Title: Stem cell use in a patient with an ischemic foot ulcer: A case study
Authors: Kohlman-Trigoboff D, Lawson J, Murphy M
Source: J Vasc Nurs. 2006 Jun;24(2):56-61
PODIATRIC RELEVANCE:
The podiatric physician frequently encounters patients suffering from peripheral arterial disease with chronic pedal ulceration. Despite proper wound care and medical management, the outlook for the PAD patient with no distal flow to the foot or tibial region is dismal. The use of endothelial progenitor cells to stimulate angiogenesis in select patients with peripheral vascular disease may show promise in reducing the incidence of amputation.
METHODS:
Inclusion criteria for enrollment in the study include patient age greater than 18 years of age with unreconstructable grade II category 4 ischemia (rest pain) and grade III category 5 ischemia (ulceration or tissue necrosis). The patient must have an ABI of <0.5, a resting toe pressure of <0.4 , or a metatarsal pulse volume recording waveform that is barely pulsatile. The patient must be competent to give consent. Exclusion criteria includes poorly controlled diabetics (HbA1C > 6.5), renal insufficiency (creatinine >1.6), or congestive heart failure (ejection fracture < 30%). Other exclusion criteria include history of retinopathy, malignancy, or pregnancy. Under general anesthesia, 500 mL of bone marrow was harvested from the ileum of the patient. The mononuclear cell fraction of the bone marrow was isolated using density gradient centrifugation and then concentrated to a final volume of 30 mL. The mononuclear cell suspension was then injected into the gastrocnemius muscle of the ischemic leg, being delivered in 0.75 to 1 mL aliquots. Patients were seen for clinical evaluation at the following: 1,2,4,6,8,10 and 12 weeks posttreatment. Patients had an arteriogram performed before treatment and again at 12 weeks posttreatment. A pulse examination was performed at each visit. Noninvasive arterial studies were performed at the preoperative 4-,8-, and 12 week visits. All data was recorded on case report forms.
RESULTS:
A 67 year old female who met the inclusion criteria was evaluated in the case study. The patient had a total of 41 stem cell injections. Postoperative pain control was problematic. Of note, her ABI at week 1 through 12 was approximately twofold of preoperative values. PT Doppler signal was monophasic preoperatively and triphasic throughout the course of the study. The patient had dependent rubor until week 10 post injection therapy. Arteriogram following 12 weeks of treatment revealed collateralization of the calf/foot.
COMMENTS:
The article provides an overview of the theory behind the use of endothelial progenitor cells to stimulate angiogenesis. The patient history in this case indicates arterial insufficiency for 8 to 10 years with ulceration present approximately 6 months prior to stem cell therapy. It is unclear what type of wound care was provided prior to and throughout the study, and when the ulceration finally healed. I believe that the multidisciplinary approach to the diabetic foot should be applied to the patient with peripheral vascular disease to enhance patient outcomes. More studies will be needed to evaluate the efficacy of this novel approach to the patient with peripheral arterial disease.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.