Implantation Of Mononuclear Cells Research Articles

Prognostic Factors After Bone Marrow-Derived Mononuclear Cell Implantation in No-Option Chronic Limb-Threatening Ischemia Patients with Atherosclerotic Lower Extremity Artery Disease

Previous studies have reported the efficacy and safety of therapeutic angiogenesis through bone marrow-derived mononuclear cell (BM-MNC) implantation in patients with no-option chronic limb-threatening ischemia (CLTI) from atherosclerotic lower extremity artery disease (LEAD). However, uncertain clinical prognostic factors impact treatment outcomes. This study aimed to elucidate the long-term outcomes of patients with atherosclerotic LEAD-derived no-option CLTI after BM-MNC implantation and to identify prognostic factors.In this retrospective, single-center, observational study, the primary endpoints included the long-term prognosis of BM-MNC implantation and factors influencing 1-year outcomes. A total of 92 limbs in 84 patients were analyzed in the final cohort (mean age: 67 years; male, 65%). The 5- and 10-year overall survival rates were 50.0% and 31.0%, respectively, while the 5- and 10-year amputation-free survival rates were 37.6% and 23.3%, respectively. Multivariate logistic analysis linked all-cause mortality to age ≥ 70 years, hemodialysis, smoking, and a controlling nutrition status score ≥ 5. Major amputation or mortality was associated with male sex, hemodialysis, and C-reactive protein levels ≥ 3.0 mg/dL. No adverse events were associated with therapeutic angiogenesis.These findings endorse the feasibility and safety of BM-MNC implantation for patients with no-option CLTI due to atherosclerotic LEAD. Moreover, the study highlights the significance of several prognostic factors, including advanced age, hemodialysis, smoking, and inflammatory markers, in influencing the long-term outcomes of this treatment.

Systematic literature review to inform the Portuguese recommendations for the management of Raynaud's phenomenon and digital ulcers in systemic sclerosis and other connective tissue diseases.

To perform a systematic literature review (SLR) aimed at evaluating the efficacy and safety of pharmacological and non-pharmacological treatments for Raynaud's phenomenon (RP) and digital ulcers (DU) in patients with systemic sclerosis (SSc) and other connective tissue diseases (CTD), in order to inform the Portuguese recommendations for managing RP and DU in these patients. A SLR was conducted until May 2022 to identify studies assessing the efficacy and safety of pharmacological and non-pharmacological interventions for RP and DU in SSc and other CTD. Eligible study designs included randomized controlled trials (RCTs), controlled clinical trials, and their extensions for assessing efficacy and safety of interventions. Observational studies with a comparator were included for evaluating the efficacy and safety of non-pharmacological interventions and safety of pharmacological interventions. The risk of bias of each study was assessed using standard tools. Out of 71 publications meeting the inclusion criteria, 59 evaluated pharmacological and 12 non-pharmacological interventions. We found moderate quality evidence supporting the efficacy of calcium channel blockers, phosphodiesterase-5 inhibitors, and intravenous prostacyclin analogues in reducing RP frequency, severity, and duration. Intravenous iloprost had a small to moderate effect size in improving DU healing. Phosphodiesterase-5 inhibitors were effective in reducing total DU count, new DU occurrence, and enhancing DU healing. Bosentan effectively prevented new DU in SSc patients. No new safety concerns were associated with these treatments. The studies on non-pharmacological interventions were, in general, of low quality, and had a small sample size. Warming measures decreased frequency and duration of RP attacks; laser therapy improved RP-related outcomes; local oxygen-ozone therapy improved RP outcomes as an add-on therapy; bone marrow mononuclear cell implantation improved DU-associated pain; periarterial sympathectomy and vascular bypass reduced DU number and finger amputation risk. The available evidence supports the efficacy and safety of pharmacological interventions, namely nifedipine, sildenafil, iloprost, and bosentan in treating RP and DU in patients with SSc and other CTD. Scarce and low-quality evidence does support the use of some non-pharmacological interventions but with only a modest effect size. This SLR underscores the limited availability of high-quality evidence for determining the optimal treatment.

Abstract 18185: A Multicenter Prospective Trial of Therapeutic Angiogenesis Using Bone Marrow-Derived Mononuclear for Patients With Critical Limb-Threatening Ischemia Caused by Thromboangiitis Obliterans

Background: Thromboangiitis obliterans (TAO) can develop critical limb-threatening ischemia (CLTI). Despite conventional treatments, such as smoking cessation or revascularization, young patients require limb amputation. Therapeutic angiogenesis using bone marrow-derived mononuclear cell (BM-MNC) implantation has demonstrated long-term efficacy and safety in patients with CLTI, particularly those with TAO. To expand BM-MNC implantation in clinical practice, further evidence is required in CLTI patients with TAO. We aimed to determine the efficacy of BM-MNC implantation in a prospective trial. Methods: This multicenter, prospective, interventional trial was performed under an advanced medical care program. We enrolled 22 patients with CLTI and skin perfusion pressure (SPP) <30 mmHg; they underwent BM-MNC implantation within 28 days (Figure.1). The follow-up period was 180 days, and the primary endpoint was an improvement in the SPP value in the affected target limb 180 days after the implantation. One patient dropped out from the follow-up. Results: The mean age was 47.6 years (male: 90.5%, Fontaine classification IV: 57.1%). The SPP value significantly improved on day 180 (p<0.001) (Figure. 2). The secondary endpoints, i.e., numerical rating scale scores and transcutaneous oxygen pressure values significantly improved within day 180. The 3-year major amputation-free and overall survival probability in the safety analysis set were 95.5% and 89.5%, respectively (Figure. 3). No severe adverse events occurred. Conclusions: We believe that the BM-MNC implantation will likely become a feasible and safe therapy for CLTI patients caused by TAO.

Prognostic Factors and Predictors of Mortality in Patients with Critical Limb Ischemia: A Current Clinical Perspective

Critical limb ischemia (CLI) is an end-stage peripheral arterial disease (PAD). Mortality, limb loss, pain, and diminished health-related quality of life are highly prevalent in CLI patients. 20 to 50% CLI Mortality is intensely observed within the first six months to five years of CLI diagnosis, respectively. Prognostic treatments, including autologous bone marrow mononuclear cell implantation (BMMNCI), low-intensity pulsed ultrasound (LIPUS) technology, and medication therapy using Cilostazol, are available. In addition, required prognostic factors such as timely access to medical care can control the death. Impaired mobility, old age, low BMI, CKD (end-stage), T2DM, COPD (oxygen-dependent), HF, smoking, high Wound, Ischemia, and Foot Infection are the additional predictors for CLI-related mortality. Due to the poor survival and prognosis, it is crucial to identify the prognostic factors that will lead to better clinical benefits, including amputation-free survival rate and improved quality of life. This review highlights the current clinical perspective on the prognostic factors and predictors of mortality in CLI patients.

Relationship between cell number and clinical outcomes of autologous bone-marrow mononuclear cell implantation in critical limb ischemia

Cell therapy using intramuscular injections of autologous bone-marrow mononuclear cells (BM-MNCs) improves clinical symptoms and can prevent limb amputation in atherosclerotic peripheral arterial disease (PAD) patients with critical limb ischemia (CLI). The purpose of this study was to evaluate the effects of the number of implanted BM-MNCs on clinical outcomes in atherosclerotic PAD patients with CLI who underwent cell therapy. This study was a retrospective observational study with median follow-up period of 13.5 years (range, 6.8–15.5 years) from BM-MNC implantation procedure. The mean number of implanted cells was 1.2 ± 0.7 × 109 per limb. There was no significant difference in number of BM-MNCs implanted between the no major amputation group and major amputation group (1.1 ± 0.7 × 109 vs. 1.5 ± 0.8 × 109 per limb, P = 0.138). There was also no significant difference in number of BM-MNCs implanted between the no death group and death group (1.5 ± 0.9 × 109 vs. 1.8 ± 0.8 × 109 per patient, P = 0.404). Differences in the number of BM-MNCs (mean number, 1.2 ± 0.7 × 109 per limb) for cell therapy did not alter the major amputation-free survival rate or mortality rate in atherosclerotic PAD patients with CLI. A large number of BM-MNCs will not improve limb salvage outcome or mortality.

Therapeutic Angiogenesis Using Bone Marrow-Derived Mononuclear Cell Implantation for Patients With Critical Limb-Threatening Ischemia Caused by Thromboangiitis Obliterans - Study Protocol for a Multicenter Prospective Interventional Trial.

Background: Patients with thromboangiitis obliterans (TAO) can develop critical limb-threatening ischemia (CLTI) and require limb amputation. Smoking cessation and exercise therapy are recommended as standard treatments, and revascularization by bypass surgery or endovascular therapy (EVT) is required for patients with CLTI. However, there are many cases in which revascularization is difficult because of vascular characteristics, and the patency rate after revascularization remains unsatisfactory. Therapeutic angiogenesis using bone marrow-derived mononuclear cell (BM-MNC) implantation is used clinically, with many trials demonstrating long-term efficacy and safety of the technique in patients with CLTI, especially that caused by TAO. To expand the use of BM-MNCs implantation in clinical practice, further evidence is required in patients with CLTI caused by TAO.Methods and Results: This trial is a multicenter, prospective, non-randomized interventional trial of an Advanced Medicine B treatment approach. We aim to enroll 25 patients aged 20–80 years with Fontaine classification Stage III or IV, who will undergo BM-MNC implantation. The primary endpoint is the improvement in skin perfusion pressure of the target limb 180 days after BM-MNC implantation, whereas secondary endpoints are improvements in rest pain or ulcer size. We will also investigate rates of major or minor amputation, survival, and adverse events during follow-up.Conclusions: BM-MNC implantation is expected to be an efficacious and feasible treatment for patients with CLTI caused by TAO.

Impact of Therapeutic Angiogenesis Using Autologous Bone Marrow-derived Mononuclear Cell Implantation in Patients with No-option Critical Limb Ischemia.

Recently, the limb salvage rate of patients with critical limb ischemia (CLI) has been improved due to the development of revascularization and wound care treatment. However, many patients with CLI are refractory to standard treatments, including revascularization such as endovascular treatment or surgical bypass. Establishment of a new cell therapy is required to improve the limb salvage rate and prognosis in patients with CLI. In 1997, endothelial progenitor cells were found to be derived from the bone marrow to circulate as CD34 surface antigen positive cells in peripheral blood and to affect therapeutic angiogenesis in ischemic tissues. Later, therapeutic angiogenesis using autologous bone marrow-derived mononuclear cell (BM-MNC) implantation was performed for patients with no-option CLI in clinical practice. Several reports showed the safety and efficacy of the BM-MNC implantation in patients with CLI caused by arteriosclerosis obliterans, thromboangiitis obliterans (TAO), and collagen diseases. In particular, in patients with CLI caused by TAO, limb salvage rate was significantly improved compared with standard treatments. The BM-MNC implantation may be feasible and safe in patients with no-option CLI. Here, we review the efficacy of BM-MNC implantation in no-option CLI, with a focus on therapeutic angiogenesis.

Long-Term Clinical Outcomes of Autologous Bone Marrow Mononuclear Cell Implantation in Patients With Severe Thromboangiitis Obliterans.

Patients with severe Buerger disease, also known as thromboangiitis obliterans (TAO), are at risk of major limb amputation. It has been shown that autologous bone marrow mononuclear cell (BM-MNC) implantation improves the condition of critical limb ischemia in TAO patients. This study was conducted to further clarify the long-term (>10 years) results of autologous BM-MNC implantation in patients with TAO. An observational study was conducted of the long-term results of BM-MNC implantation in 47 lower limbs of 27 patients with TAO. The mean (±SD) follow-up period was 12.0±8.6 years. There was no major amputation event up to 10 years of follow-up in patients treated with BM-MNC implantation. The overall amputation-free survival rates were significantly higher in patients who underwent BM-MNC implantation than in internal controls and historical controls. There was no significant difference in amputation-free survival rates between the historical and internal controls. There was also no significant difference in overall survival between patients who underwent BM-MNC implantation and the historical controls. BM-MNC transplantation successfully prevented major limb amputation over a period of >10 years in patients with severe TAO who had no other therapeutic options.

Use of autologous peripheral blood mononuclear cells in a case of diabetic foot

The implantation of peripheral blood mononuclear cells (PBMNC), an autologous concentrate with high angiogenic and regenerative capability is an innovative therapeutic approach in the treatment of peripheral arteriopathies of patients with critical limb ischemia. We describe the case of a 59-year-old patient with type 2 diabetes mellitus who had a gangrene of the right toe. The critical limb ischemia required an angioplasty that was ineffective due to the widespread, obstructive, intractable and calcific disease of the distal tibial vessels and of the foot vessels. Because of the therapeutic failure, being the patient otherwise candidated for major amputation, it was decided to use a PBMNC therapy. This approach consists in the inoculation in the perilesional area and along the vascular axes of the affected lower limb of a concentrate of mononuclear cells taken from peripheral blood by using a selective filtration separation system. The patient underwent to amputation of the first necrotic toe and three PBMNC treatment sessions with complete surgical wound haeling and limb rescue. KEYWORDS diabetes mellitus; critical limb ischemia; mononuclear cells therapy.

Review of the Long-term Effects of Autologous Bone-Marrow Mononuclear Cell Implantation on Clinical Outcomes in Patients with Critical Limb Ischemia

Critical limb ischemia (CLI) is associated with a high risk of limb amputation. It has been shown that cell therapy is safe and has beneficial effects on ischemic clinical symptoms in patients with CLI. The aim of this study was to further investigate the outcomes of intramuscular injection of autologous bone-marrow mononuclear cells (BM-MNCs) in a long-term follow-up period in atherosclerotic peripheral arterial disease (PAD) patients who have no optional therapy. This study was a retrospective and observational study that was carried out to evaluate long-term clinical outcomes in 42 lower limbs of 30 patients with atherosclerotic PAD who underwent BM-MNC implantation. The median follow-up period was 9.25 (range, 6–16) years. The overall amputation-free rates were 73.0% at 5 years after BM-MNC implantation and 70.4% at 10 years in patients with atherosclerotic PAD. The overall amputation-free rates at 5 years and at 10 years after implantation of BM-MNCs were significantly higher in atherosclerotic PAD patients than in internal controls and historical controls. There were no significant differences in amputation rates between the internal control group and historical control group. The rate of overall survival was not significantly different between the BM-MNC implantation group and the historical control group. Implantation of autologous BM-MNCs is feasible for a long-term follow-up period in patients with CLI who have no optional therapy.

Impact of Therapeutic Angiogenesis Using Autologous Bone Marrow-Derived Mononuclear Cells Implantation in Critical Limb Ischemia With Scleroderma - Subanalysis of the Long-Term Clinical Outcomes Survey.

Many patients with collagen disease (CD), particularly scleroderma (SSc), develop critical limb ischemia (CLI), which leads to limb amputation. However, conventional therapies, including revascularization via surgical bypass, showed poor outcomes in CLI patients with CD. Many CLI patients with SSc showed poor responses to combination therapies including intravenous iloprost, PDE-5 inhibitors, and bosentan. Therefore, new methods of improving the peripheral circulation for limb salvage are required. This study was a subanalysis of the long-term clinical outcomes after autologous bone marrow-derived mononuclear cells (BM-MNC) in CLI patients with SSc. We assessed no-option CLI patients with CD who underwent BM-MNC implantation at 10 institutes; 69 patients (39 with SSc-related diseases (SSc group) and 30 with other CDs (non-SSc group)), were included. The median follow-up duration was 36.5 months. The 10-year overall survival rate was 59.1% in the SSc group and 82.4% in the non-SSc group. The 10-year major amputation-free rates were 97.4% and 82.6%, respectively. The number of major or minor amputations in the SSc group trended to be less than that in the non-SSc group. Significant improvements in visual analog scale scores were observed in both groups. The BM-MNC implantation may be feasible in no-option CLI patients with CD. In the SSc group, limb salvage rate tended to be higher than in the non-SSc group.

Cell-Based Therapy in Cardiac Regeneration: An Overview.

Although pioneering preclinical research on the use of cell therapy for cardiac regeneration was conducted in the last quarter of the 20th century,1,2 a preponderance of advances have occurred in the 21st century, making this a relatively young field. In the first important clinical trial of cardiac cell therapy, begun in 2001, Menasche et al3 implanted autologous skeletal myoblasts into postinfarct scar at the time of coronary artery bypass surgery. Although the transplanted cells remained viable and exhibited contraction, they formed the nidus for serious ventricular tachyarrhythmias, which led to premature discontinuation of the trial. Despite this outcome, the trial energized the field, accelerating both preclinical and clinical research, albeit not with skeletal myoblasts. The extensive progress in cardiac regeneration is reviewed in this Compendium, and as occurs frequently in science, important observations have led to more questions and challenges (Table). View this table: Table. Important Challenges to Cell Therapy for Cardiac Regeneration Many cell types have been evaluated as candidates for cardiac regeneration. Among the earliest clinical trials, Zeiher’s group infused autologous bone marrow-derived progenitor cells into the coronary arteries of patients with acute,4 as well as healed myocardial infarction (MI)5 and reported improvements in left ventricular (LV) function. However, these results have not been fully confirmed by later studies, as pointed out in the review in the Compendium by Banarjee, Bolli, and Hare.6 Pittenger et al7 were among the first to direct attention to bone marrow-derived (stromal) mesenchymal stem cells (MSCs), emphasizing that these cells proliferated extensively in culture and suggesting that they could be attractive candidates for transplantation. In 2004, Chen et al8 reported that intracoronary infusion of autologous bone marrow-derived MSCs improved cardiac function. Zimmet and Hare pointed out that MSCs lack histocompatibility type II markers and elude rejection by …

Use of autologous bone marrow stem cell implantation for osteonecrosis of the knee in sickle cell disease: a preliminary report

BackgroundThe purpose of our study was to evaluate safety, feasibility and clinical results of bone marrow mononuclear cell (BMC) implantation for early-stage osteonecrosis of the knee (OK) secondary to sickle cell disease.MethodsThirty-three SCD patients (45 knees) with OK treated with BMC implantation in the osteonecrotic lesion were clinically and functionally evaluated through the American Knee Society Clinical Score (KSS), Knee Functional Score (KFS) and Numeric Rating Scale (NRS) pain score. MRI and radiographic examinations of the knee were assessed during a period of five years after intervention.ResultsNo complications or serious adverse event were associated with BMC implantation. From preoperative assessment to the latest follow-up, there was a significant (p < 0.001) improvement of clinical KSS (64.3 ± 9.7, range: 45–80 and 2.2 ± 4.1, range: 84–100, respectively), KFS (44.5 ± 8.0, range: 30–55 and 91.6 ± 5.8, range: 80–100, respectively) and reduction of NRS pain score (6.7 ± 1.2, range: 4–9 and 3.4 ± 1.0, range: 2–5, respectively). In total, 87% of patients (29/33) consistently experienced improvements in joint function and activity level as compared to preoperative score. No patient had additional surgery following BMC implantation. Radiographic assessment showed joint preservation and no progression to subchondral collapse at most recent follow-up.ConclusionsThe technique of BMC implantation is a promising, relatively simple and safe procedure for OK in SCD patients. Larger and long-term controlled trials are needed to support its clinical effectiveness.Trial registrationClinicalTrials.gov NCT02448121. Retrospectively registered 19 May 2015.

Long-term follow-up of patients with Buerger's disease after autologous stem cell therapy.

Objective:We investigated the long-term results of autologous bone marrow mononuclear cells (ABMMNCs) implantation in patients with Buerger’s disease (BD).Methods:Twenty-eight patients (25 males and 3 females) who had BD and critical unilateral limb ischemia were investigated between April 2003 and August 2005. The patients were administered multiple injections of CD34+ and CD45+ positive ABMMNCs into the gastrocnemius muscle, the intermetatarsal region, and the dorsum of the foot (n=26) or forearm (n=2) and saline injection into the contralateral limb.Results:The mean follow-up time was 139.6±10.5 months. No complication related to stem cell therapy was observed during the follow-up. The ankle–brachial pressure index evaluated at 6 months and 120 months was compared to the baseline scores (p<0.001 and p=0.021, respectively). Digital subtraction angiography (DSA) was performed for all patients at baseline, 6 months, and 120 months. The angiographic improvement was 78.5% and 57.1% at 6 and 120 months, respectively. Patients demonstrated a significant improvement in the quality of life parameters at 6 months compared to baseline (p=0.008) and 120 months compared to the baseline (p=0.009). The 10-year amputation-free rate was 96% (95% CI=0.71-1) in ABMMNC-implanted limbs and 93% (95% CI=0.33–0.94) in saline-injected limbs (p=1).Conclusion:Autologous stem cell therapy could be an alternative therapeutic method for BD at long-term follow-up.

Autologous Bone Marrow Mononuclear Cell Implantation and Its Impact on the Outcome of Patients With Critical Limb Ischemia - Results of a Randomized, Double-Blind, Placebo-Controlled Trial.

Cell therapy is a therapeutic option for patients presenting with nonrevascularizable critical limb ischemia (CLI). However there is a lack of firm evidence on its efficacy because of the paucity of randomized controlled trials. The BALI trial was a multicenter, randomized, controlled, double-blind clinical trial that included 38 patients. For all of them, 500 mL of bone marrow were collected for preparation of a BM-MNC product that was implanted in patients assigned to active treatment. For the placebo group, a placebo cell-free product was implanted. Within 6 months after inclusion, major amputations had to be performed in 5 of the 19 placebo-treated patients and in 3 of the 17 BM-MNC-treated patients. According to a classical logistic regression analysis there was no significant difference. However, when using the jackknife analysis, 6 months after inclusion BM-MNC implantation was associated with a lower risk of major amputation (odds ratio (OR): 0.55; 95% confidence interval (CI): 0.52-0.58; P<0.0001) and of occurrence of any event (major or minor amputation, or revascularization) (OR: 0.30; 95% CI: 0.29-0.31; P<0.0001). The secondary endpoints (i.e., pain, ulcers, TcPO2, and ankle-brachial index value) were not statistically different between groups. Our results suggested that cell therapy reduced the risk of major amputation in patients presenting with nonrevascularizable CLI.

Abstract 519: Therapeutic Angiogenesis by Peripheral Blood Mononuclear Cells and its Rationale for Designing a New Trial

Background: Clinical trials of therapeutic angiogenesis that treat chronic critical limb ischemia (CLI) are revealing mixed results. This may partly be due to unapt patient selection or suboptimal study protocols. Here, from our registry, we report demographic and procedural characteristics of patients who underwent major limb amputation despite therapeutic angiogenesis. Methods: Registry of CLI patients who were treated by peripheral blood mononuclear cell (PBMNC) implantation was retrospectively analyzed. Cases that underwent major limb amputation within 6 months of the therapy were further investigated to clarify any features that might have affected their limb outcomes. Results and Discussions: Among total of 112 patients in the registry, eight cases lost to follow up and were excluded from this study. Sixteen patients (16/104, 15.4%) underwent major limb amputation within 6 months after therapeutic angiogenesis. Six amputees had active infection in the treated limb. Unlike excellent outcome by bone marrow derived cells, any patients with systemic sclerosis treated by PBMNC had poor limb salvage. However, half (8/16) of the amputees had experienced blood flow recovery, at least for transient period of two weeks. Among these patients, five limbs showed significant recovery of crural blood flow, while in the ipsilateral foot, distal blood flow deteriorated, indicating the flow steal phenomenon induced by cell therapy, which induces strong vasodilatation. Excluding patients with active infection or systemic sclerosis halved the limb amputation rate. Careful selection of sites to implant cells according to anatomical distribution of arterial blood flow could even have improved the limb salvage rate. Conclusion: When designing a clinical trial of therapeutic angiogenesis, (1) excluding patients with active infections, (2) proper treatment site considering anatomical distribution of arterial blood flow to avoid steal phenomenon, and (3) selection of cell source according to etiology of CLI, may clarify the efficacy of therapeutic angiogenesis.

Retraction Note: Peripheral blood mono-nuclear cells implantation in patients with peripheral arterial disease: a pilot study for clinical and biochemical outcome of neoangiogenesis.

Substantial progresses in the management of peripheral arterial disease (PAD) have been made in the past two decades. Progress in the understanding of the endothelial-platelet interaction during health and disease state has resulted in better antiplatelet drugs that can prevent platelet aggregation, activation and thrombosis during angioplasty and stenting. A role in physiological and pathological angiogenesis in adults has been recently shown in bone marrow–derived circulating endothelial progenitors (BM-DCEPs) identified in the peripheral blood. These findings have paved the way for the development of therapeutic neovascularization techniques using endothelial progenitors. This pilot study includes five patients, aged 60 to 75, with a history of claudication and recruited from September 2010 to February 2011 at the A.O.U. Federico II of Naples. PBMNCs have been implanted three times in the limb with the worst ABI value in all the patients included in the study. The clinical follow up was performed during the subsequent 12 months from the beginning of the treatment. In four patients there was a regression of ulcerative lesions. One patient’s condition improved after the first implantation but later did not respond to the further treatments. All patients achieved a pain relief as judged by the numeric pain scale. Pain relief remained satisfactory in three patients for one year. Pain gradually returned to the pre-treatment level in two patients. All patients referred an ameliorating in their quality of life expressed even by an improvement in claudication free walking distance. These improvements are reflected also by intra-arterial digital subtraction angiography (IADSA) that shows an improvement of arterial vascularization. The data from this study suggest an efficacy of BM-DCEPs implantation in terms of improvement of the vascularization and quality of life in patients affected by Peripheral Arterial Disease. Nevertheless a double-blind placebo-controlled study is needed to confirm our findings.

Imaging Angiogenesis Using 99mTc-Macroaggregated Albumin Scintigraphy in Patients with Peripheral Artery Disease.

One problem of vascular angiogenesis therapy is the lack of reliable methods for evaluating blood flow in the microcirculation. We aimed to assess whether (99m)Tc-macroaggregated albumin perfusion scintigraphy ((99m)Tc-MAA) predicts quantitated blood flow after therapeutic angiogenesis in patients with peripheral artery disease. Forty-six patients with peripheral artery disease were treated with bone marrow mononuclear cell implantation (BMCI). Before and 4 wk after BMCI, blood flow was evaluated via transcutaneous oxygen tension (TcPO2), ankle-brachial index, intravenous (99m)Tc-tetrofosmin perfusion scintigraphy ((99m)Tc-TF), and intraaortic (99m)Tc-MAA. Four weeks after BMCI, TcPO2 improved significantly (20.4 ± 14.4 to 36.0 ± 20.0 mm Hg, P < 0.01), but ankle-brachial index did not (0.65 ± 0.30 to 0.76 ± 0.24, P = 0.07). Improvement in (99m)Tc-TF count (0.60 ± 0.23 to 0.77 ± 0.29 count ratio/pixel, P < 0.01) and (99m)Tc-MAA count (5.21 ± 3.56 to 10.33 ± 7.18 count ratio/pixel, P = 0.02) was observed in the foot region but not the lower limb region, using both methods. When these data were normalized by subtracting the pixel count of the untreated side, the improvements in (99m)Tc-TF count (-0.04 ± 0.26 to 0.08 ± 0.32 count ratio/pixel, P = 0.04) and (99m)Tc-MAA count (1.49 ± 3.64 to 5.59 ± 4.84 count ratio/pixel, P = 0.03) in the foot remained significant. (99m)Tc-MAA indicated that the newly developed arteries were approximately 25 μm in diameter. BMCI induced angiogenesis in the foot, which was detected using (99m)Tc-TF and (99m)Tc-MAA. (99m)Tc-MAA is a useful method to quantitate blood flow, estimate vascular size, and evaluate flow distribution after therapeutic angiogenesis.

Autologous bone marrow mononuclear cell implantation therapy is an effective limb salvage strategy for patients with severe peripheral arterial disease

This study was conducted to determine if intramuscular and intra-arterial stem cell injections delay or prevent major limb amputations, improve ankle-brachial index measurements, relieve rest pain, and improve ulcer healing. A prospective case series with interventions occurring between December 2007 and September 2012 and a 3-month minimum follow-up was conducted at an urban tertiary care referral hospital. Patients with severe limb-threatening peripheral arterial disease, without other options for revascularization, were eligible for enrollment. Dual intramuscular and intra-arterial injection of bone marrow mononuclear cells harvested from the iliac crest was performed. Major limb amputation at 3 months was the primary outcome measure. Secondary outcome measures included ankle-brachial index measurements, rest pain, and ulceration healing. Kaplan-Meier survivorship was performed to ascertain overall survivorship of the procedure. No complications related to the procedure were reported. Of 49 patients (56 limbs) enrolled, two patients (two limbs) died, but had not undergone major amputation, and five limbs (8.9%) underwent major amputation within the first 3 months. Three-month follow-up evaluations were conducted on the remaining 49 limbs (42 patients). Median postprocedure revised Rutherford and Fontaine classifications were significantly lower compared with median baseline classifications. After 3 months, seven patients (nine limbs) died but had not undergone major amputation, and seven limbs (14.3%) underwent major amputation. At a mean follow-up of 18.2 months, the remaining 33 limbs (29 patients) had not undergone a major amputation. Freedom from major adverse limb events (MALE) was 91.1% (95% confidence interval, 79.9-96.2) at 3 months and 75.6% (95% confidence interval, 59.4-86.1) at 12 months. This procedure was designed to improve limb perfusion in an effort to salvage limbs in patients for whom amputation was the only viable treatment option. The results of this analysis indicate that it is an effective strategy for limb salvage for patients with severe peripheral arterial disease.

Limb rescue: a new autologous-peripheral blood mononuclear cells technology in critical limb ischemia and chronic ulcers.

Therapeutic angiogenesis by autologous-peripheral blood mononuclear cells (A-PBMNC) implantation has been shown to be a safe and effective treatment for critical limb ischemia (CLI). We herein report our investigation of the long-term efficacy of implantation of A-PBMNC produced by selective filtration to treat patients with CLI, for which surgical bypass and/or percutaneous transluminal angioplasty are not possible. This is a prospective, and not a randomized, study based on a treated group who did not respond to conventional therapy (n=43) when implanted with A-PBMNC cells versus a historically matched control group. Patients of both groups were suffering from CLI Fontaine scale IV with chronic ulcers and various accompanying conditions (diabetes, heart disease, kidney failure, etc.). Treated patients were implanted with 12 mL of A-PBMNC, 0.2-0.3 mL for each bolus, collected by selective filtration from 120 mL of peripheral blood in the ischemic area of the limbs. Patients were not mobilized by granulocyte colony-stimulating factor, and the A-PBMNC treatment was repeated for a maximum of three times. The A-PBMNC-treated group showed a statistically significant improvement of limb rescue of 95.3% versus 52.2% of the control group (p<0.001), and the result had been maintained for 2 years. The A-PBMNC group also showed reduction in pain at rest, increased maximum walking distance, and healing of the wound, which led to an overall improvement in the quality of life. Post-treatment radiological studies showed an improvement of vascularization with the formation of new collateral and by histological findings. Within 2 years of follow-up, none of the patients whom we treated showed any major or systemic adverse effects. The local injection of A-PBMNC showed striking early and long-term effects together with a favorable safety profile, significantly decreasing the risk of amputation. Our results are comparable with published data obtained by injection of bone marrow mononuclear cells, but with a lot less invasive approach. Moreover the intraoperative selective filtration system we used is fast, safe, not operator dependent, and easy to use in a sterile operating theatre. This system aims to produce fresh A-PBMNC as a valuable treatment option, particularly for those difficult patients who cannot undergo revascularization.