Endothelial progenitor cell vascular endothelial growth factor gene transfer for vascular regeneration

Emerging hurdles in stem cell therapy for peripheral vascular disease

Peripheral vascular disease (PVD) is a growing medical problem in Western societies and presents itself mainly in two different clinical forms. Intermittent claudication is an early moderate manifestation, while patients with critical limb ischemia suffer from severe muscle tissue loss or ulcers and are at high risk for limb amputation. Unfortunately, many patients cannot be helped with currently available surgical or endovascular revascularization procedures because of the complex anatomy of the vascular occlusion and/or the presence of other risk factors. Noninvasive stem cell therapy has been proposed as an alternative for such patients. Although pioneering clinical experience with stem cell-related therapy seems promising, it is too early for general clinical use of this technique, since many questions remain unanswered. Indeed, while questions about safety, dose, and administration route/timing/frequency are the first ones to be addressed when designing a stem cell-based clinical approach, there is accumulating evidence from recent (pre-)clinical studies that other issues may also be at stake. For instance, the choice of stem cells to be used and its precise mechanism of action, the need/possibility for concurrent tissue regeneration in case of irreversible tissue loss, the differentiation degree and specific vascular identity of the transplanted cells, and the long-term survival of engrafted cells in the absence of a normal supportive tissue environment should be well considered. Here, rather than presenting a comprehensive and extensive overview on the current literature on stem/progenitor cells and revascularization, we highlight some of the outstanding issues emerging from the recent (pre-)clinical literature that may codetermine the successful application of stem cells in a wide range of PVD patients in the future.

Role of inflammation and oxidative stress in endothelial progenitor cell function and mobilization: therapeutic implications for cardiovascular diseases

Endothelial progenitor cells (EPCs) are mobilized from the bone marrow into the peripheral circulation, home to sites of injury, and incorporate into foci of neovascularization, thereby improving blood flow and tissue recovery. Patients with cardiovascular diseases, including coronary artery disease, heart failure, hypertension, and diabetes, have been shown to exhibit reduced number and functional capacity of EPCs. Considerable evidence indicates that EPCs constitute an important endogenous system to maintain endothelial integrity and vascular homeostasis, while reduced number of EPCs has recently been shown to predict future cardiovascular events. Thus, enhancement of EPCs could be of potential benefit for individuals with cardiovascular diseases. The interplay between inflammation and oxidative stress is involved in the initiation, progression, and complications of cardiovascular diseases. Emerging evidence from in vitro and clinical studies suggests that inflammatory and oxidative changes influence EPC mobilization. Drugs with anti-inflammatory and antioxidant properties, currently administered to patients with cardiovascular diseases, such as statins, have been demonstrated to exert beneficial effects on EPC biology. A better understanding of the inflammatory and oxidative mechanisms leading to the numerical and functional impairment of EPCs would provide additional insight into the pathogenesis of cardiovascular disease and create novel therapeutic targets.

Tissue engineering using autologous microcirculatory beds as vascularized bioscaffolds

Classic tissue engineering paradigms are limited by the incorporation of a functional vasculature and a reliable means for reimplantation into the host circulation. We have developed a novel approach to overcome these obstacles using autologous explanted microcirculatory beds (EMBs) as bioscaffolds for engineering complex three-dimensional constructs. In this study, EMBs consisting of an afferent artery, capillary beds, efferent vein, and surrounding parenchymal tissue are explanted and maintained for 24 h ex vivo in a bioreactor that preserves EMB viability and function. Given the rapidly advancing field of stem cell biology, EMBs were subsequently seeded with three distinct stem cell populations, multipotent adult progenitor cells (MAPCs), and bone marrow and adipose tissue-derived mesenchymal stem cells (MSCs). We demonstrate MAPCs, as well as MSCs, are able to egress from the microcirculation into the parenchymal space, forming proliferative clusters. Likewise, human adipose tissue-derived MSCs were also found to egress from the vasculature and seed into the EMBs, suggesting feasibility of this technology for clinical applications. We further demonstrate that MSCs can be transfected to express a luciferase protein and continue to remain viable and maintain luciferase expression in vivo. By using the vascular network of EMBs, EMBs can be perfused ex vivo and seeded with stem cells, which can potentially be directed to differentiate into neo-organs or transfected to replace failing organs and deficient proteins.

Effects of granulocyte-colony stimulating factor on the repair of balloon-injured arteries

BACKGROUND

The dysfunction of vascular endothelial cells plays a key role in starting arterial restenosis. The circulating endothelial progenitor cells (EPCs) can be mobilised by cytokines and are recruited to sites of injury, where they may participate in intima repair and the recovery of endothelial function. In the present study, we examined the hypothesis that mobilisation of EPCs by exogenous recombinant human granulocyte-colony stimulating factor (rhG-CSF) can promote vascular proliferation, reduce vascular inflammation and decrease the rate of restenosis.

METHODS

Male rats were randomly divided into the rhG-CSF and control groups. The animals were injected daily with 30 microg/kg rhG-CSF or 0.9% NaCl subcutaneously for 7 days, then the animals underwent balloon angioplasty of the common carotid artery. The animals were euthanased at 2 or 4 weeks after injury, and the carotid arteries were harvested and processed for immunohistochemistry, scanning electron microscopy (SEM), morphometric analysis of endothelialisation and neointimal formation at 1 hour, and 3, 7, 14 and 28 days after injury. Immunohistochemistry for proliferation cell nuclear antigen (PCNA) and reverse transcriptase polymerase chain reaction (RT-PCR) for endothelial nitric oxide synthase (eNOS) mRNA were also conducted for evaluating the proliferation of cells of the vessel wall and the possible mechanism of the repairing.

RESULTS

Four weeks after balloon damage, SEM showed increased re-endothelialisation of the denuded vessels in the G-CSF treated animals compared with the control animals [(60.6 +/- 7.3)% versus (41.6 +/- 3.3)%, p < 0.01]. Re-endothelialisation was paralleled by a decrease in inflammation in the vessel wall. Histological examination showed that neointimal formation, vascular smooth muscle cells and fibrous tissue of the G-CSF group were less than those of the control group. Morphometry showed the lumen area of the G-CSF group was larger than that of the control group, and the neointimal area and percent of intimal hyperplasia were significantly smaller than those of the control group. Immunohistochemical staining for PCNA positive cells was less in the G-CSF treated animals compared with the control animals (42.9% versus 72.8%, p < 0.01).

CONCLUSION

rhG-CSF-induced mobilisation of EPCs regenerated endothelium and inhibited neointimal hyperplasia after vascular injury. This cytokine therapy may be a feasible strategy for the promotion of re-endothelialisation after angioplasty.

Endothelial progenitor cells in neovascularization of infarcted myocardium

Historically, revascularization of ischemic tissue was believed to occur through the migration and proliferation of endothelial cells in nearby tissues; however, evidence accumulated in recent years indicates that a subpopulation of adult, peripheral-blood cells, collectively referred to as endothelial progenitor cells (EPCs), can differentiate into mature endothelial cells. After ischemic insult, EPCs are believed to home to sites of neovascularization, where they contribute to vascular regeneration by forming a structural component of capillaries and by secreting angiogenic factors; new evidence indicates that EPCs can also differentiate into cardiomyocytes and smooth-muscle cells. These insights into the molecular and cellular processes of tissue formation suggest that cardiac function may be preserved after myocardial infarction by transplanting EPCs into ischemic heart tissue, thereby enhancing vascular and myocardial recovery. This therapeutic strategy has been effective in animal models of ischemic disorders, and results from randomized clinical trials suggest that cell-based strategies may be safe and feasible for treatment of myocardial infarction in humans and have provided early evidence of efficacy. However, the scarcity of EPCs in the peripheral blood and evidence that several disease states reduce EPC number and/or function have prompted the development of several strategies to overcome these limitations, such as the administration of genetically modified EPCs that overexpress angiogenic growth factors. To optimize therapeutic outcomes, researchers must continue to refine methods of EPC purification, expansion, and administration, and to develop techniques that overcome the intrinsic scarcity and phenotypic deficiencies of EPCs.

IFATS collection: The role of human adipose-derived stromal cells in inflammatory microvascular remodeling and evidence of a perivascular phenotype

A growing body of literature suggests that human adipose-derived stromal cells (hASCs) possess developmental plasticity both in vitro and in vivo, and might represent a viable cell source for therapeutic angiogenesis and tissue engineering. We investigate their phenotypic similarity to perivascular cell types, ability to contribute to in vivo microvascular remodeling, and ability to modulate vascular stability. We evaluated hASC surface expression of vascular and stem/progenitor cell markers in vitro, as well as any effects of platelet-derived growth factor B chain (PDGF-BB) and vascular endothelial growth factor 165 on in vitro hASC migration. To ascertain in vivo behavior of hASCs in an angiogenic environment, hASCs were isolated, expanded in culture, labeled with a fluorescent marker, and injected into adult nude rat mesenteries that were stimulated to undergo microvascular remodeling. Ten, 30, and 60 days after injection, tissues from anesthetized animals were harvested and processed with immunohistochemical techniques to determine hASC quantity, positional fate in relation to microvessels, and expression of endothelial and perivascular cell markers. After 60 days, 29% of hASCs exhibited perivascular morphologies compared with 11% of injected human lung fibroblasts. hASCs exhibiting perivascular morphologies also expressed markers characteristic of vascular pericytes: smooth muscle alpha-actin (10%) and neuron-glia antigen 2 (8%). In tissues treated with hASCs, vascular density was significantly increased over age-matched controls lacking hASCs. This study demonstrates that hASCs express pericyte lineage markers in vivo and in vitro, exhibit increased migration in response to PDGF-BB in vitro, exhibit perivascular morphology when injected in vivo, and contribute to increases in microvascular density during angiogenesis by migrating toward vessels. Disclosure of potential conflicts of interest is found at the end of this article.

Targeting cancer stem cells to modulate alternative vascularization mechanisms

Recently, many papers have shown that tumor vascularization can be explained by angiogenesis, recruitment, cooption, vasculogenic mimicry and by mosaic vessels. In particular, vasculogenic mimicry seems to be different from mosaic blood vessels, where tumor cells form a part of the surface of the vessel while the remaining part is covered by endothelium. In this case, tumor cells in apparent contact with the lumen do not show an endothelial phenotype. More recently, vasculogenic mimicry was proposed to occur in patients with multiple myeloma due to bone marrow macrophages. Herein, all these data are, for the first time, discussed critically in comparison to cancer stem cells-which show high trans-differentiative capacity-and bone-marrow derived stem cells. In fact, the presence of alternative vasculogenic patterns might be due to the presence of stem cell population (cancer stem cells or bone-marrow stem cells). In this connection, the literature is discussed extensively and possible models are proposed. Pharmacological perspectives will also discuss.

Induction of angiogenesis in tissue-engineered scaffolds designed for bone repair: a combined gene therapy-cell transplantation approach

One of the fundamental principles underlying tissue engineering approaches is that newly formed tissue must maintain sufficient vascularization to support its growth. Efforts to induce vascular growth into tissue-engineered scaffolds have recently been dedicated to developing novel strategies to deliver specific biological factors that direct the recruitment of endothelial cell (EC) progenitors and their differentiation. The challenge, however, lies in orchestration of the cells, appropriate biological factors, and optimal factor doses. This study reports an approach as a step forward to resolving this dilemma by combining an ex vivo gene transfer strategy and EC transplantation. The utility of this approach was evaluated by using 3D poly(lactide-co-glycolide) (PLAGA) sintered microsphere scaffolds for bone tissue engineering applications. Our goal was achieved by isolation and transfection of adipose-derived stromal cells (ADSCs) with adenovirus encoding the cDNA of VEGF. We demonstrated that the combination of VEGF releasing ADSCs and ECs results in marked vascular growth within PLAGA scaffolds. We thereby delineate the potential of ADSCs to promote vascular growth into biomaterials.

Genetic enhancement of stem cell engraftment, survival, and efficacy

Cell-based therapies for the prevention and treatment of cardiac dysfunction offer the potential to significantly modulate cardiac function and improve outcomes in patients with cardiovascular disease. To date several clinical studies have suggested the potential efficacy of several different stem cell types; however, the benefits seen in clinical trials have been inconsistent and modest. In parallel, preclinical studies have identified key events in the process of cell-based myocardial repair, including stem cell homing, engraftment, survival, paracrine factor release, and differentiation that need to be optimized to maximize cardiac repair and function. The inconsistent and modest benefits seen in clinical trials combined with the preclinical identification of mediators responsible for key events in cell-based cardiac repair offers the potential for cell-based therapy to advance to cell-based gene therapy in an attempt to optimize these key events in the hope of maximizing clinical benefit. Below we discuss potential key events in cardiac repair and the mediators of these events that could be of potential interest for genetic enhancement of stem cell-based cardiac repair.

Gene and stem cell therapy in peripheral arterial occlusive disease

Abstract

Peripheral arterial occlusive disease (PAOD) is a manifestation of systemic atherosclerosis strongly associated with a high risk of cardiovascular morbidity and mortality. In a considerable proportion of patients with PAOD, revascularization either by endovascular means or by open surgery combined with best possible risk factor modification does not achieve limb salvage or relief of ischaemic rest pain. As a consequence, novel therapeutic strategies have been developed over the last two decades aiming to promote neovascularization and remodelling of collaterals. Gene and stem cell therapy are the main directions for clinical investigation concepts. For both, preclinical studies have shown promising results using a wide variety of genes encoding for growth factors and populations of adult stem cells, respectively. As a consequence, clinical trials have been performed applying gene and stem cell-based concepts. However, it has become apparent that a straightforward translation into humans is not possible. While several trials reported relief of symptoms and functional improvement, other trials did not confirm this early promise of efficacy. Ongoing clinical trials with an improved study design are needed to confirm the potential that gene and cell therapy may have and to prevent the gaps in our scientific knowledge that will jeopardize the establishment of angiogenic therapy as an additional medical treatment of PAOD. This review summarizes the experimental background and presents the current status of clinical applications and future perspectives of the therapeutic use of gene and cell therapy strategies for PAOD.

Stem cells for cardiovascular repair - the challenges of the aging heart

The discovery of extracardiac progenitor cells and resident cardiac stem cells in recent years has led to a great deal of interest in the development of therapeutic strategies that target these endogenous cell sources for promotion of cardiovascular repair mechanisms in the diseased heart. Cardiovascular risk increases with age and among many factors, the age-associated decline in cardiac and vascular regenerative capacity may contribute to the progressive deterioration of cardiovascular health. Thus, understanding the mechanisms which underlie the dysregulation of cardiac stem and progenitor cells may lead to the identification of novel targets and approaches to reverse this decline. In this review, we outline the current knowledge about cardiac stem and progenitor cells, their contribution to cardiovascular regenerative processes and factors that may affect their decreased function in aging individuals. Moreover, we describe the therapeutic strategies that are currently being tested in clinical trials as well as potential new avenues of investigation for the future.

Angiogenesis by transplantation of HIF-1 alpha modified EPCs into ischemic limbs

Hypoxia inducible factor-1 alpha (HIF-1 alpha) is a key determinant of oxygen-dependent gene regulation in angiogenesis. HIF-1 alpha overexpression may be beneficial in cell therapy of hypoxia-induced pathophysiological processes, such as ischemic heart disease. To address this issue, human peripheral blood mononuclear cells (PBMNCs) were induced to differentiate into endothelial progenitor cells (EPCs), and then were transfected with either an HIF-1 alpha-expressing or a control vector and cultured under normoxia or hypoxia. Hypoxia-induced HIF-1 alpha mRNA and protein expression was increased after HIF-1 alpha transfection. This was accompanied by VEGF mRNA induction and increased VEGF secretion. Hypoxia-stimulated VEGF mRNA induction was significantly abrogated by HIF-1 alpha-specific siRNA. Functional studies showed that HIF-1 alpha overexpression further promoted hypoxia-induced EPC differentiation, proliferation and migration. The expressions of endothelial cell markers CD31, VEGFR2 (Flk-1) and eNOS as well as VEGF and NO secretions were also increased. Furthermore, in an in vivo model of hindlimb ischemia, HIF-1 alpha-transfected EPCs homed to the site of ischemia. A higher revascularization potential was also demonstrated by increased capillary density at the injury site. Our results revealed that endothelial progenitor cells ex vivo modification by hypoxia inducible factor-1 alpha gene transfection is feasible and may offer significant advantages in terms of EPC expansion and treatment efficacy.

Heme oxygenase-1 and carbon monoxide in vascular pathobiology: focus on angiogenesis

Angiogenesis involves the formation of new blood vessels and is critical for fundamental events such as development and repair after injury. Perturbances in angiogenesis contribute to the pathogenesis of diverse clinical conditions including cancer, complications of diabetes mellitus, ischemia/reperfusion injury of the heart and other organs, and preeclampsia, as well as a number of inflammatory disorders. Recent work has identified heme oxygenase-1 and its gaseous product, carbon monoxide, to possess potent proangiogenic properties in addition to well-recognized antiinflammatory, antioxidant, and antiapoptotic effects. Angiogenic factors, such as vascular endothelial growth factor and stromal cell-derived factor-1, mediate their proangiogenic effects through induction of heme oxygenase-1, making it an attractive target for therapeutic intervention. This review will provide an overview of the role of heme oxygenase-1 and carbon monoxide in angiogenesis.

Growth factor-induced therapeutic neovascularization for ischaemic vascular disease: time for a re-evaluation?

PURPOSE OF REVIEW

Therapeutic angiogenesis and arteriogenesis represent an alternative treatment modality for patients with advanced ischaemic coronary or peripheral artery occlusive disease, who are unsuitable for standard revascularization procedures.

RECENT DEVELOPMENTS

Proof-of-concept evidence for therapeutic growth factor, both gene and protein-mediated neovascularization was provided in animal models of chronic myocardial and hindlimb ischaemia. Early human, phase I, trials utilizing the prototypical growth factor families, vascular endothelial growth factor and fibroblast growth factor, documented safety and suggested improvements in anginal symptoms and functional status. Large, randomized, placebo-controlled phase II/III clinical trials have, however, yielded variable results as such studies have suffered from significant limitations in therapeutic approach or design, which limits the ability to draw firm conclusions.

SUMMARY

Future trials must incorporate robust delivery strategies and address issues of study design including proper patient selection. Laboratory-based refinements in therapy, including a focus on the promotion of arteriogenesis and the modification of patient 'endotheliopathy', will all further enhance the potential of therapeutic neovascularization strategies.

Increased VEGFR2 expression during human late endothelial progenitor cells expansion enhances in vitro angiogenesis with up-regulation of integrin alpha(6)

In vitro expansion of late endothelial progenitor cells (EPCs) might yield a cell therapy product useful for myocardial and leg ischaemia, but the influence of EPC expansion on the angiogenic properties of these cells is unknown. In the present study, we investigated the effect of in vitro EPC expansion on vascular endothelial growth factor (VEGF) receptor expression. EPCs were obtained from CD34⁺ cord blood cells and expanded for up to 5 weeks. Real-time quantitative reverse-transcription polymerase chain reaction (RT-PCR) showed that VEGFR2 expression, contrary to VEGFR1 and VEGFR3 expression, was significantly higher on expanded EPCs than on freshly isolated CD34⁺ cells or on human umbilical vein endothelial cells (HUVECs). Quantitative flow cytometry confirmed that VEGFR2 density on EPCs increased during the expansion process and was significantly higher than on HUVECs. The impact of VEGFR2 increase was studied on the three theoretical steps of angiogenesis, i.e., EPC proliferation, migration and differentiation. VEGFR2 up-regulation had no effect on VEGF-induced cell proliferation, but significantly enhanced EPC migration and pseudotubes formation dependent on integrin α₆ subunit overexpression. In vitro expansion of late EPCs increases the expression of VEGFR2, the main VEGF receptor, with possible implications for EPC-based angiogenic therapy.

Vascular morphogenesis by adult bone marrow progenitor cells in three-dimensional fibrin matrices

The neovascularization of tissues is accomplished by two distinct processes: de novo formation of blood vessels through the assembly of progenitor cells during early prenatal development (vasculogenesis), and expansion of a pre-existing vascular network by endothelial cell sprouting (angiogenesis), the main mechanism of blood vessel growth in postnatal life. Evidence exists that adult bone marrow (BM)-derived progenitor cells can contribute to the formation of new vessels by their incorporation into sites of active angiogenesis. Aim of this study was to investigate the in vitro self-organizing capacity of human BM mononuclear cells (BMMNC) to induce vascular morphogenesis in a three-dimensional (3D) matrix environment in the absence of pre-existing vessels. Whole BMMNC as well as the adherent and non-adherent fractions of BMMNC were embedded in fibrin gels and cultured for 3-4 weeks without additional growth factors. The expression of hematopoietic-, endothelial-, smooth muscle lineage, and stem cell markers was analyzed by immunohistochemistry and confocal laser-scanning microscopy. The culture of unselected BMMNC in 3D fibrin matrices led to the formation of cell clusters expressing the endothelial progenitor cell (EPC) markers CD133, CD34, vascular endothelial growth factor receptor (VEGFR)-2, and c-kit, with stellar shaped spreading of peripheral elongated cells forming tube-like structures with increasing complexity over time. Cluster formation was dependent on the presence of both adherent and non-adherent BMMNC without the requirement of external growth factors. Developed vascular structures expressed the endothelial markers CD34, VEGFR-2, CD31, von Willebrand Factor (vWF), and podocalyxin, showed basement-membrane-lined lumina containing CD45+ cells and were surrounded by alpha-smooth muscle actin (SMA) expressing mural cells. Our data demonstrate that adult human BM progenitor cells can induce a dynamic self organization process to create vascular structures within avascular 3D fibrin matrices suggesting a possible alternative mechanism of adult vascular development without involvement of pre-existing vascular structures.

Cyclosporin A suppresses proliferation of endothelial progenitor cells: involvement of nitric oxide synthase inhibition

OBJECTIVE

To investigate the effects of the potent immunosuppressive agent cyclosporin A (CsA) on the proliferation of human endothelial progenitor cells (EPCs) and endothelial nitric oxide synthase (eNOS) expression in EPCs.

METHODS AND RESULTS

The EPCs were obtained from cultured mononuclear cells, which were isolated from the peripheral blood of healthy adults, and stimulated with CsA (10 microg/mL) in the presence or absence of either vascular endothelial growth factor (VEGF; 50 ng/mL) or L-arginine (1 mM). To explore the effect of different concentrations of CsA alone on EPC proliferation, some cells were treated with CsA in a series of final concentrations ranging from 0 to 10 microg/mL. Cell proliferation and apoptosis were determined, respectively, by the Cell Counting Kit-8 assay and terminal deoxynucleotidyl transferase-mediated nick end labeling staining. The expression of eNOS was assayed by reverse transcription-polymerase chain reaction analysis while nitric oxide (NO) generation was detected using the Griess method. The effects of CsA on EPC proliferation, apoptosis, and eNOS/NO production were dose dependent in the concentration ranging from 0.1 microg/mL to 10 microg/mL. Treatment with VEGF (50 ng/mL) significantly promoted EPC proliferation and eNOS/NO production, which were completely abrogated by pre-incubation with CsA (10 microg/mL). The supplement of L-arginine (1 mM) promoted NO production that enhanced EPC proliferation and attenuated the effect of CsA on EPC proliferation and apoptosis.

CONCLUSION

CsA significantly inhibited proliferation, eNOS mRNA expression and NO production of human EPCs, in a dose-dependent manner.

Stem cell therapies in cardiovascular disease A "realistic" appraisal

The possibility of reconstituting the damaged heart has introduced a new paradigm in cardiovascular biology and created the potential for a new therapeutic approach in the cardiovascular field, where there is a compelling need for innovative treatments. While the results of animal and early clinical studies are encouraging, the more direct use of cell-based therapies in patients is still long-reached. Gaps in our basic understanding of mechanisms, lack of important randomized, double blind, and controlled clinical trials, as well as technology development for cell production are among challenges to be overcome before full translation of cell based therapies in clinical arena. This review focuses on summarizing the latest knowledge in stem cell therapy for cardiovascular diseases.

Proliferation hemangiomas formation through dual mechanism of vascular endothelial growth factor mediated endothelial progenitor cells proliferation and mobilization through matrix metalloproteinases 9

Infantile hemangioma is the most common tumor of infancy and the mechanism leading to proliferation hemangiomas formation is poorly understood and currently no successful treatment modality exists. We hypothesize that EPCs formed during proliferation hemangiomas, as the result of vascular endothelial growth factor (VEGF) stimulation through MMP9, play the major role in the control of cell proliferation and capillary-like vessels production. Accepting the hypothesis to be correct, a therapy that inhibits EPC mobilization and proliferation can be used to prevent the proliferation hemangiomas formation. Current therapies are only partially effective and safe because they could not eliminate all the relative factors of proliferation hemangiomas formation at all, such as: EPCs in the peripheral blood, and at the same time inducing death (apoptosis and necrosis) of other normal cells. A more efficient prevention of proliferation hemangiomas could be achieved using specific drugs or biologic methods that inhibit EPC mobilization and proliferation. Therapy based on gene therapy, capable to specifically inhibit VEGF and MMP9 expression in gene level, can be possibly effective.

Chaotic dynamic stabilities and instabilities of hematopoietic stem cell growth plasticity

The hematopoietic system consists of: (1) a network of stem and progenitor cells of varying degrees of maturity interacting with other cells that possess supportive and regulatory capacities and (2) vascular stem cell niches with supporting stem cells in their self-renewal, proliferation, differentiation, and mobilization to the circulation. Recent data suggest that selective expression of organ-specific chemokines promotes the mobilization of bone-marrow-derived pluripotent cells, a process that is essential for tissue vascularization and organ regeneration. Despite intensive investigation, the pathways by which mechanical signals are converted to biochemical responses are not completely understood. Recent studies have suggested that chromatin shifts and cell cycle effects stem cell gene expression, and thus results in changes of its surface receptor expression at different points of the cell cycle machinery, therefore changing cell cycle transit. This review will attempt to discuss new approaches to determine the regulation of stem cell growth and differentiation by underlying the significance of the chaotic dynamics of transcriptional networks within a cell, with a combination of chemokines and cytokines in the environment, and mechanical forces, such as: stretch, strain and laminar flow, all involving both cooperation and competition.

A comparison of the tube forming potentials of early and late endothelial progenitor cells

The identification of circulating endothelial progenitor cells (EPCs) has revolutionized approaches to cell-based therapy for injured and ischemic tissues. However, the mechanisms by which EPCs promote the formation of new vessels remain unclear. In this study, we obtained early EPCs from human peripheral blood and late EPCs from umbilical cord blood. Human umbilical vascular endothelial cells (HUVECs) were also used. Cells were evaluated for their tube-forming potential using our novel in vitro assay system. Cells were seeded linearly along a 60 mum wide path generated by photolithographic methods. After cells had established a linear pattern on the substrate, they were transferred onto Matrigel. Late EPCs formed tubular structures similar to those of HUVECs, whereas early EPCs randomly migrated and failed to form tubular structures. Moreover, late EPCs participate in tubule formation with HUVECs. Interestingly, late EPCs in Matrigel migrated toward pre-existing tubular structures constructed by HUVECs, after which they were incorporated into the tubules. In contrast, early EPCs promote sprouting of HUVECs from tubular structures. The phenomena were also observed in the in vivo model. These observations suggest that early EPCs cause the disorganization of pre-existing vessels, whereas late EPCs constitute and orchestrate vascular tube formation.

Umbilical cord blood-derived progenitor cells enhance muscle regeneration in mouse hindlimb ischemia model

Progenitor cell therapy is a potential new treatment option for ischemic conditions in the myocardium and skeletal muscles. However, it remains unclear whether umbilical cord blood (UCB)-derived progenitor cells can provide therapeutic effects in ischemic muscles and whether ex vivo gene transfer can be used for improving the effect. In this study, the use of a lentiviral vector led to efficient transduction of both UCB-derived hematopoietic stem cells (HSCs) and mesenchymal stem cells (MSCs). Our method resulted in a long-term transgene expression and did not alter the differentiation potential of either HSCs or MSCs. In addition, we studied the therapeutic potential of CD133(+) and MSC progenitor cells transduced ex vivo with lentiviruses encoding the mature form of vascular endothelial growth factor D (VEGF-D(DeltaNDeltaC)) or the enhanced green fluorescent protein (eGFP) marker gene in a nude mouse model of skeletal muscle ischemia. Progenitor cells enhanced the regeneration of ischemic muscles without a detectable long-term engraftment of either CD133(+) or MSC progenitor cells. Our results show that, rather than directly participating in angiogenesis or skeletal myogenesis, UCB-derived progenitor cells indirectly enhance the regenerative capacity of skeletal muscle after acute ischemic injury. However, VEGF-D gene transfer of progenitor cells did not improve the therapeutic effect in ischemic muscles.

Tumor microenvironment: the role of the tumor stroma in cancer

The tumor microenvironment, composed of non-cancer cells and their stroma, has become recognized as a major factor influencing the growth of cancer. The microenvironment has been implicated in the regulation of cell growth, determining metastatic potential and possibly determining location of metastatic disease, and impacting the outcome of therapy. While the stromal cells are not malignant per se, their role in supporting cancer growth is so vital to the survival of the tumor that they have become an attractive target for chemotherapeutic agents. In this review, we will discuss the various cellular and molecular components of the stromal environment, their effects on cancer cell dynamics, and the rationale and implications of targeting this environment for control of cancer. Additionally, we will emphasize the role of the bone marrow-derived cell in providing cells for the stroma.

Therapeutic myocardial angiogenesis

Armed with an improved understanding of the mediators of angiogenesis, physicians and scientists have made significant efforts at harnessing this naturally occurring process in order to treat patients with a variety of peripheral vascular and coronary ischemic syndromes. There is a growing population of patients with end-stage coronary artery disease (CAD) who are no longer candidates for mechanical revascularization, yet suffer from chronic myocardial ischemia who may benefit from regeneration of the depleted microvasculature.

Roles for VEGF in the adult

The role of VEGF during development and in pathology is well known, but its function in normal adult tissues is poorly understood. Adverse effects associated with the use of anti-angiogenic therapies targeting VEGF in human pathologies have begun to reveal potential functions of VEGF in quiescent vasculature. Further clues from expression studies of VEGF and its receptors in the adult, from the disease preeclampsia, and from experimental neutralization studies, have suggested that VEGF is involved in endothelial cell survival and fenestration, as well as in the signaling and maintenance of non-endothelial cells. The various biochemical properties of VEGF, and its interaction with other growth factors, may be an important point in determining whether VEGF functions as a maintenance factor versus an angiogenic factor. A thorough understanding of the function of VEGF in the adult may lead to more efficacious pro- and anti-angiogenic therapies.

Endothelial progenitor cells and cerebrovascular diseases

Identifying factors that may increase the risk of stroke and assessing if treatment of such conditions may lower that risk are important in the management of cerebrovascular disease. Tobacco smoking, poor diet, hypertension and hyperlipidemia remain the major risk factors, and treatment of these conditions has been shown to significantly reduce stroke. In recent years, research has shown that stem cells from a variety of sources can be used as a tool to study and prevent the events that lead to stroke. In this regard, a population of adult stem cells, called endothelial progenitor cells (EPCs), have been identified in peripheral blood and may play an important role in tissue vascularization and endothelium homeostasis in the adult. Most of the studies on EPCs have been carried out on patients with cardiovascular diseases; however, there is emerging evidence which suggests that the introduction or mobilization of EPCs can restore tissue vascularization even after cerebrovascular diseases (CVD), such as ischemic stroke or intracerebral haemorrhage. In this review, we discuss the present level of knowledge about the characteristics of EPCs, their possible therapeutic role in CVD and how they could alter clinical practice in the future.

Stem Cell Therapy: A Hope for Dying Hearts

The restoration of functional myocardium following heart failure still remains a formidable challenge among researchers. Irreversible damage caused by myocardial infarction is followed by left ventricular remodeling. The current pharmacologic and interventional strategies fail to regenerate dead myocardium and are usually insufficient to meet the challenge caused by necrotic cardiac myocytes. There is growing evidence, suggesting that the heart has the ability to regenerate through the activation of resident cardiac stem cells or through the recruitment of a stem cell population from other tissues such as bone marrow. These new findings belie the earlier conception about the poor regenerating ability of myocardial tissue. Stem cell therapy is a promising new approach for myocardial repair. However, it has been limited by the paucity of cell sources for functional human cardiomyocytes. Moreover, cells isolated from different sources exhibit idiosyncratic characteristics including modes of isolation, ease of expansion in culture, proliferative ability, characteristic markers, etc., which are the basis for several technical manipulations to achieve successful engraftment. Clinical trials show some evidence for the successful integration of stem cells of extracardiac origin in adult human heart with an improved functional outcome. This may be attributed to the discrepancies in the methods of detection, study subject selection (early or late post transplantation), presence of inflammation, and false identification of infiltrating leukocytes. This review discusses these issues in a comprehensive manner so that their physiological significance in animal as well as in human studies can be better understood.

Systemic inhibition of tumour angiogenesis by endothelial cell-based gene therapy

Angiogenesis and post-natal vasculogenesis are two processes involved in the formation of new vessels, and both are essential for tumour growth and metastases. We isolated endothelial cells from human blood mononuclear cells by selective culture. These blood outgrowth cells expressed endothelial cell markers and responded correctly to functional assays. To evaluate the potential of blood outgrowth endothelial cells (BOECs) to construct functional vessels in vivo, NOD-SCID mice were implanted with Lewis lung carcinoma cells subcutaneously (s.c.). Blood outgrowth endothelial cells were then injected through the tail vein. Initial distribution of these cells occurred throughout the lung, liver, spleen, and tumour vessels, but they were only found in the spleen, liver, and tumour tissue 48 h after injection. By day 24, they were mainly found in the tumour vasculature. Tumour vessel counts were also increased in mice receiving BOEC injections as compared to saline injections. We engineered BOECs to deliver an angiogenic inhibitor directly to tumour endothelium by transducing them with the gene for human endostatin. These cells maintained an endothelial phenotype and decreased tumour vascularisation and tumour volume in mice. We conclude that BOECs have the potential for tumour-specific delivery of cancer gene therapy.

[Endothelial progenitor cells for vascular medicine]

The regenerative potential of stem cells has recently been under intense investigation. In vitro, stem and progenitor cells have the ability for self-renewal and differentiation into organ-specific cell types. In vivo, transplantation of these cells may reconstitute organ systems, as shown in animal models of disease. In contrast, differentiated cells do not exhibit such characteristics. Human endothelial progenitor cells (EPCs) have been isolated from the peripheral blood of adult individuals, expanded in vitro and committed to an endothelial lineage in culture. The transplantation of these human EPCs has been shown to facilitate successful salvage of limb vasculature and perfusion in athymic nude mice with severe hindlimb ischemia, while differentiated endothelial cells (human microvascular endothelial cells) failed to accomplish limb-saving neovascularization. Future studies will clarify the mechanisms and circumstances that may be responsible for modulating the contribution of vasculogenesis to postnatal neovascularization. Specifically in this regard, it is intriguing to consider the possibility that certain angiogenic growth factors acknowledged to promote both angiogenesis and vasculogenesis in the embryo, but have been assumed to promote neovascularization exclusively by angiogenesis in the adult, may in fact promote migration, proliferation, and mobilization of EPCs from bone marrow. The possibility that modulation of vasculogenesis can be used therapeutically to augment as well as inhibit neovascularization deserves further investigation.

Age-related BM-MNC dysfunction hampers neovascularization

Although ischemia-induced neovascularization is reportedly impaired with aging, the effect of aged-bone marrow mononuclear cells (BM-MNCs) on neovascularization has not been investigated. The neovascularization capacity of BM-MNCs obtained from 8-week-old mice (young) was compared to those obtained from 18-month-old mice (old), both in vivo and in vitro. Neovascularization in ischemic limbs was significantly impaired in old mice. Whereas transplantation of young BM-MNCs significantly improved blood perfusion, tissue capillary density, and vascular endothelial growth factor (VEGF) production in transplanted ischemic limbs, no such effects were observed with old BM-MNCs. Old BM-MNCs also showed a significant impairment of in vitro VEGF production and migratory capacity in response to VEGF. The number of Dil/lectin-positive cells was significantly lower in old mice, but there was no difference in the number of AC133(+)/CD34(+) and CD34(+)/VEGF-R2(+) positive cells between young and old BM-MNCs. Transplantation of young BM-MNCs improved neovascularization and VEGF production in the ischemic limbs of old recipients, with results that were similar to those obtained in young recipients. These results indicate that the neovascularization capacity of transplanted BM-MNCs is impaired with aging. However, aging does not hamper the revitalization of neovascularization in the murine host in response to transplantation of young BM-MNCs.

The impact of insulin resistance on endothelial function, progenitor cells and repair

The structural and functional integrity of the vascular endothelium plays a critical role in vascular homeostasis. Insulin resistance, an important risk factor for cardiovascular disease, is thought to promote atherosclerosis through a reciprocal relationship with endothelial dysfunction. In health, cumulative damage to endothelial cells incurred by exposure to risk factors is mitigated by endogenous reparative processes. Disruption of the balance between endothelial damage and repair may mediate atherosclerotic progression. Bone marrow-derived 'endothelial progenitor cells' (EPC) have been identified as significant contributors to endogenous vascular repair. Insulin resistance is associated with a spectrum of biochemical abnormalities which have the potential to reduce the availability of EPCs and diminish their capacity for vascular repair. Many lifestyle and pharmacological interventions which improve insulin resistance also increase the numbers and functionality of EPCs. Cell-based therapies may also hold promise for the prevention and treatment of cardiovascular disease.

Combination of VEGF(165)/Angiopoietin-1 gene and endothelial progenitor cells for therapeutic neovascularization

Previous studies have established that vascular endothelial growth factor (VEGF), Angiopoietin-1 (Ang1) and endothelial progenitor cells (EPCs) play important roles in neovascularization, suggesting that combination of them would be a promising therapy for ischemic diseases. So we constructed the adeno-associated virus-2 (AAV-2) vectors simultaneously encoding human VEGF(165) and Ang1 (AAV-Ang1/VEGF), and investigated the combination therapeutic effect of AAV-Ang1/VEGF with EPCs in a rabbit ischemic hindlimb model. In the present study we found that AAV-Ang1/VEGF could successfully and efficiently transfer VEGF(165) and Ang1 gene into bone marrow derived EPCs for gene therapy. Combined administration of AAV-Ang1/VEGF with EPCs had higher blood flow recovery, cellularity, capillary density and smooth muscle alpha-actin positive vessel density than administration of either of them alone. Furthermore, the strategy of pre-intramuscular injection of AAV-Ang1/VEGF followed by EPCs transplantation had a higher therapeutic effect than the strategy of transplantation of AAV-Ang1/VEGF transduced EPCs. It seemed that the former strategy may be a promising therapy for ischemic diseases.

Vascular Delay Revisited

The technique of vascular delay has been used by plastic surgeons for nearly 500 years and has proven useful for reliably transferring tissue and allowing for a greater volume of tissue to be reliably harvested. Delay procedures are an essential plastic surgical tool for a variety of aesthetic and reconstructive procedures. Despite the widespread use of vascular delay procedures, the mechanism by which this phenomenon occurs remains unclear. A number of groups have exhaustively examined microvascular changes that occur during vascular delay. Theories have been proposed ranging from the dilation of choke vessels to changes in metabolism and new blood vessel formation. Inherent in these theories is the concept that ischemia is able to act as the primary stimulus for vascular changes. The purpose of this review is to revisit the theories proposed to underlie the delay phenomenon in light of recent advances in vascular biology. In particular, the participation of bone marrow-derived endothelial progenitor cells in the delay phenomenon is explored. Greater understanding of the role these cells play in new blood vessel formation will be of considerable clinical benefit to high-risk patients in future applications of delay procedures.

Radionuclide reporter gene imaging for cardiac gene therapy

INTRODUCTION

In the field of cardiac gene therapy, angiogenic gene therapy has been most extensively investigated. The first clinical trial of cardiac angiogenic gene therapy was reported in 1998, and at the peak, more than 20 clinical trial protocols were under evaluation. However, most trials have ceased owing to the lack of decisive proof of therapeutic effects and the potential risks of viral vectors. In order to further advance cardiac angiogenic gene therapy, remaining open issues need to be resolved: there needs to be improvement of gene transfer methods, regulation of gene expression, development of much safer vectors and optimisation of therapeutic genes. For these purposes, imaging of gene expression in living organisms is of great importance. In radionuclide reporter gene imaging, "reporter genes" transferred into cell nuclei encode for a protein that retains a complementary "reporter probe" of a positron or single-photon emitter; thus expression of the reporter genes can be imaged with positron emission tomography or single-photon emission computed tomography. Accordingly, in the setting of gene therapy, the location, magnitude and duration of the therapeutic gene co-expression with the reporter genes can be monitored non-invasively. In the near future, gene therapy may evolve into combination therapy with stem/progenitor cell transplantation, so-called cell-based gene therapy or gene-modified cell therapy.

CONCLUSION

Radionuclide reporter gene imaging is now expected to contribute in providing evidence on the usefulness of this novel therapeutic approach, as well as in investigating the molecular mechanisms underlying neovascularisation and safety issues relevant to further progress in conventional gene therapy.

Role of the SDF-1/CXCR4 axis in the pathogenesis of lung injury and fibrosis

Stromal cell-derived factor-1 (SDF-1) participates in mobilizing bone marrow-derived stem cells, via its receptor CXCR4. We studied the role of the SDF-1/CXCR4 axis in a rodent model of bleomycin-induced lung injury in C57BL/6 wild-type and matrix metalloproteinase (MMP)-9 knockout mice. After intratracheal instillation of bleomycin, SDF-1 levels in serum and bronchial alveolar lavage fluid increased. These changes were accompanied by increased numbers of CXCR4(+) cells in the lung and a decrease in a population of CXCR4(+) cells in the bone marrow that did not occur in MMP-9(-)/(-) mice. Both SDF-1 and lung lysates from bleomycin-treated mice induced migration of bone marrow-derived stem cells in vitro that was blocked by a CXCR4 antagonist, TN14003. Treatment of mice with TN14003 with bleomycin-induced lung injury significantly attenuated lung fibrosis. Lung tissue from patients with idiopathic pulmonary fibrosis had higher numbers of cells expressing both SDF-1 and CXCR4 than did normal lungs. Our data suggest that the SDF-1/CXCR4 axis is important in the complex sequence of events triggered by bleomycin exposure that eventuates in lung repair. SDF-1 participates in mobilizing bone marrow-derived stem cells, via its receptor CXCR4.

Endothelial progenitor cells as therapeutic vectors in cardiovascular disorders: from experimental models to human trials

Cell-based therapy approaches for the restoration of blood flow in ischemic organs has recently received growing interest. A considerable number of reports have documented the presence of circulating, bone marrow-derived endothelial progenitor cells (EPC) in adult peripheral blood. These putative cells are thought to participate in postnatal growth of new blood vessels. Mounting evidence from animal studies point to potential therapeutic applications of EPCs in the treatment of a wide range of cardiovascular (CV) disorders, while preliminary results from the pilot clinical trials still remain equivocal. Here, we review the experimental data that has accumulated so far from animal and clinical studies regarding the potential importance of EPCs. In addition, we discuss the potential hurdles as well as future options of EPC-based therapy.

Targeted delivery of CX3CL1 to multiple lung tumors by mesenchymal stem cells

MSCs are nonhematopoietic stem cells capable of differentiating into various mesoderm-type cells. MSCs have been considered to be a potential vehicle for cell-based gene therapy because MSCs are relatively easily expanded in vitro and have the propensity to migrate to and proliferate in the tumor tissue after systemic administration. Here, we demonstrated the tropism of mouse MSCs to tumor cells in vitro and multiple tumor tissues in the lung after i.v. injection of green fluorescent protein-positive MSCs in vivo. We transduced CX3CL1 (fractalkine), an immunostimulatory chemokine, to the mouse MSCs ex vivo using an adenoviral vector with the Arg-Gly-Asp-4C peptide in the fiber knob. Intravenous injection of CX3CL1-expressing MSCs to the mice bearing lung metastases of C26 and B16F10 cells strongly inhibited the development of lung metastases and thus prolonged the survival of these tumor-bearing mice. This antitumor effect depended on both innate and adaptive immunity. These results suggest that MSCs can be used as a vehicle for introducing biological agents into multiple lung tumor tissues. Disclosure of potential conflicts of interest is found at the end of this article.

Endothelial progenitor cells for postnatal vasculogenesis

Bone marrow-derived endothelial progenitor cells (EPCs) are present in the systemic circulation, are augmented in response to certain cytokines and/or tissue ischemia, and are home to--as well as incorporate into--sites of neovascularization. On the basis of these aspects, EPCs have attractive potential therapeutic applications for cardiovascular ischemic diseases as a novel cell-based strategy, mainly via a vasculogenesis mechanism. This review provides an update of the biology of EPCs, as well as highlighting the potential use of these cells for therapeutic regeneration.

Endothelial progenitor cells: characterization, in vitro expansion, and prospects for autologous cell therapy

Injection of hematopoietic stem cells or endothelial progenitor cells (EPCs) expanded ex vivo has been shown to augment neovascularization in adult patients, but the precise origin and identity of the cell population responsible for these clinical benefits are controversial. The limited quantity of EPCs in the circulation has been the main obstacle to clinical trials. Several authors have therefore attempted to expand these cells ex vivo in order to obtain a homogeneous cell therapy product. One possible means of expanding EPCs ex vivo is to activate the thrombin receptor PAR-1 with the specific peptide SFLLRN. Indeed, PAR-1 activation promotes cell proliferation and C-X-C chemokine receptor type 4 (CXCR4) dependent migration and differentiation, with an overall angiogenic effect. This review summarizes the results and rationale of clinical trials of angiogenic therapy, the nature of EPCs, the different methods of ex vivo expansion, and current methods of quantification.