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Quiroz HJ, Parikh PP, Lassance-Soares RM, Regueiro MM, Li Y, Shao H, Vazquez-Padron R, Percival J, Liu ZJ, Velazquez OC. Gangrene, revascularization, and limb function improved with E-selectin/adeno-associated virus gene therapy. JVS Vasc Sci 2020; 2:20-32. [PMID: 34617055 PMCID: PMC8489216 DOI: 10.1016/j.jvssci.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/19/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Novel therapeutic angiogenic concepts for critical limb ischemia are still needed for limb salvage. E-selectin, a cell-adhesion molecule, is vital for recruitment of the stem/progenitor cells necessary for neovascularization in ischemic tissues. We hypothesized that priming ischemic limb tissue with E-selectin/adeno-associated virus (AAV) gene therapy, in a murine hindlimb ischemia and gangrene model, would increase therapeutic angiogenesis and improve gangrene. METHODS FVB/NJ mice were given intramuscular hindlimb injections of either E-selectin/AAV or LacZ/AAV and then underwent induction of gangrene via femoral artery ligation and concomitant systemic injections of the nitric oxide synthesis inhibitor L-NAME (L-NG-Nitro arginine methyl ester; 40 mg/kg). Gangrene was evaluated via the Faber hindlimb appearance score. The rate of ischemic limb reperfusion and ischemic tissue angiogenesis were evaluated using laser Doppler perfusion imaging and DiI perfusion with confocal laser scanning microscopy of the ischemic footpads, respectively. The treadmill exhaustion test was performed on postoperative day (POD) 8 to determine hindlimb functionality. RESULTS The E-selectin/AAV-treated mice (n = 10) had decreased Faber ischemia scores compared with those of the LacZ/AAV-treated mice (n = 7) at both PODs 7 and 14 (P < .05 and P < .01, respectively), improved laser Doppler perfusion imaging reperfusion indexes by POD 14 (P < .01), and greater gangrene footpad capillary density (P < .001). E-selectin/AAV-treated mice also had improved exercise tolerance (P < .05) and lower relative muscular atrophy (P < .01). CONCLUSION We surmised that E-selectin/AAV gene therapy would significantly promote hindlimb angiogenesis, reperfusion, and limb functionality in mice with hindlimb ischemia and gangrene. Our findings highlight the reported novel gene therapy approach to critical limb ischemia as a potential therapeutic option for future clinical studies.
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Affiliation(s)
- Hallie J. Quiroz
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Punam P. Parikh
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Roberta M. Lassance-Soares
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Manuela M. Regueiro
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Yan Li
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Hongwei Shao
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Roberto Vazquez-Padron
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Justin Percival
- Department of Molecular and Cellular Pharmacology, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Zhao-Jun Liu
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
| | - Omaida C. Velazquez
- Division of Vascular Surgery, DeWitt-Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla
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Apaydin EA, Richardson AS, Baxi S, Vockley J, Akinniranye O, Ross R, Larkin J, Motala A, Azhar G, Hempel S. An evidence map of randomised controlled trials evaluating genetic therapies. BMJ Evid Based Med 2020; 26:bmjebm-2020-111448. [PMID: 33172937 DOI: 10.1136/bmjebm-2020-111448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Genetic therapies replace or inactivate disease-causing genes or introduce new or modified genes. These therapies have the potential to cure in a single application rather than treating symptoms through repeated administrations. This evidence map provides a broad overview of the genetic therapies that have been evaluated in randomised controlled trials (RCTs) for efficacy and safety. ELIGIBILITY CRITERIA Two independent reviewers screened publications using predetermined eligibility criteria. Study details and data on safety and efficacy were abstracted from included trials. Results were visualised in an evidence map. INFORMATION SOURCES We searched PubMed, EMBASE, Web of Science, ClinicalTrials.gov and grey literature to November 2018. RISK OF BIAS Only RCTs were included in this review to reduce the risk of selection bias in the evaluation of genetic therapy safety and efficacy. INCLUDED STUDIES We identified 119 RCTs evaluating genetic therapies for a variety of clinical conditions. SYNTHESIS OF RESULTS On average, samples included 107 participants (range: 1-1022), and were followed for 15 months (range: 0-124). Interventions using adenoviruses (40%) to treat cardiovascular diseases (29%) were the most common. DESCRIPTION OF THE EFFECT In RCTs reporting safety and efficacy outcomes, in the majority (60%) genetic therapies were associated with improved symptoms but in nearly half (45%) serious adverse event (SAEs) were also reported. Improvement was reported in trials treating cancer, cardiovascular, ocular and muscular diseases. However, only 19 trials reported symptom improvement for at least 1 year. STRENGTHS AND LIMITATIONS OF EVIDENCE This is the first comprehensive evidence map of RCTs evaluating the safety and efficacy of genetic therapies. Evidence for long-term effectiveness and safety is still sparse. This lack of evidence has implications for the use, ethics, pricing and logistics of genetic therapies. INTERPRETATION This evidence map provides a broad overview of research studies that allow strong evidence statements regarding the safety and efficacy of genetic therapies. Most interventions improve symptoms, but SAE are also common. More research is needed to evaluate genetic therapies with regard to the potential to cure diseases.
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Affiliation(s)
- Eric A Apaydin
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, California, USA
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Andrea S Richardson
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Pittsburgh, Pennsylvania, USA
| | - Sangita Baxi
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, California, USA
| | - Jerry Vockley
- Division of Medical Genetics, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Olamigoke Akinniranye
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, California, USA
| | - Rachel Ross
- West Los Angeles Medical Center, Kaiser Foundation Hospitals, Los Angeles, California, USA
| | - Jody Larkin
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, California, USA
| | - Aneesa Motala
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, California, USA
| | - Gulrez Azhar
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, California, USA
| | - Susanne Hempel
- Southern California Evidence-based Practice Center, Health Care, RAND Corporation, Santa Monica, California, USA
- Southern California Evidence Review Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Boutagy NE, Sessa WC. Dynamic Protein Palmitoylation Cycling: A New Pathway Impacting Peripheral Arterial Disease? Circ Res 2020; 127:266-268. [PMID: 32614718 DOI: 10.1161/circresaha.120.317113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nabil E Boutagy
- From the Department of Pharmacology (N.E.B., W.C.S.), Yale University School of Medicine, New Haven, CT.,Vascular Biology and Therapeutics Program (N.E.B., W.C.S.), Yale University School of Medicine, New Haven, CT
| | - William C Sessa
- From the Department of Pharmacology (N.E.B., W.C.S.), Yale University School of Medicine, New Haven, CT.,Vascular Biology and Therapeutics Program (N.E.B., W.C.S.), Yale University School of Medicine, New Haven, CT.,Department of Cardiology (W.C.S.), Yale University School of Medicine, New Haven, CT
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Boutagy NE, Ravera S, Papademetris X, Onofrey JA, Zhuang ZW, Wu J, Feher A, Stacy MR, French BA, Annex BH, Carrasco N, Sinusas AJ. Noninvasive In Vivo Quantification of Adeno-Associated Virus Serotype 9-Mediated Expression of the Sodium/Iodide Symporter Under Hindlimb Ischemia and Neuraminidase Desialylation in Skeletal Muscle Using Single-Photon Emission Computed Tomography/Computed Tomography. Circ Cardiovasc Imaging 2019; 12:e009063. [PMID: 31296047 DOI: 10.1161/circimaging.119.009063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We propose micro single-photon emission computed tomography/computed tomography imaging of the hNIS (human sodium/iodide symporter) to noninvasively quantify adeno-associated virus 9 (AAV9)-mediated gene expression in a murine model of peripheral artery disease. METHODS AAV9-hNIS (2×1011 viral genome particles) was injected into nonischemic or ischemic gastrocnemius muscles of C57Bl/6J mice following unilateral hindlimb ischemia ± the α-sialidase NA (neuraminidase). Control nonischemic limbs were injected with phosphate buffered saline or remained noninjected. Twelve mice underwent micro single-photon emission computed tomography/computed tomography imaging after serial injection of pertechnetate (99mTcO4-), a NIS substrate, up to 28 days after AAV9-hNIS injection. Twenty four animals were euthanized at selected times over 1 month for ex vivo validation. Forty-two animals were imaged with 99mTcO4- ± the selective NIS inhibitor perchlorate on day 10, to ascertain specificity of radiotracer uptake. Tissue was harvested for ex vivo validation. A modified version of the U-Net deep learning algorithm was used for image quantification. RESULTS As quantitated by standardized uptake value, there was a gradual temporal increase in 99mTcO4- uptake in muscles treated with AAV9-hNIS. Hindlimb ischemia, NA, and hindlimb ischemia plus NA increased the magnitude of 99mTcO4- uptake by 4- to 5-fold compared with nonischemic muscle treated with only AAV9-hNIS. Perchlorate treatment significantly reduced 99mTcO4- uptake in AAV9-hNIS-treated muscles, demonstrating uptake specificity. The imaging results correlated well with ex vivo well counting (r2=0.9375; P<0.0001) and immunoblot analysis of NIS protein (r2=0.65; P<0.0001). CONCLUSIONS Micro single-photon emission computed tomography/computed tomography imaging of hNIS-mediated 99mTcO4- uptake allows for accurate in vivo quantification of AAV9-driven gene expression, which increases under ischemic conditions or neuraminidase desialylation in skeletal muscle.
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Affiliation(s)
- Nabil E Boutagy
- Department of Medicine, Section of Cardiovascular Medicine, Yale Translational Research Imaging Center (N.E.B., Z.W.Z., A.F., M.R.S., A.J.S.), Yale School of Medicine, New Haven, CT
| | - Silvia Ravera
- Department of Cellular and Molecular Physiology (S.R., N.C.), Yale School of Medicine, New Haven, CT
| | - Xenophon Papademetris
- Department of Radiology and Biomedical Imaging (X.P., J.A.O., J.W., A.J.S.), Yale School of Medicine, New Haven, CT
| | - John A Onofrey
- Department of Radiology and Biomedical Imaging (X.P., J.A.O., J.W., A.J.S.), Yale School of Medicine, New Haven, CT
| | - Zhen W Zhuang
- Department of Medicine, Section of Cardiovascular Medicine, Yale Translational Research Imaging Center (N.E.B., Z.W.Z., A.F., M.R.S., A.J.S.), Yale School of Medicine, New Haven, CT
| | - Jing Wu
- Department of Radiology and Biomedical Imaging (X.P., J.A.O., J.W., A.J.S.), Yale School of Medicine, New Haven, CT
| | - Attila Feher
- Department of Medicine, Section of Cardiovascular Medicine, Yale Translational Research Imaging Center (N.E.B., Z.W.Z., A.F., M.R.S., A.J.S.), Yale School of Medicine, New Haven, CT
| | - Mitchel R Stacy
- Department of Medicine, Section of Cardiovascular Medicine, Yale Translational Research Imaging Center (N.E.B., Z.W.Z., A.F., M.R.S., A.J.S.), Yale School of Medicine, New Haven, CT
| | - Brent A French
- Department of Biomedical Engineering (B.A.F., B.H.A.), University of Virginia, Charlottesville
- Division of Cardiovascular Medicine, Department of Medicine (B.A.F., B.H.A.), University of Virginia, Charlottesville
| | - Brian H Annex
- Department of Biomedical Engineering (B.A.F., B.H.A.), University of Virginia, Charlottesville
- Division of Cardiovascular Medicine, Department of Medicine (B.A.F., B.H.A.), University of Virginia, Charlottesville
| | - Nancy Carrasco
- Department of Cellular and Molecular Physiology (S.R., N.C.), Yale School of Medicine, New Haven, CT
| | - Albert J Sinusas
- Department of Medicine, Section of Cardiovascular Medicine, Yale Translational Research Imaging Center (N.E.B., Z.W.Z., A.F., M.R.S., A.J.S.), Yale School of Medicine, New Haven, CT
- Department of Radiology and Biomedical Imaging (X.P., J.A.O., J.W., A.J.S.), Yale School of Medicine, New Haven, CT
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Abstract
BACKGROUND Peripheral arterial disease (PAD), caused by narrowing of the arteries in the limbs, is increasing in incidence and prevalence as our population is ageing and as diabetes is becoming more prevalent. PAD can cause pain in the limbs while walking, known as intermittent claudication, or can be more severe and cause pain while at rest, ulceration, and ultimately gangrene and limb loss. This more severe stage of PAD is known as 'critical limb ischaemia'. Treatments for PAD include medications that help to reduce the increased risk of cardiovascular events and help improve blood flow, as well as endovascular or surgical repair or bypass of the blocked arteries. However, many people are unresponsive to medications and are not suited to surgical or endovascular treatment, leaving amputation as the last option. Gene therapy is a novel approach in which genetic material encoding for proteins that may help increase revascularisation is injected into the affected limbs of patients. This type of treatment has been shown to be safe, but its efficacy, especially regarding ulcer healing, effects on quality of life, and other symptomatic outcomes remain unknown. OBJECTIVES To assess the effects of gene therapy for symptomatic peripheral arterial disease. SEARCH METHODS The Cochrane Vascular Information Specialist searched Cochrane CENTRAL, the Cochrane Vascular Specialised Register, MEDLINE Ovid, Embase Ovid, CINAHL, and AMED, along with trials registries (all searched 27 November 2017). We also checked reference lists of included studies and systematic reviews for further studies. SELECTION CRITERIA We included randomised and quasi-randomised studies that evaluated gene therapy versus no gene therapy in people with PAD. We excluded studies that evaluated direct growth hormone treatment or cell-based treatments. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, performed quality assessment, and extracted data from the included studies. We collected pertinent information on each study, as well as data for the outcomes of amputation-free survival, ulcer healing, quality of life, amputation, all-cause mortality, ankle brachial index, symptom scores, and claudication distance. MAIN RESULTS We included in this review a total of 17 studies with 1988 participants (evidence current until November 2017). Three studies limited their inclusion to people with intermittent claudication, 12 limited inclusion to people with varying levels of critical limb ischaemia, and two included people with either condition. Study investigators evaluated many different types of gene therapies, using different protocols. Most studies evaluated growth factor-encoding gene therapy, with six studies using vascular endothelial growth factor (VEGF)-encoding genes, four using hepatocyte growth factor (HGF)-encoding genes, and three using fibroblast growth factor (FGF)-encoded genes. Two studies evaluated hypoxia-inducible factor 1-alpha (HIF-1α) gene therapy, one study used a developmental endothelial locus-1 gene therapy, and the final study evaluated a stromal cell-derived factor-1 (SDF-1) gene therapy. Most studies reported outcomes after 12 months of follow-up, but follow-up ranged from three months to two years.Overall risk of bias varied between studies, with many studies not providing sufficient detail for adequate determination of low risk of bias for many domains. Two studies did not utilise a placebo control, leading to risk of performance bias. Several studies reported in previous protocols or in their Methods sections that they would report on certain outcomes for which no data were then reported, increasing risk of reporting bias. All included studies reported sponsorships from corporate entities that led to unclear risk of other bias. The overall quality of evidence ranged from moderate to very low, generally as the result of heterogeneity and imprecision, with few or no studies reporting on outcomes.Evidence suggests no clear differences for the outcomes of amputation-free survival, major amputation, and all-cause mortality between those treated with gene therapy and those not receiving this treatment (all moderate-quality evidence). Low-quality evidence suggests improvement in complete ulcer healing with gene therapy (odds ratio (OR) 2.16, 95% confidence interval (CI) 1.02 to 4.59; P = 0.04). We could not combine data on quality of life and can draw no conclusions at this time regarding this outcome (very low-quality evidence). We included one study in the meta-analysis for ankle brachial index, which showed no clear differences between treatments, but we can draw no overall association (low-quality evidence). We combined in a meta-analysis pain symptom scores as assessed by visual analogue scales from two studies and found no clear differences between treatment groups (very low-quality evidence). We carried out extensive subgroup analyses by PAD classification, dosage schedule, vector type, and gene used but identified no substantial differences. AUTHORS' CONCLUSIONS Moderate-quality evidence shows no clear differences in amputation-free survival, major amputation, and all-cause mortality between those treated with gene therapy and those not receiving gene therapy. Some evidence suggests that gene therapy may lead to improved complete ulcer healing, but this outcome needs to be explored with improved reporting of the measure, such as decreased ulcer area in cm², and better description of ulcer types and healing. Further standardised data that are amenable to meta-analysis are needed to evaluate other outcomes such as quality of life, ankle brachial index, symptom scores, and claudication distance.
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Affiliation(s)
- Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | - Aaron Liew
- Newcastle UniversityInstitute of Cellular Medicine4th Floor, William Leech BuildingFramlington PlaceNewcastle upon TyneUKNE2 4HH
- National University of Ireland Galway (NUIG), Portiuncula University Hospital & Galway University Hospital, Saolta University Health Care GroupGalwayIreland
| | - Vish Bhattacharya
- Queen Elizabeth HospitalDepartment of General and Vascular SurgeryQueen Elizabeth AvenueSheriff HillGatesheadTyne and WearUKNE9 6SX
| | - James Shaw
- Newcastle UniversityInstitute of Cellular Medicine4th Floor, William Leech BuildingFramlington PlaceNewcastle upon TyneUKNE2 4HH
| | - Gerard Stansby
- Freeman HospitalNorthern Vascular CentreNewcastle upon TyneUKNE7 7DN
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Parikh PP, Lassance-Soares RM, Shao H, Regueiro MM, Li Y, Liu ZJ, Velazquez OC. Intramuscular E-selectin/adeno-associated virus gene therapy promotes wound healing in an ischemic mouse model. J Surg Res 2018; 228:68-76. [DOI: 10.1016/j.jss.2018.02.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/05/2018] [Accepted: 02/27/2018] [Indexed: 12/01/2022]
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Abstract
BACKGROUND Peripheral artery disease (PAD) is associated with a high clinical and socioeconomic burden. Treatments to alleviate the symptoms of PAD and decrease the risks of amputation and death are a high societal priority. A number of growth factors have shown a potential to stimulate angiogenesis. Growth factors delivered directly (as recombinant proteins), or indirectly (e.g. by viral vectors or DNA plasmids encoding these factors), have emerged as a promising strategy to treat patients with PAD. OBJECTIVES To assess the effects of growth factors that promote angiogenesis for treating people with PAD of the lower extremities. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Specialised Register (June 2016) and CENTRAL (2016, Issue 5). We searched trial registries for details of ongoing or unpublished studies. We also checked the reference lists of relevant publications and, if necessary, tried to contact the trialists for details of the studies. SELECTION CRITERIA We included randomised controlled trials comparing growth factors (delivered directly or indirectly) with no intervention, placebo or any other intervention not based on the growth factor's action in patients with PAD of the lower extremities. The primary outcomes were limb amputation, death and adverse events. The secondary outcomes comprised walking ability, haemodynamic measures, ulceration and rest pain. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials and assessed the risk of bias. We used outcomes of the studies at low risk of bias for the main analysis and of all studies in the sensitivity analyses. We calculated odds ratios (OR) for dichotomous outcomes and mean differences for continuous outcomes with 95% confidence intervals (CI). We evaluated statistical heterogeneity using the I2 statistic and Cochrane's Q test. We conducted meta-analysis for the overall effect and for each growth factor as a subgroup analysis using OR in a fixed-effect model. We evaluated the robustness of the results in a sensitivity analysis using risk ratio (RR) and/or a random-effects model. We also assessed the quality of the evidence for each outcome. MAIN RESULTS We included 20 trials in the review and used 14 studies (on approximately 1400 participants) with published results in the analyses. Six published studies compared fibroblast growth factors (FGF), four studies hepatocyte growth factors (HGF) and another four studies vascular endothelial growth factors (VEGF), versus placebo or no therapy. Six of these studies exclusively or mainly investigated participants with intermittent claudication and eight studies exclusively participants with critical limb ischaemia. Follow-up generally ranged from three months to one year. Two small studies provided some data at 2 years and one of them also at 10 years.The direction and size of effects for growth factors on major limb amputations (OR 0.99, 95% CI 0.71 to 1.38; 10 studies, N = 1075) and death (OR 0.99, 95% CI 0.69 to 1.41; 12 studies, N = 1371) at up to two years are uncertain. The quality of the evidence is low due to risk of bias and imprecision (at one year, moderate-quality evidence due to imprecision). However, growth factors may decrease the rate of any limb amputations (OR 0.56, 95% CI 0.31 to 0.99; 6 studies, N = 415). The quality of the evidence is low due to risk of bias and selective reporting.The direction and size of effects for growth factors on serious adverse events (OR 1.09, 95% CI 0.79 to 1.50; 13 studies, N = 1411) and on any adverse events (OR 1.10, 95% CI 0.73 to 1.64; 4 studies, N = 709) at up to two years are also uncertain. The quality of the evidence is low due to risk of bias and imprecision (for serious adverse events at one year, moderate-quality evidence due to imprecision).Growth factors may improve haemodynamic measures (low-quality evidence), ulceration (very low-quality evidence) and rest pain (very low-quality evidence) up to one year, but they have little or no effect on walking ability (low-quality evidence). We did not identify any relevant differences in effects between growth factors (FGF, HGF and VEGF). AUTHORS' CONCLUSIONS The results of this review do not support the use of therapy with the growth factors FGF, HGF or VEGF in people with PAD of the lower extremities to prevent death or major limb amputation or to improve walking ability. However, the use of these growth factors may improve haemodynamic measures and decrease the rate of any limb amputations (probably due to preventing minor amputations) with an uncertain effect on adverse events; an improvement of ulceration and rest pain is very uncertain. New trials at low risk of bias are needed to generate evidence with more certainty.
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Affiliation(s)
- Vitali Gorenoi
- Hannover Medical SchoolEvidence based Medicine & Health Technology Assessment Working Group, Institute for Epidemiology, Social Medicine and Health Systems ResearchCarl‐Neuberg‐Str. 1HannoverGermany30625
| | - Michael U Brehm
- Hannover Medical SchoolDepartment for Cardiology and AngiologyCarl‐Neuberg‐Str. 1HannoverGermany30265
| | - Armin Koch
- Institute for Biometry, Hannover Medical SchoolCarl‐Neuberg‐Str. 1HannoverGermany30625
| | - Anja Hagen
- Hannover Medical SchoolEvidence based Medicine & Health Technology Assessment Working Group, Institute for Epidemiology, Social Medicine and Health Systems ResearchCarl‐Neuberg‐Str. 1HannoverGermany30625
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Boden J, Lassance-Soares RM, Wang H, Wei Y, Spiga MG, Adi J, Layman H, Yu H, Vazquez-Padron RI, Andreopoulos F, Webster KA. Vascular Regeneration in Ischemic Hindlimb by Adeno-Associated Virus Expressing Conditionally Silenced Vascular Endothelial Growth Factor. J Am Heart Assoc 2016; 5:e001815. [PMID: 27231018 PMCID: PMC4937238 DOI: 10.1161/jaha.115.001815] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/19/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Critical limb ischemia (CLI) is the extreme manifestation of peripheral artery disease, a major unmet clinical need for which lower limb amputation is the only option for many patients. After 2 decades in development, therapeutic angiogenesis has been tested clinically via intramuscular delivery of proangiogenic proteins, genes, and stem cells. Efficacy has been modest to absent, and the largest phase 3 trial of gene therapy for CLI reported a worsening trend of plasmid fibroblast growth factor. In all clinical trials to date, gene therapy has used unregulated vectors with limited duration of expression. Only unregulated extended expression vectors such as adeno-associated virus (AAV) and lentivirus have been tested in preclinical models. METHODS AND RESULTS We present preclinical results of ischemia (hypoxia)-regulated conditionally silenced (CS) AAV-human vascular endothelial growth factor (hVEGF) gene delivery that shows efficacy and safety in a setting where other strategies fail. In a BALB/c mouse model of CLI, we show that gene therapy with AAV-CS-hVEGF, but not unregulated AAV or plasmid, vectors conferred limb salvage, protection from necrosis, and vascular regeneration when delivered via intramuscular or intra-arterial routes. All vector treatments conferred increased capillary density, but organized longitudinal arteries were selectively generated by AAV-CS-hVEGF. AAV-CS-hVEGF therapy reversibly activated angiogenic and vasculogenic genes, including Notch, SDF1, Angiopoietin, and Ephrin-B2. Reoxygenation extinguished VEGF expression and inactivated the program with no apparent adverse side effects. CONCLUSIONS Restriction of angiogenic growth factor expression to regions of ischemia supports the safe and stable reperfusion of hindlimbs in a clinically relevant murine model of CLI.
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Affiliation(s)
- Jeffrey Boden
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Roberta Marques Lassance-Soares
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Huilan Wang
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Yuntao Wei
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Maria-Grazia Spiga
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL
| | - Jennipher Adi
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL
| | - Hans Layman
- Department of Bioengineering, University of Miami Miller School of Medicine, Miami, FL
| | - Hong Yu
- Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Roberto I Vazquez-Padron
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Fotios Andreopoulos
- Department of Bioengineering, University of Miami Miller School of Medicine, Miami, FL
| | - Keith A Webster
- Department of Molecular and Cellular Pharmacology, University of Miami Miller School of Medicine, Miami, FL Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, FL Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Sarker M, Chen X, Schreyer D. Experimental approaches to vascularisation within tissue engineering constructs. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2015; 26:683-734. [DOI: 10.1080/09205063.2015.1059018] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Katwal AB, Konkalmatt PR, Piras BA, Hazarika S, Li SS, John Lye R, Sanders JM, Ferrante EA, Yan Z, Annex BH, French BA. Adeno-associated virus serotype 9 efficiently targets ischemic skeletal muscle following systemic delivery. Gene Ther 2013; 20:930-8. [PMID: 23535898 PMCID: PMC3758463 DOI: 10.1038/gt.2013.16] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 01/22/2013] [Accepted: 02/20/2013] [Indexed: 02/07/2023]
Abstract
Targeting therapeutic gene expression to the skeletal muscle following intravenous (IV) administration is an attractive strategy for treating peripheral arterial disease (PAD), except that vector access to the ischemic limb could be a limiting factor. As adeno-associated virus serotype 9 (AAV-9) transduces skeletal muscle at high efficiency following systemic delivery, we employed AAV-9 vectors bearing luciferase or enhanced green fluorescent protein (eGFP) reporter genes to test the hypothesis that increased desialylation of cell-surface glycans secondary to hindlimb ischemia (HLI) might help offset the reduction in tissue perfusion that occurs in mouse models of PAD. The utility of the creatine kinase-based (CK6) promoter for restricting gene expression to the skeletal muscle was also examined by comparing it with the cytomegalovirus (CMV) promoter after systemic administration following surgically induced HLI. Despite reduced blood flow to the ischemic limbs, CK6 promoter-driven luciferase activities in the ischemic gastrocnemius (GA) muscles were ∼34-, ∼28- and ∼150-fold higher than in the fully perfused contralateral GA, heart and liver, respectively, 10 days after IV administration. Furthermore, luciferase activity from the CK6 promoter in the ischemic GA muscles was ∼twofold higher than with CMV, while in the liver CK6-driven activity was ∼42-fold lower than with CMV, demonstrating that the specificity of ischemic skeletal muscle transduction can be further improved with the muscle-specific promoters. Studies with Evans blue dye and fluorescently labeled lectins revealed that vascular permeability and desialylation of the cell-surface glycans were increased in the ischemic hindlimbs. Furthermore, AAV9/CK6/Luc vector genome copy numbers were ∼sixfold higher in the ischemic muscle compared with the non-ischemic muscle in the HLI model, whereas this trend was reversed when the same genome was packaged in the AAV-1 capsid (which binds sialylated, as opposed to desialylated glycans), further underscoring the importance of desialylation in the ischemic enhancement of transduction displayed by AAV-9. Taken together, these findings suggest two complementary mechanisms contributing to the preferential transduction of ischemic muscle by AAV-9: increased vascular permeability and desialylation. In conclusion, ischemic muscle is preferentially targeted following systemic administration of AAV-9 in a mouse model of HLI. Unmasking of the primary AAV-9 receptor as a result of ischemia may contribute importantly to this effect.
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Affiliation(s)
- A B Katwal
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, VA 22903, USA
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Abstract
The generalized term 'peripheral vascular disease' (PVD) may be used to refer to vascular disorders in any non-coronary arterial bed. The more specific term 'peripheral arterial disease' (PAD) is used to refer to a more specific process, atherosclerotic disease of the lower extremities. PAD is common. Conservative estimates suggest more than 8 million Americans may be affected by PAD. Since atherosclerosis is a systemic process, PAD should be identified as a coronary heart disease risk equivalent. However, PAD remains an under-diagnosed and under-recognized risk for cardiovascular morbidity and mortality. PAD symptoms may range from non-specific ambulatory leg complaints, to typical symptoms of intermittent claudication to critical limb ischaemia with rest pain, gangrene or ulceration. These symptoms directly impact quality of life and may affect functional capacity. There are two therapeutic goals for patients with PAD: first, to reduce the risk of cardiovascular events and second, to manage the lower extremity symptoms. This manuscript reviews the medical management of patients with PAD, briefly discussing the goals of cardiovascular risk factor modification and then focusing on pharmacological management strategies for patients with intermittent claudication and critical limb ischaemia.
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Affiliation(s)
- Farzana Nawaz Ali
- Department of Family Medicine, University Hospitals Case Medical Center, Cleveland, OH 44106, USA
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Transient embolization with microspheres of polyhydroxyalkanoate renders efficient adenoviral transduction of pancreatic capillary in vivo. J Gene Med 2012; 14:530-9. [DOI: 10.1002/jgm.2650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Mughal NA, Russell DA, Ponnambalam S, Homer-Vanniasinkam S. Gene therapy in the treatment of peripheral arterial disease. Br J Surg 2011; 99:6-15. [PMID: 22068822 DOI: 10.1002/bjs.7743] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peripheral arterial disease remains a significant global health burden despite revolutionary improvements in endovascular techniques over the past decade. The durability of intervention for critical limb ischaemia is poor, and the condition is associated with high morbidity and mortality rates. To address this deficiency, alternative therapeutic options are being explored. Advances in the fields of gene therapy and therapeutic angiogenesis have led to these being advocated as potential future treatments. METHODS Relevant medical literature from PubMed, Embase, the Cochrane Library and Google Scholar from the inception of these databases to June 2011 was reviewed. RESULTS Encouraging outcomes in preclinical trials using a variety of proangiogenic growth factors have led to numerous efficacy and safety studies. However, no clinical study has shown significant benefit for gene therapy over placebo. CONCLUSION Identifying the optimal site for gene delivery, choice of vector and duration of treatment is needed if gene therapy is to become a credible therapeutic option for peripheral arterial disease.
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Affiliation(s)
- N A Mughal
- Leeds Vascular Institute, Leeds General Infirmary, University of Leeds, Leeds, UK.
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Belch J, Hiatt WR, Baumgartner I, Driver IV, Nikol S, Norgren L, Van Belle E. Effect of fibroblast growth factor NV1FGF on amputation and death: a randomised placebo-controlled trial of gene therapy in critical limb ischaemia. Lancet 2011; 377:1929-37. [PMID: 21621834 DOI: 10.1016/s0140-6736(11)60394-2] [Citation(s) in RCA: 230] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with critical limb ischaemia have a high rate of amputation and mortality. We tested the hypothesis that non-viral 1 fibroblast growth factor (NV1FGF) would improve amputation-free survival. METHODS In this phase 3 trial (EFC6145/TAMARIS), 525 patients with critical limb ischaemia unsuitable for revascularisation were enrolled from 171 sites in 30 countries. All had ischaemic ulcer in legs or minor skin gangrene and met haemodynamic criteria (ankle pressure <70 mm Hg or a toe pressure <50 mm Hg, or both, or a transcutaneous oxygen pressure <30 mm Hg on the treated leg). Patients were randomly assigned to either NV1FGF at 0·2 mg/mL or matching placebo (visually identical) in a 1:1 ratio. Randomisation was done with a central interactive voice response system by block size 4 and was stratified by diabetes status and country. Investigators, patients, and study teams were masked to treatment. Patients received eight intramuscular injections of their assigned treatment in the index leg on days 1, 15, 29, and 43. The primary endpoint was time to major amputation or death at 1 year analysed by intention to treat with a log-rank test using a multivariate Cox proportional hazard model. This trial is registered with ClinicalTrials.gov, number NCT00566657. FINDINGS 259 patients were assigned to NV1FGF and 266 to placebo. All 525 patients were analysed. The mean age was 70 years (range 50-92), 365 (70%) were men, 280 (53%) had diabetes, and 248 (47%) had a history of coronary artery disease. The primary endpoint or components of the primary did not differ between treatment groups, with major amputation or death in 86 patients (33%) in the placebo group, and 96 (36%) in the active group (hazard ratio 1·11, 95% CI 0·83-1·49; p=0·48). No significant safety issues were recorded. INTERPRETATION TAMARIS provided no evidence that NV1FGF is effective in reduction of amputation or death in patients with critical limb ischaemia. Thus, this group of patients remains a major therapeutic challenge for the clinician. FUNDING Sanofi-Aventis, Paris, France.
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Affiliation(s)
- Jill Belch
- The Institute of Cardiovascular Research, Vascular and Inflammatory Diseases Research Unit, Ninewells Hospital and Medical School, Dundee, UK.
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Sneider EB, Nowicki PT, Messina LM. Regenerative medicine in the treatment of peripheral arterial disease. J Cell Biochem 2010; 108:753-61. [PMID: 19711369 DOI: 10.1002/jcb.22315] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The last decade has witnessed a dramatic increase in the mechanistic understanding of angiogenesis and arteriogenesis, the two processes by which the body responds to obstruction of large conduit arteries. This knowledge has been translated into novel therapeutic approaches to the treatment of peripheral arterial disease, a condition characterized by progressive narrowing of lower extremity arteries and heretofore solely amenable to surgical revascularization. Clinical trials of molecular, genetic, and cell-based treatments for peripheral artery obstruction have generally provided encouraging results.
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Affiliation(s)
- Erica B Sneider
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA
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