- Email: [email protected]
Adipose mesenchymal stromal cell therapy in a desperate case of right-hand ischemia
Cytotherapy, 2016; 18: 725–728
MESENCHYMAL STROMAL CELLS
Adipose mesenchymal stromal cell therapy in a desperate case of right-hand ischemia
ANDRÉS EDUARDO SALAZAR ÁLVAREZ1, MARIANO GARCÍA ARRANZ2, LUIS RIERA DEL MORAL1, COVADONGA MENDIETA AZCONA1, ISRAEL LEBLIC RAMÍREZ1 & ÁLVARO FERNÁNDEZ HEREDERO1 1
Department ofVascular Surgery, Hospital Universitario La Paz, Madrid, Spain, and 2Health Research Institute, Unit of Cell Therapy Research, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain Upper limb critical ischemia is rarely due to arteriosclerosis alone. Cases with no surgical option are even less frequent [1]. A growing body of evidence suggests possible benefits of regenerative medicine in this condition using stem cells and growth factors, especially in cases with no other options [2,3]. The use of adipose tissue–derived progenitors as a therapeutic has grown substantially in the past decade. Multiple laboratories have established that stromal cells similar to those identified in bone marrow can be isolated in a reproducible manner from adipose tissue that is either resected as intact tissue or aspirated using tumescent liposuction.The minced adipose tissue is then digested by one or more of the following: collagenase, dispase, trypsin or related enzymes. After neutralization of the enzymes, the released elements, defined as the stromal vascular fraction (SVF), are separated from the mature adipocytes by differential centrifugation. The SVF consists of a heterogeneous mesenchymal population of cells that includes not only adipose stromal and hematopoietic stem and progenitor cells but also endothelial cells, erythrocytes, fibroblasts, lymphocytes, monocyte/ macrophages and pericytes, among others.When SVF cells are seeded into culture, a subset of elongated cells begins to adhere to the tissue culture plastic ware (Figure 1A). These cells can be purified further using a combination of washing steps and culture expansion with media similar to those used for bone marrow mesenchymal stromal cells to deplete most of the hematopoietic cell population from the SVF cells. This process allows the emergence of an adherent cell
population termed adipose tissue–derived stromal cells (ASC). Although ASC are less heterogeneous than SVF cells, they are by no means homogeneous. ASC include multipotent cells with the ability to differentiate into adipocytes, chondrocytes and osteoblasts, among other lineage pathways [4]. One main difference between SVF cell and ASC suspensions is the high level of CD45+ cells in the SVF cells and the low or undetectable level in ASC. The International Society for Cellular Therapy has proposed adaptation of the characterization strategy for MSC for the phenotyping of the SVF cells using multicolor analysis [4]. We report the case of a multifactorial dominanthand ischemia in which all surgical and endovascular options had been performed with no result before successful treatment with this new line of treatment, avoiding major amputation. Case report A 57-year-old woman was referred to our center with important pallor, coldness and severe pain of her right hand. Four years earlier, she had right breast cancer successfully treated with surgery and radiotherapy. She had been treated for right-hand moderate claudication for two years with pain medication by her oncologist, who considered the pain secondary to her previous surgery. She had a history of tabaquism with no other cardiovascular risks factors. On physical examination, there were no palpable pulses in the right arm, and the hand/hand index was
Correspondence: Andrés Eduardo Salazar Álvarez, MD, Department of Vascular Surgery, Hospital Universitario La Paz, Paseo La Castellana, 261, CP 28046 Madrid, Spain. E-mail: [email protected] (Received 5 July 2014; accepted 20 March 2016) ISSN 1465-3249 Copyright © 2016 International Society for Cellular Therapy. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcyt.2016.03.297
726
A. E. Salazar Álvarez et al.
A
B
Figure 1. A. CT Scan showing vascularization before stem cells therapy. B. Necrosed arteriovenous fistulae (AVF) scar before stem cells therapy.
0.4. The hand/hand index is an extrapolation of the well-known ankle/brachial index (range 0.9–1.2). The patient was assessed by the department of Internal Medicine, Rheumatology and Hematology, which performed all necessary tests to rule out autoimmune and hematologic diseases, all of which were negative. Nonetheless, after discussing the case with the ethical committee of our hospital, treatment with antagonists of endothelin receptors (Bosentan®) was attempted based on the safety and good results obtained in similar experiences treating non-
revascularizable patients with critical limb ischemia different from scleroderma [5]. With the diagnosis of critical ischemia of the upper dominant right limb of unknown etiology, she had several interventions, both surgical and endovascular, to attempt revascularization (Table I; Figure 1). After all procedures, she was discharged with complete anticoagulation with acenocoumarol and antiplatelet medication with aspirin.Two months after the last procedure, she asked for a major amputation of the limb because of severe pain, functional impairment, and
Table I. Sequence of treatments applied. Date 3/2009–2011 3/2011
Guiding symptom
4/2011
Upper right limb moderate claudication Occasional pain of the hand at rest; coldness Pain at rest
6/2011 8/2011
Pain at rest and mild motor impairment Severe acute ischemia of the hand
9/2011
Acute ischemia of the hand (moderate)
9/2011
Worsening ischemia; severe pain at rest and motor impairment Acute ischemia of the hand (moderate)
9/2011 11/2011 12/2011 12/2011
2/2012
Severe acute ischemia of the hand Severe acute ischemia of the hand with moderate motor impairment Acute ischemia of the hand (moderate)
Rest pain and necrosis of AF scar; complete motor impairment; patient asked for amputation
Diagnostic Absence of pulses (oncology) Axillar occlusion (vascular surgery, hemodynamic study + CT Angio) Axillar and common carotid artery occlusion Occluded bypass Occluded bypass; CT scan: adequate humeral runoff Occluded bypass; echo Doppler Occluded bypass; echo Doppler Occluded bypass (secondary to hypotension) Occluded bypass; echo Doppler Occluded bypass; echo Doppler Occluded bypass and fistula; echo Doppler Occluded bypass and fistula; echo Doppler
Intervention Quit smoking + AAS 21 days of IV prostanoids + heparin Subclavian-humeral bypass (Dacron) Catheter guided thrombolysisa Substitution of Dacron for inverted ISV bypass (subclavian-humeral) Conservative approach; new cycle of prostanoids New crossover ISV subclavian-humeral bypass Thrombectomya Thrombectomya Thrombectomya; radiocephalic AF (to improve runoff) Medular stimulation and Bosentan (thoracic sympathectomy not possible due to intense fibrosis) Stem cell + PDF therapy
AAS, aspirin; AF, arteriovenous fistula; ISV, internal saphenous vein; IV, intravenous; PDF, platelet-derived fraction. a No anatomic defect view in the digital subtraction angiography.
Stromal cell therapy in a desperate case of right hand ischemia Table II. Flow cytometry of cells.
CD marker (reference) CD 11b (Serotec MCA551F) CD 13 (Serotec MCA1270F) CD 34 (Serotec MCA547F) CD 44 (Serotec MCA89F) CD 45 (Serotec MCA87F) CD 90 (Serotec MCA90F) CD 105 (Serotec MCA1557F)
SVF
ASC (passage 1 7 days)
ASC (passage 3 28 days)
+ + ++ ++ + ++ +
– +++ + +++ – +++ +++
– ++ – +++ – +++ +++
Analysis of the cells during extraction and culture (SVF and ASC) by flow cytometry. Percentage of positive marker: < 2%; + ≥2– 30%; ++ ≥30–70%; +++ >70%.
necrosed scar from the previous surgery. Our hospital has an open line of research in stem cell therapy, so we offered her a new therapy based on the adipose MSC properties for neovascularization. The Spanish Medical Agency and the Local Institutional Board Committee authorized the compassionate use of the treatment, and the patient gave her consent. She was transferred to surgery, where liposuction was performed under local anesthesia and mild sedation. In the same surgical area, the process was performed according to previously published data [6]. SVF were isolated from a small lipoaspirate (250 mL) according to a published protocol by Zuk et al. by enzymatic digestion of adipose tissue [7], with the final cell pellet containing 19.8 × 106 cells. They were resuspended in 50 mL of saline solution, and 0.5 mL (0.2 × 106 cells) was used for characterization
727
studies and quantification of the cell growth. We injected all the SVF cells (19.6 × 106) intramuscularly all along the arm and the hand in 50 small (1-mL) aliquots following the course of the major arterial branches. We prefer to use this approach rather than the intra-arterial injection because we believe that the most important effect of this therapy is its local stimuli and it permits broader spread of the treatment through the extremity. The total duration of the process from the liposuction to the injection of the cells lasted less than 3 h, and the cells were neither cultured nor passed (Table II). We also injected 4 mL of platelet-rich plasma (PRP) at the necrosed scar.The PRP was obtained by simple centrifugation of 12 mL of blood obtained at the same time and activated with calcium carbonate. Two days after the procedure, the patient experienced an important decrease in analgesics consumption and was discharged on the seventh postoperative day after a second injection of PRP at the necrosed area at bedside. She continued treatment with acenocoumarol, aspirin, statins and a new 3-month cycle of endothelin receptor antagonist (Bosentan). One month after discharge, the necrosed ulcer was completely healed and mobility was almost normal, with claudication of the limb on mild effort. A new computed tomography (CT) scan was not able to determine any major vessel distal to the elbow. Six months after discharge, she remained pulseless but asymptomatic and returned to her manual job (Figure 2). The hemodynamic study revealed improvement in the Doppler signals with hand/hand index of 0.75. One year after de main procedure, she describes mild claudication of the limb.
Figure 2. Physical examination 6 months after stem cells treatment.
728
A. E. Salazar Álvarez et al.
Discussion Upper limb ischemia, although less frequent than inferior limb ischemia, can be a serious situation, especially in young working people. In this patient, we assumed that the previous breast surgery and radiotherapy was responsible for the ischemia because she had few cardiovascular risk factors, and the surgical and endovascular failures made us question the true origin of her condition. The desperate situation of a right-handed, young, active patient made us explore all possibilities before amputation. Stem cell therapy is a new line of treatment that is being adopted worldwide. It is a low-hazard treatment that can result in the increase of arterial perfusion, reduce inflammation and resolve pain or impediments to the healing processes [8]. Inflammatory diseases might have a better response to stem cell therapy than arteriosclerosis alone, but they also tend to respond better to medical treatment. Tissue perfusion was clinically improved by restoration of skin temperature, mobility, venous filling and necrosis healing.We performed a control CT scan that could not confirm new vessel formation, but a new hemodynamic study confirmed improvement, as evidenced by the hand/hand index >0.15 (when revascularization treatment is performed, clinical success is indicated by improvement ≥0.15 on the index). The exact mechanism of improved perfusion is not well known, but secretion of a large amount of cytokines such as endothelial growth factor, vasculogenesis promoted by endothelial progenitor cells and the anti-inflammatory and immunomodulating properties [9] of these cells might be responsible for the clinical response [10]. These factors may explain the early pain relief and improvement in vascularization at mid and long term. Adipose mesenchymal cells have the advantage of being easy to obtain without risk or discomfort for the patient [11,12]. The patient was simultaneously receiving PRP, and thus a direct beneficial impact of the cells should be carefully assessed. We did not find randomized controlled trials comparing these two techniques in the literature, although their combined use in the practice is common. Although the direct mechanism is still unknown, they seem to potentiate each other’s effects [13]. This patient experienced a durable improvement in ischemic pain, motor impairment and necrotic ulcer healing with this approach. We believe that the multilevel action of this therapy might have a role in future
treatment strategies, especially in small-vessel pathology or inflammatory disease of the upper extremities, but additional investigation is needed to asses the utility of this treatment. References [1] Comerota AJ, Link A, Douville J, Burchardt E. Upper extremity ischemia treated with tissue repair cells from adult bone marrow. J Vasc Surg 2010;52:723–9. [2] Koshikawa M, Shimodaira S, Yoshioka T, Kasai H, Watanabe N, Wada Y, et al. Therapeutic angiogenesis by bone marrow implantation for critical hand ischemia in patients with peripheral arterial disease: a pilot study. Curr Med Res Opin 2006;22(4):793–8. [3] Sprengers RW, Moll FL, Verhaar MC. Stem cell therapy in PAD. Eur J Vasc Endovasc Surg 2010;39(Suppl. 1):S38–43. [4] Bourin P, Bunnel BA, Casteilla L, Dominici M, Katz A, March KL, et al. Stromal cells from the adipose tissue-derived stromal vascular fraction and culture expanded adipose tissue-derived stromal/stem cells: a joint statement of the International Federation for Adipose Therapeutics and Science (IFATS) and the International Society for Cellular Therapy (ISCT). Cytotherapy 2013;15:641e648. [5] Martin Conejero A, Muela Mendez M, Gonzalez Sanchez S, Martinez Lopez I, Rial Horcajo R, Serrano Hernando F. Efecto del Bosentan en Pacientes con úlceras digitales de etiología isquémica. Angiología 2011;63(1):7–10. [6] Garcia-Olmo D, Garcia Aranz M, Garcia LG, Cuellar ES, Blanco IF, Prianes LA, et al. Autologous stem cell transplantation for treatment of rectovaginal fistula in perianal Crohn’s disease: a new cell-based therapy. Int J Colorectal Dis 2003;18:451–4. [7] Zuk PA, Zhu M, Mizuno H, Huang J, Futrell JW, Katz AJ, et al. Multilineage cells from human adipose tissue: implications for cell-based therapies. Tissue Eng 2001;7:211– 28. [8] Lawall H, Bramlage P, Amann B. Treatment of peripheral arterial disease using stem and progenitor cell therapy. J Vasc Surg 2011;53(2):445–53. [9] Koenen P, Spanholtz TA, Maegele M, Stürmer E, Brockamp T, Neugebauer E, et al. Acute and chronic wound fluids inversely influence adipose-derived stem cell function: molecular insights into impaired wound healing. Int Wound J 2013;12(1):10–16. [10] McIntosh KR, Frazier T, Rowan BG, Gimble JM. Evolution and future prospects of adipose-derived immunomodulatory cell therapeutics. Expert Rev Clin Immunol 2013;9(2):175–84. [11] Garcia-Olmo D, Garcia-Arranz M, Herreros D, Pascual I, Peiro C, Rodriguez-Montes JA. A phase I clinical trial of the treatment of Crohn’s fistula by adipose mesenchymal stem cell transplantation. Dis Colon Rectum 2005;48(7):1416–23. [12] Alvarez PD, García-Arranz M, Georgiev-Hristov T, García-Olmo D. A new bronchoscopic treatment of tracheomediastinal fistula using autologous adipose-derived stem cells. Thorax 2008;63(4):374–6. [13] Roubelakis MG, Trohatou O, Roubelakis A, Mili E, Kalaitzopoulos I, Papazoglou G, et al. Platelet-rich plasma (PRP) promotes fetal mesenchymal stem/stromal cell migration and wound healing process. Stem Cell Rev 2014;10(3):417– 28.
MESENCHYMAL STROMAL CELLS
Adipose mesenchymal stromal cell therapy in a desperate case of right-hand ischemia
ANDRÉS EDUARDO SALAZAR ÁLVAREZ1, MARIANO GARCÍA ARRANZ2, LUIS RIERA DEL MORAL1, COVADONGA MENDIETA AZCONA1, ISRAEL LEBLIC RAMÍREZ1 & ÁLVARO FERNÁNDEZ HEREDERO1 1
Department ofVascular Surgery, Hospital Universitario La Paz, Madrid, Spain, and 2Health Research Institute, Unit of Cell Therapy Research, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain Upper limb critical ischemia is rarely due to arteriosclerosis alone. Cases with no surgical option are even less frequent [1]. A growing body of evidence suggests possible benefits of regenerative medicine in this condition using stem cells and growth factors, especially in cases with no other options [2,3]. The use of adipose tissue–derived progenitors as a therapeutic has grown substantially in the past decade. Multiple laboratories have established that stromal cells similar to those identified in bone marrow can be isolated in a reproducible manner from adipose tissue that is either resected as intact tissue or aspirated using tumescent liposuction.The minced adipose tissue is then digested by one or more of the following: collagenase, dispase, trypsin or related enzymes. After neutralization of the enzymes, the released elements, defined as the stromal vascular fraction (SVF), are separated from the mature adipocytes by differential centrifugation. The SVF consists of a heterogeneous mesenchymal population of cells that includes not only adipose stromal and hematopoietic stem and progenitor cells but also endothelial cells, erythrocytes, fibroblasts, lymphocytes, monocyte/ macrophages and pericytes, among others.When SVF cells are seeded into culture, a subset of elongated cells begins to adhere to the tissue culture plastic ware (Figure 1A). These cells can be purified further using a combination of washing steps and culture expansion with media similar to those used for bone marrow mesenchymal stromal cells to deplete most of the hematopoietic cell population from the SVF cells. This process allows the emergence of an adherent cell
population termed adipose tissue–derived stromal cells (ASC). Although ASC are less heterogeneous than SVF cells, they are by no means homogeneous. ASC include multipotent cells with the ability to differentiate into adipocytes, chondrocytes and osteoblasts, among other lineage pathways [4]. One main difference between SVF cell and ASC suspensions is the high level of CD45+ cells in the SVF cells and the low or undetectable level in ASC. The International Society for Cellular Therapy has proposed adaptation of the characterization strategy for MSC for the phenotyping of the SVF cells using multicolor analysis [4]. We report the case of a multifactorial dominanthand ischemia in which all surgical and endovascular options had been performed with no result before successful treatment with this new line of treatment, avoiding major amputation. Case report A 57-year-old woman was referred to our center with important pallor, coldness and severe pain of her right hand. Four years earlier, she had right breast cancer successfully treated with surgery and radiotherapy. She had been treated for right-hand moderate claudication for two years with pain medication by her oncologist, who considered the pain secondary to her previous surgery. She had a history of tabaquism with no other cardiovascular risks factors. On physical examination, there were no palpable pulses in the right arm, and the hand/hand index was
Correspondence: Andrés Eduardo Salazar Álvarez, MD, Department of Vascular Surgery, Hospital Universitario La Paz, Paseo La Castellana, 261, CP 28046 Madrid, Spain. E-mail: [email protected] (Received 5 July 2014; accepted 20 March 2016) ISSN 1465-3249 Copyright © 2016 International Society for Cellular Therapy. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcyt.2016.03.297
726
A. E. Salazar Álvarez et al.
A
B
Figure 1. A. CT Scan showing vascularization before stem cells therapy. B. Necrosed arteriovenous fistulae (AVF) scar before stem cells therapy.
0.4. The hand/hand index is an extrapolation of the well-known ankle/brachial index (range 0.9–1.2). The patient was assessed by the department of Internal Medicine, Rheumatology and Hematology, which performed all necessary tests to rule out autoimmune and hematologic diseases, all of which were negative. Nonetheless, after discussing the case with the ethical committee of our hospital, treatment with antagonists of endothelin receptors (Bosentan®) was attempted based on the safety and good results obtained in similar experiences treating non-
revascularizable patients with critical limb ischemia different from scleroderma [5]. With the diagnosis of critical ischemia of the upper dominant right limb of unknown etiology, she had several interventions, both surgical and endovascular, to attempt revascularization (Table I; Figure 1). After all procedures, she was discharged with complete anticoagulation with acenocoumarol and antiplatelet medication with aspirin.Two months after the last procedure, she asked for a major amputation of the limb because of severe pain, functional impairment, and
Table I. Sequence of treatments applied. Date 3/2009–2011 3/2011
Guiding symptom
4/2011
Upper right limb moderate claudication Occasional pain of the hand at rest; coldness Pain at rest
6/2011 8/2011
Pain at rest and mild motor impairment Severe acute ischemia of the hand
9/2011
Acute ischemia of the hand (moderate)
9/2011
Worsening ischemia; severe pain at rest and motor impairment Acute ischemia of the hand (moderate)
9/2011 11/2011 12/2011 12/2011
2/2012
Severe acute ischemia of the hand Severe acute ischemia of the hand with moderate motor impairment Acute ischemia of the hand (moderate)
Rest pain and necrosis of AF scar; complete motor impairment; patient asked for amputation
Diagnostic Absence of pulses (oncology) Axillar occlusion (vascular surgery, hemodynamic study + CT Angio) Axillar and common carotid artery occlusion Occluded bypass Occluded bypass; CT scan: adequate humeral runoff Occluded bypass; echo Doppler Occluded bypass; echo Doppler Occluded bypass (secondary to hypotension) Occluded bypass; echo Doppler Occluded bypass; echo Doppler Occluded bypass and fistula; echo Doppler Occluded bypass and fistula; echo Doppler
Intervention Quit smoking + AAS 21 days of IV prostanoids + heparin Subclavian-humeral bypass (Dacron) Catheter guided thrombolysisa Substitution of Dacron for inverted ISV bypass (subclavian-humeral) Conservative approach; new cycle of prostanoids New crossover ISV subclavian-humeral bypass Thrombectomya Thrombectomya Thrombectomya; radiocephalic AF (to improve runoff) Medular stimulation and Bosentan (thoracic sympathectomy not possible due to intense fibrosis) Stem cell + PDF therapy
AAS, aspirin; AF, arteriovenous fistula; ISV, internal saphenous vein; IV, intravenous; PDF, platelet-derived fraction. a No anatomic defect view in the digital subtraction angiography.
Stromal cell therapy in a desperate case of right hand ischemia Table II. Flow cytometry of cells.
CD marker (reference) CD 11b (Serotec MCA551F) CD 13 (Serotec MCA1270F) CD 34 (Serotec MCA547F) CD 44 (Serotec MCA89F) CD 45 (Serotec MCA87F) CD 90 (Serotec MCA90F) CD 105 (Serotec MCA1557F)
SVF
ASC (passage 1 7 days)
ASC (passage 3 28 days)
+ + ++ ++ + ++ +
– +++ + +++ – +++ +++
– ++ – +++ – +++ +++
Analysis of the cells during extraction and culture (SVF and ASC) by flow cytometry. Percentage of positive marker: < 2%; + ≥2– 30%; ++ ≥30–70%; +++ >70%.
necrosed scar from the previous surgery. Our hospital has an open line of research in stem cell therapy, so we offered her a new therapy based on the adipose MSC properties for neovascularization. The Spanish Medical Agency and the Local Institutional Board Committee authorized the compassionate use of the treatment, and the patient gave her consent. She was transferred to surgery, where liposuction was performed under local anesthesia and mild sedation. In the same surgical area, the process was performed according to previously published data [6]. SVF were isolated from a small lipoaspirate (250 mL) according to a published protocol by Zuk et al. by enzymatic digestion of adipose tissue [7], with the final cell pellet containing 19.8 × 106 cells. They were resuspended in 50 mL of saline solution, and 0.5 mL (0.2 × 106 cells) was used for characterization
727
studies and quantification of the cell growth. We injected all the SVF cells (19.6 × 106) intramuscularly all along the arm and the hand in 50 small (1-mL) aliquots following the course of the major arterial branches. We prefer to use this approach rather than the intra-arterial injection because we believe that the most important effect of this therapy is its local stimuli and it permits broader spread of the treatment through the extremity. The total duration of the process from the liposuction to the injection of the cells lasted less than 3 h, and the cells were neither cultured nor passed (Table II). We also injected 4 mL of platelet-rich plasma (PRP) at the necrosed scar.The PRP was obtained by simple centrifugation of 12 mL of blood obtained at the same time and activated with calcium carbonate. Two days after the procedure, the patient experienced an important decrease in analgesics consumption and was discharged on the seventh postoperative day after a second injection of PRP at the necrosed area at bedside. She continued treatment with acenocoumarol, aspirin, statins and a new 3-month cycle of endothelin receptor antagonist (Bosentan). One month after discharge, the necrosed ulcer was completely healed and mobility was almost normal, with claudication of the limb on mild effort. A new computed tomography (CT) scan was not able to determine any major vessel distal to the elbow. Six months after discharge, she remained pulseless but asymptomatic and returned to her manual job (Figure 2). The hemodynamic study revealed improvement in the Doppler signals with hand/hand index of 0.75. One year after de main procedure, she describes mild claudication of the limb.
Figure 2. Physical examination 6 months after stem cells treatment.
728
A. E. Salazar Álvarez et al.
Discussion Upper limb ischemia, although less frequent than inferior limb ischemia, can be a serious situation, especially in young working people. In this patient, we assumed that the previous breast surgery and radiotherapy was responsible for the ischemia because she had few cardiovascular risk factors, and the surgical and endovascular failures made us question the true origin of her condition. The desperate situation of a right-handed, young, active patient made us explore all possibilities before amputation. Stem cell therapy is a new line of treatment that is being adopted worldwide. It is a low-hazard treatment that can result in the increase of arterial perfusion, reduce inflammation and resolve pain or impediments to the healing processes [8]. Inflammatory diseases might have a better response to stem cell therapy than arteriosclerosis alone, but they also tend to respond better to medical treatment. Tissue perfusion was clinically improved by restoration of skin temperature, mobility, venous filling and necrosis healing.We performed a control CT scan that could not confirm new vessel formation, but a new hemodynamic study confirmed improvement, as evidenced by the hand/hand index >0.15 (when revascularization treatment is performed, clinical success is indicated by improvement ≥0.15 on the index). The exact mechanism of improved perfusion is not well known, but secretion of a large amount of cytokines such as endothelial growth factor, vasculogenesis promoted by endothelial progenitor cells and the anti-inflammatory and immunomodulating properties [9] of these cells might be responsible for the clinical response [10]. These factors may explain the early pain relief and improvement in vascularization at mid and long term. Adipose mesenchymal cells have the advantage of being easy to obtain without risk or discomfort for the patient [11,12]. The patient was simultaneously receiving PRP, and thus a direct beneficial impact of the cells should be carefully assessed. We did not find randomized controlled trials comparing these two techniques in the literature, although their combined use in the practice is common. Although the direct mechanism is still unknown, they seem to potentiate each other’s effects [13]. This patient experienced a durable improvement in ischemic pain, motor impairment and necrotic ulcer healing with this approach. We believe that the multilevel action of this therapy might have a role in future
treatment strategies, especially in small-vessel pathology or inflammatory disease of the upper extremities, but additional investigation is needed to asses the utility of this treatment. References [1] Comerota AJ, Link A, Douville J, Burchardt E. Upper extremity ischemia treated with tissue repair cells from adult bone marrow. J Vasc Surg 2010;52:723–9. [2] Koshikawa M, Shimodaira S, Yoshioka T, Kasai H, Watanabe N, Wada Y, et al. Therapeutic angiogenesis by bone marrow implantation for critical hand ischemia in patients with peripheral arterial disease: a pilot study. Curr Med Res Opin 2006;22(4):793–8. [3] Sprengers RW, Moll FL, Verhaar MC. Stem cell therapy in PAD. Eur J Vasc Endovasc Surg 2010;39(Suppl. 1):S38–43. [4] Bourin P, Bunnel BA, Casteilla L, Dominici M, Katz A, March KL, et al. Stromal cells from the adipose tissue-derived stromal vascular fraction and culture expanded adipose tissue-derived stromal/stem cells: a joint statement of the International Federation for Adipose Therapeutics and Science (IFATS) and the International Society for Cellular Therapy (ISCT). Cytotherapy 2013;15:641e648. [5] Martin Conejero A, Muela Mendez M, Gonzalez Sanchez S, Martinez Lopez I, Rial Horcajo R, Serrano Hernando F. Efecto del Bosentan en Pacientes con úlceras digitales de etiología isquémica. Angiología 2011;63(1):7–10. [6] Garcia-Olmo D, Garcia Aranz M, Garcia LG, Cuellar ES, Blanco IF, Prianes LA, et al. Autologous stem cell transplantation for treatment of rectovaginal fistula in perianal Crohn’s disease: a new cell-based therapy. Int J Colorectal Dis 2003;18:451–4. [7] Zuk PA, Zhu M, Mizuno H, Huang J, Futrell JW, Katz AJ, et al. Multilineage cells from human adipose tissue: implications for cell-based therapies. Tissue Eng 2001;7:211– 28. [8] Lawall H, Bramlage P, Amann B. Treatment of peripheral arterial disease using stem and progenitor cell therapy. J Vasc Surg 2011;53(2):445–53. [9] Koenen P, Spanholtz TA, Maegele M, Stürmer E, Brockamp T, Neugebauer E, et al. Acute and chronic wound fluids inversely influence adipose-derived stem cell function: molecular insights into impaired wound healing. Int Wound J 2013;12(1):10–16. [10] McIntosh KR, Frazier T, Rowan BG, Gimble JM. Evolution and future prospects of adipose-derived immunomodulatory cell therapeutics. Expert Rev Clin Immunol 2013;9(2):175–84. [11] Garcia-Olmo D, Garcia-Arranz M, Herreros D, Pascual I, Peiro C, Rodriguez-Montes JA. A phase I clinical trial of the treatment of Crohn’s fistula by adipose mesenchymal stem cell transplantation. Dis Colon Rectum 2005;48(7):1416–23. [12] Alvarez PD, García-Arranz M, Georgiev-Hristov T, García-Olmo D. A new bronchoscopic treatment of tracheomediastinal fistula using autologous adipose-derived stem cells. Thorax 2008;63(4):374–6. [13] Roubelakis MG, Trohatou O, Roubelakis A, Mili E, Kalaitzopoulos I, Papazoglou G, et al. Platelet-rich plasma (PRP) promotes fetal mesenchymal stem/stromal cell migration and wound healing process. Stem Cell Rev 2014;10(3):417– 28.