Angiogenic gene therapy. A leg to stand on?

Introduction to gene therapy: a clinical aftermath

Despite three decades of huge progress in molecular genetics, in cloning of disease causative gene as well as technology breakthroughs in viral biotechnology, out of thousands of gene therapy clinical trials that have been initiated, only very few are now reaching regulatory approval. We shall review some of the major hurdles, and based on the current either positive or negative examples, we try to initiate drawing a learning curve from experience and possibly identify the major drivers for future successful achievement of human gene therapy trials.

Growth factors for therapeutic angiogenesis in peripheral arterial disease

PURPOSE OF REVIEW

Peripheral arterial disease is a common disease that has few treatment options. Angiogenesis is defined as the growth of new blood vessels from preexisting vasculature. Therapeutic angiogenesis is an investigational method that uses vascular growth to alleviate disorders of tissue ischemia, such as coronary artery disease and peripheral arterial disease. There have been tremendous changes in the field of therapeutic angiogenesis over the past decade, and there is much promise for the future.

RECENT FINDINGS

Initial preclinical work with cytokine growth factor delivery resulted in a great deal of enthusiasm, but larger clinical studies have failed to achieve similar success. With an increased understanding of the complex mechanisms involved in angiogenesis, gene therapy and cell therapy have moved to the forefront of therapeutic angiogenesis. Novel therapies which target multiple different angiogenic pathways are also being developed and tested.

SUMMARY

Therapeutic angiogenesis is an exciting field that continues to evolve. This review will focus on the different growth factors being used, their routes of delivery, the results of clinical trials, and some of the novel therapies being developed.

Laser revascularization of ischemic skeletal muscle

BACKGROUND

Clinical trials have shown that transmyocardial laser revascularization is an effective secondary treatment for ischemic heart disease patients. Laser revascularization may also provide an alternative method for treating peripheral vascular disease.

METHODS

The purpose of this study was to investigate the potential for laser revascularization in ischemic skeletal muscle. Eighteen rabbits (3-4 kg) were instrumented chronically with transit time ultrasound flowprobes on both common iliac arteries. All rabbits performed graded exercise tests on a treadmill where maximal blood flow was recorded. Unilateral hindlimb ischemia was produced by ligation of one femoral artery. At week 3 postligation, 10 rabbits received laser therapy and 8 underwent a sham surgery. In each of four muscles (gracilius, medialis, sartorius, and biceps femoris) 5 to 22 laser channels were created (average = 52 channels per leg).

RESULTS

At week 3 postligation the maximal blood flow of the ischemic limb for the treated group was 64 +/- 3 ml/min (mean +/- SEM) and at 6 weeks postlaser therapy maximal blood flow increased to 75 +/- 5 ml/min. The sham surgery group had a maximal blood flow of 58 +/- 4 ml/min at week 3 postligation and 66 +/- 3 ml/min at week 6 postsham surgery.

CONCLUSION

These results indicate that laser therapy does not induce angiogenesis and vascular remodeling in the ischemic hindlimb of a rabbit which exceeds that seen with a sham surgery.

Endogenous vascular remodeling in ischemic skeletal muscle: a role for nitric oxide

To test the hypothesis that nitric oxide (NO) production is essential for endogenous vascular remodeling in ischemic skeletal muscle, 22 New Zealand White rabbits were chronically instrumented with transit-time flow probes on the common iliac arteries and underwent femoral ligation to produce unilateral hindlimb ischemia. Iliac blood flow and arterial pressure were recorded at rest and during a graded exercise test. An osmotic pump connected to a femoral arterial catheter continuously delivered N-nitro-l-arginine methyl ester (a NO synthase inhibitor) or a control solution (N-nitro-d-arginine methyl ester or phenylephrine) to the ischemic limb over a 2-wk period. At 1, 3, and 6 wk after femoral ligation, maximal treadmill exercise blood flow in the ischemic limb was reduced compared with baseline in each group. However, maximal exercise blood flow was significantly (P < 0.05) lower in the l-NAME-treated group than in controls for the duration of the study: 48 +/- 4 vs. 60 +/- 5 ml/min at 6 wk. Consistent with the reduction in maximal blood flow response, the duration of voluntary exercise was also substantially (P < 0.05) shorter in the l-NAME-treated group: 539 +/- 67 vs. 889 +/- 87 s. Resting blood flow was unaffected by femoral ligation in either group. The results of this study show that endogenous vascular remodeling, which partially alleviated the initial deficit in blood flow, was interrupted by NO synthase inhibition. Therefore, we conclude that NO is essential for endogenous collateral development and angiogenesis in ischemic skeletal muscle in the rabbit.

Growth factor activation of the estrogen receptor in vascular cells occurs via a mitogen-activated protein kinase-independent pathway

The classical estrogen receptor ERalpha mediates many of the known cardiovascular effects of estrogen and is expressed in male and female vascular cells. Estrogen-independent activation of ERalpha is known to occur in cells from reproductive tissues, but has not been investigated previously in vascular cells. In this study, transient transfection assays in human saphenous vein smooth muscle cells (HSVSMC) and pulmonary vein endothelial cells (PVEC) demonstrated ERalpha-dependent activation of estrogen response element-based, and vascular endothelial growth factor-based reporter plasmids by both estrogen-deficient FBS (ED-FBS) and EGF. In nonvascular cells, ERalpha-mediated gene expression can be activated via mitogen-activated protein (MAP) kinase- induced phosphorylation of serine 118 of ERalpha. However, in vascular cells, we found that pharmacologic inhibition of MAP kinase did not alter EGF-mediated ERalpha activation. In addition, a mutant ER containing an alanine-for-serine substitution at position 118 was activated to the same degree as the wild-type receptor by ED-FBS and EGF in both HSVSMC and PVEC. Furthermore, constitutively active MAP kinase kinase (MAPKK) activated ERalpha in Cos1 cells as expected, but MAPKK inhibited ER activation in PVEC. We conclude that growth factors also stimulate ERalpha-mediated gene expression in vascular cells, but find that this occurs via a MAP kinase-independent pathway distinct from that reported previously in nonvascular cells.