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Tatarlar E, Yusuf E, Kocatürk Ö. A phantom study: Evaluation of a novel three-lumen balloon catheter for potential treatment of intractable limb ischemia. Med Eng Phys 2023; 115:103981. [PMID: 37120176 DOI: 10.1016/j.medengphy.2023.103981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 04/05/2023] [Accepted: 04/13/2023] [Indexed: 05/01/2023]
Abstract
Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease (PAD) which induces extremity rest pain, extremity gangrene or ulcers that mostly might lead to limb loss. One of the most common criteria of CLI is 50 mmHg or less systolic ankle arterial pressure. In this study, a custom made three-lumen catheter (9 Fr) including a distal inflatable balloon in between the inflow and outflow lumen holes was designed and fabricated based on the patented design of Hyper Perfusion Catheter. The proposed catheter design aims to increase ankle systolic pressure to 60 mmHg or more to promote healing and/or alleviating severe pain due to intractable ischemia for patients with CLI. To simulate the blood circulation of related anatomy, in vitro CLI model phantom was designed and constructed by using a modified hemodialysis circuit, a hemodialysis pump and a tube set for cardio-pulmonary bypass surgery. A blood mimicking fluid (BMF) with dynamic viscosity of 4.1 mPa.s was used at 22 ºC to prime the phantom. The data was collected by a custom-made circuit design in real time and all measurements were verified with commercial certificated medical devices. The results of in vitro CLI model phantom experiments have shown that it is feasible to elevate the pressure distal to the occlusion (representing ankle pressure) above 80 mmHg without affecting the systemic pressure.
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Affiliation(s)
- Efecan Tatarlar
- Bogazici University, Kandilli, Rasathane Cd. No:104 D:7, Üsküdar, Istanbul, 34684, Turkey.
| | - Emir Yusuf
- Acibadem Hospital Group, İnönü, Nizamiye Cd. No:9 D:1, 34373 Şişli, Istanbul, Turkey.
| | - Özgür Kocatürk
- Bogazici University, Kandilli, Rasathane Cd. No:104 D:7, Üsküdar, Istanbul, 34684, Turkey.
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2
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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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Bonanni M, Rehak L, Massaro G, Benedetto D, Matteucci A, Russo G, Esperto F, Federici M, Mauriello A, Sangiorgi GM. Autologous Immune Cell-Based Regenerative Therapies to Treat Vasculogenic Erectile Dysfunction: Is the Immuno-Centric Revolution Ready for the Prime Time? Biomedicines 2022; 10:biomedicines10051091. [PMID: 35625828 PMCID: PMC9138496 DOI: 10.3390/biomedicines10051091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
About 35% of patients affected by erectile dysfunction (ED) do not respond to oral phosphodiesterase-5 inhibitors (PDE5i) and more severe vasculogenic refractory ED affects diabetic patients. Innovative approaches, such as regenerative therapies, including stem cell therapy (SCT) and platelet-rich plasma (PRP), are currently under investigation. Recent data point out that the regenerative capacity of stem cells is strongly influenced by local immune responses, with macrophages playing a pivotal role in the injury response and as a coordinator of tissue regeneration, suggesting that control of the immune response could be an appealing approach in regenerative medicine. A new generation of autologous cell therapy based on immune cells instead of stem cells, which could change regenerative medicine for good, is discussed. Increasing safety and efficacy data are coming from clinical trials using peripheral blood mononuclear cells to treat no-option critical limb ischemia and diabetic foot. In this review, ongoing phase 1/phase 2 stem cell clinical trials are discussed. In addition, we examine the mechanism of action and rationale, as well as propose a new generation of regenerative therapies, evolving from typical stem cell or growth factor to immune cell-based medicine, based on autologous peripheral blood mononuclear cells (PBMNC) concentrates for the treatment of ED.
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Affiliation(s)
- Michela Bonanni
- Department of Biomedicine and Prevention, Institute of Cardiology, University of Rome Tor Vergata, 00133 Rome, Italy; (M.B.); (G.M.); (D.B.); (A.M.); (G.R.)
| | - Laura Rehak
- Athena Biomedical Innovations, 50126 Florence, Italy;
| | - Gianluca Massaro
- Department of Biomedicine and Prevention, Institute of Cardiology, University of Rome Tor Vergata, 00133 Rome, Italy; (M.B.); (G.M.); (D.B.); (A.M.); (G.R.)
| | - Daniela Benedetto
- Department of Biomedicine and Prevention, Institute of Cardiology, University of Rome Tor Vergata, 00133 Rome, Italy; (M.B.); (G.M.); (D.B.); (A.M.); (G.R.)
| | - Andrea Matteucci
- Department of Biomedicine and Prevention, Institute of Cardiology, University of Rome Tor Vergata, 00133 Rome, Italy; (M.B.); (G.M.); (D.B.); (A.M.); (G.R.)
- Division of Cardiology San Filippo Neri Hospital, 00135 Rome, Italy
| | - Giulio Russo
- Department of Biomedicine and Prevention, Institute of Cardiology, University of Rome Tor Vergata, 00133 Rome, Italy; (M.B.); (G.M.); (D.B.); (A.M.); (G.R.)
| | | | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Alessandro Mauriello
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Giuseppe Massimo Sangiorgi
- Department of Biomedicine and Prevention, Institute of Cardiology, University of Rome Tor Vergata, 00133 Rome, Italy; (M.B.); (G.M.); (D.B.); (A.M.); (G.R.)
- Correspondence:
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Stilhano RS, Denapoli PMA, Gallo CC, Samoto VY, Ingham SJM, Abdalla RJ, Koh TJ, Han SW. Regenerative effect of platelet-rich plasma in the murine ischemic limbs. Life Sci 2021; 284:119934. [PMID: 34508762 DOI: 10.1016/j.lfs.2021.119934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 12/01/2022]
Abstract
AIMS The purpose of this study was to investigate the effect of PPRP (pure PRP) and LPRP (PRP with leukocytes) on recovery from limb ischemia and on expression of growth factors involved in angiogenesis, myogenesis and fibrogenesis. MATERIAL AND METHODS PPRP and LPRP prepared by centrifugation were added to cultures of C2C12 and NIH3T3 cells (1 or 10% PRPs) to evaluate alterations in cell metabolism and expression of growth factors by MTT, ELISA and RT-qPCR, respectively. To evaluate in vivo regenerative effects, PRPs were injected into the ischemic limbs of BALB/c mice and muscle mass/strength and histomorphometry were evaluated after 30 days. KEY FINDINGS Mice treated with PRPs after limb ischemia showed an increase in the size of myofibers and muscle strength, reduced fibrosis and adipocytes, and decreased capillary density and necrosis scores compared to untreated mice. In cell culture, serum deprivation reduced the viability of C2C12 and NIH3T3 cells to about 50%, but the addition of 1% PRPs completely recovered this loss. Both PRPs, downregulated most of the tested genes; however, angiogenic gene Vegfa in C2C12 and the fibrogenic genes Col1a1 and Col3a1 in NIH3T3 cells were upregulated by LPRP. SIGNIFICANCE PPRP and LPRP had similar effects in regulation of genes involved in angiogenesis, myogenesis and fibrogenesis. However, the presence of leucocytes did not significantly affect regenerative activities of PRP in the ischemic limb.
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Affiliation(s)
- Roberta Sessa Stilhano
- Center for Gene Therapy Investigation, Universidade Federal de São Paulo (UNIFESP), Brazil; Department of Physiological Sciences, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), Brazil
| | | | | | - Vivian Yochiko Samoto
- Center for Gene Therapy Investigation, Universidade Federal de São Paulo (UNIFESP), Brazil
| | | | - Rene Jorge Abdalla
- Department of Orthopedic Surgery, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil
| | - Timothy Jon Koh
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, United States of America
| | - Sang Won Han
- Center for Gene Therapy Investigation, Universidade Federal de São Paulo (UNIFESP), Brazil; Department of Biophysics, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brazil.
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Magenta A, Florio MC, Ruggeri M, Furgiuele S. Autologous cell therapy in diabetes‑associated critical limb ischemia: From basic studies to clinical outcomes (Review). Int J Mol Med 2021; 48:173. [PMID: 34278463 DOI: 10.3892/ijmm.2021.5006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/30/2020] [Indexed: 01/13/2023] Open
Abstract
Cell therapy is becoming an attractive alternative for the treatment of patients with no‑option critical limb ischemia (CLI). The main benefits of cell therapy are the induction of therapeutic angiogenesis and neovascularization that lead to an increase in blood flow in the ischemic limb and tissue regeneration in non‑healing cutaneous trophic lesions. In the present review, the current state of the art of strategies in the cell therapy field are summarized, focusing on intra‑operative autologous cell concentrates in diabetic patients with CLI, examining different sources of cell concentrates and their mechanisms of action. The present study underlined the detrimental effects of the diabetic condition on different sources of autologous cells used in cell therapy, and also in delaying wound healing capacity. Moreover, relevant clinical trials and critical issues arising from cell therapy trials are discussed. Finally, the new concept of cell therapy as an adjuvant therapy to increase wound healing in revascularized diabetic patients is introduced.
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Affiliation(s)
| | - Maria Cristina Florio
- Laboratory of Cardiovascular Science, National Institute on Aging (NIA), National Institutes of Health (NIH), Baltimore, MD 21224, USA
| | - Massimo Ruggeri
- Department of Vascular Surgery, San Camillo de Lellis Hospital, I‑02100 Rieti, Italy
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Autologous Peripheral Blood Mononuclear Cells for Limb Salvage in Diabetic Foot Patients with No-Option Critical Limb Ischemia. J Clin Med 2021; 10:jcm10102213. [PMID: 34065278 PMCID: PMC8161401 DOI: 10.3390/jcm10102213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 01/21/2023] Open
Abstract
Peripheral blood mononuclear cells (PBMNCs) are reported to prevent major amputation and healing in no-option critical limb ischemia (NO-CLI). The aim of this study is to evaluate PBMNC treatment in comparison to standard treatment in NO-CLI patients with diabetic foot ulcers (DFUs). The study included 76 NO-CLI patients admitted to our centers because of CLI with DFUs. All patients were treated with the same standard care (control group), but 38 patients were also treated with autologous PBMNC implants. Major amputations, overall mortality, and number of healed patients were evaluated as the primary endpoint. Only 4 out 38 amputations (10.5%) were observed in the PBMNC group, while 15 out of 38 amputations (39.5%) were recorded in the control group (p = 0.0037). The Kaplan-Meier curves and the log-rank test results showed a significantly lower amputation rate in the PBMNCs group vs. the control group (p = 0.000). At two years follow-up, nearly 80% of the PBMNCs group was still alive vs. only 20% of the control group (p = 0.000). In the PBMNC group, 33 patients healed (86.6%) while only one patient healed in the control group (p = 0.000). PBMNCs showed a positive clinical outcome at two years follow-up in patients with DFUs and NO-CLI, significantly reducing the amputation rate and improving survival and wound healing. According to our study results, intramuscular and peri-lesional injection of autologous PBMNCs could prevent amputations in NO-CLI diabetic patients.
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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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Berndt R, Albrecht M, Rusch R. Strategies to Overcome the Barrier of Ischemic Microenvironment in Cell Therapy of Cardiovascular Disease. Int J Mol Sci 2021; 22:ijms22052312. [PMID: 33669136 PMCID: PMC7956787 DOI: 10.3390/ijms22052312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 12/11/2022] Open
Abstract
The transplantation of various immune cell types are promising approaches for the treatment of ischemic cardiovascular disease including myocardial infarction (MI) and peripheral arterial disease (PAD). Major limitation of these so-called Advanced Therapy Medicinal Products (ATMPs) is the ischemic microenvironment affecting cell homeostasis and limiting the demanded effect of the transplanted cell products. Accordingly, different clinical and experimental strategies have been evolved to overcome these obstacles. Here, we give a short review of the different experimental and clinical strategies to solve these issues due to ischemic cardiovascular disease.
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Affiliation(s)
- Rouven Berndt
- Clinic of Cardiovascular Surgery, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
- Vascular Research Center, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
- Correspondence: ; Tel.: +49-(0431)-500-22033; Fax: +49-(0431)-500-22024
| | - Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - René Rusch
- Clinic of Cardiovascular Surgery, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
- Vascular Research Center, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
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Berndt R. Transplantation von reprogrammierten Zellen monozytären Ursprungs. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-0310-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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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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Wang SK, Green LA, Drucker NA, Motaganahalli RL, Fajardo A, Murphy MP. Rationale and design of the Clinical and Histologic Analysis of Mesenchymal Stromal Cells in AmPutations (CHAMP) trial investigating the therapeutic mechanism of mesenchymal stromal cells in the treatment of critical limb ischemia. J Vasc Surg 2018; 68:176-181.e1. [PMID: 29395424 PMCID: PMC6019117 DOI: 10.1016/j.jvs.2017.09.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/29/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Currently, there are no accepted nonsurgical therapies that improve the delivery of blood-derived nutrients to patients with critical limb ischemia. Here, we describe the ongoing phase 1/2 Clinical and Histologic Analysis of Mesenchymal Stromal Cells in AmPutations (CHAMP) trial, which will provide crucial evidence of the safety profile of mesenchymal stromal cells (MSCs) and explore their therapeutic mechanisms in the setting of critical limb ischemia requiring below-knee amputation (BKA). METHODS In the CHAMP and the parallel marrowCHAMP trials (hereafter grouped together as CHAMP), a total of 32 extremities with rest pain or tissue loss requiring BKA will be enrolled to receive intramuscular injections of allogeneic MSCs (CHAMP; n = 16) or autogenous concentrated bone marrow aspirate (marrowCHAMP; n = 16) along the distribution of the BKA myocutaneous flap and proximal tibialis anterior. After treatment, subjects are randomized to BKA at four time points after injection (days 3, 7, 14, and 21). At the time of amputation, skeletal muscle is collected at 2-cm increments from the tibialis injection site and used to determine proangiogenic cytokine description, MSC retention, quantification of proangiogenic hematopoietic progenitor cells, and histologic description. Clinical limb perfusion before and after treatment will be quantified using transcutaneous oximetry, toe-brachial index, ankle-brachial index, and indocyanine angiography. Additional clinical end points include all-cause mortality, need for amputation revision, and gangrene incidence during the 6-month post-treatment follow-up. RESULTS Enrollment is under way, with 10 patients treated per protocol thus far. We anticipate full conclusion of follow-up within the next 24 months. CONCLUSIONS CHAMP will be pivotal in characterizing the safety, efficacy, and, most important, therapeutic mechanism of allogeneic MSCs and autogenous concentrated bone marrow aspirate in ischemic skeletal muscle.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Linden A Green
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Natalie A Drucker
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, and VA Center for Molecular and Cellular Therapeutics in Cardiovascular Disease, Indianapolis, Ind.
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Berndt R, Hummitzsch L, Heß K, Albrecht M, Zitta K, Rusch R, Sarras B, Bayer A, Cremer J, Faendrich F, Groß J. Allogeneic transplantation of programmable cells of monocytic origin (PCMO) improves angiogenesis and tissue recovery in critical limb ischemia (CLI): a translational approach. Stem Cell Res Ther 2018; 9:117. [PMID: 29703251 PMCID: PMC5921555 DOI: 10.1186/s13287-018-0871-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/18/2018] [Accepted: 04/12/2018] [Indexed: 01/05/2023] Open
Abstract
BACKROUND Employing growth factor-induced partial reprogramming in vitro, peripheral human blood monocytes can acquire a state of plasticity along with expression of various markers of pluripotency. These so-called programmable cells of monocytic origin (PCMO) hold great promise in regenerative therapies. The aim of this translational study was to explore and exploit the functional properties of PCMO for allogeneic cell transplantation therapy in critical limb ischemia (CLI). METHODS Using our previously described differentiation protocol, murine and human monocytes were differentiated into PCMO. We examined paracrine secretion of pro-angiogenic and tissue recovery-associated proteins under hypoxia and induction of angiogenesis by PCMO in vitro. Allogeneic cell transplantation of PCMO was performed in a hind limb ischemia mouse model in comparison to cell transplantation of native monocytes and a placebo group. Moreover, we analyzed retrospectively four healing attempts with PCMO in patients with peripheral artery disease (PAD; Rutherford classification, stage 5 and 6). Statistical analysis was performed by using one-way ANOVA, Tukey's test or the Student's t test, p < 0.05. RESULTS Cell culture experiments revealed good resilience of PCMO under hypoxia, enhanced paracrine release of pro-angiogenic and tissue recovery-associated proteins and induction of angiogenesis in vitro by PCMO. Animal experiments demonstrated significantly enhanced SO2 saturation, blood flow, neoangiogenesis and tissue recovery after treatment with PCMO compared to treatment with native monocytes and placebo. Finally, first therapeutic application of PCMO in humans demonstrated increased vascular collaterals and improved wound healing in patients with chronic CLI without exaggerated immune response, malignant processes or extended infection after 12 months. In all patients minor and/or major amputations of the lower extremity could be avoided. CONCLUSIONS In summary, PCMO improve angiogenesis and tissue recovery in chronic ischemic muscle and first clinical results promise to provide an effective and safe treatment of CLI.
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Affiliation(s)
- Rouven Berndt
- Department of Cardiaovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Hs 18, D-24105, Kiel, Germany.
| | - Lars Hummitzsch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Katharina Heß
- Institute of Neuropathology, University Hospital Münster, Münster, Germany
| | - Martin Albrecht
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Karina Zitta
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Rene Rusch
- Department of Cardiaovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Hs 18, D-24105, Kiel, Germany
| | - Beke Sarras
- Department of Cardiaovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Hs 18, D-24105, Kiel, Germany
| | - Andreas Bayer
- Department of Cardiaovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Hs 18, D-24105, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiaovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Hs 18, D-24105, Kiel, Germany
| | - Fred Faendrich
- Department of Applied Cell Therapy, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Justus Groß
- Department of Cardiaovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Hs 18, D-24105, Kiel, Germany
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13
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Berndt R, Albrecht M. Reprogrammierte Monozyten in der kardiovaskulären Therapie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-017-0204-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Wang SK, Green LA, Gutwein AR, Drucker NA, Babbey CM, Gupta AK, Fajardo A, Motaganahalli RL, Wilson MG, Murphy MP. Ethnic minorities with critical limb ischemia derive equal amputation risk reduction from autologous cell therapy compared with whites. J Vasc Surg 2018; 68:560-566. [PMID: 29503004 DOI: 10.1016/j.jvs.2017.11.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/28/2017] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Ethnic minorities (nonwhites) with critical limb ischemia (CLI) have historically performed worse compared with whites with regard to major amputation risk reduction and amputation-free survival (AFS) after peripheral vascular intervention. This post hoc analysis was completed to determine whether this precedent also extended to treatment of CLI without a suitable revascularization option with intramuscular injections of concentrated bone marrow aspirate (cBMA). METHODS The treatment arm of the randomized, double-blind, multicenter MarrowStim PAD Kit for the Treatment of Critical Limb Ischemia in Subjects with Severe Peripheral Arterial Disease (MOBILE) trial was stratified by ethnicity and evaluated for demographics, comorbidities, and outcomes. The primary and therapeutic end point was 1-year AFS and major amputation, respectively. Noninferiority analysis was performed with the margin set at historically reported hazard ratios. RESULTS Thirty-seven minority (African American, Hispanic, other) CLI patients (9 placebo, 28 cBMA) with no suitable revascularization option were randomized to cBMA or placebo at a 3:1 ratio during the MOBILE trial. At 1-year follow-up for the treatment group, overall AFS was 80%. Of the 28 minority patients randomized to cBMA intervention, an 89% AFS rate was observed compared with 77% in whites. Specifically, 22 of 24 (92%) African Americans survived amputation free at 1-year follow-up. Noninferiority testing confirmed no difference between whites and the ethnic minority treated with cBMA with respect to major amputation reduction; however, noninferiority could not be confirmed with regard to AFS. No significant differences favoring whites treated with cBMA were noted in the secondary end points of vascular quality of life, limb pain, ankle-brachial index, toe-brachial index, transcutaneous oximetry, and 6-minute walk testing. CONCLUSIONS This post hoc analysis of the MOBILE trial demonstrates noninferiority of cBMA intervention in minorities with no-option CLI for the therapeutic end point of major amputation prevention. cBMA represents a novel treatment paradigm and should be explored for minorities with poor revascularization options who face impending amputation secondary to progressive CLI.
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Affiliation(s)
- S Keisin Wang
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Linden A Green
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Ashley R Gutwein
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Natalie A Drucker
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Clifford M Babbey
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Alok K Gupta
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Andres Fajardo
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael G Wilson
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Ind
| | - Michael P Murphy
- Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Ind.
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