강동경희대병원

외과 조진현

Autologous Stem Cell Therapy

for Diabetic Limb Ischemia

제24차대한당뇨병학회춘계학술대회

Cerebrovascular disease

Retinopathy

Coronary artery disease

Nephropathy

Peripheral vascular disease

Diabetic foot

Claudication Resting pain

Gangrene

Peripheral Vascular Disease

Claudication

Current Treatment of PAD

Treatment

1. Risk factor modification

2. Exercise

3. Medication, eg Cilostazol

Bypass surgery

Endovascular surgery

Treatment

Primary amputation

2009. 5. 2009. 9. 2009. 11.

Treatment

?

Up to 30% of patients are not candidates

for surgical or endovascular treatment

due to high operative risk or

unfavorable vascular involvement.

Lawall et al. JVS 2011;53:445-53

New vessel

growth

Therapeutic

angiogenesis

Clinical trials Our study

New Vessel Growth

� Two forms of compensatory vessel growth

1. Angiogenesis

2. Arteriogenesis

� Angiogenesis

- sprouting of small endothelial tubes from pre-existing

capillary beds in response to local hypoxia

- the formation of a capillary network

→ small capillaries with diameter of 10-20µm

→ cannot sufficiently compensate for a large occluded artery

New Vessel Growth

� Arteriogenesis

- arterio-arterial collateral connections increase in size and

diameter with increased endothelial shear stress and

circulating monocyte

- increased collateral growth

→ restores blood flow 4 to 6 weeks after initial occlusion of

the large artery

New Vessel Growth

Angiogenesis & Arteriogenesis

Inadequate for restoring the flow

in a large number of patients

Therapeutic Angiogenesis

� Therapeutic angiogenesis

- enhance natural angiogenesis by the administration of

stem cells or gene

- lead to pain relief and wound healing by the development

of collateral vessels

� Two types of stem cell

1. embryonic stem cell

2. adult stem cell

(수정란) (배반포)

(낭배)

� Embryonic stem cell

- differentiate into multiple cellular lineages

Therapeutic Angiogenesis

� 문제점- 암 발생- 개체 복제- 윤리적 문제

Therapeutic Angiogenesis

� Adult stem cell

- peripheral blood, bone marrow, cord blood, placenta

- easily and safely harvested for isolation

- cell; mononuclear cell,

multipotent adult precursor cell(MAPC)

hematopoietic stem cell (HSC)

endothelial progenitor cell (EPC)

Therapeutic Angiogenesis

Clinical Trials

Tateishi-Yuyama et al. Lancet 2002;360:427-35

Fadini et al. Atherosclerosis 2010;209:10-17.

� Most clinical trials using BM or PB mononuclear cells

1. isolation & culture of mononuclear cell

→ complex and expensive

2. danger of contamination

3. risk of the removal of the unknown positive cells

or growth factors

� Our assumption

1. unknown cells and growth factors in whole BM

→ promote angiogenesis

2. autologous whole BM transplantation

→ induce angiogenesis for ischemic limbs

Our Study

� Animal studies (2002 ~)

- whole bone marrow stem cell

- bone marrow derived mononuclear cell

- bone marrow derived MSC

- cord blood derived MNS

- cord blood derived MSC

- adipose tissue derived MSC

� Clinical studies (2004 ~)

- autologous whole bone marrow stem cell

1) fenestration of tibia

2) aspiration from iliac bone

- Mongrel dog : male, 20-25 ㎏

- femoral artery; occluded with ameroid constrictor

� Animal study(1)

- chronic ischemic limb model

- 20ml whole bone marrow from femur

Ameroid Constrictor Size

Swelling Time (days)

0 5 10 15 20 25

Inner Diameter(mm)

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

Superficial femoral artery : after 8 weeks

� Method

- inject BM stem cells into the ischemic hind limb muscle

- primary end-point

; angiogenic effect 8 weeks after stem cell injection

1. angiography

2. number of capillary endothelial cells

� Result

- right limb; control limb (20ml of normal saline)

- left limb; 20ml autologous whole bone marrow stem cell

Journal of Korean Society of Vascular Surgery 2005;21(2): 113-117.

� Clinical study(2)

- patients with Buerger’s disease

- autologous whole bone marrow stem cell implantation

with tibial fenestration technique

Tibia Fibula

� Study protocol

� Patient demographics

- total 27 patients ( 34 limbs);

26 male (33 limbs) / 1 female (1 limb)

- mean age : 37.6 ± 6.9 years

- mean follow-up (Mo); 19.1 ± 3.5 (12.4 - 25)

* (A, C, E) : pre-operative status (B, D, F) : post-operative status

* B : +1 D : +2 F : +3 angiogenic status

� Result; angiographic findings

Classification Limbs

+3 2

+2 5

+1 9

0 6

� Result; angiogram in 22 limbs among 34 limbs

� Clinical study(3)

- patients with ASO and TAO who are not candidate for

surgery

- aspiration of whole bone marrow from iliac bone

- inject whole bone marrow stem cell into the ischemic limbs

(tibial fenestration; unable to count the number of stem cells

- period; July 2004 to June 2009

- 90 ischemic limbs in 67 patients

- primary end-point; angiographic and clinical outcomes

New classification (2009)

1. angiographic scoring system

2. clinical outcome scoring system

New Vessel Formation(1)

Recanalization of major run-off vessel

New Vessel Formation(2)

Angiogenesis; development of new vessel

New Vessel Formation(3)

Arteriogenesis; increased diameter

2 1 0 -1 -2

Recanlization

of major run-off

vessel

≥ 50% segmental

recanalization in

previous length of

major run-off vessel

≤ 50% segmental

recanalization in

previous length

ofmajor run-off

vessel

No change

of major

run-off

vessel

extent

≤ 50%

progressionof

occlusion in

previous length of

major run-off

vessel

≥ 50% progression

of occlusion in

previous length of

major run-off vessel

Angiogenesis Development of

first order collateral

vessel(s)

Development of

more than second

order collateral

vessel(s)

No change

of overall

collateral

extent

Loss of more

thansecond order

collateral vessel(s)

Loss of first order

collateral vessel(s)

Arteriogenesis Increased diameter

and length of

existing collateral

vessel(s)

Increased diameter

or length of

existing collateral

vessel(s)

No change

of overall

collateral

extent

Decreased

diameteror length

of preexisting

collateral vessel(s)

Decreased

diameter and length

of existing collateral

vessel(s)

Angiographic outcomes defined as “aggravated”, “no change”, and “improved” by

cut-off value ‘0’ and ‘1’ showing statistically significant change of the sum of each

category

� Angiographic scoring system

Aggravated No change Improved

Claudication � Statistically significant

decrease of pain-free walking

distance

� Development of new ischemic

lesion

�Any amputation

� No statistically

significant change

of pain-free

walking distance

� Statistically significant increase

of pain-free waling distance

� Return to normal activity

Rest pain � Development of new ischemic

lesion

�Any amputation

� No change of rest

pain

� Relief of rest pain

Tissue loss � Any amputation due to

aggravation of initial wound or

after planned debridement of

non-viable tissue

� Development of new ischemic

lesion

� No change of

wound

� Complete healing of initial

wound or after planned debride-

ment of non-viable tissue

� Clinical outcome scoring system

� Patient demographics

- 90 ischemic limbs with 67 patients

- mean age: 39.8 ± 7.9 years

- mean follow-up period: 29.3 ± 18.1 months

- symptoms

1. intermittent claudication : 44 limbs

2. critical limb ischemia : 46 limbs

� Result; angiographic outcome (n=37)

- recanalization of the run-off vessels: 3 limbs (8.1%)

- angiogenesis; 16 limbs (43.2%)

- arteriogenesis; 15 limbs (40.5%)

Rates of angiographic improvement : 43.2 %

Pre

stem cell therapy

Post

stem cell therapy

� Result; clinical improvement-55.6%

� Result; amputation free rate

� Therapeutic angiogenesis can be new

therapeutic strategy for PAD.

� Autologous whole BM stem cells transplantation

is a safe, effective method for inducing

therapeutic angiogenesis in patient with PAD

Conclusion