Critical Limb Ischemia

Combination Bm-MSC With Bm-MNC Is Better Than Bm-MNC Alone in Resolution of Large Ischemic Ulcers: A Phase II/III Clinical Randomised Study

Cytotherapy 2016; Volume 18, Issue 6, Supplement, S21, June, 2016

H Hanafiah1, I Azim1, SP Chin3, MY Farina1, S Shazana1, NA Nur’ Ain3, SK Cheong3,4, SAW Fadilah1,2

1Department of Surgery, 2Cell Therapy Center, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, 3Cytopeutics, Malaysia, 4Tunku Abdul Rahman University, Malaysia.

We have demonstrated that BM-MSC with BM-MNC is superior to BM-MNC alone in the resolution of severe foot ulcer secondary to critical limb ischemic, particularly for larger ulcers. It have been proven through Digital subtraction angiography (DSA) images below that showed restoration of peripheral blood flow in two of patients who received intra-muscular injection of BM-MSC+MNC. MSC proven possess the ability in promoting neovascularization and can enhance wound closer by inhibiting apoptosis of wound healing cells.

BM-MSC and MNC implantation - baseline

Figure 1: A 35 year old patient (Patient 1). Arrows in (A) indicatethat there is no flow below the ankle at baseline. Arrows in (B)indicate the newly visible collateral vessels below the ankle at 5months after BM-MSC+MC implantation.

Figure 2: A 58 year old male patient (Patient 2). Arrows in (Baseline) indicate that there is no flow below the ankle at baseline. Arrows in (5 months) indicate the newly visible collateral vessels below the ankle at 5 months after BM-MSC+MC implantation.

Background: We previously demonstrated that combination bone marrow derived cultured mesenchymal stromal cell (BM-MSC) with bone marrow derived unselected mononuclear cell (BM-MNC) may help induce angiogenesis in diabetic patients with critical limb ischemia. In this new randomized Phase II/III clinical trial, we compared autologous BM-MSC with BM-MNC (Group A) versus BM-MNC alone (Group B) in severe lower limb ulcers secondary to critical limb ischemia with the aim of avoiding amputations.

Methods: Seven consecutive patients were randomized and underwent bone marrow aspiration (BMA) to collect 500mls that was then centrifuged and separated to obtain the unselected BM-MNC fraction. Group A (N=3) patients underwent intra-muscular injection of the BM-MNC 1 hour after BMA on the affected limb, followed by intra-muscular injection of in-vitro expanded BM-MSC. Group B (N=4) patients underwent injection of BM-MNC after BMA only. One patient in Group B had ulcers on each leg.

Results: All patients tolerated the BMA and injection well. The ulcer size at baseline, 1 month, 2 months and 5 months were as follows: Group A (22.5±14.2 vs. 6.3±10.1, 2.5±3.5, 0.0±0.0cm2; p=0.07). Group B (25.4±12.0 vs. 29.1±22.8, 45.2±41.7,54.8±52.7cm2; p=0.84). All ulcers in Group A were completely healed by 5 months irrespective of baseline size (10-38cm2). In Group B, 2 ulcers (both smaller than 20 cm2) resolved while 3 ulcers (all greater than 20cm2) enlarged in size. Digital subtraction angiography (DSA) showed restoration of peripheral blood flow in all Group A patients. However there were no difference in ankle brachial index at baseline to end of follow-up within both groups.

Conclusions: We have demonstrated that BM-MSC with BM-MNC is superior to BM-MNC alone in the resolution of severe foot ulcer secondary to critical limb ischemia, particularly for large ulcers.