Intra-arterial administration of Bone- marrow mononuclear cells in patients with critical limb ischemia – a randomized placebo-controlled trial PROVASA.

Intra-arterial administration of Bone-marrow mononuclear cells in patients with

critical limb ischemia –a randomized placebo-controlled

trial PROVASA

Intra-arterial administration of Bone-marrow mononuclear cells in patients with

critical limb ischemia –a randomized placebo-controlled

trial PROVASA

D.H.Walter, H. Krankenberg, J. Balzer, C. Kalka, I. Baumgartner, M. Schlüter, T.Tonn, F.Seeger S.Dimmeler, E.Lindhoff-

Last, A.M.Zeiher

MVZ Prof. Mathey, Prof. Schofer, Hamburg, Cardiology - Angiology and Radiology, Frankfurt

Inselspital BernBlutspendedienst Hessen

ClinicalTrials.gov number : NCT00282646

D.H.Walter, H. Krankenberg, J. Balzer, C. Kalka, I. Baumgartner, M. Schlüter, T.Tonn, F.Seeger S.Dimmeler, E.Lindhoff-

Last, A.M.Zeiher

MVZ Prof. Mathey, Prof. Schofer, Hamburg, Cardiology - Angiology and Radiology, Frankfurt

Inselspital BernBlutspendedienst Hessen

ClinicalTrials.gov number : NCT00282646

I do not have any potential conflict of interest

Intra-arterial Application of Bone-Marrow Mononuclear Cells

Isolation of mononuclear cells (Ficoll)

BSD HessenGMP Facility

Bone-marrow(50 ml,

Local anesthesia)

*

Intracoronary

In PAOD: no randomized placebo controlled trials available

PROVASABackground

*

REPAIR AMI

Schächinger V et al.

NEJM 2006

Critical limb ischemia

Rutherford 4-6

*

PROVASAStudy Flow Chart

40 Patients

R

BMC Placebo

BMC

(Optional BMC)Extended Protocol

Baseline

3 Months (open-label)

6 Months

1:1

Long-term F/U Mean 30.2 months (6-57 months)

Randomized-start, Randomized-start, placebo controlled, placebo controlled,

multicenter trial with a multicenter trial with a cross-over phasecross-over phase

PROVASAEndpoints

• Primary Endpoint• Change in ankle-brachial index (ABI) at 3 and 6

months

• Secondary Endpoint• Wound healing

• Pain reduction

• Amputation-free survival

PROVASAInclusion/Exclusion Criteria

• Patients with Fontaine III or IVwho were not candidates for interventional or surgical revascularization or who failed to respond to interventional or surgical procedures.

• PAOD or thrombangitis obliterans (TAO)

• Exclusion:prior PTA or Bypass < 3 months

• Creatinine > 2.0 mg/dl at time ot treatment

PROVASAPatient Characteristics

BMCBMCN=19N=19

PlaceboPlaceboN=21N=21 P

Age, years 64.4 ±15 64.5 ±16 NS

Men 16 (84%) 13 (62%) NS

Hx of smoking 10 (53%) 10 (48%) NS

Current smoker 4 (21%) 1 (5%) NS

Diabetes 10 (53%) 10 (48%) NS

IDDM 9 (47%) 6 (29%) NS

Hypertension 14 (74%) 14 (67%) NS

Hyperlipidemia 15 (79%) 16 (76%) NS

Kidney dysfunction 7 (37%) 6 (29%) NS

Hx of CAD 10 (53%) 10 (48%) NS

Prior MI 6 (32%) 4 (21%) NS

Heart failure (LVEF ≤ 35%) 3 (16%) 1 (5%) NS

PROVASAPAD/Procedural Characteristics

BMCBMCN=19N=19

PlaceboPlaceboN=21N=21 P

Femoropopliteal occlusion 6 (32%) 7 (33%) NS

Infrapopliteal disease 13 (68%) 14 (67%)Buerger’s disease (TAO) 3 (16%) 5 (24%) NS

Mediasclerosis 5 (26%) 3 (14%) NS

Rutherford category NS

4 (rest pain) 4 (21%) 6 (29%) 5 (minor tissue loss) 12 (63%) 14 (67%) 6 (gangrene) 3 (16%) 1 (5%)Prior PTA > 3 months prior 3 (16%) 10 (48%) 0.04

Prior peripheral surgery 3 (16%) 9 (43%) NS

Prior minor amputation 3 (16%) 2 (10%) NS

BMC therapy @ 3 months 14 (74%) 19 (90%) NS

BMC therapy > 6 months 5 (26%) 6 (29%) NS

PROVASAResults

• Ankle-brachial index (1ry EP)in 26 patients with complete serial measurements

0.00

0.20

0.40

0.60

0.80

1.00

1.20

BL M3 M6

Med

ian

AB

I

IQR

0.800.710.65

P*=0.040

* Repeated measures ANOVA

All ptsBMC

P**=0.014

**Holm test (post hoc)

Pooled data

PROVASAResults

• Ankle-brachial index (1ry EP)in 26 patients with complete serial measurements

0.00

0.20

0.40

0.60

0.80

1.00

1.20

BL M3 M6

Med

ian

AB

I

IQR

BMC (n=11)

Placebo (n=15)

0.85

0.700.64

0.66

All ptsBMC

P†=0.836

Randomized-Start

PROVASAThe Primary Endpoint Dilemma

• ABI values were not useful as primary endpoint

• Changes in ABI do not correlate well with ulcer healing and limb salvage

• In patients with thrombangiitis obliterans (TAO) as well as in patients with extensive mediasclerosis, ABI values do not reflect the degree of distal ischemia and tissue necrosis.

PROVASAUlcer Healing- quantitative Analysis

PROVASAUlcer Healing- quantitative Analysis

Figure 3A

4

0

1

2

3

5

BM-MNC (n=10)

Placebo (n=12)

P=0.014

All BM-MNCRandomized-Start

Mea

n U

lcer

Are

a (c

m²)

P=0.009

P=0.5

SE

P=0.2

P=0.059

P=0.09

Mea

n R

edu

ctio

n o

f U

lcer

Are

a (c

m²)

1x BM-MNC (n=10 ) + (n = 11)

Placebo (n=12) 2x BM-MNC (n=19)

P=0.16 vs Placebo

P=0.018 vs Placebo

PROVASAUlcer Area- Absolute Reduction

PROVASAPatients with Complete Ulcer Healing

NS

P=0.037All BMC vs. PlaceboMean time to ulcer

healing 10.9 months

All ptsBMC

• No difference in complete ulcer healing within 3 months between BMC vs Placebo

• Complete healing of ulcers 20/30 patients (66.6%)

• 20/21 (95%) complete healing in patients with stable ulcers, 17/21 (81%) after repeated BMC !

PROVASAUlcer healing

PROVASAPain Analysis-Serial Values

BM-MNC (n=10)

Placebo (n=15)

P=0.02

All BM-MNCRandomized-Start

Pai

n s

cale

P=0.13

M6M3BL

SE

P=0.004 P=0.3

P=0.002

P=0.009 P=0.343

P=0.014

PROVASAPain Analysis-Absolute Reduction

1x BM-MNC (n=15 ) + (n = 10)

Placebo (n=15) 2x BM-MNC (n=10)

Pai

n s

cale

P=0.002 vs Placebo

P=0.1 vs Placebo

PROVASAAmputation-free survival

Pts at risk 40 29 28 Pts at risk 40 29 28

All ptsBMC

• No difference within 3 months

(BMC vs Placebo)

• Maj. amputations in patients with advanced lesions/gangrene

Eve

nt-

free

su

rviv

al

6 M : 76%

Cell Number and Functional Capacity (Migration)

Cell number

Functional capacity

Mig

rati

on

Nu

mb

er o

f C

ells

x10

6

p =0.016

p =0.003

Factor P Exp (B)Hazard 95% CI

Age 0.7 1.01 1.01 - 1.07

Ulcer size 0.5 0.9 0.65 - 1.25

EF 0.08 1.09 0.99 - 1.20

Pain at baseline 0.12 0.82 0.65 - 1.05

Creatinine < 1.4 mg/dl 0.11 6.13 0.66 - 56

Buerger’s disease (TAO) 0.8 1.26 0.17 - 9.0

Cell number 0.003 1.02 1.008 - 1.038

Repeated BM-MNC (≥ 2 applications)

0.018 6.17 1.35 - 28

Cell function 0.049 0.99 0.98 – 1.00

Multivariate AnalysisClinical Improvement (Healing or Pain Reduction)Clinical Improvement (Healing or Pain Reduction)

Repeated BM-MNC administration as well as the number and functionality of administered BM-MNC were significant independent predictors for clinical improvement

PROVASAConclusions (1)

• Intraarterial administration of BM-MNC significantly promotes ulcer healing and reduces rest pain until 3 months versus Placebo

• Successful ulcer healing associated with improved limb salvage requires repeated administration of functionally competent BM-MNC

• Patients with thrombangiitis obliterans generally responded well, critically ill patients with extensive gangrene and impending amputation did not derive any benefit.

PROVASAConclusions (2)

• Thus, large scale randomized trials are warranted to assess the clinical effect of repeated BM-MNC administration in patients with critical limb ischemia with stable ulcers and/or rest pain.

• Complete ulcer healing occurred at a mean of 10.9 months after BM-MNC administration

• To assess potential clinical benefits of cell therapy in patients with critical limb ischemia, a follow-up period of at least 18 months will be required.

FrankfurtKardiologie:

D. Walter (Coordinator)A. Zeiher (PI)S. Dimmeler

Angiologie:

A. Kopalla E. Lindhoff-Last

Radiologie:

J. Balzer,

Institut für Transfusionsmedizin

BSD Hessen:T. Tonn

Hamburg

H. KrankenbergM. Schlüter

D. Walter (Coordinator)

Bern

C. Kalka

I.Baumgartner

PROVASABack-up slides

Responders

• Younger age • Better ejection fraction • Smaller ulcer size (< 2.3 cm² , p =0.038)• Less rest pain at baseline• Better renal function (creatinine < 1.4 mg/dl) • TAO (all 8 TAO) responders versus 18 of 32 (56%)

atherosclerotic PAOD improved clinically by BM-MNC treatments (P=0.02 TAO vs. PAOD).

• Patients with gangrene (Rutherford 6) did not respond at all.

All BM-MNCRandomized-Start

BM-MNC (n=6)

Placebo (n=10)

TC

O2 (

mm

Hg

)

P=0.52

P=0.17

P=0.14

P=0.032 P=0.018

P=0.058

PROVASAUlcer Healing- quantitative Analysis

Mea

n U

lcer

Are

a (c

m²)

All BM-MNCRandomized-Start