Objective To explore the effective autologous bone marrow stem cell dosage for treatment of severe lower limb ischemia. Methods From December 2003 to December 2004, 22 cases of bilateral lower limb ischemia were treated with autologous bone morrow cell transplantation. All the patients were randomly divided into two groups according to ischemia degree. In group A(severe ischemia side), the amount of transplanted autologous bone marrow cells was more than 1×108, and ingroup B(mild ischemia side), the amount was less than 1×105. A series of subjective indexes, such as improvement of pain, cold sensation and numbness, and objective indexes, such as increase of ankle/brachial index (ABI) and transcutaneous oxygen pressure (TcPO2), angiography, amputation rate, and improvement of foot wound healing were used to evaluate the effect of autologous bone marrow stem cells implantation. Results The rates of pain relief were 90.0% in group A and 16.7% in group B (Plt;0.01); the rates of cold sensation relief were 90.5% in group A and 5.3% in group B（Plt;0.01）;the improvement of numbness was 62.5% in group A and 9.1% in group B（Plt;0.01）. Increase of ABI was 31.8% and 0 in groups A and B respectively（Plt;0.01） at 4 weeks after implantation. Increase of TcPO2was 94.4% and 11.1% in groups A and B respectively（Plt;0.01） at 4 weeks after implantation. Twelve cases of angiography showed rich new collateral vessels in 100% of the limbs in group A while no remarkable new collateral vessel in group B. The amputation rates were 4.5% in group A and 27.3% in group B（Plt;0.05） at 4 weeks after implantation. The rate of improvement of foot wound healing was 75% in group A and there was no changein wound healing in group B after 4 weeks of implantation. Conclusion The effectiveness of autologous bone marrow stem cell implantation depends on the number of implanted stem cells. Effectiveness is expected in most patients if the implanted stem cell is more than 1×108, whereas there would be little effect if the cell number is less than 1×105.
ObjectiveTo study the effect of exogenous insulin on inducing angiogenesis and the expression of vascular endothelial growth factor (VEGF) of hindlimb ischemia of rats with diabetic. MethodsThe hindlimb ischemic model of diabetic rat was established by the ligation of femoral blood vessels of hindlimb in twenty healthy male SD rats and which were divided into model group (n=10) and treatment group (n=10). Another 10 normal rats were selected as control group. Then the expression of VEGF protein and capillary density of muscle tissues of rat hindlimb were detected by Western blot analysis and alkaline phosphatase (APK) stain method, respectively. ResultsThe differences of body weight and blood glucose level of rats before operation and on day 7 after operation were not significant in the control group (Pgt;0.05). The body weight of rat was significantly lower on day 7 after operation than that before operation in the model group (Plt;0.05), while the difference of blood glucose level of rats was not significant in the model group (Pgt;0.05). The body weight and blood glucose level of rat significantly decreased in the treatment group on day 7 after subcutaneous injection of insulin as compared with the level before operation (Plt;0.05). Compared with the control group, the body weight decreased and blood glucose level increased in the model group and treatment group, and the difference was significant (Plt;0.05, Plt;0.01). The body weight of rat in the treatment group was not different from that in the model group (Pgt;0.05), but the blood glucose level of rat on day 7 after operation in the treatment group was significantly lower than that in the model group (Plt;0.05). The relative expression of VEGF protein of muscle tissues of ischemic hindlimbs in the treatment group (155.06±10.26) was significantly higher than that in the model group (94.30±11.23), Plt;0.05, while no expression was found in the control group. The capillary density of muscle tissues of right hindlimb in the control group was significantly higher than that in the model group or treatment group (Plt;0.05), and furthermore, which was higher in the treatment group than that in the model group (Plt;0.05). The difference of capillary density of muscle tissues of left hindlimb was not different among three groups (Pgt;0.05). The capillary density of muscle tissues of right hindlimb was not different from that of left hindlimb in the control group (Pgt;0.05) and which was significantly lower than that of left hindlimb in the model group or treatment group (Plt;0.05). ConclusionInsulin may increase the expression of VEGF protein in ischemic muscle tissue of diabetic rats and protect the ischemic muscle.
ObjectiveTo evaluate the dynamic changes of blood flow and blood pressure of acute hindlimb ischemia of rats by laser Doppler flowmetry (LDF) and laser Doppler perfusion imaging (LDPI). MethodsThe acute hindlimb ischemia model of rats was established by resection of rats femoral arteries of left hindlimb. The blood flow and blood pressure between operated and nonoperated hindlimbs were examined by LDF on 2, 7, 14, 28, and 49 d after operation. And the blood flow was evaluated by LDPI on 7 d after operation. ResultsAll rats survived after operation and no hindlimb necrosis occurred. The mean score was 2 on 14 d after operation and 1 on 49 d after operation. The ratio of blood flow between operated and nonoperated hindlimbs on 2 d after operation significantly increased from 1 to 1.31±0.439 (P=0.021). The ratio of blood flow on 7 d (0.82±0.538) and 14 d (0.93±0.294) after operation was significantly lower than that on 2 d after operation (P=0.032 and P=0.019), although the difference between the two former was not significant (P=0.502). Furthermore, the ratio of blood flow on 28 d after operation reached the bottom (0.41±1.970), which was obviously lower than that on 2, 7, and 14 d after operation (P=0.004, P=0.007, and P=0.006). The blood flow of operated hindlimbs recovered approximately the value before operation (0.98±0.093), which was significantly lower than that on 2 d (P=0.010), higher than that on 28 d (P=0.005), but not different from that on 7 d and 14 d after operation (P=0.126 and P=0.382). The ratio of blood pressure between operated and nonoperated hindlimbs on 2 d after operation significantly increased from 1 to 0.47±0.375 (P=0.031). The ratio of blood pressure decreased on 7 d after operation (0.44±0.118), which was not different from that on 2 d after operation (P=0.203). Furthermore, the ratio of blood pressure on 14 d after operation reached the bottom (0.35±0.115), which was obviously lower than that on 2 d and 7 d after operation (P=0.001 and P=0.036). On 28 d after operation, the ratio of blood pressure increased (0.54±0.146), which was significantly higher than that on 14 d after operation (P=0.008), while not different from that on 2 d (P=0.493) and 7 d after operation (P=0.551). The ratio of blood pressure recovered approximately the value before operation (0.97±0.094), which was significantly higher than that on 2, 7, 14, and 28 d (P=0.013, P=0.021, P=0.002, and P=0.031). ConclusionAcute hindlimb ischemia model of rats can be established by resection of rats femoral arteries of left hindlimb and the most serious stage of hindlimb ischemia is on 14-28 d after operation. LDF and LDPI are of importance for monitoring the dynamic changes of rats hindlimb ischemia after operation.
ObjectiveTo assess the efficacy and safety of low-(10 mg) and high-dose (20 mg) of recombinant tissue typeplasminogen activator (rt-PA) catheter-directed thrombolysis for lower limb ischemia by using meta-analysis. MethodsThe literatures of randomized clinical trials (RCT) concerning low-versus high-dose rt-PA catheter-directed thrombolysis for lower limb ischemia study were searched using the national and international electronic databases.The literatures were screened and quality evaluated according to the inclusion and exclusion criteria, and analyzed by using the Cochrane Center the RevMan 5.2 software. ResultsA total of 4 RCT studies, with a total of 360 patients (192 patients in low dose group and 168 patients in high-dose group) were included.No statistical difference were noted in low-versus high-dose group with regard to ankle-brachial index (RR=0.20, 95%CI=-0.43-0.02, P=0.07), 30 days amputation-free survival (RR=1.00, 95%CI=0.94-1.08, P=0.91), 6 months the probability of restenosis (RR=1.00, 95%CI=0.60-1.67, P=1.00), and the incidence of groin hematoma (< 5 cm, RR=1.24, 95%CI=0.56-2.77, P=0.59).But the incidence of bleeding and the incidence of stress ulcer in low-dose group were lower than those in high-dose group (RR=2.38, 95%CI=1.10-5.15, P=0.03;RR=2.49, 95%CI=1.21-5.13, P=0.01). ConclusionTwo doses of rt-PA treatment of limb ischemia similar efficacy, but the incidence of low-dose regimen of complications is significantly lower than the high dose regimen.
Objective To compare the effectiveness of autologous implantation between bone marrow stem cells and peripheral blood stem cells for treatment of lower limb ischemia. Methods From December 2004 to December 2005, 42 patients with unilateral lower limb ischemia were treated with both autologous bone marrow stem cell implantation(group A, n=21)and autologous peripheral blood stem cell implantation (group B, n=21). Fortytwo patients included 32 males and 10 females. The age ranged from 34 to 80 years, with a mean of 65.6 years. Of the patients, there were 28, 8 and 6 patients suffered from diabetic lower limb ischemia, Burger’s disese and atherosclotic occlusion, respectively. Ischemic history was from 3 months to 5 years, with amean of 2.1 years. A series of subjective indexes (such as improvement of pain, cold sensation and numbness) and objective indexes such as increase of ankle brachial index (ABI), transcutaneous oxygen pressure (TcPO2), angiography, amputation rate, and improvement of foot wound healing, were used to evaluate the effect. Results After 4 weeks of implantation, the rate of pain relief was 88.2% in group A and 89.5% in group B (Pgt;0.05) ; the rate of cold sensation relief was 94.4% in group A and 94.7% in group B（Pgt;0.05）; improvement of numbness was 69.2% and 66.7% respectively in groups A and B（Pgt;0.05）. Increaseof ABI was 38.1% in group A and 33.3% in group B（Pgt;0.05）; increase of TcPO2 was 85.7% and 90.5% respectively in groups A and B（Pgt;0.05）; angiography was performed in 12 patients (group A) and 9patients (group B), and the new formed collateral vessel rate was 83.3% in group A and 77.8% in group B（Pgt;0.05）; the amputation rate was 9.1% in groups A and B（Pgt;0.05）; the rate of improvement of foot wound healing was 60.0% in group A and 66.7% in group B(P＞0.05). Forty patients were followed up 3-15 months(mean 8 months). The improvement rate of subjective symptoms was 75.0% in group A and 70.0% in group B (Pgt;0.05); increase of ABI was 60.0% in group A and 65.0% in group B; increase of TcPO2 was 80.0% and 75.0% respectively in groups A and B; the new formed collateral vessel rate was 90.0% in group A and 84.6% in group B. All ulcers healed except 1 case in group B. Conclusion Bone marrow stem cell graft and peripheral blood stem cell graft are all effective in treatingower limb ischemia.
Sepsis-associated organ dysfunction arises from uncontrolled inflammation and immune dysregulation, causing microcirculatory impairment and multi-organ failure. Stellate ganglion block (SGB) may confer organ protection by regulating the sympathetic nervous system and hypothalamic-pituitary-adrenal axis to suppress excessive inflammation and oxidative stress. Available evidence, mainly from experimental and small clinical studies, suggests potential benefits of SGB in sepsis-induced acute lung injury, ventricular arrhythmias, and limb ischemia, which require confirmation in multicenter randomized controlled trials. This review outlines the mechanisms and clinical advances of SGB in sepsis-related organ dysfunction, providing a theoretical basis for its application in critical care.
Objective To observe the clinical efficiency of the implantation of the autologous bone marrow mononuclear cells for treatment of lower limb ischemia after the bone marrow stimulation. Methods From May to December 2005, 43 ischemic limbs in 35 patients (23 males,12 females; aged 3490 years,averaged 71.3 year) were treated. Of the 35 patients, 30 had diabetic lowerlimb ischemia with 38 lower ischemic limbs, 2 had atherosclerosis obliterans with 2 ischemic lower limbs, and 3 had thromboangiitis obliterans with 3 ischemic lower limbs. Five patients with 5 ischemic limbs were in stage Ⅰ lower limb ischemia (intermittentclaudication), 15 patients with ischemic 19 limbs were in stage Ⅱ (rest pain),9 patients with 12 ischemic limbs were in stage Ⅲa(ulceration), and 6 patients with 7 ischemic lower limbs in stage Ⅲb (gangrene); 88.4% of all the ischemic lower limbs （38/43）had a pain, 79.1%（34/43） had coldness, and 69.8%（30/43）had limb numbness. The bone marrow of each patient was stimulated by an injection of the recombinant human granulocyte-macrophage colony-stimulatory factor 300 μg/d for 2-3 days. The bone marrow 130-200 ml was drawn from the iliac spine and the mononuclear cells were obtained. Each patient received implantation of the autologous bone marrow mononuclear cells by an intramuscular injection, an arterial intraluminal injection or a combined injection of the two routes.Results The pain relief was found in 94.7% of theischemic lower limbs, and pain improvement in 97.1% . Relived numbness was found in 93.3%. The distance of the claudication was increased by all the ischemic limbs. An increase in the ankle/ brachial index (ABI)was found in 47.9%. The transcutaneous oxygen pressure (TcPO2) increased in 92.3%. The ulcer heal rate was 9.1% (1/11). Markedlyreduced ulcer wound was found in 27.3% (3/11). The amputation rate was 6.3% (3/48). Arterial angiography revealed that there was a new collateral vessel formationin 91.2%. Complications were as follows: fever and mild fatigue-developed respectively in 1 patient after the bone marrow stimulation, but relieved by themselves. Acute but mild myocardial infarction was found in 1 patient with a slight precordial pain and elevation of myocardial enzymes 1 week after transplantation of the bone marrow mononuclear cells, but recovered after medical treatment. The follow-up averaged 5 months. According to the subjective criteria, the overall efficacy was90%. ABI increased in 62.5% of the patients after operation and the value of TcPO2 was higher in 90% of the patients after this kind of therapy. Arterial angiography revealed a new collateral vessel formation in 90.5% of the 21 ischemic limbs. The foot ulcer healed in 7 and obviously improved in 3. Three of the foot ulcer patients were discharged 2-3 months after the amputation was performed on the diseased toes. Conclusion Implantation of the autologous bone marrow mononuclear cells after the bone marrow stimulation of treatment of the lower limb ischemia has advantages of less marrow aspiration, more mononuclear cell content, satisfactory shortterm effect, and relatively high safety. Itis a new method of treating the lower limb ischemia besides the autologous bone marrow and peripheral blood mononuclear cell implantation. The longterm effect of this method needs a further study.
Objective To evaluate the effectiveness and safety of autologous hemopoietic stem cell implantation for peripheral arterial disease (PAD). Methods Randomized controlled trials (RCTs) were identified from CBM (1978 to September 2010), CNKI (1979 to September 2010), MEDLINE (1950 to September 2010), Pubmed (1950 to September 2010), Embase (1970 to September 2010), and Cochrane l ibrary (issue 4, 2010). The papers of the RCTs of cl inical therapeutic studieson PAD treated by autologous hemopoietic stem cell implantation were included and analyzed according to the criteria of the Cochrane handbook. Results Eight RCTs involving 280 patients and 322 extremities were included, with majority of trials of low methodological qual ity. Meta-analysis indicated that autologous hemopoietic stem cell transplantation had an increased ulcer cure rate [RD=0.38, 95% CI= (0.25, 0.50)], a significant improvement in the ankle brachial index [MD=0.11, 95%CI= (0.04, 0.18)], transcutaneous oxygen tension [MD=7.33, 95%CI= (3.14, 11.51)], and pain-free walking distance [SMD=1.35, 95%CI= (0.90, 1.79)], a significant reduction in rest pain scores [MD= —1.70, 95%CI= (—2.15, —1.25)], and a significant benefit in terms of l imb salvage [RD= —0.19, 95%CI= (—0.31, —0.07)]. Only 2 trials reported the side effects of autologous hemopoietic stem cell transplantation, such as l imbs swell ing and concentrations of serum creatine phosphokinase increasing, and the long-term safety was not reported. Conclusion Based on the review, autologous hemopoietic stem cell transplantation may have positive effect on “no-option” patients with PAD. However, the evidence is not b enough due to the general low methodological qual ity, so we can not draw a rel iable conclusion about the effects of autologous stem cell transplantation for PAD at the moment. Further larger, randomized, double bl ind, placebo-controlled, and multicenter trials are needed.
ObjectiveTo investigate the protective effect of Shenfu injection on liver injury in rats with hind limb ischemia-reperfusion and its mechanism. MethodsSixty-four male rats were randomly divided into sham operation group, ischemia-reperfusion group, Shenfu group〔Shenfu injection 7.5 mL/kg injection of peritoneal(ip), given 10 min before ischemia-reperfusion〕, Shenfu+Znpp group(Shenfu injection 7.5 mL/kg+Znpp 5 mg/kg ip, given 10 min before ischemia-reperfusion), 16 rats in each group. The rat model of hind limb ischemia-reperfusion injury was reproduced by occluding the hind limb artery of the rats for 3 h and subsequent reperfusing for 4 h. The liver tissues were gathered for malondialdehyde(MDA)and superoxide dismutase(SOD)determination. The expression of hemeoxygenase 1(HO-1)protein in the liver tissues was detected by immunohistochemistry. The pathological changes of liver were observed under the light microscope. The changes of serum glutamate-pyruvate transaminase(GPT)and glutamine oxaloacetic transaminase(GOT)were observed respectively. Results①Compared with the sham operation group, the contents of MDA, GPT, GOT, and the expression of HO-1 protein were markedly increased in the ischemia-reperfusion group, Shenfu group, and Shenfu+Znpp group(P < 0.05), the activities of SOD were markedly decreased in the ischemia-reperfusion group and Shenfu+Znpp group(P < 0.05).②Compared with the ischemia-reperfusion group, the contents of MDA, serum GPT, GOT, and the expression of HO-1 protein were markedly decreased, the activity of SOD was markedly increased in the Shenfu group(P < 0.05).③Compared with the Shenfu group, the contents of MDA, GPT, GOT were markedly increased, the activity of SOD was markedly decreased in the Shenfu+Znpp group(P < 0.05). Unde ther light microscope, the pathological changes induced by ischemia-reperfusion were significantly attenuated by the Shenfu injection in the Shenfu group and were reversed by the Znpp in the Shenfu+Znpp group. ConclusionShenfu injection inhibits liver tissue injury during hind limb ischemia-reperfusion, this protective effect might be partly through induction of HO-1.
Objective To summarize the research progress of gene-based therapeutic angiogenesis in lower limb ischemia, so as to provide a new method for non-invasive treatment of lower limb ischemia. Method The literatures on studies of gene-based therapeutic angiogenesis in lower limb ischemia in recent years were read and reviewed. Results The incidence of peripheral arterial disease had been increasing annually. How to effectively reduce the amputation rate and mortality rate of patients with critical limb ischemia was still a clinical problem that needs to be solved urgently. A large number of basic and clinical studies had shown that gene-based therapeutic angiogenesis could effectively induce angiogenesis and collateral circulation in ischemic tissue of lower limb, leading to the significant improvements of blood perfusion in ischemic areas. Additionally, the construction of many kinds of new non-viral gene delivery vectors could also improve the safety and effectiveness of gene therapy to a certain extent. Conclusion Although promising therapeutic effect of gene-based therapeutic angiogenesis brings new ideas and strategies for the treatment of lower limb ischemia, issues still exist that have not been solved.