Stem cells therapy for peripheral arterial occlusive disease

Stem Cells Therapy for Peripheral Arterial Occlusive Disease

Dong-Ik Kim, MD. , Ph.D ([email protected])Division of Vascular Surgery, Samsung Medical Center

Sungkyunkwan University School of Medicine, Seoul, Korea

Prospect of Stem Cell Therapy

• Will the stem cell be effective for the

treatment of peripheral arterial occlusive

disease in the future?

Yes, it will be.

Evidences of Stem Cell Effect

• Animal Study

• Clinical Study

Animal Study (2002 - )

• Whole bone marrow stem cell

• Bone marrow derived mononuclear cell

• Bone marrow derived MSC

• Cord blood derived MNC

• Cord blood derived MSC

• Adipose tissue derived MSC

vWF HNA Merge

Angiogenesis : Differentiated from injected stem cell

Angiogenesis - angiogram

Control Treat

Dog Ischemic Limb Model- Mongrel Dog : male, 20-25 ㎏ - Femoral Arteries : occluded with ameroid constrictor

Mouse limb ischemia model

Animal Model

• Methods of stem cell injection : intramuscular injection

• Harvest : 8 weeks & 6 month after stem cell injection

• Assessment for angiogenic effect

1) Angiography

2) Immunohistochemical staining

0.8

1

1.2

1.4

1.6

1.8

2

2.2

2.4

capillary rato

HCB-MNC

Control 4x10^6 4x10^7 4x10^8

*

**

**

Human cord blood mononuclear cell transplantation : capillary ratios

Human cord blood mononuclear cell transplantation: Angiogenic factor - Western blot

(A) (B) (C)

(D) (E) (F)

Human cord blood mononuclear cell transplantation : Angiogenic factor - Tunnel assay & immunohistochemical stain

*

*

*

*

* **

*

#

#

#

#

Human cord blood mononuclear cell transplantation : Angiogenic gene expression - Real Time-PCR

Conclusions from animal study

• Angiogenesis comes from injected stem cells

• Paracrine effect of injected stem cells

1) secretion of cytokines : PDGF, VEGF etc.

Evidences of Stem Cell Effect

• Animal Study

• Clinical Study

Lists of Clinical Trials

• Autologous whole bone marrow stem cell implantation : Tibia bone fenestration technique (2004- 2006 )

• Autologous whole bone marrow stem cell implantation :

aspiration from iliac bone (2007- 2009)

• Homologous HCB-MNC Injection (2008-2010)

• Homologous HCB-MSC transplantation (2011- 2012)

T F

Autologous whole bone marrow stem cell implantation (2004):

Tibia bone fenestration technique

Demographics

• Total 27 patients ( 34 limbs)

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

• Mean age : 37.6 ± 6.9 years

• Mean FU periods : 19.1 ± 3.5 month (12.4 - 25month)

Angiographic findings

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

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

Results : Angiogram

Classification Limbs

+3 2

+2 5

+1 9

0 6

* postoperative angiogram were obtained in 22

limbs among 34 limbs.

Pre stem cell therapy

Poststem cell therapy

Rates of clinical improvement : 79.7 %

Clinical Trials






VİDEO

July 2004 - June 2009

90 ischemic limbs with 67 patients 1. Mean age: 39.8 ± 7.9 years 2. Mean follow-up period: 29.3 ± 18.1 months

Symptoms 1. Intermittent claudication : 44 limbs 2. Critical limb ischemia : 46 limbs

Demographics

Angiographic outcomes (n=37)1. recanalization of the run-off vessels: 3 limbs (8.1%)2. development of new collateral vessels (angiogenesis) : 16 limbs (43.2%)3. increased diameter and/or length of preexisting collateral vessels (arteriogenesis) : 15 limbs (40.5%)

Rates of angiographic improvement : 43.2 %

Rates of clinical improvement : 55.6 %

Results

Number of injected cells

Total MNCs (/ml) CD34+ (/ml)

Mean No. P Mean No. P

PB

Day 0 2.71×106 ± 1.13×106 0.247 2.23×105 ± 2.57×105 0.620

Day 1 3.19×106 ± 1.77×106 0.688 3.34×105 ± 3.43×105 0.509

Day 2 2.87×106 ± 1.68×106 0.472 3.59×105 ± 4.61×105 0.906

BM Day 3 4.46×106 ± 1.02×107 0.090 1.62×105 ± 2.53×105 0.167

CD133+ (/ml) CD34+CD133+ (/ml)

Mean No. P Mean No. P

PB

Day 0 1.22×105 ± 1.61×105 0.943 6.19×104 ± 1.63×105 0.143

Day 1 2.13×105 ± 2.42×105 0.464 8.38×104 ± 9.19×104 0.150

Day 2 2.04×105 ± 2.05×105 0.706 6.84×104 ± 6.93×104 0.345

BM Day 3 1.16×105 ± 1.35×105 0.142 4.73×104 ± 6.74×104 0.225

Clinical Trials






• 7 ischemic limbs with 7 patients• Number of injected stem cells : 4×108

• Safety : No adverse effect • Rates of clinical improvement : 57%• Rates of angiographic improvement : 71.4%

Homologous HCB-MNC Injection

Clinical Trials






• Title : The Safety of Human Cord Blood-derived Mesenchymal Stem Cells Therapy in Patients with PAOD : Phase I Clinical Study• KFDA approval : 2011. 5 • IRB approval from SMC : 2011. 5 • Target disease : peripheral arterial occlusive disease• Inclusion criteria : Rutherford’s classification IIb, III, IV• Source of Stem Cells : Human Cord Blood-derived Mesenchymal Stem Cells • Injected cell number : 1 X 107 • Injection site : calf muscle & vicinity of tibioperoneal artery

HCB –MSC injection (Phase I Study)

• Primary endpoint : Safety evaluation (1,3,6 month)1) death 2) cardiovascular event3) anaphylactic shock or allergic reaction4) acute or chronic graft-versus host disease5) procedure-related complications

• Secondary endpoint1) wound healing rate2) change of segmental limb pressure3) change of the scale for gauging changes in clinical status

End Point of Phase I study

NoAGE

pre postGauging change

Angio TotalRutherford category

Sx VAS ABIRutherford category

Sx VAS ABI

1 31 5 Ulcer 7 ATA 0.31PTA 0.46

2 Healed 0 ATA 0.44PTA 0.47 +1 +2

2 46 3 Claudication 7 ATA 0

PTA 0.682 improve 1 ATA 0

PTA 0.8 +2

3∫ 72 3 Claudication 7 ATA 0.24

PTA 0.472 improve 3 ATA 0.46

PTA 0.52 +1 +2

4 56 4 Claudication 7

ATA 0.26PTA 0.3

3 improve 5ATA 0.19 PTA 0.73 +2

5 56 5 Ulcer 8 ATA 0.32PTA 0.36

4 Healed 2 ATA 0.19PTA 0.33 +1

6* 48 5 Ulcer 10 ATA 0PTA 1.02


7 77 6 Ulcer 6ATA 0.57PTA

06 improve 2

ATA 0.56PTA

00 +1

8 48 3 Claudication 8 ATA 0.4

PTA 0.613 improve 5 ATA 0.25

PTA 0.44 0

9∬ 44 5 Ulcer 5 ATA 0.55PTA 0.68

5 improve 2 ATA 0.59PTA 0.68 0

10* 47 5 Ulcer 5 ATA 1.08PTA 0.68


*: Toe amputation, ∫: Cr elevation, ∬: urticaria

Results : HCB –MSC injection

• Ministry of Health and Welfare• Approve the autologous bone marrow stem cell therapy for PAOD

as a New Health Technology (2013.2)• Autologous Bone Marrow Stem Cell Transplantation became a

common treatment modality to the patient for PAOD in Korea.

Stem Cell therapy for PAOD in Korea

Conclusions from clinical trials

• Stem cell therapy is safe and effective for the treatment for the peripheral arterial occlusive disease.

What’s your choice?

International Journal of Stem Cells (http://www.ijstemcell.com)

Acknowledgment

Thank you

Stem cells therapy for peripheral arterial occlusive disease

Presentations & Public Speaking