Safety and efficacy of granulocyte–colony-stimulating factor administration following autologous intramuscular implantation of bone marrow mononuclear cells: a randomized controlled trial in patients with advanced lower limb ischemia

Background aimsThe aim was to investigate the therapeutic effect of granulocyte–colony-stimulating factor (G-CSF) administration following implantation of autologous bone marrow mononuclear cells (BM MNC) for patients with lower limb ischemia.MethodsThe design was a randomized controlled trial. Fifteen patients with severe chronic limb ischemia were treated with autologous BM MNC [without G-CSF (MNC–G-CSF) or combined with G-CSF administration for 5 days following transplantation (MNC+G-CSF)].ResultsAll clinical parameters, including ankle brachial index, visual analog scale and pain-free walking distance, showed a mean improvement from baseline, which was measured at 4 and 24 weeks after transplantation in both groups. However, in three (20%) patients, the clinical course did not improve and limb salvage was not achieved. No significant difference was observed among the patients treated in the MNC–G-CSF and MNC+G-CSF groups. No severe adverse reactions were reported during the study period. No relationship was observed between both the numbers of viable MNC or CD34⁺ cells and the clinical outcome.ConclusionsAutologous transplantation of BM MNC into ischemic lower limbs is safe, feasible and efficient for patients with severe peripheral artery disease. However, the administration of G-CSF following cell transplantation does not improve the effect of BM MNC implantation and therefore would not have any beneficial value in clinical applications of such cases.     

Marrow changes and reduced proliferative capacity of mesenchymal stromal cells from patients with “no-option” critical limb ischemia; observations on feasibility of the autologous approach from a clinical trial

Background aimsApproximately 1 in 3 patients with critical limb ischemia (CLI) are not suitable for surgical or endovascular revascularization. Those “no-option” patients are at high risk of amputation and death. Autologous bone marrow mesenchymal stromal cells (MSCs) may provide a limb salvage option. In this study, bone marrow characteristics and expansion potentials of CLI-derived MSCs produced during a phase 1b clinical trial were compared with young healthy donor MSCs to determine the feasibility of an autologous approach. Cells were produced under Good Manufacturing Practice conditions and underwent appropriate release testing.MethodsFive bone marrow aspirates derived from patients with CLI were compared with six young healthy donor marrows in terms of number of colony-forming units–fibroblast (CFUF) and mononuclear cells. The mean population doubling times and final cell yields were used to evaluate expansion potential. The effect of increasing the volume of marrow on the CFUF count and final cell yield was evaluated by comparing 5 CLI-derived MSCs batches produced from a targeted 30 mL of marrow aspirate to five batches produced from a targeted 100 mL of marrow.ResultsCLI-derived marrow aspirate showed significantly lower numbers of mononuclear cells with no difference in the number of CFUFs when compared with healthy donors’ marrow aspirate. CLI-derived MSCs showed a significantly longer population doubling time and reduced final cell yield compared with young healthy donors' MSCs. The poor growth kinetics of CLI MSCs were not mitigated by increasing the bone marrow aspirate from 30 to 100 mL.ConclusionsIn addition to the previously reported karyotype abnormalities in MSCs isolated from patients with CLI, but not in cells from healthy donors, the feasibility of autologous transplantation of bone marrow MSCs for patients with no-option CLI is further limited by the increased expansion time and the reduced cell yield.     

Autologous bone marrow mesenchymal stromal cell therapy for “no-option” critical limb ischemia is limited by karyotype abnormalities

BackgroundCritical limb ischemia (CLI) is the most severe manifestation of peripheral vascular disease. Revascularization is the preferred therapy, but it is not achievable in 25%–40% of patients due to diffuse anatomic distribution of the disease or medical comorbidities. No-option CLI represents an unmet medical need. Mesenchymal stromal cells (MSCs) may provide salvage therapy through their angiogenic and tissue-trophic properties. This article reports a phase 1b clinical study examining the safety and feasibility of intramuscular transplantation of autologous bone-marrow MSCs for patients with no-option CLI.MethodsTwelve patients were enrolled in the clinical trial, and nine proceeded to bone marrow aspiration and culture expansion of MSCs.ResultsA high rate of karyotype abnormality (>30%) was detected in the produced cell batches, resulting in failure of release for clinical administration. Four patients were treated with the investigational medicinal product (IMP), three with a low dose of 20 × 10⁶ MSCs and one with a mid-dose of 40 × 10⁶ MSCs. There were no serious adverse events related to trial interventions, including bone marrow aspiration, IMP injection or therapy.ConclusionsThe results of this trial conclude that an autologous cell therapy approach with MSCs for critical limb ischemia is limited by the high rate of karyotype abnormalities.     

Comparison of the effect of stem cell therapy and percutaneous transluminal angioplasty on diabetic foot disease in patients with critical limb ischemia

Background aimsThe aim of our study was to compare the effect of autologous stem cell therapy (SCT) and percutaneous transluminal angioplasty (PTA) on diabetic foot disease (DFD) in patients with critical limb ischemia (CLI).MethodsThirty-one patients with DFD and CLI treated by autologous stem cells and 30 patients treated by PTA were included in the study; 23 patients with the same inclusion criteria who could not undergo PTA or SCT formed the control group. Amputation-free survival, transcutaneous oxygen pressure (TcPO₂) and wound healing were assessed over 12 months.ResultsAmputation-free survival after 6 and 12 months was significantly greater in the SCT and PTA groups compared with controls (P = 0.001 and P = 0.0029, respectively) without significant differences between the active treatment groups. Increase in TcPO₂ did not differ between SCT and PTA groups until 12 months (both Ps < 0.05 compared with baseline), whereas TcPO₂ in the control group did not change over the follow-up period. More healed ulcers were observed up to 12 months in the SCT group compared with the PTA and control groups (84 versus 57.7 versus 44.4 %; P = 0.042).ConclusionsOur study showed comparable effects of SCT and PTA on CLI, a major amputation rate that was superior to conservative therapy in patients with diabetic foot and an observable effect of SCT on wound healing. Our results support SCT as a potential promising treatment in patients with CLI and diabetic foot.     

Cell therapy in critical limb ischemia: current developments and future progress

Critical limb ischemia (CLI) is a syndrome manifested by ischemic rest pain, non-healing ulcers and tissue loss. CLI patients are at very high risk of amputation and experience poor physical function, leading to severe morbidity and mortality. The fundamental goal for CLI treatment is to relieve ischemic rest pain, heal ulcers, prevent limb loss and improve the quality of life, thereby extending the survival of the patient. Surgical or endovascular revascularization aimed at increasing blood flow is currently available for limb salvage in CLI. However, up to 30% of CLI patients are not suitable for such interventions because of high operative risk or unfavorable vascular anatomy. Therefore exploring new and more effective strategies for revascularization of ischemic limbs is imperative for the establishment of a viable therapeutic alternative. With the emergence of new approaches, this review describes up-to-date progress and developments in cell-based therapy as a novel and promising alternative for CLI treatment. Preliminary clinical data have established the safety, feasibility and efficacy of stem cells, and numerous studies are underway to consolidate this evidence further. However, significant hurdles remain to be addressed before this research can be responsibly translated to the bedside. In particular, we need better understanding of the behavior of cells post-transplantation and to learn how to control their survival and migration proliferation/differentiation in the hostile pathologic environment. Future research should focus on methods of isolation, optimal dosage, appropriate cell type, route of administration, role of tissue-derived factors and supportive endogenous stimulation.     

Autologous transplantation of CD34+ bone marrow derived mononuclear cells in management of non-reconstructable critical lower limb ischemia

Patients with a decrease in limb perfusion with a potential threat to limb viability manifested by ischemic rest pain, ischemic ulcers, and/or gangrene are considered to have critical limb ischemia (CLI). Because of this generally poor outcome, there is a strong need for attempting any procedure to save the affected limb. The aim of this work is to evaluate the possibility to use stem cell therapy as a treatment option for patients with chronic critical lower limb ischemia with no distal run off. This study includes 20 patients with chronic critical lower limb ischemia with no distal run off who are unsuitable for vascular or endovascular option. These patients underwent stem cell therapy (SCT) by autologous transplantation of bone marrow derived mononuclear cells. 55 % of patients treated with SCT showed improvement of the rest pain after the first month, 60 % continued improvement of the rest pain after 6 months, 75 % after 1 year and 80 % after 2 years and continued without any deterioration till the third year. Limb salvage rate after STC was 80 % after the first year till the end of the second and third years. SCT can result in angiogenesis in patients with no-option CLI, providing a foundation for the application of this therapy to leg ischemia.     

Autologous bone marrow mononuclear cell therapy improves symptoms in patients with end-stage peripheral arterial disease and reduces inflammation-associated parameters

Background aimsThe purpose of this study was to evaluate the effect of autologous bone marrow mononuclear cells (BM-MNCs) on symptoms and perfusion indices in severely symptomatic patients with peripheral arterial disease (PAD) without further option for endovascular or surgical revascularization.MethodsOnly patients with severe symptomatic PAD (Fontaine class IIb-IV, Rutherford category 3–6) not amenable for revascularization were treated. Bone marrow from both cristae iliacae was harvested; MNCs were isolated by the Ficoll density-gradient method and transplanted by means of intra-arterial and intramuscular injection in the index limb. Functional (pain score, ulcer healing, maximum walking distance) and perfusion indices such as ankle-brachial-index and transcutaneous oxygen pressure were documented before and after BM-MNC therapy. Additionally, serum concentration of C-reactive protein and interleukin-6 were measured as markers of inflammation before and after BM-MNC treatment.ResultsSixteen consecutive patients (four women; mean age, 63.0 ± 13 years) were treated with a mean dose of 4.2 ± 2.2 × 10⁸ BM-MNCs. At 6 months' follow-up, ankle-brachial-index, transcutaneous oxygen pressure and maximum walking distance significantly increased, whereas C-reactive protein and interleukin-6 conversely decreased (P < 0.01 versus baseline values), resulting in 88% limb salvage, 75% pain reduction and 71% complete wound healing and/or reduction of ulcer size. One major and one minor amputation were performed, both in patients with Rutherford category 6.ConclusionsAutologous BM-MNC therapy in patients with end-stage PAD improves tissue perfusion indices and decreases markers of inflammation. If our observations could be confirmed by large-scale, randomized controlled trials, BM-MNC transplantation could become an alternative therapeutic option for patients with end-stage PAD.     

微波射频保肢术及截肢术治疗胫骨远端骨肉瘤的临床疗效比较

目的:探讨和比较截肢术和微波射频保肢术治疗胫骨远端骨肉瘤的临床效果和安全性。方法:选择2000年-2013年我院收治的明确诊断为胫骨远端骨肉瘤的患者79例,其中27例给予截肢治疗(截肢组),52例给予微波射频保肢和重建治疗(保守治疗组)。评价和比较两组患者的生存情况、局部复发情况、MSTS关节功能评分及并发症的发生情况。结果:两组患者的生存曲线、局部复发率和并发症的发生率比较均无统计学差异(P0.05),但保守治疗组的MSTS关节功能评分显著高于截肢组,差异有统计学意义(P0.05)。结论:微波射频保肢术治疗胫骨远端骨肉瘤患者不会降低患者的生存几率,且在改善患者的关节功能方面有明显的优势。     

Phase I trial: the use of autologous cultured adipose-derived stroma/stem cells to treat patients with non-revascularizable critical limb ischemia

Background aimsNon-revascularizable critical limb ischemia (CLI) is the most severe stage of peripheral arterial disease, with no therapeutic option. Extensive preclinical studies have demonstrated that adipose-derived stroma cell (ASC) transplantation strongly improves revascularization and tissue perfusion in ischemic limbs. This study, named ACellDREAM, is the first phase I trial to evaluate the feasibility and safety of intramuscular injections of autologous ASC in non-revascularizable CLI patients.MethodsSeven patients were consecutively enrolled, on the basis of the following criteria: (i) lower-limb rest pain or ulcer; (ii) ankle systolic oxygen pressure <50 or 70 mm Hg for non-diabetic and diabetic patients, respectively, or first-toe systolic oxygen pressure <30 mm Hg or 50 mm Hg for non-diabetic and diabetic patients, respectively; (iii) not suitable for revascularization. ASCs from abdominal fat were grown for 2 weeks and were then characterized.ResultsMore than 200 million cells were obtained, with almost total homogeneity and no karyotype abnormality. The expressions of stemness markers Oct4 and Nanog were very low, whereas expression of telomerase was undetectable in human ASCs compared with human embryonic stem cells. ASCs (10⁸) were then intramuscularly injected into the ischemic leg of patients, with no complication, as judged by an independent committee. Trans-cutaneous oxygen pressure tended to increase in most patients. Ulcer evolution and wound healing showed improvement.ConclusionsThese data demonstrate the feasibility and safety of autologous ASC transplantation in patients with objectively proven CLI not suitable for revascularization. The improved wound healing also supports a putative functional efficiency.     

Early endothelial progenitor cells in bone marrow are a biomarker of cell therapy success in patients with critical limb ischemia

Background aimsEndothelial progenitor cells (EPC) have been proposed for autologous angiogenic therapy. The objectives of this study were to quantify EPC in the peripheral blood and bone marrow mononuclear cells (BM-MNC) of patients with critical limb ischemia that had received BM-MNC as a cell therapy product, and to study the putative relationship between the presence of EPC and the process of neovascularization in toe or transmetatarsal amputation specimens.MethodsEarly and late endothelial progenitor cells (CFU-EC and ECFC) were cultivated and quantified according to published methods in peripheral blood and BM-MNC from patients with critical limb ischemia (CLI; n = 11) enrolled in the OPTIPEC trial (http://clinicaltrials.gov/ct2/show/NCT00377897) to receive BM-MNC as a cell therapy product.ResultsEight out of the 11 patients had undergone amputations. Three of the patients displayed a neoangiogenic process that was associated with a higher number of CFU-EC in BM-MNC, while CD3⁺, CFU-GM and CD34⁺ in BM-MNC, and EPC in peripheral blood, did not correlate with the appearance of newly formed vessels. As expected, circulating CFU-EC and ECFC counts were significantly lower in CLI patients compared with age-matched controls.ConclusionsIn patients with critical limb ischemia, EPC in peripheral blood were decreased compared with healthy individuals. However, in BM-MNC we found that relative numbers of CFU-EC could be used as an indicator to discriminate patients with neoangiogenic processes. These results need to be confirmed in a randomized study.     

Analysis of possible factors relating to prognosis in autologous peripheral blood mononuclear cell transplantation for critical limb ischemia

Background aimsAutologous transplantation of granulocyte colony-stimulating factor–mobilized peripheral blood mononuclear cells (M-PBMNCs) has been shown to be effective in treating critical limb ischemia (CLI); however, the studies of the possible prognosis predictors after autologous M-PBMNC transplantation are inadequate. The objective of the study was to assess the possible factors affecting the results of M-PBMNC transplantation for CLI.MethodsWe reviewed the clinical profiles of 87 patients with CLI who were treated with M-PBMNC implantation in the Blood Diseases Hospital, Chinese Academy of Medical Sciences, between December 2002 and December 2011, and we followed these patients. The patients were divided into a good prognosis group and a poor prognosis group on the basis of whether amputation was performed. The significant differences of clinical variables between two groups were analyzed by means of the Mann-Whitney test and χ² test, and logistic regression analysis was used to study the variables representing the possible prognostic factors for amputation.ResultsOf the 87 patients, three patients died and one patient was lost during the follow-up period. We analyzed 83 patients. The diseases included CLI complicated by diabetes mellitus gangrene (35 cases, 42.2%), arteriosclerosis obliterans (31 cases, 37.3%) and thromboangiitis (17 cases, 20.5%). The mean age was 62 years (range, 30–87). The median follow-up time for the surviving patients was 5 years. The 5-year amputation-free rate was 72.2%, and no adverse effects related to M-PBMNC transplantation were observed.ConclusionsThe significant prognostic factors associated with poor angiogenesis were fibrinogen >4 g/L and fasting blood glucose >6 mmol/L.     

Critical evaluation of endovascular surgery for limb salvage

Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia mandates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reintervention, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, randomized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comorbidities and benefit from a multidisciplinary, team approach to care.     

MESS评分在肢体严重软组织损伤治疗中的应用评估

目的:探讨MESS评分在治疗肢体严重软组织损伤中的应用价值。方法:回顾性分析我科2010年8月至2014年5月收治的50例肢体严重软组织损伤患者的临床资料,其中男34例,女16例,年龄23~53岁,平均38岁。所有患者入院时均采用MESS评分表进行评分,根据病情给予清创、保肢或截肢以及创面修复等系列治疗,并随访3个月~3年。按照治疗结果将患者分为保肢组、Ⅰ期截肢组和Ⅱ期截肢组,分析和比较三组的MESS分值、住院天数、手术次数、并发症的发生率及患者满意率。结果:保肢组32例,MESS评分6-11分,平均8.63±1.26分。截肢组18例,MESS评分11-14分,其中Ⅰ期截肢组10例,平均12.60±0.97分;Ⅱ期截肢组8例,平均12.88±0.83分。保肢组患者的MESS分值显著低于Ⅰ期截肢组(P0.05)和Ⅱ期截肢组(P0.05)。此外,保肢组患者满意率显著高于Ⅰ期截肢组(P0.05)和Ⅱ期截肢组(P0.05)。而Ⅰ期截肢组的住院时间、手术次数和并发症发生率均短于或少于Ⅱ期截肢组,患者满意率高于Ⅱ期截肢组(P0.05)。结论:对于MESS评分11分的患者行保肢治疗可收到满意的效果,而对MESS评分11分的患者,采取Ⅰ期截肢的治疗效果优于Ⅱ期截肢。     

Further evidence for a role of endothelin-1 (ET-1) in critical limb ischaemia

Critical limb ischaemia (CLI), due to atherosclerotic arterial occlusion, affects over 20,000 people per year in the United Kingdom with many facing lower limb amputation and early death. A role for endothelin-1 (ET-1) in atherosclerosis is well-established and increased circulating and tissue levels of this peptide have been detected in patients with CLI. ET-1 and its receptors were identified in atherosclerotic popliteal arteries obtained from CLI patients undergoing lower limb amputation. In addition, plasma ET-1 levels were compared with those of non-ischaemic controls. ET-1 was associated with regions of atherosclerotic plaque, particularly in regions with high macrophage content. This peptide was also associated with endothelial cells lining the main vessel lumen as well as adventitial microvessels. ET_A and ET_B receptors were located within regions of plaque, adventitial microvessels and perivascular nerves. There was a statistically significant increase (P < 0.001) in plasma ET-1 in CLI patients when compared with controls. These results reveal sources of ET-1 in atherosclerotic popliteal arteries that potentially contribute to increased circulating levels of this peptide. Identification of variable receptor distributions in ischaemic tissue suggests a therapeutic potential of selective receptor targeting in patients with CLI.     

Tissue therapy with autologous dermal and epidermal culture cells for diabetic foot ulcers

A great part of diabetic ulcers on the lower extremities have difficult healing and represent the most common cause of non-traumatic amputation In case of patients unresponsive to the classical therapy with debridement, dressings and systemic antibiotic therapy, cell therapy may be an excellent indication. The objective of this study was to assess the efficacy of autologous skin cell (fibroblasts and keratinocytes) implants cultivated ex vivo and applied to long-standing (9?C34?years) skin ulcers of five diabetic patients (4 DM2 and 1 DM1) with autologous fibrin glue. There were six ulcers of onset between 4?months and 20?years before and from 4.0 to 36.62?cm² in size, located on the lower limbs and unresponsive to the several conventional treatments. Complete healing was observed in five ulcers (83.3%), after 21?C120?days. The patient who presented the largest ulcer had partial improvement in 40?days. It is believed that the more distal ulcer location is, the worse is its prognosis. There probably is a correlation between healing time, ulcer size and prior duration. No adverse reactions derived from the treatment occurred. It is concluded that this method is an excellent therapeutic option for diabetic ulcers, allowing faster healing. Its great advantage is being a minimally invasive procedure that can be carried out in an outpatient clinic.     

Bone Marrow Alterations and Lower Endothelial Progenitor Cell Numbers in Critical Limb Ischemia Patients

Background

Critical limb ischemia (CLI) is characterized by lower extremity artery obstruction and a largely unexplained impaired ischemic neovascularization response. Bone marrow (BM) derived endothelial progenitor cells (EPC) contribute to neovascularization. We hypothesize that reduced levels and function of circulating progenitor cells and alterations in the BM contribute to impaired neovascularization in CLI.

Methods

Levels of primitive (CD34⁺ and CD133⁺) progenitors and CD34⁺KDR⁺ EPC were analyzed using flow cytometry in blood and BM from 101 CLI patients in the JUVENTAS-trial ({"type":"clinical-trial","attrs":{"text":"NCT00371371","term_id":"NCT00371371"}}NCT00371371) and healthy controls. Blood levels of markers for endothelial injury (sE-selectin, sICAM-1, sVCAM-1, and thrombomodulin), and progenitor cell mobilizing and inflammatory factors were assessed by conventional and multiplex ELISA. BM levels and activity of the EPC mobilizing protease MMP-9 were assessed by ELISA and zymography. Circulating angiogenic cells (CAC) were cultured and their paracrine function was assessed.

Results

Endothelial injury markers were higher in CLI (P<0.01). CLI patients had higher levels of VEGF, SDF-1α, SCF, G-CSF (P<0.05) and of IL-6, IL-8 and IP-10 (P<0.05). Circulating EPC and BM CD34⁺ cells (P<0.05), lymphocytic expression of CXCR4 and CD26 in BM (P<0.05), and BM levels and activity of MMP-9 (P<0.01) were lower in CLI. Multivariate regression analysis showed an inverse association between IL-6 and BM CD34⁺ cell levels (P = 0.007). CAC from CLI patients had reduced paracrine function (P<0.0001).

Conclusion

CLI patients have reduced levels of circulating EPC, despite profound endothelial injury and an EPC mobilizing response. Moreover, CLI patients have lower BM CD34⁺-cell levels, which were inversely associated with the inflammatory marker IL-6, and lower BM MMP-9 levels and activity. The results of this study suggest that inflammation-induced BM exhaustion and a disturbed progenitor cell mobilization response due to reduced levels and activity of MMP-9 in the BM and alterations in the SDF-1α/CXCR4 interaction contribute to the attenuated neovascularization in CLI patients.     

Comparison of Early versus Late Below Knee Amputation After Trauma With Standardized Prosthetic Care

BackgroundHigh energy, lower extremity trauma is associated with longstanding pain and functional limitations. The clinical decision to proceed with early amputation or limb salvage is often controversial. This study was designed to compare differences in complications, costs, and clinical outcomes of below knee amputation (BKA) performed early after injury or after attempted limb salvage in a hospital with standardized prosthetic care following amputation.MethodsThis is a retrospective comparative study of subjects who underwent BKA for a traumatic injury at a single level 1 trauma center and received standardized prosthetic care from a single manufacturer from 1999-2016 with minimum 2-year post-amputation follow up. Outcomes collected included demographics, surgical management, unplanned re-operations, and hospital and prosthetic cost data 2 years from time of injury.ResultsOverall, 79 subjects met criteria. Early amputation (EA) was defined by median duration between injury and amputation (6 weeks) with 41 subjects in the EA group and 38 subjects in the late amputation (LA) group. Subjects in the EA group were more likely to have open fractures, high energy mechanism, and less likely to have medical comorbidities. Post-amputation infection was common in both groups (17/41 (42%) vs 17/38 (45%), p=0.77). Subjects undergoing EA were more likely to require unplanned post-amputation revision, 22/41 (54%) versus 10/38 (27%), p=0.017. Hospital costs and prosthetics/orthotics costs from the time of injury to two years following amputation were comparable, with mean hospital EA costs $136,044 versus LA costs $125,065, p=0.38. Mean prosthetics/orthotics costs of EA subjects were $33,252 versus LA costs $37,684, p=0.59.ConclusionUnplanned post-amputation revision surgeries were more common when BKA was performed early after trauma. Otherwise, outcomes and cost were comparable when amputation was performed early versus late. Level of Evidence: IV     

Processing of autologous bone marrow cells by apheresis technology for cell-based cardiovascular regeneration

Background aims. Bone marrow (BM)-derived mononuclear cell (MNC) preparations are increasingly used in experimental studies exploring the potential effect of progenitor cell-derived therapies in cardiocirculatory diseases. We analyzed the cellular BM composition, side-effects and other process-related variables of BM harvest and BM-MNC preparation in 80 patients with cardiovascular disease. Methods. BM (median 828 mL, range 223-1038 mL) was collected from the iliac crest. After BM harvest the MNC fraction was enriched by semi-automatic apheresis to reduce the total volume of the transplant. Autologous red blood cells (RBC) were salvaged from the initial BM harvest and autotransfused to the patients. Results. There were no serious side-effects related to BM collection, particularly no serious bleeding complications. Twenty- five of 80 (31%) patients developed mild pain. BM harvest resulted in the collection of a median of 2.8 × 10(9) MNC, containing a median of 66.5 × 10(6) CD34/45 cells, 39.5 × 10(6) CD133/45 cells and 50.3 × 10(6) CD34/CD133 cells. Apheresis technology-based MNC enrichment of harvested BM resulted in a progenitor cell recovery of 69-75.3% of total cells. Additional salvage of RBC from the initial BM harvest resulted in the recovery of a median of 175.0 mL autologous RBC mass. Transfusion of salvaged RBC was well tolerated and resulted in a significant increase in hemoglobin levels. Conclusions. Collection of BM of up to 1 L in combination with in vitro processing using a semi-automated apheresis device is a safe and feasible approach to increasing the number of progenitor cells necessary for cellular therapies, particularly when combined with RBC salvage.     

Evaluation of surgical results in lower limb atherosclerotic ischemia comparing men and women]

Multicenter studies involved 1449 male and 131 female patients operated for the atherosclerotic ischemia of the lower limbs. About 50% of all limbs were in the III or IV stage of ischemia (according to Fontaine's classification) before surgery. Atherosclerotic lesions involved mainly aortoiliac segment in the majority of patients. Early results of surgery were similar in both men and women. An improvement during a 5-year follow up period was noted more frequently in women than in men--86% and 68.5% of limbs respectively. Late result of lumbar sympathectomy was similar in both groups. Limb amputation and mortality rates were similar in both groups in the early postoperative period and during a 5-year follow up as well.     

The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient

Current literature indicates poor survival and limb salvage rates in renal failure diabetic patients who present with ulcerated or gangrenous lower extremities. Even in those limbs that were successfully revascularized, the amputation rate was as high as 37 percent. This has led some to advocate immediate amputation when treating the threatened limb of a renal failure diabetic patient. The authors reviewed all renal failure diabetic patients in their wound registry to determine whether such pessimism was warranted. The authors then analyzed the relative roles of revascularization and aggressive wound care on long-term limb salvage. Forty-five consecutive renal failure diabetic patients with 71 wounds in 54 limbs were identified. Twenty-seven patients had chronic renal insufficiency, 15 patients had end-stage renal disease, and three patients received kidney transplants. The revascularization procedures (46 percent of all limbs) included angioplasty, femoral-popliteal, femoral-distal, and popliteal-distal bypasses. Forty-three amputations in combination with 67 soft-tissue repairs (delayed primary wound closure, skin grafts, local flaps, pedicled flaps, and free flaps) were necessary to close the defects. After a mean follow-up of over 3 years, the data indicate that 79 percent of wounds healed, 89 percent of all limbs were salvaged, and 49 percent of patients survived. Revascularization improved the threatened limb's salvage rate from negligible to a level similar to that of the adequately vascularized limb. Fifteen out of 71 wounds did not heal because of the patient's early postoperative death, ischemia not amenable to revascularization, or noncompliance. Six below-knee amputations were performed (one despite a patent bypass and five in adequately vascularized patients). The average time for wounds to heal in the revascularized patients was 79 days versus 71 days in adequately vascularized patients. There was an overall 43 percent complication rate. Of the patients who were alive after the 3-year follow-up, 73 percent were independently ambulating, whereas 27 percent were bound to wheelchair or bed. Eighty-two percent of patients were very satisfied with the salvage attempt, 18 percent were moderately satisfied, and all patients said they would go through the process again. The authors believe that salvaging the threatened extremity in the renal failure diabetic patient is justified whether or not the limb requires revascularization. Revascularization improved the limb salvage rate, patient survival, and days for wounds to heal to a level comparable to that of the adequately vascularized limb. The key to subsequently achieving high salvage rates is the quality of perioperative wound care (e.g., serial debridements, antibiotics, dressings) and the timing and selection of appropriate soft-tissue coverage.