the efficacy and long-term safety of autologous cells derived from different sources, prepared using different protocols, administered at different doses, and delivered via different routes for the treatment of 'no-option' CLI patients, remain to be confirmed.Future RCTs with larger numbers of participants are needed to determine the efficacy of cell-based therapy for CLI patients, along with the optimal cell source, phenotype, dose, and route of implantation. Longer follow-up is needed to confirm the durability of angiogenic potential and the long-term safety of cell-based therapy.
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Affiliation(s)
- S Fadilah Abdul Wahid
- Universiti Kebangsaan Malaysia Medical CentreCell Therapy CenterJalan Yaacob LatifKuala LumpurMalaysia56000
- Universiti Kebangsaan Malaysia Medical CentreClinical Haematology & Stem Cell Transplantation Services, Department of MedicineKuala LumpurMalaysia
| | - Nor Azimah Ismail
- Universiti Kebangsaan Malaysia Medical CentreCell Therapy CenterJalan Yaacob LatifKuala LumpurMalaysia56000
| | - Wan Fariza Wan Jamaludin
- Universiti Kebangsaan Malaysia Medical CentreCell Therapy CenterJalan Yaacob LatifKuala LumpurMalaysia56000
| | - Nor Asiah Muhamad
- Ministry of HealthInstitute for Public HealthKuala LumpurFederal TeritoryMalaysia50590
| | | | - Hanafiah Harunarashid
- Universiti Kebangsaan Malaysia Medical CentreUnit of Vascular Surgery, Department of SurgeryJalan Yaacob LatifKuala LumpurKuala LumpurMalaysia56000
| | - Nai Ming Lai
- Taylor's UniversitySchool of MedicineSubang JayaMalaysia
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Liotta F, Annunziato F, Castellani S, Boddi M, Alterini B, Castellini G, Mazzanti B, Cosmi L, Acquafresca M, Bartalesi F, Dilaghi B, Dorigo W, Graziani G, Bartolozzi B, Bellandi G, Carli G, Bartoloni A, Fargion A, Fassio F, Fontanari P, Landini G, Lucente EAM, Michelagnoli S, Orsi Battaglini C, Panigada G, Pigozzi C, Querci V, Santarlasci V, Parronchi P, Troisi N, Baggiore C, Romagnani P, Mannucci E, Saccardi R, Pratesi C, Gensini G, Romagnani S, Maggi E. Therapeutic Efficacy of Autologous Non-Mobilized Enriched Circulating Endothelial Progenitors in Patients With Critical Limb Ischemia - The SCELTA Trial. Circ J 2018; 82:1688-1698. [PMID: 29576595 DOI: 10.1253/circj.cj-17-0720] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The therapeutic efficacy of bone marrow mononuclear cells (BM-MNC) autotransplantation in critical limb ischemia (CLI) has been reported. Variable proportions of circulating monocytes express low levels of CD34 (CD14+CD34lowcells) and behave in vitro as endothelial progenitor cells (EPCs). The aim of the present randomized clinical trial was to compare the safety and therapeutic effects of enriched circulating EPCs (ECEPCs) with BM-MNC administration.Methods and Results:ECEPCs (obtained from non-mobilized peripheral blood by immunomagnetic selection of CD14+and CD34+cells) or BM-MNC were injected into the gastrocnemius of the affected limb in 23 and 17 patients, respectively. After a mean of 25.2±18.6-month follow-up, both groups showed significant and progressive improvement in muscle perfusion (primary endpoint), rest pain, consumption of analgesics, pain-free walking distance, wound healing, quality of life, ankle-brachial index, toe-brachial index, and transcutaneous PO2. In ECEPC-treated patients, there was a positive correlation between injected CD14+CD34lowcell counts and the increase in muscle perfusion. The safety profile was comparable between the ECEPC and BM-MNC treatment arms. In both groups, the number of deaths and major amputations was lower compared with eligible untreated patients and historical reference patients. CONCLUSIONS This study supports previous trials showing the efficacy of BM-MNC autotransplantation in CLI patients and demonstrates comparable therapeutic efficacy between BM-MNC and EPEPCs.
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Affiliation(s)
- Francesco Liotta
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | - Francesco Annunziato
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | - Sergio Castellani
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | - Maria Boddi
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | | | | | | | - Lorenzo Cosmi
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | | | | | | | | | | | | | | | - Giulia Carli
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | | | | | | | | | | | | | | | - Carolina Orsi Battaglini
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | | | | | - Valentina Querci
- Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | - Veronica Santarlasci
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | - Paola Parronchi
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | | | | | - Paola Romagnani
- Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | | | | | | | - Gianfranco Gensini
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | - Sergio Romagnani
- Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
| | - Enrico Maggi
- Careggi University Hospital.,Department of Experimental and Clinical Medicine, Center of Excellence Denothe, University of Florence
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Pan T, Wei Z, Fang Y, Dong Z, Fu W. Therapeutic efficacy of CD34+ cell-involved mononuclear cell therapy for no-option critical limb ischemia: A meta-analysis of randomized controlled clinical trials. Vasc Med 2018; 23:219-231. [PMID: 29457540 DOI: 10.1177/1358863x17752556] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Early-phase clinical trials in patients with critical limb ischemia (CLI) have shown positive results of mononuclear cell therapy. The current meta-analysis investigated whether cluster of differentiation (CD) 34+ mononuclear cell therapy (CD34+MCT) is effective for no-option CLI. Ten randomized controlled clinical studies of CD34+MCT for no-option CLI with 479 patients were identified and analyzed for pooled results. Compared to control groups, the CD34+MCT was associated with lower total amputation (odds ratio (OR): 0.45, p=0.01; 95% confidence interval (CI): 0.24–0.85) and a higher complete ulcer healing rate (OR: 2.80, p=0.008; 95% CI: 1.31–6.02), but showed no advantage in major amputation (OR: 0.58, p=0.11; 95% CI: 0.29–1.14) and all-cause mortality (OR: 0.82, p=0.62; 95% CI: 0.36–1.83) . Studies with a high CD34+ cell dosage showed significant results in major amputation (OR: 0.38, p=0.002; 95% CI: 0.21–0.70), total amputation (OR: 0.31, p=0.0002; 95% CI: 0.17–0.57) and complete ulcer healing (OR: 7.58, p=0.0005; 95% CI: 2.40–23.88), which were not observed in the low-dose studies. However, inclusion of placebo-controlled studies showed no improvement of the CD34+MCT in total amputation (OR: 0.67, p=0.42; 95% CI: 0.25–1.79), major amputation (OR: 1.31, p=0.43; 95% CI: 0.67–2.54) or complete ulcer healing (OR: 1.52, p=0.27; 95% CI: 0.72–3.21), which were extremely significant in non-placebo-controlled studies ( p<0.001). In conclusion, the significant results of CD34+MCT might not support its therapeutic benefit due to high placebo-effect risk and considerable heterogeneity caused by distinct cell doses. More sizable double-blinded, randomized, placebo-controlled trials with higher CD34+ cell dosage are needed in the future.
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Affiliation(s)
- Tianyue Pan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Wei
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Fang
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Frangogiannis NG. Cell therapy for peripheral artery disease. Curr Opin Pharmacol 2018; 39:27-34. [PMID: 29452987 DOI: 10.1016/j.coph.2018.01.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 12/28/2022]
Abstract
Patients with severe peripheral artery disease (PAD) who are not candidates for revascularization have poor prognosis. Cell therapy using peripheral blood-derived or bone marrow-derived mononuclear cells, mesenchymal stem cells, or marker-specific subsets of bone marrow cells with angiogenic properties may hold promise for no-option PAD patients. Injected cells may exert beneficial actions by enhancing local angiogenesis (either through maturation of endothelial progenitors, or through secretion of angiogenic mediators), or by transducing cytoprotective signals that preserve tissue structure. Despite extensive research, robust clinical evidence supporting the use of cell therapy in patients with critical limb ischemia is lacking. Larger, well-designed placebo-controlled clinical trials did not support the positive results of smaller less rigorous studies. There is a need for high-quality clinical studies to test the effectiveness of cell therapy in PAD patients. Moreover, fundamental cell biological studies are needed to identify the optimal cell types, and to develop strategies that may enhance homing, survival and effectiveness of the injected cells.
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Affiliation(s)
- Nikolaos G Frangogiannis
- The Wilf Family Cardiovascular Research Institute, Department of Medicine (Cardiology), Albert Einstein College of Medicine, Bronx, NY, United States.
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